Big Toe Pain
In BJJ, big toe pain can be big a problem. When training on the mats toes can get caught in the gaps, twisted in all directions and hyper-extended. “Turf toe” is a specific type of sprain to the first metatarsal-phalangeal joint, also known as the base of the big toe. Turf toe refers to when the big toe is hyper-extended and the collateral ligaments, plantar plate, cartilage and/or sesamoid bone is injured. The extent of injury can vary dramatically from a mild ligamentous sprain to complete rupture of all of the surrounding soft tissue structures. The main symptoms are pain, weakness, and instability.
Components of the first metatarsal-phalangeal joint:
The Plantar Plate refers to thick sturdy tissue at the bottom of the joint that links the bones together. Its role is to prevent excessive extension.
The Collateral Ligaments are located on the inside and outside of the big toe joint. They are rigid and connect the bones together to provide side-to-side stability.
The Flexor Hallucis Brevis tendon runs underneath the first metatarsal bone and connects to the phalynx bone. It has a role of providing stability and strength to the big toe.
The Sesamoids of the MTP joint are located within the flexor halluces tendon and help it move and transmit forces better.
Cartilage is a tough smooth elastic type tissue that covers the ends of the bone at the joint. The role of cartilage is to help the joint manage friction, shear, compression and tensile forces.
Most of the stability of the MTP joint is from the ligaments, capsule and flexor muscle complex. In normal walking, this complex of structures at the MTP joint must withstand 40-60% of the body’s own weight. These forces can increase by as much as 8 times the athlete’s body weight during a running jump. Furthermore, to consider added the weight and strength of an opponent thrown into the mix, the amount of forces going through this tiny joint is immense.
There are 3 different grades used to categorise the severity of damage:
Grade 1: A stretching of the plantar structures of the MTP joint. Usually there is very localised tenderness with touch and a small amount of swelling. Grade 1 injuries usually require 3-5 days of rest after the initial injury, after which the use of gentle range of motion exercises to maintain mobility in the joint is employed. After about 1-2 weeks, the joint can usually be taped with a return to modified activities.
Grade 2: There is partial tearing of the plantar capsular ligamentous complex. Usually this is accompanied by a more widespread tenderness and moderate amount of bruising and swelling. The toe typically feels quite painful to move. If a grade 2 or 3 sprain is suspected, an MRI can be used to assess the damage.
Grade 3: There is complete rupture of the joint complex. There will be severe pain, bruising and swelling. This severity of injury may require 8 weeks of recovery and immobilization. For full resolution of symptoms it can take as long as 6 months. It is recommended that the MTP joint should have between 50-60 degrees of painless passive dorsiflexion before explosive activities such as running are resumed. Surgical repair is sometimes considered for grade 3 injuries.
A useful tool that may be used for the immobilization period for grade 1 and 2 sprains is taping. Taping the big toe into slight flexion with rigid strapping tape will provide a degree of support and protection to the injured tissues by preventing hyperextension. Taping is particularly useful for protecting the structures in the early stages of returning to the mats.
Step 1: Place the circular anchor taping around the big toe and mid foot.
Step 2: Place the longitudinal taping from the big toe to the mid foot.
Step 3: Re-tape around the anchors to lock it in place.
Something else to be aware of is which movements pose a greater risk for re-injuring the tissues. Aggravating positions for big toe pain in BJJ are usually most top positions when you are on the toes as well as standing, so it might be a good idea to focus on your bottom game while letting the injury heal.
Following immobilization, the goal of rehabilitation is to restore mobility to the injured and surrounding segments joints of the foot and ankle, restore strength and endurance to the muscles, and to restore proprioception. While turf toe normally responds well to conservative treatment, other conditions such as fractures and gout can in some cases be misdiagnosed as turf toe. It is therefore important to have the injury appropriately diagnosed by your healthcare provider.
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