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Sunday, April 14, 2019

The Complex Biomechanics of the Big Toe Joint

I have recently had a wonderful vacation with my wife in Hawaii. During that time, I was working each day on a book on biomechanics for podiatrists. I will share here something that took 5 days to write just on the complexity of the big toe. It is meant to tell you that if you have big toe joint pain, or you are treating a patient with big toe joint pain, there are so many options mechanically to help as you work on the inflammation and nerve hypersensitivity, and making an accurate diagnosis. The book will be several years in the making, and I am still looking for a publisher. I hope it shows you the possibilities available. Most of the modalities listed can be found in the blog.

Coastline near Poipu Beach on the island of Kauai

  First Metatarsal Phalangeal (Big Toe) Joint Mechanical Challenges

by Richard L Blake, DPM

    The big toe joint is a fascinating area to try to help because of all the variables that come into play. Since the end of normal stance in the gait cycle ends up with us pushing off the hallux with first metatarsal plantar flexion, and our goal in treatment is not to have the patient limp or favor in any way which would negatively affect the entire chain above and lead to other problems, we have a difficult assignment. I tell my patients with chronic big toe joint pain, from sesamoid issues, to hallux rigidus, to chronic turf toe, that they made need multiple orthotic devices and a variety of other helpful modifications and accessories. I thought this would easily be the area the inverted  orthotic device would work for, and it does for some, but the higher the arch you make (in order to transfer weight to the arch and shift the weight to the center of the foot in propulsion) the more plantarflexed the first metatarsal becomes. The more plantarflexed the first metatarsal, the more chance the big toe joint will be forced down into the ground worsening the pain. Therefore, where the Inverted Technique or even an orthotic made expertly for a pes cavus foot type made work some of the time, some of the time they do not and you have to make a flatter arched orthotic device or no orthotic device at all. Below we will talk about each one of these mechanical changes.

    The four big issues involving the first metatarsal phalangeal joint are:
  1. Bunions
  2. Hallux Limitus/Rigidus
  3. Sesamoid Injuries
  4. Turf Toe Syndrome
Each of these problems, and other problems involving the big toe joint, will have certain mechanical changes that help. I hope the list below helps you think outside your normal routine in creating a stable joint and getting the pain levels quickly to that 0-2 healing environment. I commonly think of pain in the big toe joint coming from excessive ground pressure, too much bend, malalignment with valgus forces, superficial pressure from shoe gear, or compression forces across the joint. To affect many of these causes, you have to do treatments that affect the patient in the propulsive phase of gait.Think of these as you work through the 32 common  mechanical changes done to the big toe joint.

Common Mechanical Changes at the First Metatarsal Phalangeal Joint
  1. Spica Taping
  2. Bunion Taping
  3. Toe Separators
  4. Dancer’s Padding
  5. Cluffy wedges
  6. Morton’s extensions
  7. Orthotic Devices for Weight Shift with no extrinsic post
  8. Orthotic Devices of Stability only with no extrinsic post
  9. No Heel Lift
  10. Zero Drop Shoes
  11. Rocker Shoes
  12. Bike Shoes with Embedded Cleats
  13. Cam Walkers or Removable Boots
  14. Stiff Shoes (including post operative shoes)
  15. Flexible Shoes
  16. Forefoot Padding
  17. Skip Lacing
  18. Deep Toe Box
  19. Wide Toe Box
  20. Shoe Stretching
  21. Carbon Plate Full
  22. Carbon Plate Morton’s Extension
  23. Carbon Plate Dancer’s Modification
  24. Proximal Padding Dorsal or Medial
  25. Metatarsal Padding sub 2nd through 4th or 5th
  26. Self Mobilization for Hallux Limitus
  27. Metatarsal Doming
  28. Abductor Hallucis Strengthening
  29. Flexor and Extensor Hallucis Longus Tendon strengthening
  30. Night Splints and Yoga Toes
  31. Correct Toes
  32. No Achilles Tightness
    Spica taping is a technique with several variations that primarily limits the bend, or dorsiflexion, of the big toe joint. One of the variations is to help the same tape align the hallux that is drifting lateral causing lateral impingement. Spica taping is commonly learned with KT tape or RockTape since it goes around the bends of the toe fairly easy. If the patient needs more restriction, and has the basic skill down, then 3M Nexcare Waterproof Tape is used. This is a skill I want my patients to learn and perfect. It is part of my initial experimentation into what helps eliminate the joint pain. Typically one inch wide tape 7 to 8 inches long is centered dorsally over the top of the hallux. First the medial leg is brought down under the big toe joint and then run under the first metatarsal. Second the lateral leg is brought down under the big toe joint, and then run parallel to the first strip along the orientation of the first metatarsal. At least one half of the lateral leg should be touching the skin so that the tape can last 3-4 days. Make sure with KT or RockTape that you then rub in the finished product for a minute to activate the glue. The big toe itself when you are finished should be just slightly below the 2nd toe. Spica taping is classic for hallux rigidus and turf toe, but can hold the toe down with sesamoid injuries distributing the weight bearing somewhat away from the sesamoid. Spica taping can increase the compressive forces across the joint, which may hurt, so you just have to try to see if it makes sense.
