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One “Hallacious” Problem! Hypomobility of the Big Toe

 

By Keats Snideman RKC, CSCS, LMT, CNMT

 Have you ever stubbed one of your toes really hard?  Hurts a lot doesn’t it? In fact, more four letter words have probably been uttered in the agonizing seconds immediately following the dreaded event than almost any other accidental (yet non-serious) injury. Fortunately, unless you break the darn thing, the stubbed toe probably stays sore for a couple of days and then fades away with no recurring or lingering pain or alterations in function.

Such is not always the case with athletic injuries to the toes and specifically the big toe. One of the most common injuries to this toe (also called the “hallux),” is the ubiquitous “turf toe” injury, which is essentially a hyper-extension injury (or more accurately a hyper-dorsiflexion injury).

                                                                                                      

 The Dreaded Turf Toe Injury!

 This is a common injury among speed and power athletes and is commonly seen with too much play on artificial turf and hard surfaces like basketball courts. While seemingly trivial, this initial insult to the big toe often sets the stage for future degenerative changes that over time, can severely limit range of motion and cause other dysfunctions up the kinetic chain which will be discussed below.

This injury is no stranger to the author as I suffered the injury during high school playing field hockey (field hockey…yeah yeah, I know what you’re thinking..and no, I did not wear a skirt!).

Me playing Field Hockey in High School; gotta love the short shorts!

 Thus, the remainder of this article will dive into the many body-wide ramifications that can occur when adequate range of motion (primarily in 1stMPJ dorsiflexion) does not exist. Finally, I will also give some practical treatment advice in the form of some videos I filmed with my twin brother Franz Snideman and my friend and colleague Patrick Ward. Hopefully, by the end of this article, you will never look at the big toe the same again!

 With a Stiff Big Toe, it’s Hard to Go!

 The primary dysfunction we’re going to discuss here is called Hallux Limutus/Rigidus, which is a combination of degenerative changes and restricted range of motion in dorsiflexion of the 1st MPJ. There is another condition called functional hallux limitus (FHL)that is similar to hallux rigidus except that degenerative changes are not seen on an x-ray. The main finding with FHL is that normal ROM is found during non-weight bearing of this joint which subsequently is significantly reduced during weight bearing gait (walking and running). The usual sequence of events that occur in response to an injury like turf toe is to first develop FHL, followed by hallux limitus, and then finally as the arthritic changes worsen, hallux rigidus sets in. Hallux Rigidus Sucks!

Before we continue, here is a video doing some basic anatomy of the bony structures of the foot:

Here is a video off Youtube that explains more about Hallux Limitus and Rigidus:

 Before we go any further it might be helpful to go over the expected normal ROM for this joint. Typically, the theoretical model that has been taught in schools of Podiatric and Orthopedic Medicine respectively has been to look for 65-75 degrees of dorsiflexion. There is some confusion however with these numbers since not every clinician or researcher was being clear as to how the measurement was being taken, weight-bearing or non-weight bearing? The real key is what happens in this joint during walking and running (i.e. weight bearing), the more practical/functional way we use the 1st MPJ. And until recently, there has been very little data and no definitive accurate methodology to measure the ROM during gait.

                 Like Former President Bush, the Research Can Be Confusing!

In 1999 however, a study was published by Nawoczenski, et al, which looked at the motion of the 1stMPJ in 10 healthy people during gait. To measure the motion of the hallux relative to the first metatarsal bone, they used an electromagnetic tracking device. What they found was that the average dorsiflexion ROM during gait was around 42 degrees. The average ROM tested during non-weight bearing of this same group was 57 degrees. Therefore, there are some researchers who now recommend that the gold standard “normal” ROM for this joint during weight-bearing should be 45 degrees. But this was during walking, what about running?

There is no published data that I could find on this but in an article in Podiatry Today (How to Treat Halux Rigidus in Runners, by Doug Richie Jr., DPM, April 2009), unpublished research by Mari Adad, DPM, showed that the average ROM of dorsiflexion during running was found to be only 26 degrees! This is considerably lower than the 42 degrees found in the research by Nawoczenski as mentioned above. This may account why several runners with hallux rigidus/limitus may feel worse when walking as compared to running. I could not find any data on the ROM during sprinting, which is my recreational sport so if anyone knows of any, please send it my way! (ksnideman@gmail.com)

There’s a Lack of Scientific Data on Sprinting and the Big Toe!

 Regardless of what the research says about the exact requirements of dorsiflexion at the hallux, a lack of ROM can cause the following disruptions/compensations up the kinetic chain (Chaitow & DeLany 2002):

  •  Closer to the foot, the lack of 1stMPJ dorsiflexion will cause limited plantar flexion at the ankle joint (talo-crural joint) which will strain the Achilles/gastroc-soleus musculo-tendinous complex. This can lead to pain and subsequent tendonosis of the Achilles region and plantar fascia problems. Excessive pronation of the foot will often be seen as well even though the weight will often be shifted to the outside of the foot to avoid stressing the big toe.

