Tuesday, September 25, 2012

Turf Toe Injury - diagnosis and treatment

With the beginning of the NFL season and college football in full swing, I decided to talk about an injury called turf toe which is a common football injury. Turf toe is an injury to the first metatarsophalangeal joint (MTP) that is described as a sprain or tear to the capsule or ligamentous structures.  The American Orthopaedic Foot and Ankle Society defines turf toe as a plantar capsular ligament sprain. (Tewes, 1994)  The anatomy, predisposing factors and causes of turf toe are important in order to understand this sports-related injury.  The diagnosis, treatment and forms of rehabilitation will be illustrated as well as specific complications if left untreated.

            The anatomy of the first MTP joint is fairly complex.  It is a synovial joint incorporating four articulating bones.  They are the first metatarsal, a proximal phalanx, and a medial and lateral sesamoid bone.  The sesamoid bones are located inferiorly and “act as fulcrums to increase the power of the muscles which cross them”. (AthleticAdvisor, 2005)  The first MTP joint is surrounded by a capsule which serves as attachment sights for the abductor hallicus, adductor hallicus and the flexor hallicus brevis on the plantar side.  While the tendon of extensor hallicus longus forms the roof of the capsule on the dorsal great toe. (Dykyj, 1989)  The last muscle in this complex is the flexor hallicus longus which runs between the two sesamoid bones attaching to the distal phalanx.

            The mechanism of injury involves a hyperextension to the first MTP joint which results in capsular damage and or compression to the dorsal articular surface. (Rodeo, 1990)  The shoe or cleat grips hard into the turf, causing the foot to go into forced dorsiflexion during push-off.  The increase in number of cleats on the football shoes leads to increased traction and an increase in incidence of turf toe. (Clanton et al. 1986)  Also, with the foot in this toe-off position, it is common in football for an external force to drive the toe into further dorsiflexion.  Other predisposing factors include increased flexibility of the forefoot, which will allow hyperextension of the first MTP joint.  (Clanton et al. 1986)  Clanton suggests that a stiffened forefoot in the boot of football players sustained less turf toe injuries. (Clanton et al. 1986)  Coker suggested that shoe fit could be a contributing factor, explaining that wider feet require large sized shoes, subjecting the first MTP joint to greater flexion and extension stress. (Coker et al. 1978)  Probably the biggest influence on turf toe injuries is the artificial turf, hence the name of the injury.  Grass has been replaced by turf in the late 1960’s, and the reported incidence of first MTP joint injuries has increased after introducing artificial turf. (Clanton, 1994)  Football athletes are chronically in three-point stances, and require tremendous amounts of power from this position with the foot relatively flat.  This requires excessive dorsiflexion and extension of the first MTP joint. (Sammarco, 1995)   During push-off, the great toe is the last structure in contact with the ground.  Up to eight times a person’s body weight can be transferred through the great toe.  (AthleticAdvisor, 2005) 

            Diagnosis includes questioning the patient with regard to the mechanism of injury.  This will provide information about what structures may be injured.  The patient will report sudden onset of pain after forced hyperextension. (Clanton et al. 1986)  Physical exam will show evidence of swelling, ecchymosis and painful passive ranges of motion. Active ranges of motion of dorsiflexion and plantarflexion in the first MTP may be decreased.  (Bowers, 1976)  When examining the patient, he or she may have an antalgic gait, externally rotating their lower extremity to avoid dorsiflexion during push-off. (Bowers, 1976)  Imaging may be required in severe cases to rule out avulsion fractures on the first metatarsal head or proximal phalanx, or even sesamoid bone fractures. (Churchill, 1998)  It may also be advantageous to assess any articular or joint damage with plain film radiography.  Grading turf toe injuries involves interpreting signs and symptoms to assess tissue disruption.  Grade 1 sprain involves tenderness, minimal swelling, no ecchymosis and negative x-rays. (Churchill, 1998)  In this case the plantar capsule is stretched.  Grade 2 turf toe is a partially torn plantar capsule and the patient will have diffuse tenderness, moderate swelling, ecchymosis, and restriction of motion. (Churchill, 1998)  Grade 3 injuries have completely torn plantar capsules and may have a compression injury to the dorsal articular surface.  There will be severe tenderness, considerable swelling, ecchymosis and marked restriction in range of motion. (Churchill, 1998)

