Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.

What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
- a rigid high arched cavus foot
- perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
- a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
- weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
- contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
- presence of a rigid forefoot valgus
- avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop

Gait / Running Talk: Functional Hallux Limitus.

(*2 pictures attached today, toggle between the two and then read on. PS: the subheader for the photo suggests they recommend a Cheilectomy in many cases.. This was typing that came with the photo. This is not our recommendation in many cases.  Please ignore those two lines of type for now. TGG)

It is often though from an evaluation perspective that hallux limitus is a loss of the big toe extending on the forefoot (metatarsal head), such as seen in the picture above.  It is after all the easiest way to assess the joint, however it is not a true functional assessment, rather a passive ROM assessment.  Keen observers will realize that under more functional circumstances, after planting the foot on the ground, the big toe will be affixed to the ground and the limitation will come as the person attempts to move the body over that joint. With a hallux limitus the 1st metatarsal will not be able to roll downwards on the phalanx (big toe) concavity and gain purchase on the ground. This can come from joint arthrosis or some of the functional problems we have discuss in our last 2 blog posts.  This downward roll and glide, plus the body mass moving over the axis, is “functional extension” at that joint (as opposed to passive assessment function of the joint as seen in the first picture above). This joint can be referred to as the Windlass joint. Here we have the concave rounded metatarsal head (see 2nd picture) rolling up but sliding down withing the concavity of the hallux/ big  toe (roll and glide are normally in opposite directions if the axis of joint centration can be held, in functional hallux limitus this centration axis is lost, hence the limitation) . This roll and glide in descending the metatarsal head to the ground is what we refer to as “medial tripod anchoring”. Disruption of this roll and glide at these joint surfaces through this extension movement to get the metatarsal head to the ground can be found with both Functional or Ablative (true) Hallux Limitus (aka “turf toe”).  Failure of this biomechanical mechanism leads to insufficient medial tripod, aberrant toe off mechanics, probably pain, and risk for bunion and hallux valgus formation (because when the medial tripod is not anchored the functional mechanics of the adductor hallucis muscle changes and ends up pulling the hallux laterally). 

Just taking you through a more functional perspective on hallux limitus. It is not as simple as “the joint is stuck”. And forcing the range won’t make it unstuck ! It will just create more dorsal bony abutment at the top of the joint, and pain.  If you have any chance of fixing this monumentally misunderstood problem, you must understand this blog posting, and the last two blog posts.  To fix this problem, if it is still functional and not ablative (fixed and permanent),  you will have to use your brain and not your fingers ! 

On another day we will talk about the cluffy wedge that you see under the big toe (hallux) in the picture above. We will give you our perspective on the device, how we make our own version of a wedge and some of our concerns for its use.

Alot of our patients joke around when they come in to see us with a problem.  We like humor in our offices.  Their joke frequently is, “must be something wrong with that big toe again !”….. even if it is shoulder or neck pain.  And interestingly, alot of the time they are somewhat right.  If you screw up toe off, the rest of the movement is compensation. 

The Big toe, …… it is often on the menu.

Shawn and Ivo