Turf toe.

It's the fourth quarter. You're winning by two, with a dog-tired defense. Your opponent has been up and down the field in the second half, scoring at will, and gaining all of the momentum.

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Your team has the ball deep in your own territory. All you have to do is pick up a couple first downs and you can follow that with a sigh of relief.

You turn to your star running back, and he is limping up and down the sideline. You suddenly remember his three game battle with turf toe. What is your decision? You run your fingers through your rain-soaked hair. You think to yourself, "Do I put my injured star back on that muddy field, or do I go with my No. 2 running back, who is prone to fumbling.

How can you avoid this situation?

The first metarsophalangeal joint (MTP) is the junction between the big toe and the foot. This joint is protected by a cartilage cap. The tearing of this cap is often referred to by most authors as "turf toe." Turf toe can become very painful and debilitating. (1) This condition has sidelined the likes of Jeremy Shockey (2), Eddie George, and Terrell Owens (3) and a number of other tough players.

Turf toe is a common injury to football players due to hyperextension (bending backwards) of the big toe. Turf toe injuries have been on the rise due to artificial playing surfaces and more flexible foot wear.

As previously noted, this condition is most commonly brought on by hyperextension of the big toe. This can occur with repetitive motion such as pass blocking or running the football multiple times during a game or throughout a season. (4) Usually, this injury will occur with repetitive motions, but it can also happen when a player's foot is planted and the toes are bent backwards. (1)

When turf toe is present due to repetitive motion, it becomes progressively painful in a matter of days. Turf toe can become a chronic injury that can hamper athletes for several weeks.

The big toe may appear swollen with limited range of motion, and quite often can be painful to the touch. It is most certainly painful with weight-bearing activities. The most common forms of treatment include: rest, ice, and non-steroidal anti-inflammatories.

Most physicians recommend stopping the activity that aggravates the toe. Treatment may also include stabilizing the toe. This is usually accomplished by some form of athletic tape or foam insert. (1) Due to these limited treatment options, your athletes suffering from turf toe become less agile, tentative, frustrated, and may become inactive for most of the season.

How can players rebound from this injury quicker than traditional treatments?

One treatment that has been making strides (no pun intended) is Active Release Technique[R] (ART).

Active Release has been taught to many disciplines, such as Chiropractors, Physiotherapists, Massage Therapists, Kinesiologists, and Sports Physicians. Active release is a hands on myofascial technique. Unlike other myofascial treatments, ART providers are trained with the ability to treat the entire soft tissue structure (muscle, tendon, ligament, fascia, nerve) involved in the injury. Active release providers usually take into account the complete kinetic chain when treating an injury.

For example, an ART provider would approach a turf toe injury by not only addressing the metatarsopha-langeal joint capsule, but also the surrounding muscles, ligaments and other soft tissue structures. (5)

Active Release is best used for treating repetitive strain injuries. A repetitive strain injury is a soft-tissue injury due to repetitive motions that cause muscles, nerves ligaments, fascia (the thin layer over muscle) or tendons to become inflamed and irritated.

This usually occurs slowly over time, perhaps over the course of a few days at the beginning of the season. Once again, this injury may happen with a repeated running motion of a tailback over the course of a long season.

Once this injury takes place, the body will attempt to heal this injury by producing scar tissue. Although this will help stabilize the injured area, it will result in decreased motion of the joint, loss in strength, and pain. All of these outcomes will hamper your players' performance. (5)

Two case reports of football players diagnosed with turf toe showed excellent outcomes using ART. The first study recorded involved a 25-year-old professional football player with pain under his left big toe. The pain was progressively increasing over a five-day period.

The patient developed the pain during the first week of preseason training. The condition worsened with flexion and extension of the great toe. It was also noticeably stiff upon waking and after strenuous exercise. The patient denied any blunt trauma to the toe or foot. (4)

Careful examination of the first MTP joint revealed no evidence of swelling. All active ranges of motion through the foot were full, with the exception of flexion and extension of the big toe. Passive range of motion (doctor moving the toe) was also limited due to pain. The first dorsal interossei was tender to touch and felt inflamed.

Abduction (movement away from the big toe) of the second toe was painful. The patient underwent treatment using Active Release Technique[R] to the first dorsal interosseous and surrounding muscles.

