The agony of the feet: Why turf toe is such a dreaded injury in the NFL

Donte Jackson is carted off the field in Atlanta in October 2020 after aggravating a turf toe injury. He's now fully recovered and is the second-leading tackler on the Panthers' No. 2-ranked defense, but it was a long process. David J. Griffin/Icon Sportswire

SEATED ON A cart, headed back to the Carolina locker room, a teary-eyed Donte Jackson rehearses what he wants to say to his big toe. Two weeks earlier, in Week 3 of the 2020 season, while leaping to defend a deep ball against the Chargers, the Panthers cornerback suffered one of the most dreaded and debilitating injuries in the NFL: turf toe. Now, being carted off the field against Atlanta in Week 5, one look at Jackson's face, trapped in an endless loop of pain, aggravation and soul searching, tells you all you need to know about the special kind of misery this nasty injury with the silly name inflicts.

"This thing, it has a mind of its own, it plays tricks on you," said Jackson, who is now fully recovered and is the second-leading tackler on the Panthers' No. 2-ranked defense. "You do so much work to get back and it's just, How's the toe? How's the toe? ... It has you thinking you're good to go, and one jump, one false move, one push out of a break and you're back to square one, starting the whole thing back over."

For 14 days, Jackson rehabbed around the clock. He experimented with different tape jobs, icing methods, custom insoles and cleats, all so he'd be ready to face the Panthers' divisional rivals. Everything felt great all week. Warm-ups went perfectly. And after kickoff, feeling like he had survived one of the NFL's worst rites of passage and was finally back to his 4.3 self, Jackson allowed himself to exhale.

And then, while he made a simple diagonal cut on the first defensive snap of the game -- arrgghhh -- the turf toe was back with a vengeance. Jackson held it together as best he could until he reached the locker room and then he broke down and sobbed. He caught himself cursing, pleading and then apologizing to his big toe.

It's a mea culpa that, in the NFL, at least, is long overdue.

"You never really think about your big toe or how important that thing is," Jackson said, "until you can't use it."

JUST AS IT did with Super Bowl LV and Patrick Mahomes, the entire 2021 NFL season will likely be determined by a bone no bigger than a pea and an injury most people still mistake for a fungus.

In January's divisional playoffs, after the Chiefs' second touchdown drive against the Cleveland Browns, Mahomes was seen hobbling to the trainer's tent, grimacing and grabbing at his left big toe. It was the telltale sign of turf toe, the excruciating, maddening malady that afflicts up to 50 speed and skill players each year, according to renowned specialist Dr. Robert Anderson, and has ended the careers of the fastest and toughest players in NFL history. That's not a generalization. Take a gander at HOFer Deion Sanders' mangled left big toe sometime (but definitely not before a meal) or read the 1985 headline from the early retirement of the Steel Curtain's legendary, toothless HOF linebacker Jack Lambert: "Toe Ends Lambert's 11-year Reign as Steelers LB."

"I took care of a guy a few years ago and the headline was Big Toe, Big Problem? and the message was, why is a big, strong football player out with a toe injury?" says Anderson, who has treated nearly 500 NFL players, including Mahomes, for toe, foot and ankle problems since opening a state-of-the-art facility in 2017 in Green Bay, Wisconsin. "Sexy is the wrong term, but players say 'Oh, my ACL ruptured,' and then you hear someone talking about their big toe and people are like, uh, that's it?

"People still think of turf toe as just a sprain of the big toe. When, what we've learned over the years is that people should really think of this as just like any other ligament injury in the body."

The Chiefs certainly will.

In a telling turn of events from last year's playoffs, Mahomes was forced out of that Browns game in the third quarter with a concussion. Yet while his brain was deemed sufficiently healed for him to beat the Buffalo Bills in the following week's AFC Championship Game, the nagging turf toe injury actually worsened, the pain only intensifying during the Super Bowl.

Former Pro Bowl tight end Jordan Reed, who suffered from turf toe in both feet (among other injuries) before retiring in April, compared the constant, crippling pain to a toothache on the bottom of the foot. But he says the mental anguish and fatigue are far worse than the pain.

"Every time you step -- just like with a bad toothache when you touch it, or eat something that irritates it -- it sends that shock of pain through your entire body," says Jordan, who played six seasons with Washington. "Mentally, this injury really affects guys because it limits who they are. The pain you can deal with, but the fact that I wasn't the same athlete anymore and I would never be the same athlete anymore, that was really, really hard for me. That's how important the big toe is. It will make you a lot less quick and explosive and it will change your life as an athlete, and that's what it did to me."

The injury is so pervasive that before the second week of 2021 training camp had even come to a close, Anderson had already seen his first turf toe victim, Tennessee's Tommy Hudson. The first-year tight end recovered in time to play in Week 2, in part, because the Titans organization takes turf toe seriously after watching what it did to the late former MVP quarterback Steve McNair, a player renowned for his pain threshold who suffered through two seasons of turf toe agony before giving in to surgery. (McNair actually prepared for Super Bowl XXXIV while hobbling through practice in a protective boot.)