    Bunion taping is a technique done the same as the spica taping except with different starting point and leg orientation. Bunion taping is done to center the hallux in the joint when the hallux is drifting or chronically too lateral. Done with the same tape as spica taping, the center is placed on the lateral side of the hallux with one arm going superiorly and one leg inferiorly. When applied, the hallux is placed in neutral and first the plantar arm comes under the big toe joint and laid along the medial side of the first metatarsal. This is where you and ultimately the patient has to play with how tight. It can be a balance between good correction and too much pressure. The superior arm then comes across the joint and again is laid down on the medial side of the first metatarsal with about half touching new skin and half overlapping the other arm. Remember to rub in the tape for a minute to activate the glue, especially if it will be left on for a few days. Bunion taping is done post 2nd toe surgeries when you do not want the big toe applying pressure on your surgery. It not only centers the joint, but does some restriction of the joint motion that is less than spica taping, but has some effect.
    Toe Separators (sometimes called toe spreaders) come in various shapes and sizes and materials. From the hard rubber ones that I was first exposed to as a student, now they are made of soft foams and gel. To me, a medium gel toe separator that has the shape of an hour glass is conservative bunion care 101. My mantra in bunion care is maintain stage 2. The toe separator immediately puts the bunion, which may have started the day in stage 3 or 4, back into stage 2. As you walk, with stage 2 of bunion development maintained, the forces through the big toe joint are more normal and should slow down the hideous retrograde forces. This centering of the joint will allow for normal muscle development as muscles are typically strengthened within a few degrees on either side of the range you use them. If you want to strengthen the right muscle fibers, strengthen a muscle with the joint properly aligned. This centering of the joint also helps alleviate pain from lateral joint impingement, common at the big toe joint. Even joints that do not have bunions can be negatively influenced by shoe gear and activity mechanical forces that shove the hallux laterally. You just have to think how many ballet dancers develop juvenile bunions from the en pointe positioning, especially if pointe is started when they are skeletally immature. Foam toe separators have more width and therefore work better for a lot of my patients. They are long and can go too far forward on the toe and cause ingrown toenails. For this a good scissor can shorten them. With overlapping toes, you either need the hour glass shape of the gel ones, or the toe separator that slips over the 2nd toe and has a toe separator attached medially. The patient should never take their sock off and see the toe separator resting under the second toe. This will worsen a hammertoe problem. Toe separators can and should be used after bunion surgery to help maintain the correction while the muscles and scar tissue are transforming. This is not a good idea if any work was done on the weaker 2nd toe, since the pressure of the toe separator can ruin your toe surgery.
    Dancer’s padding has a fun beginning. In the 1700s, when the French were studying their ballet, they discovered that dancers with big toe joint pain could be helped by transferring the weight off the area. Before then, if your big toe joint hurt, it would be covered to protect it, so this concept was revolutionary! So, instead of calling this padding a Reverse Morton’s Extension (a more popular name), our office honors the French and call it a dancer’s pad. It is a pad that typically goes under the 2nd through 5th metatarsal, but if the 5th metatarsal has issues, then 2 to 4 is utilized. Many materials are utilized, but my office stocks 1/8th inch adhesive felt that can be applied to anything (orthotic device, shoe insert, sandal, ballet slipper, etc). Sometimes to take enough pressure off of the big toe joint and hallux I increase the padding to ¼ inch. If you do, make sure the patient does not feel that they are actually falling into the hole which would make things worse. If you put the second pad on, do not line it up perfectly with the first layer. Off set it alittle laterally and proximally (or distally) which easies the feeling of the edges. It typically reduces the plantar pressures across the joint by 50% or more. Many times the pronation affect of the dancer’s pad to pull a patient medially must be balanced by an arch support of some kind to pull the patient laterally. I prefer OTC non plastic orthotic devices for this since the goal of plastic based orthotic devices, with or without Dannenberg modifications, are meant to make the big toe work better and move more. It just may not be the right time for that when you are trying to off load a sore sesamoid or hallux rigidus. With the recent barefoot craze, with the resultant forefoot impact load at contact, it seemed like I was making dancer’s padding all the time. I joked to my fellow podiatrists that I had to make dancer’s pads for these runners that preferred running as dancers. I typically do not make dancer’s padding that goes to the toes due to crowding issues. I love the Dr. Jill’s Gel Dancer’s Pads. They come in 1/8th inch and ¼ inch, and sometimes you need to make the hole bigger. They stick on one side and are primary for sesamoid injuries. But by making the hole bigger, they can work well for any big toe joint problem. The stick side allows you to use them on your skin or any surface. Because of that, you need several rights and several lefts of each side to really have all the combinations going forward. If you place a ⅛ on one side, you usually do not need anything unless you feel awkward on the other side. If you place a ¼ inch on one side, you at least need ⅛ inch on the other side for balance.
    Cluffy wedges was designed by Dr. James Clough (play off his last name) in Oregon. It is a small pad that fits into the sulcus under the proximal phalanx to off weight the sesamoids (big toe joint) as your weight rolls forward. The ⅛ inch adhesive felt is usually 1 inch by 1 inch or slightly smaller. It can not go under the distal phalanx or it increases big toe dorsiflexion and big toe joint weight bearing. I never used it until 10 years ago when a patient of Dr. Clough moved to San Francisco and needed a new podiatrist. She was wearing her cluffy wedge as part of a fractured sesamoid treatment. When I asked her if it was helpful, she stated she would not leave home without it. So, it became part of my treatment from that point on, and like most of these mechanical treatments, 50% of patients feel that it is very helpful. Dr. Clough, one of my students, was in the same class as Dr. Kevin Kirby, biomechanics guru extraordinaire, but when the cluffy wedge works successfully, it is Dr. Clough that I am most proud of (at least for a second or two). So, when patients present with big toe joint pain on their first visit to my office, they all leave the office with a game plan and 3 mechanical changes to begin to manipulate the symptoms: spica taping, dancer’s padding, and cluffy wedges.
