Incidence and risk factors for turf toe injuries in intercollegiate football: data from the National Collegiate Athletic Association injury surveillance system

wbldb

George, Elizabeth¹; Harris, Alex H. S.¹; Dragoo, Jason L.¹; Hunt, Kenneth J.¹

Incidence and risk factors for turf toe injuries in intercollegiate football: data from the National Collegiate Athletic Association injury surveillance system

Foot Ankle Int. February 2014;35(2):108-115

Affiliations

¹Stanford University, Redwood City, CA, USA
Abstract and keywords

Background: Turf toe is the general term for a sprain of the first metatarsophalangeal (MTP) joint complex. Previously attributed to shoe design and artificial turf, the incidence of turf toe injury has been thought to decline with the advent of newer turf designs. However, the current incidence and epidemiology remain unknown as the majority of the literature consists of small series and addresses diagnosis and treatment rather than epidemiology and prevention.

Methods: We examined data from the NCAA’s Injury Surveillance System (ISS) for 5 football seasons (2004-2005 through 2008-2009), including all preseason, regular season, and postseason practice and competition data. The incidence, epidemiology, and risk factors for turf toe injury, defined as injury to the connective tissue of the first MTP joint, plantar plate complex, and/or sesamoid fracture, were determined.

Results: The overall incidence of turf toe injuries in NCAA football players was 0.062 per 1000 athlete-exposures (A-Es; 95% CI 0.052, 0.072). Athletes were nearly 14 times more likely to sustain the injury during games compared to practice, with a mean days lost due to injury of 10.1 (7.9, 12.4). Fewer than 2% of turf toe injuries required operative intervention. There was a significantly higher injury rate on third-generation artificial surfaces compared to natural grass (0.087 per 1000 A-E [0.067, 0.11] vs 0.047 per 1000 A-E [0.036, 0.059]). The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%), and running backs and quarterbacks were the most common positions to suffer turf toe injury.

Conclusion: Our data suggest a significantly higher incidence of turf toe injuries during games, a greater susceptibility among running backs and quarterbacks, and a significant contribution of playing surface to risk of injury. Though turf toe injuries may be less common that previously reported in elite football players, these injuries warrant appropriate acute and long-term management to prevent long-term dysfunction.

Level of Evidence: Level IV, case series.

Keywords: turf toe, sesamoid fracture, NCAA football, hallux disorders, first metatarsophalangeal hyperdorsiflexion, plantar plate injury
Links

DOI: 10.1177/1071100713514038

PubMed: 24334272

Cited Works (19)

Year	Entry
2009	McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot and Ankle Clinics. June 2009;14(2):135-150.
2008	Orendurff MS, Rohr ES, Segal AD, Medley JW, Green JR III, Kadel NJ. Regional foot pressure during running, cutting, jumping, and landing. Am J Sports Med. 2008;36(3):566-571.
2009	Brophy RH, Gamradt SC, Ellis SJ, Barnes RP, Rodeo SA, Warren RF, Hillstrom H. Effect of turf toe on foot contact pressures in professional American football players. Foot Ankle Int. May 2009;30(5):405-409.
2011	Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP. Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop (Belle Meade, NJ). January 2011;40(1):40-44.
1986	Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. 1986;7(3):162-176.
1976	Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976;8(2):81-83.
1992	Hetherington VJ, Chessman GW, Steuben C. Forces on the first metatarsophalangeal joint: a pilot study. J Foot Surg. 1992;31(5):450-453.
2010	Anderson RB, Hunt KJ, McCormick JJ. Management of common sports-related injuries about the foot and ankle. J Am Acad Orthop Surg. September 2010;18(9):546-556.
2007	Dick R, Agel J, Marshall SW. National Collegiate Athletic Association Injury Surveillance System commentaries: introduction and methods. J Athl Train. April–June 2007;42(2):173-182.
2010	McCormick JJ, Anderson RB. Rehabilitation following turf toe injury and plantar plate repair. Clin Sports Med. April 2010;29(2):313-323.
2010	Dragoo JL, Braun HJ. The effect of playing surface on injury rate: a review of the current literature. Sports Med. 2010;40(11):981-990.
2006	Childs SG. The pathogenesis and biomechanics of turf toe. Orthop Nurs. 2006;25(4):276-280.
1990	Rodeo SA, O'Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. 1990;18(3):280-285.
1994	Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med. 1994;13(4):731-741.
1978	Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. Am J Sports Med. 1978;6(6):326-334.
2012	Frimenko RE, Lievers WB, Coughlin MJ, Anderson RB, Crandall JR, Kent RW. Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes. Crit Rev Biomed Eng. 2012;40(1):43-61.
2013	Hunt KJ, George E, Harris AHS, Dragoo JL. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clin J Sport Med. 2013;23(4):278-282.
2007	Dick R, Ferrara MS, Agel J, Courson R, Marshall SW, Hanley MJ, Reifsteck F. Descriptive epidemiology of collegiate men's football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. J Athl Train. April–June 2007;42(2):221-233.
2006	Ford KR, Manson NA, Evans BJ, Myer GD, Gwin RC, Heidt RS Jr., Hewett TE. Comparison of in-shoe foot loading patterns on natural grass and synthetic turf. J Sci Med Sport. December 2006;9(6):433-440.