Already in 2021, bad toes have hampered Lions Pro Bowl center Frank Ragnow, Raiders running back Josh Jacobs and Bucs wideout Scotty Miller. In the past few years, turf toe has derailed star players such as A.J. Green, Julio Jones and Davante Adams, as well as running backs James Conner, Phillip Lindsay and Antonio Gibson. In 2020, rookie Gibson, who led Washington in rushing, tore up his toe in December against the Steelers. In the two games before turf toe, Gibson piled up 209 yards and four TDs. In the two games after? He ran for 136 yards and zero TDs. Although Gibson referred to the injury as "something small," coach Ron Rivera understood just what a big deal it was. "It is concerning," Rivera said. "It's complicated for a running back because he's got to plant, cut, turn. The big toe -- that's where his power and energy that he runs with comes up."

Inside NFL locker rooms, Gibson is considered lucky because he had to endure the misery of turf toe for only the final month of the season. Last year, the Giants' Sterling Shepard jammed his toe in Week 2, and the turf toe lingered for the next three and a half excruciating months. "I didn't know much about [turf toe] at all," Shepard said at the time. "Anybody who has had it will tell you it's nothing to play [around] with. If you don't have your big toe, especially for a skill position guy, it's hard to get your job done in any way, shape or form. It's one of the more frustrating injuries I've had."

It was for Mahomes as well. Even after weeks of treatment and a custom-made carbon-fiber orthotic in his left cleat to limit the extension of his famous phalanx, turf toe still rendered even a $450 million generational talent like Mahomes a mere shell of himself in an ugly 31-9 blowout loss to the Bucs in Super Bowl LV. Now, granted, the Bucs' defense and the Chiefs' decimated offensive line had a lot to do with it, but Mahomes (0 TDs, 2 INTs, 3 sacks and a 52.3 passer rating) was unable to move as effectively against the rush or drive the ball with his normal velocity and wizardry, in large part because of that troublesome toe that was far more damaged (and painful) than anyone really understood.

WHILE IT'S CAUSED by a hyperextension of the big toe, the injury itself has very little to do with the toe. We just call it turf toe because dorsiflexion hyperextension to the hallux metatarsophalangeal joint, specifically the flexor hallucis longus tendon and the sesamoid complex, resulting in a plantar capsuloligamentous sprain is a long phrase to type. What all that terminology means is basically a strain of the sesamoid complex of bones, tendons and ligaments under the big toe's large knuckle joint, or the ball of the foot. (Those career-and-Super Bowl-changing sesamoid bones are so small they're named after the sesame seed.) And like all tendon and ligament injuries, turf toe is classified into grades of severity, with 1 being a mild strain that will heal after three to four weeks of rest and rehab, and 3 being a total rupture of the joint that requires surgical repair before it becomes arthritic with the onset of hallux rigidus, which is career-threatening, or, in Deion's case, much, much worse. Sanders says his deformed digit kept him out of "Dancing with the Stars."

Mahomes may have magnanimously insisted for weeks that the toe wasn't an issue, but mere days after the Super Bowl he flew to Green Bay for surgery by Dr. Anderson. He has since made a full recovery but not before giving us the clearest, most dramatic evidence yet that, after 40 years, maybe it's time to start taking turf toe seriously.

Although it can occur on any surface, the onset of turf toe coincided with the advent of AstroTurf in the 1970s, though it took the NFL a decade or two to understand what was happening. In 1994, Anderson performed one of the first surgical repairs of the tendon that controls the big toe, on Packers All-Pro wide receiver Sterling Sharpe. When a player like Sharpe or Mahomes accelerates, cuts or stops, especially in an explosive manner, they load more than eight times their body weight (1,840 pounds for Mahomes) onto that one big toe. When the toe catches in the turf and doesn't continue under and out in a normal running motion, and all that force and kinetic energy causes the phalanx joint to go beyond 70 to 80 degrees of dorsiflexion (toe pushing back toward the top of the foot), the complex biomechanics of this one tiny joint begin to fail spectacularly.

Connecting from the arch of the foot to the phalanx joint, there are three flexor tendons that are responsible for creating the tension and spring of the big toe. The medial (inside) flexor tendon encases the medial sesamoid bone and the lateral (outside) flexor tendon encases the lateral sesamoid bone. When we refer to the "ball" of your feet, we're talking about the sesamoids. These tiny pea-sized bones articulate, or, glide, along the underside of the toe joint, acting as a kind of pad and lever to create more efficient movement. The two minor tendons and the sesamoid bones also provide stability to the joint by keeping the larger, all-important flexor hallucis longus (FHL) tendon in proper alignment.

The FHL is the biggie. It runs between the two sesamoids and goes all the way out to the tip of the big toe and is the final link in a kinetic chain that creates and directs all of a sprinter or football player's power and explosiveness. When an athlete strains their flexor tendons or the sesamoids, the FHL is forced to work overtime providing stability to the joint and tension to the toe until it, too, gives out. With diminished tautness in all three tendons (and, not to mention, extreme inflammation) the big toe is essentially flapping in the wind, and with nothing to push off with, the player can't cut or plant their foot or move in any kind of decisive manner.

