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Saturday, February 28, 2015

Turf Toe Injury: Email Advice

Dear Dr. Blake,
Thank you for the wealth of information and encouragement you offer here!  Over the past five weeks and counting since I injured my foot, yours has been the blog I return to in my search for answers and hope that I can get back to my regular daily activities. Above any other online source, your blog has helped me maintain a sense of optimism and the feeling that I’m not alone in managing a catastrophic injury of my foot without the diagnostic team of doctors and physical therapists of a pro athlete.   I am an artist and until five weeks ago I stood at my easel to paint.  I had no idea how much I moved while I work, stepping back and forward and moving around my studio, but I realize now that my job is a physically demanding one, and I need to be on my feet.  I’m also general factotum around here and my husband has graciously picked up all the slack, but this scenario can’t hold forever.    I am a healthy, slim, reasonably fit, mid-forties woman with no underlying health conditions. I eat a primal plus dairy kind of diet with plenty of protein and fish and I supplement with vitamin D and vitamin C.  I’m on no prescription medicines.  I usually recover from injury very quickly and this has me stymied and frustrated.
I’ve tried to condense my saga to main points, but it’s still a long story.
Five and a half weeks ago:  Traumatic initial injury—hyperflexion of great toe as well as second third and fourth toes:  
I was running to answer my front door in sock feet when I tripped over my heavy tripod in its case on the floor in the front hall.  In the moment, my foot caught on the tripod and I hyperflexed my left big toe in particular, but also the second third and fourth toes.  I recovered somewhat and finished this awkward movement on the ball of my foot.  I knew then that I’d done something not good, but I shoved my foot in a winter boot and ran some errands (driving my manual transmission car with newly injured clutch foot) before returning home and taking a look at my now incredibly swollen and painfully bruised foot.
Initial symptoms: blue-black bruising on top of foot at bases and top surfaces of my three middle toes and dorsal side of great toe (which appeared somewhat flattened across the top—my other big toe curves up somewhat jauntily at the final joint).  Black blue bruising on the ball of my foot under the MTP joint.  Extensive swelling, especially of big toe and ball of foot under big toe and at bases of middle toes.
Pain, inability to bear weight on ball of foot—partly from swelling, partly from pain.  The most alarming swelling was the thickness of MTP joint preventing me from getting my foot into even the roomiest of my shoes.
My early attempt at self treatment:
Over the next few days I applied RICE—post-op shoe, compression with tensor bandages, elevation, and ice (applied as gel pack) as much as possible   I hobbled about with my weight on the outside of my left foot and a cane.  I thought this was a minor injury and that I would recover quickly.  I made several ill-advised trips in the car of over an hour wearing winter boots during this period.
Three and a half weeks ago:  First visit to family doctor; x-rays taken:
Two weeks later, with minimal improvement other than a lessening of the bruising and a small diminishment of swelling, I went to my family physician who looked at my foot, without physically manipulating it, and told me to keep doing what I was doing, sent me for an x-ray to rule out a fracture, and assured me that sprains often take several weeks to resolve.  She mentioned an Aircast in passing—in the event that something was broken and I found and purchased one the next day.
X-ray results were negative. 
My new attempts at treatment now in Aircast:
I began your contrast bathing protocol (keeping the contrast a little less contrast-y since I suffer occasional episodes of Raynauds).  I learned spica taping to immobilize my big toe—especially at night, I ordered insoles, dancer’s pads, podiatry felt, etc. and concocted a way to offload the swollen ball of my foot (suspecting some involvement of the sesamoids) and offloading the metatarsals.  It’s been quite an art to get things right, but I can be largely painfree in the boot for about an hour on my feet, after that things get very twingey as the swelling really sets in.  All this time I’d been weight bearing in the boot, climbing the stairs multiple times per day in my big old house with studio on the third floor, but using a cane when necessary.  I tried range of motion exercises especially in the warm water.   I attempted some of your rehabilitation foot exercises, but quickly realized I was not at that stage yet.  Otherwise I kept my foot elevated while sitting and sleeping.  The swelling is still alarming—even first thing in the morning.  Bruising remains under my foot and on my toes.
