When the New York Giants won the Super Bowl in 1987, tight end Mark Bavaro became known as one of the toughest players in football, a man capable of carrying tacklers on his back all the way to the end zone. It was a bittersweet season for Bavaro because he played with an agonizing ligament sprain of the metatarsophalangeal joint connecting the foot to the big toe, an injury more commonly known among football followers as turf toe.
After most games, Bavaro's right big toe was so swollen and painful he could hardly stand up. Often he hopped to the training room to receive treatment. Day after day, for the final two months of the season, Bavaro put ice on the toe, kept it elevated and took the anti-inflammatory medication Ibuprofen, downing hundreds of milligrams of the stuff with each meal. Relief finally came after the Pro Bowl, when he underwent surgery to repair the two tiny fractured sesamoid bones in the ball of the foot.
Bavaro is reliving turf toe once again in 1988, but this time it's his left big toe. Even though Giants head trainer Ronnie Barnes thinks the injury has been detected at an early stage, Bavaro is so upset about it that he refuses to discuss the matter.
"The general public laughs at the notion of a rough, tough, 250-pound football player complaining that his big toe hurts," says Giants assistant team doctor Steve O'Brien, an orthopedic surgeon at the Hospital for Special Surgery in New York. "Trainers and physicians not clued in will tell a player, 'You're dogging it. This can't hurt as much as you say it does.' But, you know, I'd much rather have a sprained ankle than a case of turf toe."
In fact, according to O'Brien, as much playing time is now lost in the NFL because of turf toe as ankle sprains, and it has become the most common injury reported by some 600 college players at the league's annual scouting combine workouts. Left undiagnosed and untreated, turf toe can develop into a career-ending arthritic condition known as hallux rigidus. When this happens, the injured big toe stiffens and the player can no longer push off on the affected foot, thereby losing most of his mobility, a critical commodity in today's speed-dominated pro game.
"No one has ever known much about the cause of turf toe," O'Brien says. "Athletes don't like to talk about it or the degree of disability they have had with the injury."
For that reason, O'Brien, 33, a quarterback at Harvard in the mid-1970s, piloted the first study on the origin of turf toe in professional athletes. Assisted by Barnes, Giants team physician Dr. Russ Warren, San Francisco 49er team physician Dr. Michael Dillingham and Cornell medical student Scott Rodeo, O'Brien examined 80 players for the Giants and 49ers in the 1986 and '87 seasons. The teams were selected at least in part because they play at home on different surfaces—the Giants on turf and the 49ers on natural grass.
Each player was asked to fill out a questionnaire detailing his age, position, shoe type, playing surface used, the circumstances of his turf toe injury, subsequent treatment and playing time missed. That was followed by an extensive physical examination, in which the range of motion of the big toes and the ankles was measured by a device called the goniometer.
The results were startling. Nearly half the players examined suffered—to one degree or another—from turf toe, with 83% of those indicating they were first injured on artificial turf. This percentage was almost the same for both clubs, regardless of the fact that the 49ers play their home games on natural grass. Says O'Brien: "There's no advantage to having a home field on grass if you still play a lot of your games on artificial turf. They [the 49ers] got injured on turf on the other playing fields."
•Turf toe occurred in 60% of the offensive players, compared with 32% on defense. The most afflicted positions were offensive line, running back, tight end and wide receiver. "That can simply be explained by the fact that players at these positions are usually on the bottom of the pile," O'Brien says. The least likely sufferers were linebackers, the lucky ones who usually end up on the top of the heap.
•The incidence of turf toe was higher among players 27 years of age or older and those in professional football at least five seasons.
•Of the turf toe sufferers, 85% had hyperextension of the metatarsophalangeal joint. In most of these cases, the front part of the player's foot was planted on the field and the heel raised. Another player then fell across the back of the leg, forcing the toe joint beyond its normal range of motion. Some offensive linemen also reported they had been injured while pushing off from their stances; many running backs and wide receivers said they had been injured in the act of making sudden stops or quick cuts or after being tackled from behind.
•Players with good range of motion in their ankles were the most susceptible to the injury. "The more flexible the athlete is, the better able he is to get up on his toes [where a majority of the injuries occur]," O'Brien explains.
•A player's height, weight, length of second toe and shoe type were not factors that contributed to the incidence of turf toe.
O'Brien believes improperly fitting shoes can result in turf toe. "Most athletic shoes are fit in length, not width," he says. "Players with wide feet are forced to wear shoes that are too long for them. Thus the foot continues to slide forward after the player's shoe has been firmly planted on the ground, frequently resulting in traumatic injury to the joint."
Prevention of turf toe? Rodeo advises teams to keep a close watch on the shock-absorbency of their stadiums' artificial turf. "The newer synthetic fields approximate natural grass in impact characteristics," he says. "But five-year-old turf behaves similarly to the asphalt underneath. It doesn't give."
Barnes recommends placing spring-steel inner soles in a sturdy pair of shoes. "They will seem uncomfortable at first and will have the feel of standing on Formica," he says. "But you'll find that you get used to them."
O'Brien's suggestion is simple: Take the injury seriously. Perhaps, he says, trainers ought to routinely tape athletes' big toes prior to both games and practices—just as they currently tape athletes' ankles.
"Turf toe is here to stay," he says. "Increased recognition will lead to better treatment and, in the long run, will mean better performance."
O'Brien, goniometer in hand, examines Ottis Anderson of the Giants for the turf toe study.