Thanks to Kevin Kolb of the Cardinals, Turf Toe has been on the brain and in the Press. So it’s time for my take on the foot and Turf Toe.  After researching it, Googling it, looking up medical reviews and articles, I saw a missing piece of the puzzle.  The typical treatments of resting, icing, taping, modalities, range of motion, soft tissue work and all that have their place and certainly help to treat the symptoms.  I don’t want to go there, the info is readily availble and, well, rather boring.  A lot of the articles addressed possibles mechanism of injury and the HOW. However, one element that was missing that seemed to be screaming for clarification was the question, “WHY.”  To me it’s the elephant in the room.

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PROS ONLY SECTION (Quick take so you don’t have to wade through all the biomechanical lingo)

 For the athletes with Turf Toe, Foot, or other Chronic problems, here’s the quick take:  If you have a knee injury that is slow healing, if you have a hamstring that heeps getting re-tweaked, if you have a chronic ankle injury, then the problem could be your FOOT.  It’s getting overlooked.  I’ve worked with so many athletes with chronic problems that had a biomechanically messed up foot that wasn’t being addressed.  It’s a piece of the puzzle that can stay hidden if not looked for.  Just treating the toe via taping, rest, exercise, etc, is NOT enough and does not address the CAUSES.  A certain foot type can play into the big toe (and chronic ankle sprains, knee injuries, hamstring strains, etc) getting chewed up and undergo additional stress causing further injury.  A biomechanical assessment will determine the causes and determine a 3D plan to address the causes and the compensations.

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The guys at the table would be the following questions: How did he strain his MCL? Why does his hamstring keep getting re-tweaked?  Why does the Achilles stay flared up? Why so many ACL injuries in these players? Why isn’t Kolb’s Turf Toe getting better?  The elephant in the room would be the FOOT.  Yes the foot.  Don’t jump off the band wagon yet.  I’m not saying the foot is the cause of every injury and is the end all.  However, it is often overlooked and is a huge player in long standing injuries and can be the missing piece of the puzzle.

This is part of my story.  I got so frustrated with doing conventional treatments and knew I was missing something.  I started looking into biomechanics and the light went on.  I had an engineer friend convey to me how engineers do an analysis of a bridge and “fix” the bridge.  They would do a stress-strain analysis of the entire structure.  They use all their mathematical genius to assess where in the structure the CAUSE is coming from, BEFORE they fix the broken down component of the structure.  Otherwise, they would be back in 6 months to have to fix it again.  All their stress-strain and analysis scenarios were aimed at finding where in the structure the problem was coming from, and it was not the broken down component.  YES, THAT’S IT! I knew that was the way I wanted to biomechanically look at the human body to find the cuase of injuries instead of using traditional means of treating symptoms.

The foot became a significant piece of the puzzle that was getting overlooked.  The foot plays into 20% of knee problems.  That is not a stat I am going to reference because it is my own stat of having worked in a clinic for 12 years.  I stand by it.  I would see about 1 in 5 knee injury athletes having some type of foot deformity that was playing into their injury.  I’m talking about non-contact injuries.

Now back to Turf Toe.  Again, great stuff out there on treatment techniques. But  what about the WHY.  What is the cause of a long standing Turf Toe problem?  Yes, I get it about the the nature of the sport (if it’s football) and repetitive extension or hyper-extension of the first MTP. But that still doesn’t address a potential CAUSE.  And that cause would be…………..  FOREFOOT VALGUS.

A forefoot valgus is where the medial, or big toe side, of the forefoot is dropped DOWN in relationship to the rest of the foot (I am throwing a plantarflexed 1st Ray in with this as well, in that it does the same thing).  A plantarflexed 1st Ray is where the 1st Ray is dropped, or plantarflexed, in relationship to the other MTP’s. In the above pic, the yellow line is a reference point of what the forefoot should look like —-STRAIGHT.  The blue line (the line of the ruler placed against this person’s forefoot) is a reference point of the forefoot valgus that this person has. The ruler or blue line should be straight. It should be EVEN with the yellow line.  But look how dropped the medial forefoot is.  It’s huge and the angle that the blue and yellow line makes is about 20 degrees or so.  That’s significant.  Make sense?

So in other words, the forefoot/1st Ray/big toe, gets to the ground first, it takes most of the ground reaction forces.  It takes the hit.  It get’s chewed up.  If you add onto that a rigid 1st MTP (or stiff BIG toe), it’s BIG trouble.  It’s simple isn’t it?  Big toe down = Increased load to the big toe.  If you are a stunt man car jumper and one of the axles is off and the same wheel lands first, and before the other whells, every time, don’t you think that tire, axle, side of the car would have some break down or damage?  HELLOOOOO!