A week and a half ago: Return to family doctor to request further diagnostics:
After the fourth week of little improvement I returned to my family doctor who, not at all happy with the lack of progress or the swelling, referred me to a sports medicine doctor.
Several Days ago: visit sports medicine doctor; have more x-rays taken:
I visited the sports medicine doctor just after the five week mark.  He and his young resident doctor took a very thorough history and physically examined my foot—pressing on all of my bones to rule out breaks and manipulating my foot and toes, and asking me to move my toes freely and against resistance. The greatest pain was on tops and side of my big toe-especially the outside tip of my big toe and underneath the MTP joint.   I couldn’t  curl my toes at the final joint—neither my big toe, nor my second toe.  I can flex and extend my big toe slightly, but it’s very stiff and causes a little pain.  If I step down hard on the ball of my foot I feel a radiating tingly twinge of pain like an elbow pain.  The two doctors examined the initial x-rays and thought they saw a fracture across the joint of my big toe that might account for the lingering swelling and inability to move my toes.   They sent me for more x-rays at a different lab again both the new doc and the radiologist ruled out a fracture (sesamoids looked fine).  I spoke to the new doctor over the phone and he’s booked me for an ultrasound in about two weeks and an MRI in about four weeks.  In the meantime, he’s asked me to stay in the boot for another two weeks, wearing a tensor bandage and or tape at night and continue with the icing. 
Meanwhile I keep expecting to improve and I don’t improve:
My MTP joint looks huge compared to my other foot.  My foot swells alarmingly after standing for any period.  After showering, I have one purple, puffy foot and one normal, bony pink foot.  I wear Crocs flip flops in the shower and still can’t direct any weight to my big toe joint.  The rest of the time, except while sleeping or sitting with foot elevated, I’m in the boot.  Even after contrast bathing, elevation and gentle ankle motions to try to get rid of the swelling, my toes and foot become swollen, and skin shiny with pressure when I put my foot down again. I have residual bruising underfoot and across my toes  As I write this, I am in a graduated toeless thigh-high compression stocking with my foot slightly elevated, boot off, but the opening seems to hit my big toe at a vulnerable spot, so I’m not sure I’ll continue wearing it.  I am going to try 2.3% Voltaren on the most swollen areas of my foot and toe.
I’ve ordered a pair of Crocs clogs which should have a toe box deep enough to accommodate my giant toe joint when I transition out of the boot.  Other shoe choices will have to wait until I can get out and about.  We’re in a deep freeze with a mountain of snow and walking is not good even for the able bodied.
After all of this, can you give me any additional advice, hope, or questions to ask my sports medicine doctor when I return?
I’ve read your good/bad pain article but remain confused about whether I risk re-injury with range of motion and strengthening exercises.  Should I be attempting toe curls with so little movement possible, or could I make a tear in the ligament/tendon worse?  Can I try standing on one foot while in the boot or is that counterproductive?   Is swelling and bruising at this stage, so long after the initial injury a normal effect of injury?  I will try anything, ask anything, pursue any course to get better.  I’d appreciate any advice or remarks you can offer. 
History: Several years ago, I had a mild case of classic turf toe after hyperextending the same great toe while gardening on soft soil and feeling as though I was walking on a bunched up sock under my toe.  I recovered completely with RICE and buddy taping after about two weeks.  In the intervening time I’ve suffered no residual effects until now. 
Foot architecture:  I have a high arch and a long first metatarsal with Egyptian foot shape. 
Please forgive my long-windedness.
Thank you again for the excellent resource of your blog.
Silvia (name changed)

