Matt Phillips

Written by Matt Phillips

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Why Your Big Toe Might be the Cause of Your Running Injuries (And How You Can Fix It)

Even though it is not talked about very often in running communities,  a “stiff big toe” (or as it’s often referred to, ‘hallux limitus’) can actually be a very common source of pain in the ankle, knee, hip or lower back.

hallux limitusNormal big toe movement

Imagine you are running, and one of your feet is about to touch the ground in front of you. The foot is pulled back slightly (dorsiflexed) in preparation for initial contact. The big toe (hallux) is probably also dorsiflexed but as your foot is still off the ground this is not significant.

However, once your foot touches the ground and starts to support your body weight, the degree of dorsiflexion that the big toe joint is able to go through becomes important.

As your body passes over the supporting foot, there comes a point called mid stance, when the hip, knee and ankle stop flexing (bending) and begin to extend (straighten). The technical term for the ankle when it extends (i.e. the foot points downwards instead of pulling back) is plantarflexion (annoying, I know).

As you can see in top image of the diagram below, normal joint motion involves the first metatarsal (bone behind the big toe) plantar flexing, and as the arrows indicate a slide & climb of the metatarsal head up onto the sesamoids (two small bones underneath the first metatarsal).

This movement permits the degree of big toe dorsiflexion required for stabilizing of the foot (via the windlass mechanism) during propulsive loading.

If slide & climb movement within the MTP (metatarsophalangeal) joint becomes restricted, the big toe will not be able to dorsiflex sufficiently, causing alternative foot mechanics to be sought, which in the long term could lead to discomfort and possible degenerative arthritis.

Functional hallux limitus

The presence of limited movement in the MTP joint (as opposed to no movement at all) is referred to as hallux limitus. It is important to differentiate two distinct sources of this limited movement: functional vs. structural.

RC25_Three_Stages

The middle image in the diagram illustrates functional hallux limits; although movement is limited, this is not the result of joint degeneration. During assessment, the toe moves freely whilst there is no weight on it.

The reduced movement is due to a ‘jamming’ of the first metatarsal with the big toe, i.e. no slide & climb.

Repetitive jamming often stimulates extra bone growth over the top of the joint, causing a characteristic bunion.

Research is still unable to determine what causes functional hallux limitus. It may be that particular dynamic foot biomechanics lead to the jamming. In some cases, the first metatarsal being abnormally long or short is thought to place extra stress on the big toe joint.

Other possible causes include: running on the toes, wearing shoes that are too small, wearing high-heel shoes too often, or as a result of a trauma e.g. stubbing the big toe or dropping a heavy object on it.

There are many ways to treat hallux limitus that do not involve surgery, so it is important to get it taken care of earlier, rather than waiting until it becomes totally restricted (hallux rigidus).

Structural hallux limitus

The last of the three images in the diagram illustrates structural hallux limitus, often thought to be a progression of the above but can also be a result of a trauma. The repeated jamming we saw in functional hallux limitus can cause a wearing down of the joint cartilage and eventual degenerative arthritis.

If present, this will show up on an X-ray, and in contrast to functional hallux limits, movement can be restricted even when you are not weight bearing. If it goes untreated, range of movement can will decrease, until eventually there is no movement at all, i.e. hallux rigidus.

Compensation and pain

Both hallux limitus and hallux rigidus can cause immense pain, so it is hardly surprising that the brain finds an alternative (compensatory) way of getting that foot off the floor.

However, compensation patterns do not eliminate the load (force) experienced when hitting the ground during running; they simply shift it to other parts of the body which can lead to pain elsewhere.

Lower leg pain

If your big toe has limited dorsiflexion, your lower leg will not be able to move correctly over your weight bearing foot (limited ankle dorsiflexion).

As a result, the calves shorten with each stride, and can become extremely tight, causing altered dynamics in the lower leg and pain in both the calf and Achilles tendon.

Knee pain

The human body is a kinetic chain. What happens at one joint will have a knock on effect at another joint. Lack of ankle dorsiflexion when running can lead to an early bending in the knee, which in turn can disrupt the whole efficiency of the gait cycle

Hip/lower back pain

Reduced ankle dorsiflexion can increase the duration of time in which the heel is off the ground. The resulting change in foot biomechanics can cause a decrease in hip extension, which may in turn force the hip flexors (on the front of the hip) to work harder than they normally would had optimum hip extension been reached.

This may manifest itself as pain in the hips and/or lower back.

Testing for hallux limitus

In reality, all therapists should be testing you for reduced big toe mobility when you present yourself with any of the above symptoms.

You can also assess yourself by watching your big toe when you walk. Does it bend back easily and push off the ground without the need for extra effort?

Bear in mind that simply pulling your big toe back is not a test for functional hallux limitus. It is the dynamic weighted movement that creates symptoms.

If you have structural hallux limitus, pain is likely to be elevated when you try pulling the toe back when not standing on it.

If you do suspect limited movement, consult a running specific sports therapist or physiotherapist as they will be able to investigate further using gait analysis and more tests. An X-ray will show up structural changes such as joint narrowing and bone spur formation.