"It's like having a windshield wiper going one way and not coming back," Anderson says. Or, think of it this way: Trying to scramble, or plant and throw with turf toe in the Super Bowl was like Mahomes trying to throw a three-finger deep bomb, without the use of his index finger.

Because the injury occurred near the end of the season, Mahomes was at least able to avoid some of the myriad residual issues associated with turf toe that make it such a dreaded affliction. For starters, that amount of trauma in such a small, confined space leaves nowhere for the swelling to go, which causes a lot of intense discomfort. The pain from turf toe is often far too acute for the painkiller Toradol to be of any help, and untreatable with pregame, targeted Marcaine shots for fear of numbing the entire foot.

More than anything, this is why NFL players fear and loathe turf toe so much they don't even like to tempt fate by talking about it. Mahomes politely passed when the topic was brought up. Texans running back Phillip Lindsay scheduled and canceled three interviews on this topic. Even Deion seemed to reject the request before it had even fully finished downloading.

As an NFL newbie, Reed wandered into the Washington training room and saw a veteran running back rehabbing turf toe by picking marbles off the floor with his toes. Although it looked silly, the poor guy was sweating bullets, his jaw was clenched shut and his face was twisted by pain.

"What are you doing?" Reed laughed.

"Man, I got turf toe," the back replied. "This sucks. Trust me: do-not-get-this."

"I was like, 'damn,'" Reed says now. "The first thing I thought was my feet are everything. My feet are why I'm here. If something ever happens to my feet, I'm finished."

BESIDES BEING FORCED to play the strangest game of marbles ever invented, mild and moderate cases of turf toe leave players in the worst kind of no-man's-land: stuck somewhere between hurt enough to significantly diminish their performance but not injured enough to completely sit out. By the end of the season, their nerves are fried, their Madden rating has plummeted and the inside of their sesamoid complex (Anderson has the pictures) looks like raw hamburger meat. Dealing with chronic turf toe, Reed says, "sent me into a depression and it takes away your confidence and who you are and that was devastating for my career." Rather than rely on opioids to deal with the constant pain, Reed turned to acupuncture, hours of physical therapy every night and cannabis, which inspired his post-football career as an investor and advocate for the marijuana industry.

Preventative taping, similar to what trainers do with ankles, would help, but players find it too restricting. And while A.J. Green still blames the artificial turf for his problems, Anderson says turf toe can occur on any surface. Before the season started, Mahomes released his first signature shoe, which includes his own snazzy logo and comes in flashy neon green. They're super cool, no doubt, but what would really help reduce turf toe, Anderson says, is the $100 billion sports shoe industry bothering to develop a cleat that won't hyperextend past 50 degrees or, better yet, increases rigidity as the foot extends.

Until then, the only reward for guys who play through the pain of turf toe is an additional laundry list of issues caused by overcompensating for their battered big toe. After getting turf toe in his left foot, Reed tore his right hamstring. He says the speed and elusiveness he lost because of turf toe also made him more susceptible to bigger hits, which, in turn, led to the multiple concussions that forced him into retirement. Lindsay's turf toe injury in Denver last season was followed by knee and hip problems. Instead of a big payday from the Broncos he signed a one-year deal with Houston. The Titans' Hudson recovered from turf toe in camp, then hurt his ankle. Jacobs' turf toe was also followed by an ankle injury. And in the playoffs, it's worth noting that Mahomes suffered turf toe in the second quarter and a concussion in the third after getting dragged down from behind.

All of this misery extending from the big toe extracts a heavy toll on even the game's toughest players.

To this day Lambert, the Steelers' former snarling linebacker, remains a mainstay on just about any all-time list of either the NFL's toughest, or best, players, including the NFL's 75th Anniversary All-Time Team. And yet turf toe was the only thing that ever managed to make him look even remotely mortal.

Lambert tore up his toe on the second play of the 1984 season inside Pittsburgh's Three Rivers Stadium, where the unforgiving playing surface was little more than green carpet laid down over cement. Because it was "just a toe" Lambert even ignored pleas from Steelers owner Art Rooney Sr. himself to rest and rehab the injury and was eventually put on injured reserve.

Ten months later in July 1985, when Lambert, then 33, retired, he said the toe still hurt and he still couldn't push off of it. "It was totally debilitating, he couldn't run without pain and he couldn't run very fast, and you could just see how very frustrating it was for him," said Joe Gordon, the former Steelers team spokesman. "It was sad because he was such a great player and he had at least two to three more good years in his career."

In a final, um, footnote on the topic of turf toe, it turns out Lambert didn't actually retire from sports altogether for another decade. Still in need of a physical outlet, Lambert turned to hockey because the skates protected and immobilized his toe and, well, his front teeth were already gone. Eventually, Lambert got good enough to hold his own in regular pickup hockey games against members of the Pittsburgh Penguins organization.

Lambert even confessed that if he had to do it all over again, he might've passed on football altogether.

After all, there's no turf toe in hockey.