Cited By (17)

Year	Entry
2014	Gambardella GV, Delott J, Korwek ZJ. Managing foot and ankle injuries in baseball players. Lower Extremity Rev. June 2014.
2014	Hotfiel T, Carl HD, Jendrissek A, Swoboda B, Barg A, Engelhardt M. Die Turf-Toe-Verletzung: ein Hyperextensionstrauma der Großzehe [Turf toe injury: extension sprain of the first metatarsophalangeal joint]. Sportverletz Sportschaden. 2014;28(3):139-145.
2016	Hsu AR, Anderson RB. Sesamoid and capsule lesions of the first metatarsophalangeal joint. In: Valderrabano V, Easley M, eds. Foot and Ankle Sports Orthopaedics. Cham, Switzerland: Springer International Publishing; 2016:355-364.
2016	Magill ME, Anderson RB. American football. In: Valderrabano V, Easley M, eds. Foot and Ankle Sports Orthopaedics. Cham, Switzerland: Springer International Publishing; 2016:413-420.
2020	Reuter S. Angewandte Sportphysiotherapie - Untere Extremität: Evidenz Für Befund Und Behandlung [in German]. Berlin: Springer; 2020.
2015	Schein AJ, Skalski MR, Patel DB, White EA, Lundquist R, Gottsegen CJ, Forrester DM, Matcuk GR Jr. Turf toe and sesamoiditis: what the radiologist needs to know. Clin Imgaging. May–June 2015;39(3):380-389.
2019	Mack CD, Hershman EB, Anderson RB, Coughlin MJ, McNitt AS, Sendor RR, Kent RW. Higher rates of lower extremity injury on synthetic turf compared with natural turf among National Football League athletes: epidemiologic confirmation of a biomechanical hypothesis. Am J Sports Med. January 2019;47(1):189-196.
2017	York PJ, Wydra FB, Hunt KJ. Injuries to the great toe. Curr Rev Musculoskel Med. March 2017;10(1):104-112.
2023	Gupta A, Singh PK, Xu AL, Bronheim RS, McDaniel CM, Aiyer AA. Turf toe injuries in the athlete: an updated review of treatment options, rehabilitation protocols, and return-to-play outcomes. Curr Rev Musculoskel Med. November 2023;16(11):563-574.
2020	Nery C, Fonseca LF, Gonçalves JP, Mansur N, Lemos A, Maringolo L, Fonseca LF. First MTP joint instability: expanding the concept of "turf-toe" injuries. Foot Ankle Surg. January 2020;26(1):47-53.
2016	Ford KR, Taylor JB, Baellow AL, Arpante AK, Wright KE, Nguyen A-D. Effects of plate stiffness on first metatarsophalangeal joint motion during unanticipated cutting and resisted sled pushing in football players. Footwear Sci. 2016;8(2):75-82.
2021	Kent R, Yoder J, O'Cain CM, Meade Spratley E, Arbogast KB, Sorochan J, McNitt A, Serensits T. Force-limiting and the mechanical response of natural turfgrass used in the National Football League: a step toward the elimination of differential lower limb injury risk on synthetic turf. J Biomech. October 11, 2021;127:110670.
2019	Poppe T, Reinhardt D, Tarakemeh A, Vopat BG, Mulcahey MK. Turf toe: presentation, diagnosis, and management. JBJS Reviews. August 2019;7(8):e7.
2017	Marchetti DC, Chang A, Ferrari M, Clanton TO. Turf toe: 40 years later and still a problem. Operative Tech Sports Med. June 2017;25(2):99-107.
2015	Lievers WB, Adamic PF. Incidence and severity of foot and ankle injuries in men’s collegiate American football. Orthop J Sports Med. 2015;3(5):2325967115581593.
2018	Mulcahey MK, Bernhardson AS, Murphy CP, Chang A, Zajac T, Sanchez G, Sanchez A, Whalen JM, Price MD, Clanton TO, Provencher MT. The epidemiology of ankle injuries identified at the National Football League Combine, 2009-2015. Orthop J Sports Med. July 18, 2018;6(7):2325967118786227.
2019	Jastifer JR, McNitt AS, Mack CD, Kent RW, McCullough KA, Coughlin MJ, Anderson RB. Synthetic turf: history, design, maintenance, and athlete safety. Sports Health. January–February 2019;11(1):84-90.