            Treatment for turf toe is very similar to other types of ligament sprains.  In the acute stages rest, ice, compression and elevation (R.I.C.E.) is an effective and conservative method to minimize inflammation in all grades of turf toe. (Churchill, 1998)  Grade 1 injuries can usually be taped to allow only for minimal extension of the great toe and limit dorsiflexion of the foot. (Nicholas, 1995)  Stiff-soled shoes or rigid orthotics with a Morton’s extension reduces motion of the first MTP joint to protect from re-injury. (Clanton, 1994)  Grade 2 injuries should avoid physical activities for 1 to 2 weeks, while grade 3 injuries should be sidelined for 3 to 6 weeks.  Grade 3 injuries may require surgery for capsule repair or removal of loose bodies. (Coker et al., 1978)  Non steroidal anti-inflammatory drugs and ultrasound can also be used in acute stages to reduce pain and inflammation.  Following the acute stages, it is essential to have a proper rehabilitation program to regain full range of motion and strength in the foot and ankle.  The strength and endurance of the foot can be addressed by using Therabands. (AthleticAdvisor, 2005)  The first MTP joint can be addressed by doing gentle range of motion exercises, and ultimately progress to more aggressive long-axis distraction manipulation to reduce the compression.  Such rehabilitation is crucial to prevent hallux rigidus, a painful progressive loss of motion in the first MTP joint. (AthleticAdvisor, 2005)  With hallux rigidus, patients report history of trauma, compression and repetitive hyperextension of the first MTP joint. (Churchill, 1998)  This may also ultimately result in degenerative arthritis of the great toe. (AthleticAdvisor, 2005) 

            In summary, turf toe is a fairly common injury seen in sports that are played on artificial turf, especially football.  This hyperextension injury of the first MTP joint has several predisposing factors, which includes increased flexibility, large shoes with many cleats, and of course the adoption of the less resilient turf.  Treatment for this capsular injury involves conventional R.I.C.E. methods and proper footwear, orthotics and taping to prevent further injury.  Rehabilitation is important to regain full function, and prevent future complications in the great toe. 

For more information Dr. Brent Moyer can be contacted at Brant Arts Chiropractic 905-637-6100. www.drbrentmoyer.com Twitter: @brantartschiro     Facebook: Brant Arts Chiropractic




            AthleticAdvisor (2005).  Turf-Toe.  http://www.athleticadvisor.com/injuries/LE/foot&ankle/turf_-_toe.htm


            Bowers K.D, (1976). Turf-toe: a shoe related football injury. Medicine Science and Sports Exercise. 8:81-83


Churchill, R.S., (1998).  Managing Injuries of the Great Toe. The Physician and Sportsmedicine.  Vol 26-9, Sept 98.


Coker, T.P. et al., (1978). Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. The American Journal of Sports Medicine. 6: 326-334.


Clanton, T.O., (1994). Turf Toe.  Clinics in Sports Medicine. 13, (4): 731-741.


Friday, September 21, 2012

8 Tips to Reduce Headaches

STRESS AND HEADACHES- 8 quick tips to reduce your headaches.

Dr. Brent Moyer BHSc., D.C.

Headaches are one of the most common medical complaints in the doctor’s office. The World Health Organization states that tension-type headache alone affects two-thirds of adult males and over 80% of females. This does not even take into account the prevalence of migraine headache, cluster headache, cervicogenic headache or medication-overuse headache (also know as rebound headache). There is not one simple cure for headaches, but the idea is to treat the cause of the headache and avoid common triggers and not just treat the head pain symptom. Stress is a very common trigger of tension-type, migraine and cluster headaches. Poor posture, lack of sleep, dehydration, history of previous neck injury, alcohol and excessive pain medication use are common headache triggers as well.