    Morton’s Extensions put more pressure on the big toe joint and hallux, but are used to immobilize the joint with hallux rigidus (arthritis). They can involve the big toe joint and whole hallux, or end at the interphalangeal joint. They can be an extension off the distal medial end of an orthotic restricting the bend between the orthotic device and forefoot extension or just a loose attachment distal to the plastic orthotic device. Morton’s extensions can be a varus wedge for the forefoot in certain biomechanical conditions even if just a 1/8th inch. Morton’s extensions can soft or hard, ⅛ th inch to ¼ inch, and of varying degrees of rigidity. Morton’s extensions, like dancer’s padding, can be applied to custom orthotic devices, OTC inserts, or simply the shoe liner. In general, Morton’ extensions are used in the Immobilization Phase of an injury, for joint restriction or immobilization, but not in the long haul. Eventually, you have to free up the joint. Morton’s extensions block normal motion. I have many patients who need a Morton’s Extension as a cast while we are calming down a joint, probably as we transition from cam walker, post operative shoe, or Hoka One One rocker bottom shoe type. Many of these patients, if they get recurrent problems, or are left which some joint sensitivity, have 2 versions of orthotic devices. They need a Morton’s extension arrangement and a more standard dancer’s padding arrangement.
My mantra is to maintain big toe joint mobility unless forced into it. The long term problems of compensation if the first metatarsal can not plantarflex is huge. In summary, the rules of Morton’s extensions:
  1. Use for the shortest time possible in the Immobilization Phase of big toe joint pain.
  2. Use as a Forefoot Varus Wedge in some athletic activities, like propulsive phase pronation in runners (in their running orthotic device only).
  3. The rigidity (or immobilization) can be increased with attaching it to a orthotic device, using firmer materials, or extending it longer to the end of the shoe.
  4. The rigidity (or immobilization) can be increased by using it with bike shoes with embedded cleats, Hoka One One rocker shoes, stiff soled hiking shoes, and hunting boots.                                                                                            
    Orthotic Devices for Weight Shift with no extrinsic post are used by the majority of podiatrists I know for big toe joint pain. As we stand, our tripod of support includes the heel, first metatarsal head, and fifth metatarsal head. So, if we have a problem with the big toe joint, we typically have to change that dynamic to distribute pressure throughout the foot. Extrinsic posts, used in some classic orthotic designs, are removed or never ordered from the lab when a patient has big toe joint pain since the post may shift the weight forward enough to increase the pressure on the joint. It is easy to put on at some point in the future. I love it when the orthotic device can capture a lot of architecture along the lateral column and metatarsals. I do not like weight bearing casting here, since these impressions flatten the metatarsal architecture. Definitely when using functional foot orthotics on a patient with big toe joint pain, there are some design concerns. I think you should design your orthotic device based on the biomechanics you want to correct, and then add all the additions we are discussing like dancer’s padding, or Morton’s extensions. But you should know the factors which have an impact. These factors that affect the success of your orthotic devices on big toe joint pain include:
  • Whether the rearfoot and arch has enough support to shift the weight laterally off the big toe joint.
  • Whether the medial arch increases the plantar declination of the first metatarsal increasing the load and bend of the first metatarsal phalanges joint (I tend to use Kirby Skives a lot here with minimal medial arch height in some of these cases).
  • Whether the stress at the end of a standard orthotic device will produce too much stress on the big toe joint. Remember when a device supports and protects and immobilizes something, the most stress is where it ends. It is a natural stress point. Just like the old acrylics used to break right in front of the rear foot post.
  • Whether the natural motion of the big toe joint needs to be immobilized more. If you think of things that orthotic devices make move or function better (big toe joint and posterior tibial tendon for example), then it should not be surprising that they can hurt more because we are letting them move or function too much. There are times that tissue should be in the Immobilization Phase instead of the Return to Activity Phase. The tissue has been injured and just not ready.
    Orthotic Devices of Stability only with no extrinsic post is a common custom or over the counter device prescribed for big toe joint pain. The difference from the last example is that there is noticeably no attempt at varus wedging in any form for weight shift. These orthotics flood my office for outside practitioners, or may be over the counter types, and they may be perfect, or just need something more. Typically these orthotics do not make the big toe function better, so may not stir up the joint. They may not shift the weight enough, so dancer’s pads, spica taping, cluffy wedges, more arch support with Hapad arches, temporary Kirby Skives that you can place in the office, varus wedges added to the plantar surface. As you work on the inflammation and nerve hypersensitivity, continue to work on the mechanics. Remember all the causes of big toe joint pain from a mechanical viewpoint: compression forces, plantar loading forces, joint malalignment forces, superficial shoe forces, and bending forces. Identify these forces that apply to your patient and gradually make changes. See what works. You may discover that a different design is going to be the best, but I typically use what the patient brings in and try to customize that first. It works in a great many times.
    No Heel Lift is the general principle in treating any metatarsal problems including big toe joint pain. It can be a challenge when the heel lift is for the short leg which just happens to be on the side of the big toe joint problem. This can be remedied by making the lift into sulcus length with a cutout for the big toe joint (lift with dancer’s pad combined). Lifts can also be part of a custom orthotic functioning as an extrinsic rearfoot post for improved medial and lateral instability. When dealing with big toe joint pain and orthotics with rearfoot posts, I remove the rearfoot post and place midfoot medial and lateral supports to hold my correction as best as possible. I use a grinding rubber ¼ inch in the medial arch and ⅛ inch under the cuboid/5th metatarsal base. The heel lifts may be on both sides and function more as Achilles supports or heel pain cushions. At times, you have to decide what is the worst pain for now and make the appropriate adjustments. Of course, for women, and even men who wear cowboy boots, shoes with heels should be restrictive for months longer than it takes the big toe joint pain to resolve.