I see this all the time in football players, basketball players and even in golfers.  Except golfers don’t get turf toe.  Since the golfer’s foot is fixed, the right rearfoot on the back swing inverts to compensate for the forefoot valgus and they roll their foot as the rearfoot throws them to the lateral border of the foot. Or they just toe out to avoid it and lose the power of their swing.

So you have turf toe and your trainer or whoever puts a graphite orthotic or Morton’s extension in your shoe to prevent extension of the big toe.  Ya, ya, I get it, in that it stops some of the problem and it is a good temporary fix.  But that is “robbing Peter to pay Paul.”  You don’t fix the problem nor get to the cause by doing that and it will cause other problems later down the pike and decrease performance on the field.

Or, they just place an off the shelf orthotic in the shoe.  To me that is just crazy.  That is taking a stab in the dark.  That is shooting an arrow at no target.  I worked with an orthopedic surgeon for a year that was a foot specialist to learn all I could about the foot.  It was an awesome experience.  However, his orthotic methods were antiquated.  He would just give everyone an off the shelf orthotic.  Mostly he did this as a pendulum swing from seeing the other end of the spectrum where athletes would get expensive custom orthotics that didn’t help either.  When you go to the eye doctor, do you just get off the shelf glasses and hope that they work?  The eye doctor is very precise and does all kinds of testing to make sure you have the right prescription.

It should be the same way with orthotics.  A forefoot valgus will need a LATERAL forefoot post.  There are different cases and philosophies on how to determine the degrees of a post.  After working with a podiatrist for 2 years, an orthopedic physician for 1 year, going to numerous foot and orthotic courses, I have seen it all.  I think the most comprehensive, functional, sport specific paradigm that yields the best results is functional testing.  I teach a whole 2 day course on this and obviously can’t cover it all in a “Kolb” article, but functional testing takes out all of the guess work and determines precise degree of posting that yields the best performance of the athlete.  Two degrees difference will not be that significant on a sedentary elderly person, but we cannot use those same “Oh well” standards on professional or high level athletes.

I use a comprehensive functional testing system and customize it for the individual being tested to determine what works best for posting or even if an orthotic is even needed at all. For example, had one person that had a forefoot varus and used 4 degree posting with functional tests of lunges, and a cutting drill; his meniscus symptoms decreased significantly, he could reach further with the lunge tests, and cut off that leg with a decreased time on the drill with the post as opposed to without it.  I performed repeat tests to make sure it wasn’t a result of practice and just getting used to the movements.  So, I thought more would be better.  Used a 6 degree post and tried again.  WRONG…… symptoms increased, quality of motion was worse, excursion distance was worse, time on the drill was worse, everything was worse (I did numerous other tests to verify the results).  After working with athletes that strive to decrease their 40 by .2 sec, posting precision is the least that can be done for them to overcome a chronic problem.

COMPENSATIONS

Asking “What kind of foot exercises should the athlete do?” is another elephant question.  It’s like asking, “What color of shoe strings should the elephant use, purple or pink? In other words, it doesn’t matter.  It’s the wrong question.  Are “towel scrunches” or toe flexion exercises really relevent?  Really??  Is having Adrian Peterson (who used to do explosive jumps onto a 3 foot platform while holding 50lb dumbbells while he was at OU)  doing towel scrunches appropriate?  Not in my house.  It’s pink shoe strings.

Compensations that need to be addressed are usually up at the hip.  If the toe is inflamed and painful then the athlete doesn’t have the range of motion to extend through it.  So he can’t get over his foot.  So his stride length shortens and the hip flexor doesn’t get eccentrically turned on as usual and tightens up.  Or, since he can’t get over it, he has to bail out, or TOE OUT, on that foot and the hip rotators get tight.  Not sure which is the chicken or the egg, but it happens and needs to be addressed.  These are HUGE components of performance and will affect every aspect of the game.

I read one comment from a specialist physician as follows, “Lineman, backs, and the secondary, are always pushing off the toes when they come out of their stance, leading to turf toe.”  Well, that would go for about every position on the field.  If that were the case, we would see a higher incidence of Turf Toe and foot injuries.  It’s not just pushing off the toe or running hard or whatever.  Could it be a forefoot valgus????????

Michael Griffith PT, CSCS

www.3dprformancesystems.com