The key is to avoid these common triggers and to be proactive in managing chronic headaches.

Here are eight tips to reduce your headaches.

  1. Deep breathing/relaxation- this can be really effective to relax during stressful events.
  2. Stretching- take breaks if you spend a lot of time in fixed positions (at work, computer, studying etc.) Prescribed neck stretches can prevent the onset of a headache.
  3. Exercise- aerobic exercise releases endorphins for pain relief and enhanced mood.
  4. Avoid teeth clenching- TMJ problems can cause headaches.
  5. Drink more water- dehydration is a common cause of headache. Stay hydrated.
  6. Avoid excessive caffeine- too many stimulants can cause headaches.
  7. Avoid high sugar foods- causes sharp spikes and declines in blood sugar levels leading to headaches.
  8. Avoid alcohol- a common trigger in migraine and cluster headaches.

Headaches also respond well to chiropractic care. A Duke University study found chiropractic care resulted in almost immediate improvement of headaches originating from the neck and had fewer side effects and longer lasting relief of tension-type headaches than commonly prescribed medications. For more information Dr. Brent Moyer can be contacted at Brant Arts Chiropractic 905-637-6100. www.drbrentmoyer.com  Twitter: @brantartschiro

Thursday, September 20, 2012

Backpack Safety for your Children

Contact: Dr. Brent Moyer
Phone: 905.637.6100
Fax: 905.637.6104
Email: brantchiro@gmail.com


 BURLINGTON, ON. September 7, 2012- With the children already back to school Brant Arts Chiropractic and Mayor Rick Goldring are declaring September Burlington Backpack Safety Month. This coincides with several other organizations throughout North America as well as the Ontario Chiropractic Association.

“Many parents do not realize the negative effects of carrying a heavy load or wearing a backpack improperly, can have on a young and growing spine.” stated Dr. Moyer.

According to the U.S. Consumer Product Safety Commission there were more than 21,000 backpack-related injuries treated at hospital emergency rooms, doctors' offices, and clinics. Injuries ranged from contusions, to sprains and strains to the back and shoulder, and even fractures.

Back pain in children is not uncommon.  When you combine improper fitting and loading of a backpack, athletic injuries and poor posture in the classroom, this can cause a child to have back, neck or shoulder pain. The Ontario Chiropractic Association states that more than 50% of young people will experience at least one episode of low back pain over their teenage years. Research states that this could be caused, to a great extent, by improper use of backpacks.

Research suggests that a child should carry no more than 10%-15% of their body weight depending upon the strength and fitness of the child. In other words, a 70 lbs. child should carry a backpack of no more than 7 pounds. Heavier objects should be put closer to the body in the backpack.

“Carrying a backpack on one shoulder forces the muscles and spine to compensate for the uneven load, causing stress on the mid and lower back. This could lead to abnormal curvatures of the spine and problems in the future.” stated Dr. Moyer.

Selecting a backpack that fits your child is critical. Choose a light material such as vinyl or canvas, not leather. Find a backpack that has shoulder straps that are cushioned and wide to displace the load. Adjust the straps to fit the child and lessen the load on the spine. A backpack should not extend beyond the lower back of a child and it should fit snugly. If there is a waist strap and chest strap, encourage your child to use it routinely.

Indications that the backpack is too heavy would be a change in posture to manage the weight, numbness or tingling in the neck, arms or hands, straps leaving red marks on the shoulders or discomfort or pain when wearing the backpack.

“Pack it Light Wear it Right” is a public education campaign of the Ontario Chiropractic Association and the Chiropractic profession. More information can be found on the OCA website www.chiropractic.on.ca.

As a public service our office, offers workshops for parents and children to evaluate their backpack safety and create awareness. We offer workshops in house or arrangements can be made to come to your school.

Dr. Brent Moyer operates Brant Arts Chiropractic and is located at 672 Brant St. Suite 201 in Burlington. www.drbrentmoyer.com