 

  •  The lack of plantar flexion leads to early knee flexion which disrupts the entire gait cycle and limits normal hip-extension.

 

  • With limited hip-extension, trunk flexion will often occur to compensate which over time, can be stressful to the intervertebral discs.

 

  •  Because of limited hip-extension, the hip-flexors are not lengthened properly (lack of pre-stretch) which makes them have to work that much harder to advance the leg on the “swing’ cycle of gait. This can lead to chronic shortening and trigger point activity in the ilopsaos, rectus femoris, TFL, Sartorius, and possibly even the short adductor muscles. I know this chronic hip-flexor pattern all too well since I’ve had it as long as I can remember since high school.

 

  • There will also be a contralateral side-bend away from the restricted side that will be coupled with a rotational force which is challenging to the facet joints and lumbar discs. Chronic quadratus lumborum (QL) and even abdominal oblique tightness and trigger point activity will usually result. The opposite S-I joint can be overly stressed as well leading to chronic shortening of the piriformis muscle in efforts to stabilize the joint.

Chronic Trigger Points in Quadratus Lumborum (QL)

  • If you follow the compensations up higher, there will even be changes to the thoracic spine (increased flexion often) with subsequent righting mechanisms of connections are mostly mechanical however which in turn lead to changes in the myo-fascial tissues, joint/connective tissues, and to nervous and vascular systems. It’s hard to effect one system without affecting them all!

 Abnormal Biomechanics Due to Hypomobile Big Toe!

 So here’s what the gait patterns look like between a normal 1stMPJ dorsiflexion range and a limited one:

                                                                                    Normal ROM                                                                                              

Limited ROM!

 And here is a potential gaiting pattern dysfunction of the entire body when viewed from the side:

                NOT GOOD…This could be me and my twin brother in 30-40 years!!

 Treatment Options

 There are many treatment options available for those suffering from Hallux Limitus/Rigidus/FHL including conservative therapies/care like orthotics, pain killers and anti-inflammatroy drugs, and finally surgery. My focus in on the conservative options, assuming that someone is not so far degenerated in the 1stMPJ that they can’t regain any lost ROM. There is a point of no return unfortunately in any joint where conservative treatment options will not be of any real value. For such individuals, this is a time for considering surgical options and very specific orthotic devices. Surgery is obviously not my area of expertise so I won’t be discussing those options and consultation with an appropriate podiatrist or orthopedic surgical specialist would be warranted.

  One thing medically I did pick up in my research for this article is that neither anti-inflammatory drugs nor cortisone injections seem to be that effective for long-term improvements. This makes sense since masking the pain and putting out fires (inflammation) temporarily does very little to alter the behavior or mechanical faults that lead to the condition in the first place!

 Anti-Inflammatory Drugs         

 Cortisone Shots

The primary conservative options I’m going to discuss include soft-tissue and joint mobilization, alteration of footwear, as well as daily mobility exercises and stretches.

 Footwear

 There are two schools of thought when it comes to treating this condition with regards to footwear:

 1)      Everyone needs supportive shoes and/or orthotic foot inserts.

2)      Try to get the ankle/foot complex to function well on its own (a la going “barefoot”).

 Orthotics for Everyone?

In reality, there are some cases where people should be wearing orthotics due to their specific condition or dysfunction while others would be better served trying to take the minimalist shoe approach and wear shoes that permit a more natural, barefoot-like gait pattern. Which route to choose must be made after careful assessment of an individual’s unique case history?

 I am personally biased towards trying to regain as much functional mobility and capacity first, before trying orthotic devices but again, this must be made on a case-by-case basis. Since not everyone gets the miracle cure from going barefoot, a shoe is often needed with some support. I recommend however that the shoe be as minimalist as possible and does not “over-support” your foot.Vibram 5-Fingers are Getting Very Popular!

 

 The Kigo Shoe, another Barefoot Option

 

                                                                                                                The Ultimate Barefoot Shoe!

 Below is a video clip of my thoughts and opinions on the barefoot versus orthotic controversy:

Self-Mobility Exercises and Stretches

 There are several stretches and self-mobilizations that can be performed daily or even several times per day to encourage better mobility at stiff/restricted segments of the ankle and foot. To recap all the possible options would be impossible but below are two videos of some self-mobilizations that I filmed with my twin brother Franz Snideman during a recent visit to Arizona.