Dr Blake's response:
     Silvia, thank you so very much for the email, and sorry it took me a long time to answer. You have the classic symptoms of Stage 3 Turf Toe, with complete rupture of one of the main ligaments in your big toe joint (which gives you the constant thickness of the big toe joint, and unending swelling and bruising. The bruising is from repeated partial healing, and then re-tearing of the delicate ligaments). I am glad the x rays are fine, although the MRI may show some bone issues. Can you speed up the MRI so the soft tissue diagnosis can be made sooner? When the tear starts to heal, the tear begins to slowly not look like a tear, only scarring/fibrosis, and the MRI can be read incorrectly. Daily I would wear the boot and spica tape. In the evening, take the tape off so you can freely contrast and massage. The massage is very important to decrease the nerve hypersensitivity which can have a mind of its own. You should be able to have your dancer's padding inside the boot (sorry the image is so blurry).

Get some NeuroEze if you think any hypersensitivity is developing. Since some cases, and you may be one, of Turf Toe Injuries need surgery, the more you do not move it now and let things scar down, the better. 3 months in the boot and spica taping typically is needed, creating that pain free environment which allows 12 hours a day of walking/standing. Your immediate bruising, and the joint signs, and your inability to walk/stand more than 1 plus hours, means you have a serious injury. After the MRI, you can get more odds on the chance of needing or avoiding surgery. I hope this helps you. Rich

PS I am closing with my Top 10 for Hallux Rigidus, which seem to apply other then exercise that move the joint. 

The top 10 initial treatments for Hallux Limitus/Rigidus are:
  1. Create a pain free (0-2 pain level) environment with some form of immobilization and/or protected weight bearing.dreamstime_m_40381369.jpg
  2. 3 times daily use topical anti-inflammatory measures with icing twice and one session of contrast baths (you don’t have to tell anyone about your rubber ducky in in the bath!!). dreamstime_m_34958737.jpg
  3. Learn how to spica tape the big toe joint for times you want to immobilize (see my video at YouTube entitled drblakeshealingsole Spica Taping).spicataping3.jpg
  4. Learn how to make dancer’s pads for any shoe or boot to off weight the big toe joint. One eighth inch adhesive felt can be purchased from for this purpose. Dancer's Pad.jpg
  5. Learn if arch supports are necessary to transfer weight to the arch and middle of your foot. You can try the Red Sole inserts sold online or at stores like REI.Your Sole Inserts.jpg
  6. See if you can get xrays and an MRI to look at the health of the joint internally.
  7. Purchase a carbon graphite plate that can be used in some shoes under the insert to limit the joint motion for some activities.
  8. If you were started in a boot to obtain a pain free environment, purchase an Evenup to keep the spine level and avoid back issues. Removable Boot with Evenup3.jpg
  9. From the day you begin treatment, begin strengthening your feet, and lower extremities. Avoid pain, but this approach will lessen the deconditioning. This can be mean a lot of core work, some cardio on stationary bikes, and specific foot exercises approved by the health care provider (as long as they do not hurt is the general rule).dreamstime_m_40635691.jpg
  10. Use adhesive felt on the top of the foot (typically 2 layers of 1/8th inch or just ¼ inch) from next to the bump at the top of the big toe joint, but not over, in any shoe that it helps take pressure off.Bunion protection.jpg