    Zero Drop Shoes is along the same lines as no heel lifts within the shoes. Starting with racing flats for runners, or dress shoes for men and women, there is now a plethora of athletic shoes from minimalistic to maximalist that offer zero drop or close to zero drop shoes. This means that there is zero to 4 mm in general transition downward from the heel to the forefoot. The traditional running shoes like the Brooks line typically are 12 mm transition or greater in some shoes. But, this is like everything we have been talking about. Some patients need this and others not. As podiatrists we now have so many choices and this variable can be helpful. The only running shoe company I know that that is exclusively zero drop is Altra. When the zero drop shoes are too soft in the heel, they can produce a damaging negative heel effect.
    Rocker Shoes have been popularized by the Hoka One One shoe company and are a must shoe to try for my big toe joint patients. There are so many styles and configurations of the padding and rocker that patients have to go to a store that have many variations. The position of the rocker has to be just right to roll the patient gently across the injury and not put pressure on the injury. Some of the shoes will naturally put a slight varus bias in the roll which may help until they break down laterally. Some of the shoes have just the right amount of cushion and stiff, others something is off. Hoka One One is only one of the companies with a rocker, as the New Balance 928 and the dress shoe line Allegria also have them. I am sure at the time you are reading this many more companies and styles will be available. The rocker effect is so much better than the rockers we used to ask shoe cobblers to put onto shoes. My patients would trip and fall on these things that stuck out on the bottom of the shoe and I got very frustrated with them. A negative, among many, of rocker shoes is sometimes the heel is too unstable. The patient should roll through the shoe without sinking back into the heel. This negative heel effect, like the original Earth shoes, is very damaging, and can be felt in some of the zero drop shoes as mentioned above.
    Bike Shoes with embedded cleats have been a wonderful find for my practice. The company Chrome, with a headquarters in my San Francisco, makes gear for the bicycle messenger industry and have a line of non-athletic looking bike shoes that can pass as semi-dress shoes. Other companies like Shimano or Pearl Izumi have these mountain bike shoes, also called hike and bike shoes. The cleat is embedded so you are not walking on awkward cleats. For big toe joint problems, and plantar fascial tears, when you want to restrict the bend of the big toe joint for 3-6 months, this can be a lot better solution than a cam walker with an EvenUp on the opposite side. I have irritated so many less backs then with the removable boots. During the rainy season, sometimes these can only be used indoors as they can be more slippery than a normal shoe with rubber traction. The motion in these is abnormal, using more hip and knee motion since you can not push off, but since they are used as a pair, the lack of asymmetry tends to work well. Remember we are trying to attain the 0-2 pain level so the injury can heal. Even if the patient is in a boot for a while to drive the pain down, these shoes or Hoka rocker shoes may be the transition before normal shoes. And, you can wear your orthotic devices, dancer’s padding, cluffy wedges, spica taping, etc. with this shoe and with the removable boot. Do what you can to drive the pain down as quickly as possible.
    Cam Walkers (Removable Boots) are the classic treatment of all big toe joint problems as the patient limps into your office and painlessly strolls out. You are starting the several month process of discovering the diagnosis (over treat please until you know that it is not a fracture), protecting the foot, and creating the 0-2 healing environment. Even without all the information, you can wonderfully start the patient on a road to recovery on day one. The 3 phases of rehabilitation are Immobilization, Re-Strengthening, and Return to Activity. The phases are blended all the time, but do not blur the distinctions of the 3 phases. Know when they are in each phase, even when you start them strengthening on day 1, and you place them back in a walker during a flare in the Return to Activity phase. When someone has injured their big toe joint, any imaging like x rays possibly suggesting arthritis vs sesamoid irregularities are not conclusive, how do we create a healing environment? The cam walker stops the bend of the big toe joint. Up to a ¼ inch adhesive felt can be placed into the walker to off weight the area. I have had too many patients come in for second opinions because the boot was the right idea, but the patient remained in pain walking in the boot. I explain to the patient that the pain has to be 0-2, walking a good deal, for 2 weeks straight, before we can think about transitioning them into bike shoes, or Hokas, or normal shoes with inserts, etc. Yet, certain diagnoses, like sesamoid fractures override that rule and require in my mind 3 straight months of immobilization before we loosen the reins. One more point about cam walkers concerns full day or partial day use. If the restriction of the boots eliminates pain, you can use it for short periods of time to just rest the tissue. Sometimes my patients will only be in the boot for 4 hours a day presumably a stressful time of the day for their injury. That can give the injury valuable rest time to help the healing process. I learned this well with my dancers at San Francisco Ballet, where they would full their full dance but spend the rest of the day resting the injury in the boot. Sometimes it was part of a medical compromise, and sometimes only an extension of the 0-2 pain level that we were achieving other ways.
    Stiff Soled Shoes (including post operative) are something every podiatrist has in their office. These can immediately stop the bend of the big toe joint in the acute phase of an injury. When a patient injures the big toe joint, you have to remind them not to bend their big toe joint. They have to walk flat footed. Many patients have to use off weight bearing padding in these also, as just stopping the bend of the joint may not be enough to reduce their pain. So many patients have stiff dress shoes (like flat forms) or stiff hiking or hunting boots that can serve this purpose. Shoe cobblers can stiffen the forefoot in some shoes, and I would try to find one with padding and hopefully a removable insert. The extra stiffener can be removed when not needed at a later date.