Norms for range of movement

The average dorsiflexion range of motion of the first MPJ during walking is thought to be around 45 degrees.

A grade system of 0-4 is used to describe the extent of hallux limitus/rigidus. Grade 0 represents a dorsiflexion range of 40-60° with no symptoms. The other end of the scale is a Grade 4 in which 0o dorsiflexion is presented along with severe joint degeneration.

Many people assume that running requires a greater range of movement in all joints than walking does.

This is not always true.

In fact, as far as dorsiflexion of the big toe goes, the required range of movement is actually less when running. This explains why some people with hallux limitus suffer less pain when running compared to walking.

Treating hallux limitus/rigidus

As we have already mentioned, diagnosis in the earlier stages allows more treatment options to prevent surgery. Depending on the cause of the symptoms, a podiatrist may be able to fit you with a suitable custom foot orthotics that will restore normal motion to the joint when weight bearing.

  • A simple change of footwear can also help: wearing something with maximal stiffness across the forefoot may decrease the dorsiflexion moment across the MTP joint and help avoid the big toe from jamming.
  • Some runners find success by swapping their running shoes for a lightweight hiking shoe.
  • Ground surface can also make a difference: try swapping the unforgiving hardness of roads (asphalt) to grass or dirt trails.
  • If the condition has progressed, and you are in severe pain, the number one priority first of all is to reduce that pain. The typical PRICE protocol (protection, rest, ice, compression, elevation) should be used until the acute symptoms have dissipated.
  • Corticosteroid injections may be help reduce severe pain, but they must be regarded as a short term way of reducing pain, and not a solution to the problem. The same goes for taking NSAIDS (Non-Steroidal Anti-Inflammatories) like Ibuprofen. They can help relieve pain but are again not a long term strategy. Whilst you mask the pain, deterioration of the toe joint can still occur.
  • Manual therapy such as joint mobilization is thought to help increase range of movement in the first MTP joint. Strengthening of the muscle that pulls down the big toe (flexor hallucis longus) and the plantar intrinsic muscles of the feet is promoted to help improve stability of the first MPJ.
  • If the restriction is structural in nature, surgery may be advised. There is little research on the long-term effects of surgical treatment for runners, but given that less dorsiflexion is required for running than walking, even if surgery does not see a full return to the 400 generally regarded as necessary for pain free walking, you may see a return that is enough to allow running.
  • In severe cases of joint degeneration (Grade 3 and 4), fusion of the first MTP joint (arthrodesis) has shown good results with regards to eliminating pain.

In summary

Hopefully this article has shown you the relevance of adequate mobility in the big toe. If you are suffering from the symptoms described above, the time to do something about it is now, rather than waiting and risking a need for surgery. If you are suffering from persistent ankle, knee, or hip pain, make sure your therapist has considered hallux limitus/rigidus.

Have you ever considered your big toe as a source of pain? 
Matt Phillips is a Running Injury Specialist & Video Gait Analyst at StrideUK & Studio57clinic. Follow Matt on Twitter: @sportinjurymatt

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References

1. Scherer, P.: ‘Understanding The Biomechanical Effects Of Hallux Limitus’ (2008) www.podiatrytoday.com/article/7486#sthash.LMfI58w9.dpuf
2. Lehman, G.: ‘Functional Hallux Limitus – The problems with testing it’ (2011) www.thebodymechanic.ca/2011/01/30/functional-hallux-limitus-the-problems-with-testing-it/’
3. Richie, D.: ‘How To Treat Hallux Rigidus In Runners (2013)
www.podiatrytoday.com/how-to-treat-hallux-rigidus-in-runners

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19 Responses on “Why Your Big Toe Might be the Cause of Your Running Injuries (And How You Can Fix It)

  1. Hi there. Thanks for the great article. Been struggling with severe pain in my toe- doctor said it’s just a strain and prescribed an anti-inflammatory gel. However, after reading this article and doing the maths, I’m pretty sure that my shoes are the problem as the pain started a couple months after I bought them (that, and that I’ve started developing a bunion on this same toe) Knowing this, is it still necessary that I see a specialist? Also, how long and how much rest is necessary? I’ve just gotten into a good rhyme and am loath to lose my momentum. Any advice is welcomed gratefully. Thanks 🙂

      • Hi Sherrie, good to hear the article got you thinking! If you only started struggling with the pain after buying the new shoes, it is definitely worth returning to your old shoes for a while to see if the problem reduces. Watch out for any coinciding rapid changes in your running frequency, intensity or duration as well though as we often subconsciously push our bodies harder after buying new shoes. As for rest, remember that total rest is rarely the answer. You need to be doing suitable mobility and strengthening exercises to help reduce pain and restore function. A sports therapist should be able to help you create a suitable exercise routine once they have assessed you. Thanks again for the comment. Let us know how it goes!

