Combat Arts Toe Injuries Overview

Overview 

Olympic Judo silver medalist Travis Stevens has talked about training and competing through a broken toe, describing it as a small but frequent martial arts injury; we have no independent source for the account beyond his own telling. In grappling and many other combat sports, injuries to the toes are certainly common. That does not make them trivial. We don't recommend his method of treating or dealing with toe injuries, and we don't recommend that a combat artist self-treat unless the injury has been confirmed by a clinician.

Symptoms

Causes

A broken toe usually comes from a direct blow — stubbing the toe on the mat or a bag frame, catching it on an opponent's knee or elbow, or a bad landing. The little toe and the big toe take the most of it. The metatarsals behind the toes break in the same sort of incidents and also under repeated load, and the fifth metatarsal, along the outer edge of the foot, is the one most often involved. It behaves quite differently from a broken toe: much of the detail that follows about zones, screws and long spells of immobilisation applies to metatarsal fractures, not to a simple broken toe, which is usually managed with a stiff-soled shoe, buddy taping to the neighbouring toe, and time. Any of these bones can be injured during rapid, violent, forceful movements, and each has its own tests and treatment plan depending on whether the injury is acute or chronic.

To learn how Toe fractures is diagnosed Click Here

Overview

Turf toe occurs due to forceful hyperextension of the first MTP joint — the big toe joint. It was first described in American football players competing on artificial turf, which is where the name comes from. It is also seen in martial artists and other athletes training on artificial mats and turfs, because these surfaces are far more rigid and give the foot less to slide on.

Symptoms

Causes

The first MTP functions as a hinge and a sliding joint. There is little bony stability between the convex metatarsal head and the concave base of the proximal phalanx. A series of attachments via the capsule, ligaments, and musculotendinous structures support the complex joint.

The strongest stabilizer of the first MTP joint is the plantar plate. It is made of the thickened joint capsule. Any violent motion, sudden kick, toe getting stuck against the mat can disrupt the attachment to the transverse head of the adductor hallucis, the flexor tendon sheath, and the deep transverse intermetatarsal ligament. The injury is classified based on the degree of injury to the plantar plate:

To learn how Turf Toe is diagnosed Click Here

Overview

Any direct blow or crush injury to the end of the toe can damage the nail bed. As blood collects in the space under the nail it exerts more pressure, which is what makes these injuries throb. A nailbed avulsion is often accompanied by a subungual haematoma, a fracture of the distal phalanx — the small bone at the very tip of the toe — or damage to the joint just behind it. Where the nail bed is cut and the bone underneath is broken, that combination is an open fracture and needs prompt medical assessment. In martial arts, nail injuries take place due to sudden moves.

Symptoms

Causes

Sometimes simply catching a toe in an opponent's gi can avulse a nail bed if they jerk away or the movement is sudden and forceful. A crush injury where the toe is trapped under an opponent, or a fracture of the toe itself from a fall or a mistimed kick, can also cause a nail bed injury.

To learn how Nailbed injuries are diagnosed Click Here

Physical Exam

During the physical exam, the skin is examined to check for any open injuries. These may require debridement and change the treatment plan. Doctors will palpate the foot for tenderness, swelling, and ecchymosis. They will test the range of motion of the foot and toes. Pain or weakness on resisted eversion of the foot points to the base of the fifth metatarsal, where the peroneus brevis tendon attaches; a fractured toe does not produce that finding.

Imaging

Plain films are done to evaluate foot fractures. The views usually include AP, lateral, and oblique images. Fractures of the fifth metatarsal — the long bone itself, not the metatarsophalangeal joint at its far end — are divided into zones.

In zone 1 injuries, the fracture is an avulsion of the tuberosity at the very base of the bone, proximal to the 4th/5th intermetatarsal articulation and not involving it.
In zone 2 injuries, the fracture line extends into the 4th/5th intermetatarsal joint — this is the Jones fracture.
In zone 3 injuries, the fracture line lies in the shaft, beyond the 4th/5th intermetatarsal joint.

Based on plain film imaging, stress fractures of the fifth metatarsal are categorized by the Torg classification system:

Type I fractures: that are early, with no sclerosis and minimal periosteal reaction.
Type II fractures: that are delayed, with sclerosis, and periosteal reaction.
Type III fractures: where there is non-union, and the medullary canal obliterated by sclerosis

CT and MRI are used if the bone is not healing or if there is a stress fracture that’s not seen on a plain film.

Lab Tests

Blood tests are not usually required unless gout or other arthritis is suspected. If these conditions exist, doctors may order Rh factor, CRP, Uric acid, and other blood tests.

To learn how Toe fractures is treated Click Here

Physical Exam

During the physical exam, the foot is inspected and palpated. The ROM, muscle strength is tested along with special testing.