    Flexible Shoes is the complete opposite of the above stiff sole option, but sometimes what is needed. Some patients put a lot of force through their first metatarsal phalangeal joint with walking and they need the shoe to be flexible and less stressful when they try to bend the joint. I am not sure if these are patients with more pronatory or supinatory gait patterns, but I assume supinatory since they are more central in their weight distribution across the metatarsals. The more pronation with over loading of the big toe joint the more stiffer the platform would have to be to protect it. Of course, it depends on all the other factors like do they use inserts with dancer’s padding, etc. When I send patients to a good shoe store to pick up some Hoka One One shoes, very stiff and very rocker, they are to put everyone we have designed in the shoe, and compare to their traditional flexible shoes. With the insert and dancer’s padding pulling their weight bearing lateral, some of these patients feel great in their traditional flexible shoes. I tell them to still get the Hokas, but alternate back and forth daily, with each shoe environment relieving the stresses produced by the other shoe environment. I love varying the stresses as long as I can keep the pain level between 0-2.
    Forefoot Padding is the opposite option of dancer’s padding or reverse Morton’s extensions. It an area is sore, pad it, and see if it feels better. So many patients have poor fat pads, especially near their bony first metatarsal heads, and the extra padding is of great comfort. In my office lab, I always have around 5 types of cushion material around ⅛ inch thick that I can add to the forefoot or heel in particular. Here I am not talking about localized padding to create a Morton’s extension or a Reverse Morton’s Extension, but a simple pad across the entire ball of the foot for more cushion. When patients like that for their injury, you know they should like shoes with a lot more forefoot padding to separate the pedal from the metal. Hannaford style cushion orthotics are full length memory foam orthotic devices that maximize the forefoot padding for these patients.
    Skip lacing can dramatically take pressure off the big toe joint. The distal medial hole may or may not be over the big toe joint, but it can still produce pressure downward from the top. This the same concept as finding the shoe with the deepest toe box as later described. You can skip both the medial and lateral last two holes distally, or you can attempt to just skip the medial hole for the maintenance of the best shoe stability. When do this, first you take out all of the laces except the most distal (closest to the toes). Make sure that the laces are even. Take out only the lace that runs through the hole near the big toe and transfer it through the hole one above (proximal) still on the medial side and then through the hole directly lateral (if you are counting from the bottom, medial second and then lateral second holes). If you think about it, if you had placed it originally in the distal medial hole, it then would have ended up here in the second lateral hole. The original distal lateral lace will also go through the second medial hole, so 2 laces through the same hole. From this point on, the lacing is normal up towards the ankle. You have succeeded in alleviating pressure from the top down onto the big toe joint. At times, with such acute problems like a gout attack to the big toe joint, you have to remove the last 2 holes, medially and laterally, so go to a shoe with Velcro closures like post operative shoes.
    Deep Toe Box unfortunately only occurs in a few selective shoes like some of the Brooks shoes. There are a slew of diabetic shoes that are extra depth, like the Ambulators, that can create space for a very protective shoe insert. In most cases, when I give a patient a list of shoes for a big toe joint problem (say neutral, stability, or motion control), I simply ask them to try to find the one that gives the most room in the big toe joint area that is still their correct size. There can be enough differences in shoes that one shoe may be better in this regard. Since shoe selection and unique features are very difficult to keep up with, the advice of the store personnel can be vital in the decision making.
    Wide Toe Box is an easier concept for the patients to grasp when selecting shoes then deep toe box. Some shoe companies run narrow in general, like Nike and Hoka One One, some run wide in general like Altra, some have narrow heels and wide forefoot like Saucony, and the trend that New Balance started offering various widths in each size. There are now so many variations across a shoe line that some of these general rules do not quite fit, with a knowledgeable shoe store a must in your treatment team. It is crucial that a shoe is the most stable in the medial midfoot. Instability in this area causes a breakdown in the entire medial column support of the entire lower extremity. Many patients break this rule by getting into a shoe that is too wide not only for the big toe joint, but for the entire width of the foot, and they swim around in the shoe too much causing worse problems like knee pain. I have had patients come in 2 sizes too big just to get the width in the forefoot. To get these patients back into more  appropriate sized shoes, or at least to stabilize their feet more, the following usually helps:
  • Skipping Shoe Lace
  • Power Lacing
  • Proximal Padding (dorsal or medial)—to be discussed soon
  • Custom or OTC Arch Supports for medial column support
  • Finding a shoe with no seams or reinforcements in the bunion area
  • Removing any padding under the big toe joint (like cutting a half circle from the shoe insert)
Occasionally this problem happens with the smaller foot of a patient with a big difference in foot lengths. You have to buy for the longest foot. As of this writing, the Brooks company will split boxes for a small fee even if the size difference is only ½ size.
    Shoe Stretching can work at times in a dress shoe to take pressure away from the dorsal or medial aspects of the first metatarsal head. It has been my experience that it only works when the shoe cobbler takes the shoe overnight to stretch. The ball and ring stretchers are still in use in many podiatrists office, but there is a skill to make the area stretched cosmetically appealing. I have not seen this work in athletic shoes, but some cobblers can remove irritative seams or bands of material that are in the way.
    Carbon Plates (Full Width) are thin rigid plates that come in all the sizes of shoes that fit under the shoe insole or orthotic device to limit toe bend. It is a simple way of taking a flexible shoe and making a temporary rigid shoe (as long as you need it). The design I use is totally flat (Otto Bock) and can work like a charm, or have major difficulties matching the curves and design of the present shoes. 2 local stores sell these and find good patient feedback. Since it does not allow your foot to bend at push off, I recommend it on both feet, which creates less asymmetry. In rainy weather, when a bike shoe with embedded cleat is not possible, this is a good alternative if you can find a shoe that it works with smoothly. Like the bike shoes you are supposed to not push off, but lift from your hips and knees (like marching). If the patient can not break the habit of trying to push off, or if they pronated too much into the plastic plate under the big toe joint, they will feel worse with this and should remove it quickly.