The muscles known as the dorsal interossei are located between the metatarsals. The metatarsals are the long skinny bones of the feet. These muscles are responsible for stabilizing the toes. The patient also received chiropractic adjustments to mobilize the first MTP joint (big toe joint).

The patient was seen a total of three times. After those treatments the patient had complete resolution of symptoms throughout the course of the regular season!

The second case discussed was similar in nature to the first. This case involved a 29-year-old professional football player with bilateral foot pain. His pain was three days in duration during the first week of pre-season training camp. The patient's symptoms were aggravated by blocking drills that had the patient stagger his feet.

This stance put the majority of the player's body weight on the balls of his feet. The pain was localized to the first metarsophalangeal joint. This case was treated with the same protocols as the first. This case was resolved over the course of five visits. (4)

In October of 2005, a 17-year-old high school tailback presented to our clinic complaining of pain on the ball of his right foot. The pain was localized to the big toe (first MTP joint).

The patient had denied any form of trauma to the toe, and explained the pain increased the night before, during his game.

Upon examination, the patient had flat feet bilaterally. He had custom-fit shoe lifts (orthotics) for this condition. The patient exhibited full range of motion with the exception of big toe flexion and extension. Although there was no swelling present, the patient had a bunion on the medial side of his big toe.

I recommended that the patient be withheld from two days of practice. The young man was treated using Active Release Technique[R]. He was seen for three visits over the period of a week. The pain resolved in approximately a 10-day duration.

ART was administered to the extensor digitorum, extensor hallucis brevis, and adductor hallucis. The extensor digitorum is responsible for extension of the toes and the extensor hallucis brevis is responsible for extension of the big toe.

These muscles can be easily strained from a running back that may carry the ball 20 times a game and forcedly "drive" his feet into the turf for extra yards. This particular running back was the featured back in his team's offense. He frequently ran the ball 20 times or more per game and complied over 1,100 yards in a 12-game season.

It is my opinion that ART is the gold standard for treating non-surgical soft tissue injuries. Not only is this treatment well known throughout the sports world, it is also the official treatment of the Ironman Triathlon.

ART has not only helped football players with turf toe, but it has helped resolve other soft tissue conditions as well. Former great, Joe Theisman, said, "After my first Active Release Technique[R] treatment, I could move my shoulder without the sharp pain." (6) Retired Atlanta Falcons tailback, Jamal Anderson, his been under the care of an ART provider to improve the range of motion and strength of his knees. (7) Current players also seek the help of ART providers. Dan Kreider, the starting fullback for the Super Bowl Champion Pittsburgh Steelers, has been using ART not only to treat his turf toe, but a number of injuries including strained rotator cuff muscles. (8)

So, the next time your players are fighting off a nagging injury, such as turf toe, give ART serious consideration.

To find an ART provider in your area, visit www.activerelease.com and click on the "Find a Provider" link.

Once your players receive Active Release Technique[R] treatments they will most likely return to the game quicker and stronger then they would have with older more traditional therapies.

Remember, X's and O's don't win football games, players win football games, and when it's the fourth quarter with the game on the line, I'm sure you'll want your star running back at full strength!

References:

1. Curtin University of Technology. 24 June 2006 <http://podiatry.curtin.edu.au/encyclo-pedia/turf_toe/>

2. Giants.com. June 24 2006 <http://www.giants.com/team/player.asp?player_id=48>

3. ProFootballWeekly.com. 24 June 2006 <http://archive.profootballweekly.com/content/archives/fantasy_2000/injuries_weekendlLasp>

4. Pajaczkowski, Jason. "Mimicking turf toe: myofsopahy of the first dorsal interosseous muscle treated with ART[R]." J Can Chiropr Assoc 2003: 28-32.

5. Abelson B., and Abelson Kamali. Release Your Pain. Calgary: Rowan Tree Books, 2004.

6. ChiroSport Specialists of Dallas. 24 June 2006 <http://www.sportdocusa.com/>

7. LaScala Active Release Techniques[R] (A.R.T.). June 24 2006 <http://www.drlascala.com/html/active_release_techniques_test.html>

8. Siegenthaler Active Release Techniques[R] Chiropractic & Rehabilitation Center. 24 June 2006 <http://www.artchiro.com/offer.html>.

By Eric McGraw, D.C., New Bern, N.C.