Soft-tissue Mobilization

A great place to start here is with releasing the stiff and shortened tissues that are either directly or indirectly affecting the 1stRay/MPJ. We could probably start at the pelvis and lumbar spine and look at lumbar erector spinae, QL muscles, the hip-flexors (psoas, iliacus, TFL, Sartorius), quads (primarily rectus femoris) and groin; all the muscles indicated to be potentially shortened in a lower Cross Syndrome. Increased tone in these muscles can cause anterior rotation and a forward displacement of the pelvis in the saggital plane which can shit the weight of the body more anterior on to the toes and balls of the feet; the typical resting position for a power/speed athlete. Many endurance athletes may fit this criterion as well.

Lower Crossed Syndrome (Vladimir Janda)

From here, the lower leg should be treated in its entirety which can be conveniently broken down into 3 compartments:

 The Anterior Compartment: which consists of the anterior tibialis, extensor hallucis longus, extensor digitorum longus, and the peroneus tertius (if present).

The Lateral Compartment: which consists of the peroneus longus and brevis.

The Posterior Compartment: which consists of a superficial layer which houses the gastrocnemius, soleus, and plantaris mucles; and a deep layer which contains the tibialis posterior, flexor hallucis longus, and the flexor digitorum longus muscle.

Moving to the foot, the dorsal (top) and plantar (bottom) surfaces would then be examined with specific attention paid to the muscles attaching to the first ray including the two sesamoid bones that sit under the distal end of the 1st metatarsal bone.

The Sesamoid Bones are Very Important!

Here is a video of my friend and colleague Patrick Ward talking more about treatment options for big toe dysfunctions.

Joint Mobilizations

 To perform specific joint mobilizations requires the proper license so many of these techniques are out of the scope of a typical personal trainer or strength and conditioning coach. With that said, it still important for the fitness or even massage professional to understand the basics of joint mobilization and realize when a referral might be needed to a competent rehabilitation professional trained and skilled in joint mobilization techniques. The techniques I will summarize come from the greats in the field of manual medicine such as Geoffery Maitland, James Cyriax, Freddie Kaltenborn, and Brian Mulligan.

There are several different types of joint mobilization techniques and the proper one to use is based on several key issues:

1)  The current state of pain of the joint in question

2) The level of degenerative changes present in the joint to be mobilized.

In the case of the big toe (1st MPJ), what is often needed is not only a regaining of basic physiological motion(i.e. flexion, extension, etc..);  but also to re-esatablish the proper accessory motionswhich must accompany the phsyiological ones. The accessory joint motions are classified as:  compression, distraction, slide, roll, and spin. These are more specifically known as joint-play motion  and they cannot be made actively or consciously; they occur (or should occur) as a result of normal joint motion. So in the case of walking for example, when toeing off the ground, the normal dosri-flexion that must occur at the 1st MPJ must be accomanied by a dorsal glide and so a combination of traction of anterior to posterior glides might be helpful to try and restore the normal joint play. Again, these mobilizations are much more complex than simple massage/soft-tissue techniques and must be performed by a licnesed health care provider trained in such techniques.

Other Problems of the First Toe/Differential Diagnosis

Many other conditions can disrupt the healthy functioning of the big toes including Hallux Valgus (often seen with bunions and often involved with Hallux limitus/FHL), Hallux Varus, hammer Toes, claw toes, gout, neuropathy, infection, cancer, tumors and many other rare, systemic conditions that are  beyond scope of this article. If you have big toe pain or dysfunction (and the compensatory pain it often cause up the kinetic chain), it always best to get medically evaluated first before trying any self-treatment options so you know what you are really dealing with.

Hallux Valgus!    

Bunion 

 Conclusion/Putting it All Together

I hope that this has been a helpful and possibly eye-opening article and that some of you reading will come away with some strategies and ideas for dealing with limitations of movement in the 1st MPJ. If you have no big toe issues yourself, you probably might know someone who does, so please pass this on to them. Also, please send comments or feedback to ksnideman@gmail.com. Thanks for reading!

Keats

Resources

1). Clinical Applications of Neuromuscular Techniques, Volume 2: The Lower Bodyby Leon Chaitow and Judith Walker Delany. 2002 Elsevier Science Limited.

2) Evaluation, Treatment and Prevention of Musculoskeletal Disorders, Volume 2: Extremities (3rd Edition) by John P. Tomberlin and H. Duane Saunders. 1994 The Saunders Group.

3) How To Treat Hallux Rigidus in Runners, by Doug Richie Jr., DPM. Podiatry Today (www.podiatrytoday.com) April 2009 (pgs. 46-56).

4) Nawocenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of of first metatarso-phalangeal joint during Gait. J of Bone Joint Surgery, 81(3): 370-6, 1999.

5) Contributions from Franz Snideman, RKC-TL, CK-FMS and Patrick Ward, CSCS, LMT, CNMT

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