    Carbon Plates with Morton’s Extension work well with an orthotic device on top. Here only the first metatarsal head and hallux have the carbon plate distally. You want a varus biased orthotic device that gets you into the middle of the foot well. However, with some severely pronated feet, this is nearly impossible. If you can get the weight more central, this device works well allowing normal motion without big toe bend and it is appropriate to only use on the side needed due to big toe joint pain. A common problem with this design is when the hallux is too lateral and falls off of the plate. Sometimes you have to use bunion taping (as previously described) and/or toe separators (also previously described) to get the hallux over the Morton’s extension. And again, if the patient pronates too severely into the Morton’s extension, the pressure can be too much, and may be more a candidate for the next design.
    Carbon Plate Dancer’s Modification is definitely my favorite design. It limits the big toe joint and big toe pressures, it limits the motion in general across all of the metatarsal phalangeal joints, does not lift up on the first metatarsal adding to its overall pressure, but it does allow more big toe joint motion, and that could be the source of pain. You can also spica tape with it. You can actually put this under the shoe insole on the first visit, spica tape, add some Dr. Jill’s dancer’s pads, and probably help most patients before they walk out the door. I always want to free up the big toe joint by various means before attempting to limit it when it is the only way to get to the 0-2 pain level. I must emphasize that  in my office, one thing is done at a time. You must do one thing at a time, watch the patient walk and/or run, get the patient’s feedback, then you can add or subtract another modality. This is the only way you can separate what is helping and what is not helping.
    Proximal Padding (dorsal or medial) is an off weighting pad typically one inch square that attempts to place pressure from a sensitive spot (say medial eminence on a bunion) to a more proximal ( or less sensitive) spot. I typically use ¼ inch adhesive felt, but sometimes ⅛ inch is enough. I typically try in the office, and if it helps, give them a foot of material. Each square can be used 3-4 times before the stick wears out. It is only used when they wear enclosed shoes that could press on the area. Of course, some tight shoes can not fit anyway else, barely fit the foot itself. And, sometimes, you have to make the design smaller so that it will not show. When it comes to taking pressure off a sore area, sometimes very little is needed. Proximal padding is used mainly for the big toe joint area when there is medial bunion pain and dorsal spur pain from hallux rigidus. A very important aspect of bunion care is to off weight the medial eminence, but also vitalize the medial eminence soft tissue. Chronic inflammatory changes at the medial eminence can lead to skin breakdown and nerve hypersensitivity. Daily 2-3 minute non painful massage with hydrating lotions can help mechanically move away inflammatory tissue and de-sensitize the area. I will even send patients to physical therapy to help the tissue get healthier.
    Metatarsal Padding (sub 2nd to 4th or 5th) is another method of shifting weight from a painful big toe joint. The difference here from a dancer’s pad is that the weight is placed on the metatarsal shafts not metatarsal heads. I tend to use small or extra small Hapad longitudinal medial arch pads and apply them onto shoe inserts, over the counter orthotic devices, and custom orthotic devices. I actually first used them in ballet slippers and en pointe shoes when I routinely treated the San Francisco Ballet and the Oakland Ballet. You can not put much into those shoes, so what you do use has to be powerful. I typically have to thin them out some, and the patients are advised how to do so. There is a website and fax number on the backing where they can find more. The goal is to keep the weight centered through mid stance and propulsion, limiting the weight through the big toe joint and hallux. Changes from 50-60% weight to 40-50% weight can make a big difference over several weeks at letting tissue heal. Patients need to roll through the ball of their feet, notably the second metatarsal head onto the distal phalanx of the hallux, in active propulsion. The weight bearing is generally moving from a lateral (or sometimes more central) heel strike to a medial push off. These metatarsal pads can help redirect that force more central, or at least share more weight bearing onto the other metatarsals and unload the big toe joint some. Some may be enough to help, and help dramatically. After you take the backing off the Hapads, you have around two days to move it around until the adhesive gets too stuck. The patients are advised that they can move the padding medially or laterally and anterior or posterior. They should never feel like they are falling into the big toe area like falling into a hole. Sometimes, the position that feels the best for them, I would never have placed there.
    Self Mobilization for Hallux Limitus is a gentle tool that patients can learn when the range of motion of the big toe joint is limited. The more natural motion I can get out of a joint the better. The technique of self mobilization was taught to me by Drs. Rue Tikker and Timothy Shea and has been a valuable part of my practice for 40 years. I remember clearly this one patient who came in fairly distraught at the limited range of motion she had after bunion surgery. We all know that over 60 degrees of first metatarsal phalangeal joint dorsiflexion is considered normal, and you need 75 degrees of motion for the wearing heels and most sporting activities. She had 41 degrees of big toe joint dorsiflexion. I taught her self mobilization and she improved the range to over 70 degrees over a 3 month period. Of course, I had taken X-rays to make sure that there was no bony restrictions. The principle of self mobilization is short, quick motions in directions that is not normal for the joint to move. So, to improve dorsiflexion or plantarflexion of the big toe joint, and to naturally break up some scar adhesions, you perform four motions:
  1. Dorsal and Plantar Gliding
  2. Side to Side Rotation
  3. Clockwise and Counter Clockwise Rotation
  4. Long Axis Extension
These are done quickly, so it is Grade 5 mobilization that you are teaching. I do them twice, and always feel that the joint is looser the 2nd time. I measure before and after mobilization and typically get 5 and sometimes 10 degrees gain. The patient must do it 3 to 4 times a day to slowly gain, and maintenance for some will be once a day indefinitely. If I start a patient doing this, it is measured every visit even 5-10 years down the line to make sure they are not slipping back. The principle of mobilization is to stabilize the proximal segment and move the distal segment. So, you stabilize the first metatarsal head so that does not move, and you grab the proximal phalanx of the hallux. Remember you are moving the proximal phalanx on the first metatarsal head in 4 ways it does not normally move. You glide it up and down, you abduct and adduct, you rotate like a clock both directions, and you pull it out straight. The last one can be the hardest angle for the patients to do, but they try.
