Patrick Willis, Tramaine Brock injuries: Considering medical implications of turf toe

San Francisco 49ers linebacker Patrick Willis sprained a toe ligament late in the second quarter of Monday's 31-17 victory over the St. Louis Rams and did not return to the game. This type of sprain is commonly referred to as turf toe. This followed Tramaine Brock's toe injury in Week 1 against the Dallas Cowboys.

Fooch's note: Earlier Wednesday, Jim Harbaugh said he would not characterize it as turf toe. However, turf toe has varying degrees of severity, and this article remains pertinent.

Turf toe is a sprain to the ligaments around the big toe joint, which works primarily as a hinge to permit up and down movement. Just behind the big toe joint in the ball of your foot are two pea-shaped bones (called sesamoids) embedded in the tendon that moves your big toe. These bones work as a pulley for the tendon and provide leverage when you walk or run. They also absorb the weight that presses on the ball of the foot.

Typically, the forefoot is fixed on the ground with the heel raised. While these injuries can happen over time and can be the result of cumulative trauma, it appears that is not the case for Tramaine Brock and Patrick Willis. It appears the injuries sustained by Brock and Willis were the result of outside force causing the foot traumatic hyperextension of the hallux MTP joint (shown in the image above).

When you are walking or running, you start each step by raising your heel and letting your body weight come forward onto the ball of your foot. You propel yourself forward by pushing off of your big toe and allowing your weight to shift to the other foot. WebMD described it well: If the toe for some reason stays flat on the ground and doesn't lift to push off, you run the risk of suddenly injuring the area around the joint. Or if you are tackled or fall forward and the toe stays flat, the effect is the same as if you were sitting and bending your big toe back by hand beyond its normal limit, causing hyperextension of the toe.That hyperextension, with enough sudden force, can -- cause a sprain in the ligaments that surround the joint.

There are long and short term effects of turf toe. In the short term, running and pushing off are compromised greatly. Players usually miss several games, because in nearly all cases -- rest is necessary. About 50% of individuals with turf toe injuries have persistent symptoms after 5 years. It can result in stiffness of the joint, arthritis, bunions (that cause deformity), and/or failure to regain push off strength.

Nonsurgical treatment is determined by the grade of the injury. Medscape outlines the following baseline conservative treatment:

• Grade 1. The RICE protocol is recommended: Rest, ice, compression, and elevation. Taping the big toe to the smaller toes will restrict motion. Non-steroidal anti-inflammatory meds may relieve pain and swelling.

Pain is usually tolerable and an athlete can continue to participate in sports using a stiff-soled shoe. Orthotics, a shoe insert with a rigid forefoot, can reduce stress on the plantar plate and provide stability.

• Grade 2. To keep the MTP joint immobilized, a walking boot may be prescribed. Afterwards, these injuries are managed with a taping regimen and the Grade 1 treatments.
Stretching and strengthening exercises can reduce joint stiffness. In most cases, an athlete with a Grade 2 injury needs 3 to 14 days of rest before returning to play.


• Grade 3. These injuries require long-term immobilization in a boot or cast rather than surgical intervention. Frequently, these injuries result in 2-6 weeks of sedentary activity. Return is generally acceptable when the majority of pain is gone.

Physical therapy should be started as soon as symptoms allow. Specific exercises help stretch and strengthen the big toe. Early PT and joint movement prevent joint stiffness.

Based on the mechanism of injury, it appears Brock suffered a Grade 3 sprain. It has been report Willis will be out against the Denver Broncos, which indicates the sprain is at least a Grade 2. Willis is also seeking a second opinion of a specialist. It is difficult to tell the severity of the injury based on the little information provided by the reports, but it never hurts to have a doctor look at the diagnostic tests to determine the full extent of the injury. getting proper treatment and rest from the onset is paramount with these types of injuries.

The normal MTP joint functions with a smooth gliding motion. Once the joint capsule is torn, there is a potential for fracture and possible dislocation. The joint can degenerate, which eventually requires surgical intervention.

My impression is Willis has suffered a grade 2 sprain and will likely miss two or three games, as he will be required to wear a walking boot to immobilize the joint. If Willis makes progress and inflammation subsides, he will likely make a complete recovery. It is important doctors monitor his pain and range of motion so no other complications develop.

It has been reported Brock will likely return after the week 9 bye. Clearly, he suffered a more serious injury, but he is well on the road to recovery as well.