The doctor will first inspect the toe for swelling and ecchymosis. They will evaluate the gait pattern and note if an antalgic gait is present that favors toe-off. During the exam, in a fighter with turf toe, toe raises on the affected side are extremely difficult to perform. Doctors will also look for deformities of the joint including dislocation, hallux valgus, or hallux varus.

While palpating, they will look for point tenderness over the plantar aspect of the MTP. Doctors will check for tenderness over the medial and lateral, and dorsal joints.

Both active and passive ROM tests are done. On passive ROM, the martial artists complain of pain on extension of the MTP. On active ROM, flexion will cause pain in the MTP.

Muscle strength is tested by making the martial artist flex their toes or extend toes against resistance. Abduction can also be done to test muscle strength.

Some special tests for turf toes include performing a valgus and varus stress test of the first MTP joint. This is to check the stability medially and laterally. The vertical Lachman test examines the degree of vertical translation. The test is positive when the MTP has more laxity than the opposite side.

Imaging

The plain films should include these views; AP, lateral, and axial sesamoid weight-bearing. Any fracture or dislocation can be seen on a radiograph. Generally, bilateral radiographs are taken. This is to compare the migration of sesamoid bone.

MRI without contrast is done to visualize soft tissues. The MRI can see a plantar plate or any injury in the surrounding soft tissues. MRI can detect inflammatory and degenerative changes in the joint.

Based on the physical exam and the imaging, turf toe is graded. The Anderson classification system grades it on a scale of 1-3 as follows:

Grade 1: Acute sprain, no bone fracture, no joint instability, normal ROM, can bear weight.
Grade 2: Partial tear of the capsule or plantar plate, painful ROM, swelling, painful weight-bearing.
Grade 3: Complete tear of the plantar plate or capsule, migration of sesamoid bone, tenderness, decreased ROM, swelling, inability to bear weight.

Lab Tests

Blood tests are not required to confirm the diagnosis of turf toe. The physical exam and imaging are more than enough to make a diagnosis.

Physical Injury

The physical examination of the nailbed is done where there is appropriate lighting to visualize the injury carefully. An assessment can be made based on the history but a physical exam may reveal hematomas or hidden fractures. The doctors look for lacerations, closed or open fractures, and any associated amputations of the toe-tip.

Imaging

Evaluation will include assessing the toe. The associated toe is examined for sensation, the range of motion at the interphalangeal joints, and capillary refill. If injuries to the bones, joints or soft tissue is suspected in addition to the nailbed, then X-rays of the affected toe and foot with two or three views are done.

Lab Tests

No lab tests are required to diagnose injuries to the nailbed.

To learn how Nailbed Injuries are treated Click Here

First Steps

A broken toe or metatarsal is not usually a medical emergency, but get seen urgently if the toe is visibly deformed or pointing the wrong way, the skin is broken over the break, the toe is numb, pale, blue or cold, or you cannot put any weight on the foot. For nondisplaced zone 1 fifth metatarsal injuries, conservative treatment is started. This includes walking boots, hard-soled shoes, or a walking cast with protected weight-bearing. Once the pain eases after 3-6 weeks, weight-bearing is allowed as tolerated. Surgery — ORIF, closed reduction and percutaneous pinning, or excision of the fragment — is considered when a substantial part of the joint surface is involved or the fracture fragments are stepped apart, and where exactly that line falls is a judgement for the treating surgeon.

Medical

Martial artists with nondisplaced zone 2 injuries or Jones fractures are also treated conservatively. They are given a short leg cast with no weight-bearing for 6-8 weeks. As the plain films show healing of the bone, weight-bearing may be permitted.

In competitive athletes, surgical therapy is preferred. Displaced fractures are also surgically treated. The surgical techniques include intramedullary screw fixation, tension band constructs, low profile plates, and screws.

Diaphyseal zone 3 stress fractures are more complicated to treat, so an initial trial with a short leg cast and no weight-bearing is the first step. These can need several months of immobilisation to prevent non-union. Competitive athletes, or those with Torg Type II or III fractures, may require surgery. That includes intramedullary screw fixation, with or without bone grafting.

During bone grafting, a small rectangular section of bone is removed at the site of the fracture and replaced by an autogenous corticocancellous bone graft, usually taken from the distal tibia. The sclerotic bone is removed before the graft is inserted.

Other fractures of the metatarsal shaft and neck are treated the same way as a nondisplaced zone 1 injury. Weight-bearing is allowed once the pain has subsided. For all fractures with delayed union or nonunion, surgery is advised. Fractures displaced by more than a few millimetres, or angulated, are reduced and splinted. If follow-up X-rays show the fracture has not healed, then percutaneous pinning or plate and screw fixation via surgery is considered.