    Metatarsal Doming or Arcing is the best way to strengthen the flexors (hallucis longus and brevis) along with Single Leg Balancing. Metatarsal doming is an isometric exercise with tightening for a six second count with 4 second relaxation and then repeated 10 times total. You can do it 3 times a day, but a conversation I had with Dr. Pribut from Washington, DC, says he has his patients do them up to 300 times a day. The first part of the exercise involves straightening all of the toes. Patients with bunions and hammertoes that they can not straighten actively, need toe separators and/or Budin splints to get everything in a straight(er) position. You want to strengthen the correct muscle fibres that pull the toes straight. With the toes straight (reasonably), you pull up on the metatarsal heads keeping the tips of your toes against the ground as you count to 6. Try to feel the tension in the metatarsal arch as you squeeze the tissue as you do in every isometric. That squeeze feel is developing muscle bulk and tone, and patients begin to feel the difference in their feet within weeks. This is different and more powerful for straightening then picking up marbles or crunching a towel. I personally think these later two exercises can make hammertoes worse, but I have also seen good strength gains when patients are doing them. I prefer when patients are learning these that they carefully watch that their toes are not curling. Once they are doing the exercise correctly and consistently, they can do it in the supermarket checkout line, etc, without having to look down.
    Abductor Hallucis Strengthening is for bunion deformities when the decision is conservative care for the short or long term. It is actually a variation of metatarsal doming. It is not straight abduction, more like abduction plantarflexion, but it does get the abductor hallucis muscle fibers working and stronger in the process. Anyone who has seen an MRI image of the abductor hallucis muscle belly knows how huge it is and how powerful it could be putting a medial pull on the hallux. As a bunion develops, and the medial side of the first metatarsal head gets stretched, while the lateral side tightens, a natural muscle imbalance occurs with the adductor hallucis at an advantage. This is made worse as the first metatarsal drifts dorsally, moving the abductor hallucis more plantarly across the joint, weakening the medial pull further. For this exercise, you need a small 3 inch section of level 1 Theraband that you tie together the ends to make a loop. The loop is then placed around each big toe, and the feet are separated until the big toes are in a straight position across the big toe joint. With one foot metatarsal doming at a time, and other foot immobile, the same motions of toe straightening then metatarsal arcing is done, 6 seconds tighten 4 seconds relax 10 times total. This should not be done if the joint is already sore. The patient should pull on the big toe in a comfortable manner and may not be able to get the toe perfectly straight. There should be no pain in doing this exercise. If the patient is just starting with night splints, toe separators, correct toes, yoga toes or gems, they will see an improvement in toe position overtime. Also, lateral capsule deep mobilization with a physical therapist can get us on the right road sooner is really stuck cases of Stage 4.
The exercise, like most strengthening exercises I show patients except pure metatarsal doming, is only done in the evening within 2 hours before going to bed.
    Flexor and Extensor Hallucis Longus Strengthening can be very important in many big toe joint injuries. Making sure the long flexor is strong in sesamoid injuries helps protect the plantar surface of the joint. Making sure the long extensor is strong in Hallux Limitus or Rigidus conditions maintaining dorsiflexion strength. Typically, when any joint is injured, strengthening all the important muscles that run across that joint is important, with one group more important than another. Many podiatrists delegate this role to physical therapists which is wonderful, but try to analyze where the importance lie and what muscles are going to help the most. My mantra is to begin strengthening as soon as the injury happens. The muscles involved weaken at an alarming rate of 1% daily with any injury, and strengthen ¼ to ½ % daily. Even simple active range of motion strengthening, like moving your big toe up and down 10 times, can activate the muscles that get lazy or shut down due to the pain of the injury. Level 1 or 2 resistive exercise bands can be used to wrap around the big toe at the level of the proximal phalanx, and 2 sets of 10 toe crawls are done against the resistance of the band. For the long extensor, the resistive band has to be attached to an immobile object like a bed post with a rope attached to the post attached to the band. The band will be parallel to you in straight line with your leg. You will then wrap the big toe and start with sets of 10 against the pull of the band. There is more information on strengthening that applies in Chapter 5. Again, any strengthening as to be done pain free, but should be started as soon as you can.
    Night Splints and Yoga Toes are two interesting products that can help big toe joint problems. The best night splint, or at least the one that is most comfortable, has a soft plastic that is sold at Night splints are to gently stretch the lateral capsule of the big toe joint when their is stage 3 or stage 4 bunion development. Because they have velcro, you need to wear a sock when wearing so that the Velcro does not attach to anything while you are sleeping. Physical therapy to perform lateral capsule loosening can be an important part of this treatment. This stretch of the tissue for a prolonged period of time each night can be very helpful at then allowing the toe separators to work better. If any conservative treatment for bunions is to work, you must consistently get the bunion into stage 2. Yoga toes came onto the market 10 plus years ago and has been an incredible help keeping soft tissues from contracting adding to digital deformities. Different from night splints, yoga toes put a straightening effect on all the toes. They are to be worn 30 minutes each day, and you can not walk in them. Some of my patients wear them longer, up to 3 hours in one case, because of the positive effect that has been seen. Slowly over time, as we wear socks and shoes, our toes get more and more deformed, and this is a positive way to start reversing that trend. YogaToe company has recently made two other designs: Yoga Gems (with a less aggressive separation) and Awesome Toes (which are meant to be worn about walking in house slippers, etc). Because of the dominance in the market of the next product called Correct Toes, I have not experimented with Awesome Toes.