  2. Thanks for the info. My podiatrist just diagnosed hallux limitus for me. The xrays show bone spurs on the top of the metatarsal joint that are causing a jamming of the joint. The strange thing is that i have no pain on the top of my foot. The discomfort is all on the bottom like i have a rock in the middle of my shoe. Turned out to be the swelling is on the bottom caused by the trauma at the top. Just the beginning of the experience for me. Hopefully I have a lot of running left to experience.

    • Hi Brian, thanks for reaching out and sharing your story. It is good to know that you have a diagnosis for your problem. Now you can begin to work on it, and hopefully the suggestions in this post can help you recover quicker!

    • Thanks for sharing Brian. Glad the article was of use to you. With the right care, I hope we hear you are happily running again as soon as possible!

  3. i am suffering from this hallux limitus..its been 8 months i cant lift my big toe ( of my left leg)..last december i had a tibia plateau fracture..it caused me the nerve injury..is there any exercise i can do for my toe? will it recover..plz let me know

    • Hi Ieffa, thanks for reaching out. Sorry to hear about your toe. This would be a question for your doctor, as we cannot diagnose you from here, but the suggestions we made in the post should help you recover, and ease off the stress on your toe. Hope this helps!

  4. Hi,

    Have been told I have functional hallucinations limitus and was given orthotics. Wore them for several months but my body just couldn’t get used to them. Is surgery an option for functional hallux limitus?

    • Hello, thanks for reaching out.We did talk about surgery as an option in the post itself, we also suggested alternative options to try to avoid it. Give our suggestions a try and see how you get on!

  5. Hi…I have seen a podiatrist several times. She doesn’t seem very interested in helping with my problem. I am an RN. I believe that I have hallux limitus/rigidus. I have a huge bump on the top of my left big toe (the affected toe) as well. My right big toe is following suit as well. I saw my x-rays. I have had casts made of both feet. And an orthotic set made to wear, several years ago. I tried to wear it. I could only wear it several hours inside the house. It hurt! My pain, Like Brian, is in the ball of my foot. The first indication of a problem was pain in my big toe. And the large bump on the top of my toe. But that is gone now. The Podiatrist says that I have no joint left in my (L) big toe. She gave me topical med to apply to foot. And suggested a New Balance orthotic to try. I also have scoliosis that was fixed with surgery and a Harrington rod when I was 17. But my curvature is back and about the same as before surgery. I need some insight from someone on how to deal with these multiple problems. I realize that my foot is making the rest of my problems worse. But no other Dr. seems to want to do any further evaluation. I need a recommendation for someone in my area (or not. I’m willing to go to them) for a total body evaluation. I obviously do not run. But those who do seem to be getting the best answers and solutions to similar problems. Can you tell me who I might consult? A gait analyst, sports med expert, or someone else? I am tired of trying to find help alone. Regular MD’s don’t seem to be interested in anything except surgeries and meds. Thanks for your time.

  6. Great article. It’s extremely important for people to be aware of this early and to make the necessary changes.

    I’m 26 years old with severe hallux rigidus that began when I was 19. I’ve had two cheilectomies on my left foot and a first mtp joint osteotomy on my right, and need another operation on each foot in the near future due to the re-degradation of the joints since the most recent operations three years ago.

    Every line in this article hits home, as since my toes have degraded steeply once again over the past months, my knee tendinitis has become aggravated again, my calves are constantly as tight as anything, my glutes are strained almost weekly, and my hips/lower back ache.

    Over the past two months I’ve gotten three separate opinions, all agreeing that imminent surgery is necessary but disagreeing on the type. I had all but ruled out arthrodesis, but then I saw an orthopedic surgeon yesterday who said the only surgery he would perform in my case would be arthrodesis on both feet. I’m extremely hesitant to permanently fuse the bones at only 26 years old. Have any of you come across runners who have had the arthrodesis performed and still could be active and comfortable? The doctor I saw yesterday assured me people can still do as much as run marathons after the arthrodesis, but I find it hard to believe it’d be comfortable to have two fused big toes for (hopefully) the next 60+ years.

    The other option I am considering is arthroplasty, getting joint implants in both feet. Have any of you come across anyone (runner or not) who have had this performed?

    Thanks in advance for your time. Been a daily issue in my life for seven years now and like I mentioned, this article hit home more than any other I’ve read on the topic.

    • Happy to help Mike. Sorry to hear it has been so much trouble for you. We have not got any information about arthroplasty, but if you wish to try it, then we would love to hear your thoughts, you might provide comfort to other runners, and you know how much that would help you to learn what others found help. Thank you for sharing. Best of luck with your recovery!

  7. Hey Guys
    Uh, you guys nailed it. My last two seasons I’ve developed a bunion on my right foot limiting my range on that toe. It is manifesting the pain on my left calf due to a poor toe off on my right side. My left calf has taken the brunt of my poor right foot toe off. My coaches are playing with different orthotics and it immediately takes the load off my calf. Any other suggestions? I can’t seem to get it just right as my pain in my calf can move due to alterations in my orthotics.
    Thanks….Very good article!

  8. I have this from ballet. Does anyone recommend a pair of sneakers? My 1st metatarsals are fused and I am in pain all the time.

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