All martial artists who undergo surgery with intramedullary screw fixation or bone grafting are made to wear a short leg cast for six weeks. Or they may be put in a plaster splint for 6 weeks. Both these options require bed rest with no weight-bearing. After 6 weeks, a gradual return to sport is permitted, as tolerated.

Home

Most acute metatarsal fractures are treated conservatively and heal in about 6 to 8 weeks. A simple broken toe is generally more forgiving still — buddy taping to the next toe, a stiff-soled shoe and a few sensible weeks of loading, with the big toe taking longer than the small ones, and with a check that the toe has not been left rotated or angled.

Diaphyseal stress fractures require up to 20 weeks for complete healing. Weight-bearing restrictions are important. Return to play is only allowed after there is radiographic evidence of complete healing.

First Steps

The initial treatment for most toe injuries regardless of grade is basic RICE therapy (rest, ice, compression, and elevation). Wear a stiff sole shoe or rocker bottom sole to limit motion. In severe injuries, a controlled ankle motion (CAM) boot or walking cast is advised. This limits motion at the joint. By minimizing motion, the plantar plate is allowed to heal. If the injury is stable, motion is allowed.

Medical

Grade 1 injuries heal in two weeks with conservative treatment. The martial artist can return to play as tolerated.

Grade 2 injuries require roughly 4 to 6 weeks to heal. Grading is a clinical judgement made after examination and imaging, not something to do on yourself — an undiagnosed grade 3 tear that gets taped and trained on will not go well. Once a clinician has graded the injury and the acute swelling has settled, taping that resists hyperextension of the MTP joint supports a graded return to play as tolerated. Corticosteroid and/or anesthetic injections are not prescribed.

Grade 3 injuries are severe, but conservative treatment is usually chosen and runs for longer. This includes immobilization with a CAM boot. Another alternative is a short-leg walking cast for 4 to 6 weeks. After the initial immobilization, progressive, gentle range of motion is permitted. Some doctors will allow protected walking with modified shoe wear. The martial artist can also wear carbon-fibre inserts or a foot-plate extension. Activity is progressed as the fighter tolerates it. Recovery from a grade 3 injury is commonly measured in many months rather than weeks.

Surgery is an option if conservative management has failed. Unstable joints, capsular avulsion injuries, deformities, cartilage injuries, loose bodies, and sesamoid fractures are some reasons surgery is considered.

Surgical alternatives are medial plantar incision. Here, surgeons will attempt the direct repair of soft tissue injury.

Home

Physical therapy is very important when it comes to the treatment of turf toe. It starts with gentle passive motion at 7 to 10 days. The foot is usually non-weight bearing in a removable splint or boot. The toe is protected for 4 weeks. After 4 weeks, active motion is increased. Ambulation in the boot is allowed. The martial artists are asked to wear a modified shoe at 2 months. They are allowed contact activity. However, the toe needs to be protected from excessive dorsiflexion at 3 to 4 months. It takes about 6 to 12 months for a full recovery. Avoid steroid injections.

First Steps

This is clinician's work, not home first aid. What you should do is cover the toe with a clean dressing, elevate it, and have it seen the same day — and mention when you last had a tetanus booster, because a torn nail bed over a broken bone is an open wound. In the clinic, under a local anaesthetic block, the injury is thoroughly cleaned with minimal debridement of both the nail bed and nail root, and a significantly disrupted nail bed and root is repositioned and repaired anatomically. If that is not done accurately and early, nail growth is affected and the new nail grows deformed. Close approximation of the nail bed preserves the skin folds surrounding the nail margins, and adhesions between the eponychium, nail bed and root are prevented by replacing the nail or packing with gauze to maintain the space.

Medical

Removing a nail, stitching a nail bed and replacing the nail are procedures carried out by a clinician under a digital nerve block. Do not attempt any of them yourself. Where there is a partial nail avulsion, where the surrounding nail fold has been disrupted, or where the nail bed underneath is lacerated, the nail is lifted off so that the bed can be seen and repaired. The nail bed is then closed with absorbable sutures, the nail is replaced to guide new growth, and the nail fold space is maintained with gauze packing. If there is a broken bone under the lacerated nail bed, that is an open fracture, so tetanus cover and antibiotics are considered at the same time.

Home

Some doctors may simply apply Vaseline gauze after the repair and allow it to separate on its own. A plaster splint applied to the plantar side of the toe and rounded at the end can protect the toe-tip. Elevate the toe and have the injury checked in three days with a dressing change. Sutures in the nail or the gauze packing under the eponychium are removed at about two weeks. If blood is trapped under the nail and the toe is throbbing, do not pierce, burn or drain the nail yourself — releasing the pressure, called trephination, is a clean procedure done by a clinician, who will also check whether the bone underneath is broken.