    Correct Toes, invented by Oregon podiatrist Dr. Ray McClanahan, is Yoga Toes for walking. When patients have bunions and hammertoes, it is a device that they should see if it works. Presumably born from the barefoot running boom 10 years ago, Correct Toes slips over each toe, gently separating them, and were designed to both walk and run while wearing. Since our feet are naturally wider than the position shoes force us into, and since Correct Toes will place each toe in a very separated position from each other, there are only a select group of shoes that they will fit into. Dr. McClanahan’s website tells the buyer what shoes are appropriate. I tell my patients to look at that list, also start with walking around the house in loose slippers to get the feel of them. Altra and Keen shoes are my go to shoes right now known for their wide forefoot. Even if the patient only wears them for a short time at home, they will get a benefit from them. Some patients have too narrow a foot for the current design, and my most common adjustment is to remove the lateral one or two holes. At least, this is still getting the separation of the 1st, 2nd, and 3rd toes. Many patients have described a greater sense of power at push off.
    No Achilles Tightness is the last in my discussion of big toe joint problems, but in some cases, the most important aspect of treatment. A tight Achilles’ tendon drives a tremendous force downward into the metatarsals, particularly the big toe joint, which the ground reactive forces have to match. This aspect of functional hallux limitus may not be picked up in our examination as it happens from the middle of mid stance into propulsion when the bend of the ankle is restricted by the tight Achilles for the first time in gait. It is why when we talk about vital measurements, Achilles flexibility is crucial to learn. When the ankle can't bend past ninety degrees (more subtle forces as the bend gets closer to 10 degrees) at the middle of mid stance, and as the body weight continues to move forward, the heel will lift up early driving abnormal pressure into the forefoot, or the midfoot collapses driving abnormal pressure into the forefoot, or the foot abducts driving abnormal pressure into the forefoot. Therefore, all forefoot pain patients, especially big toe joint, should have the Achilles’ tendons measured for any tightness issues, and corrected as soon as possible. There is more on this treatment later, but since we are talking big toe joint problems, I want to discuss one important issue. When you stretch the Achilles’ tendons, both with straight knee and bent knee positions, the actual stretching itself can put a lot of pressure on the big toe joint. You can hang the big toe joint off the end of a thick book, so as you stretch no weight goes into the big toe joint. You can also build a well with 4 books arranged to make a float for one spot. Some of my wood working patients have made their own platforms so that they can stretch, do single leg balancing, Yoga poses, etc, and protect the sore joint at the same time. Purchasing a cheap but thick sandal, and then having a shoe cobbler cut out the big toe area, can help patients avoid irritating their joints while stretching, etc.
    Avoiding Excessive Big Toe Joint Bend applies to activities that a patient may do repeatedly that can stress out the injury. Activities like plank, downward dog, running on their toes, putting something on a high shelf, our sitting position, the tightness of bed sheets that can pull our toes up, etc.

Mechanical Treatment 1st MPJ Checklist
  1. Spica Taping                          Utilized____ Helpful____
  2. Bunion Taping                       Utilized____ Helpful____
  3. Toe Separators                       Utilized____ Helpful____
  4. Dancer’s Padding                  Utilized____ Helpful____
  5. Cluffy Wedges                       Utilized____ Helpful____
  6. Morton’s Extension               Utilized____ Helpful____
  7. Orthosis (Varus)                    Utilized____ Helpful____
  8. Orthosis (Stability)                Utilized____ Helpful____
  9. Less Heel Lift                        Utilized____ Helpful____
  10. Zero Drop Shoes                    Utilized____ Helpful____
  11. Rocker Shoes                         Utilized____ Helpful____
  12. Bike Shoes Embedded Cleat  Utilized____ Helpful____
  13. Cam Walkers                          Utilized____ Helpful____
  14. Stiff Soled Shoes                    Utilized____ Helpful____
  15. Flexible Shoes                        Utilized____ Helpful____
  16. Forefoot Padding                    Utilized____ Helpful____
  17. Skip Lacing                            Utilized____ Helpful____
  18. Deep Toe Box                         Utilized____ Helpful____
  19. Wide Toe Box                         Utilized____ Helpful____
  20. Shoe Stretching                       Utilized____ Helpful____
  21. Carbon Plate (Full Width)      Utilized____ Helpful____
  22. Carbon Plate Morton’s           Utilized____ Helpful____
  23. Carbon Plate Dancer’s           Utilized____ Helpful____
  24. Proximal Padding                   Utilized____ Helpful____
  25. Metatarsal Padding                 Utilized____ Helpful____
  26. Self Mobilization                    Utilized____ Helpful____
  27. Metatarsal Doming                 Utilized____ Helpful____
  28. Abd Hallucis Strengthening   Utilized____ Helpful____
  29. FHL/EHL Strengthening        Utilized____ Helpful____
  30. Night Splints/Yoga Toes         Utilized____ Helpful____
  31. Correct Toes                            Utilized____ Helpful____
  32. No Achilles Tightness.            Utilized____ Helpful____
  33. Avoiding Excess Toe Bend.    Utilized____ Helpful____

1 comment:

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.