Patient Response:
Dr. Blake,
My MRI will probably arrive in your mailbox this week. But meanwhile, I have great news. While the MRI has been making its way to you, a random conversation at our local woodworking club (which for some reason attracts many surgeons--they especially like bowl turning on the lathe) led to an appointment with a wonderful, but very busy, foot and ankle orthopedic surgeon, much beloved by patients in our region. He takes the patients other surgeons abandon, saves limbs and gets people back on their feet.
I just got back from my appointment with him at our local fracture clinic where he examined my foot (stealthily while making conversation) finding good movement in my joints (which I hadn't moved in weeks!), and said much the same thing that you've been saying all along: get the foot moving again!  He said (as you did) that the blood pooling, residual swelling, pain and stiffness are largely a result of non-weight bearing and immobilization.  He also said that too many patients are referred on the basis of x-rays. He said "treat the patient, not the x-ray" and said the only time he would consider fusing a joint is if there was a considerable lack of function.  He said even a poorly healed or even non-union fracture of the the small bones of the foot can often pose no significant problem for the patient even when they appear "like corn flakes on the x-ray".  Anyway, all this is to say that he advised me to start remobilizing right away (contrary to the advice of my sports medicine doctor who had asked me to remain non-weight bearing for three more weeks).  The surgeon said prolonging immobilization can cause weakness leading to secondary injuries.  I'm very eager to start rebuilding my leg muscles and foot strength and reclaiming my life.  I sincerely like my sports medicine doctor, but don't know why his advice was so different from yours and the surgeon's.  It's hard to contradict a doctor's advice as a layperson. I wish I hadn't remained non-weight bearing for so long out of fear of delaying the fracture healing.  In any case, I'm looking forward with optimism.

I just purchased a pair of Wolky sandals, a new brand to me.  The model called Jewel has three adjustable velcro straps (which is wonderful for someone with a very high arch like me), a fairly rigid sole with rocker front, and a removable cork foot bed into which I've put my own cobbled- together foot bed with strategic offloading padding. They are far more attractive than typical orthopedic shoes and your other patients might find them very helpful:
It feels wonderful to be transitioning to real shoes again. I believe I will be walking without pain or crutches very soon!
Thank you again for your support and very good advice.  Please feel free to use my case for your blog if you think any part of it will be helpful for others.  Your blog was such a great source of sensible, straightforward practical advice during dark days when was very easy to fall into worst case scenario speculation.  Thanks Dr. Blake!


  1. Doctor Blake,

    Thank you so much for taking the time to respond—and so helpfully!
    I was beginning to suspect that I must be suffering a grade three sprain and although I’m sorry to have you confirm it, I’m happy to have an explanation for my slow healing. I was lucky to get an MRI appointment quickly and should have my results early next week. I don’t believe the image will be high resolution, but I hope that it will still be helpful.
    In the last few days, the joint swelling has subsided a little, enough that I can set my bare foot on the floor and have all my toes contact the floor in a somewhat normal way—though it's still no good for weight bearing. I was emboldened enough to try some of your self-mobilization exercises for Hallux Limitus, which I could do without pain, but perhaps I’m jumping the gun? I still have extremely limited range of motion in the big toe and no ability to flex the distal joint. My foot is certainly swollen and bruised especially noticeably along the side and top of my toe (and the overall thickness of the joint is still far from normal).
    I will stay in the boot with offloading padding inside and continue to strive for that pain free environment, while contrast bathing and spica taping at night. I’ve been using an over the counter bunion splint at night to keep my toe from being pulled around by the sheets. Maybe I’ll spica tape first and wear the bunion splint over top.
    I hope I was clear when I described my initial injury that the motion was one of my toes all being bent underneath my foot (is that called plantar hyperflexion?). Does the turf turf toe label cover any injury to the first MTP joint?
    Unfortunately, I think I am developing some of the nerve hypersensitivity you mention, but Neuro-eze isn’t available in Canada so I’ll try to find another source of L-Arginine cream (if that’s the essential component). I will do the massaging, which is surprisingly less painful than light touch. Is it best to massage before the contrast bathing?
    I have the Even-up now, which is a big help.
    Once again, the advice on your blog is wonderful.
    Thank you for sharing your wealth of knowledge!
    Silvia ;)

    1. Dear Silvia (or whatever name you go by now), definitely pain free Self Mob of the big toe joint is in order, you had a hyper-extension injury, not turf toe (hyperflexion), but the ramifications are the same (different structures injured). Yes, massage before contrasts. Good luck. Rich

  2. Thanks Dr.Richard Blake for your great explanation on foot drop problem. foot drop and ankle problemDoes an AFO help in jogging?


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.