How To Diagnose And Treat A Big Toe Injury

The big toe might be a small joint, but that doesn’t mean it isn’t important for runners. It serves a critical function in creating more leverage to generate forward momentum when you run, and because of this, it is susceptible to several overuse injuries.

Among runners, a big toe injury is not common. Even with a very generous definition that includes all toe injuries and injuries to the “sole” of the foot, this accounts for less than five percent of all running injuries according to one study.¹

Another study published in 2002 found that none of the injuries that affect the big toe were among the top ten most common running injuries.² For more on common running injuries please read Common Running Injuries.

Despite this, an injury to your big toe can set you back for weeks or months if you can’t diagnose it. Even though it’s very small, the big toe joint (known to medical professionals as the metatarsophalangeal joint has several distinct anatomic components, each of which is susceptible to injury.

The Mystery The Big Toe Joint

There’s a lot more going on inside your big toe joint than just two bones articulating. Because it handles so much force during walking and running, the joint has special adaptations to create additional mechanical leverage. One of these is the presence of tiny bones called sesamoids (a word that has the same root as “sesame seed,” because these bones are so small).

These function just like your kneecap. They create a mechanical advantage to multiply your force. However, the downside of this is that the sesamoids, alongside the ligaments and tendons that surround them, are vulnerable to injury.

Partially because of the rarity of big toe injuries, we don’t know a whole lot about the risk factors for them, or what kind of runners get them.

From basic biomechanical principles, we can predict that forefoot strikers and middle-distance runners may be more likely to get big toe injuries, because of the increased demands these runners place on their big toe joint.

Older runners may be at greater risk of big toe injuries too, because as we are about to see, some big toe injuries are related to chronic degenerative changes in the joint that accumulate over many years of wear and tear.

Please read 10 Things You Think Will Change As An Older Runner (But Don’t) to learn more.

How To Diagnose And Treat A Big Toe Injury In Runners

When pain in your big toe prevents you from being able to run, the first order of business is to get a solid diagnosis. Big toe pain isn’t like Achilles tendon pain, where it’s pretty easy and obvious what the problem is.

There’s a multitude of possible causes for your pain. It could be hallux rigidus, turf toe, sesamoiditis, or tendonitis of the flexor hallucis longus tendon. All of these can cause big toe pain while running.³

• Hallux rigidus is a term for a form of degenerative arthritis of the big toe joint. As you might guess from the name, one of the defining characteristics is a persistently “rigid” or stiff big toe joint. Your range of motion will be limited, and you’ll likely find walking barefoot to be more painful than walking with shoes on. You might have some swelling, too, but you won’t have any bruising. Fortunately, it’s easy for a doctor to definitively diagnose hallux rigidus and evaluate its severity with a plain x-ray. The downside is that, because it’s a degenerative condition, treatment is mostly focused on reducing stress on the joint through orthotics or shoe modifications, plus anti-inflammatories to reduce swelling. In more advanced cases, surgery is sometimes needed to cut out the bone spurs that develop in the joint as the cartilage wears away.

• Hallux valgus is the medical term for a bunion, which is probably the easiest big toe injury to diagnose. If you have pain on the side of your big toe joint, and your big toe is angled inwards, you can almost assuredly chalk it up to having a bunion. Initially, if the angle at which your big toe is pointing inwards is not too bad, you can get by with modifying your running shoes to take pressure off the outside of your foot. Some runners just take a razor blade to the shoe upper and cut a slit to reduce pressure on the side of the big toe, but buying a shoe with a roomier toe box can also work.

• Turf toe is one of the most common causes of big toe pain in athletes. Though it happens more commonly in football and soccer players, it does affect runners, too. You can think of it as the big toe equivalent of an ankle sprain: hyperextension of the joint causes damage to the ligaments that surround the big toe, and the result is substantial swelling, bruising, and severe pain when you try to walk. The ligaments need time to heal, so treatment for turf toe involves icing, rest, and using an air-cast or a similar device to immobilize the joint while it heals. It is a good idea to see a doctor for this one, because many medical professionals recommend placing the big toe joint in a specific position while it’s immobilized, to ensure that the ligaments don’t stay hyperextended when they heal.

 

Once you gradually return to running after turf toe, you can use a turf toe taping to reduce stress on the area. This taping limits the ability of the big toe to go into hyperextension, so it’s a good insurance policy when you are first starting back up.

Coming back from an injury? Then read How Much Running Can You Safely Do When Returning From An Injury to learn more.

What Is Sesamoiditis

Sesamoiditis is an inflammation of the sesamoid bones. And is characterized by pain localized directly over the ball of your foot. Pain is more strongly associated with direct pressure on the ball of the foot than with flexing or extending the big toe.

You can usually reproduce the pain by simply pushing directly on the ball of your foot with your thumb. Sesamoiditis will hurt more when walking barefoot, especially on hard surfaces.

Treating sesamoiditis involves reducing stress on the ball of your foot, hopefully to the point where the stress of running doesn’t aggravate it anymore. Rest will help, but you can also modify a standard over-the-counter orthotic with felt padding or get a custom orthotic with a divot underneath the ball of your foot.

Do keep in mind that, while this will decrease stress on the ball of your foot, it will increase stress on the rest of your forefoot, so use this method judiciously. Beyond this, there are no special exercises or anything you can do for sesamoiditis; just the same old rest and icing routine.

Stress Fracture In The Sesamoid

In some cases, ball of foot pain might not be just sesamoiditis, but a stress fracture in the sesamoid. The pain from a stress fracture will be more severe, and might limit your ability to walk at all when barefoot. The best way to diagnose a stress fracture is with an MRI, though some doctors will look at plain x-rays for evidence.

This can cause some false positives, though, since up to one-third of the population has “bipartite” sesamoids, meaning one or more of their sesamoid bones is naturally parted in two, and can be mistaken for a fractured sesamoid.⁴

Sesamoid stress fractures have a high risk of poor healing, so you’ll need to be in a boot, cast, or modified orthotic for at least several weeks to ensure that it heals properly.⁵

For more information on stress fractures, please read How To Return To Running After A Stress Fracture, Can A Tuning Fork Detect A Stress Fracture? and High Risk Stress Fractures: How To Treat Them Properly.

Flexor Hallucis Tendonitis

Finally, pain in the big toe might be due to flexor hallucis tendonitis (FHL), for short, is a tendon that helps flex your big toe downward and helps you push off the ground when you run. Because it runs underneath the sesamoids and attaches to the big toe, it can cause pain in the joint or along the arch of your foot.

In some cases, it might even be mistaken for plantar fasciitis. FHL tendonitis will cause pain that extends into the arch of your foot, and is worst when you push off the ground.

It’s worth noting that FHL tendonitis is rare to begin with, and is rarer still in the region of the tendon that passes under the big toe joint. The good news is that, as a tendon injury, it should be amenable to stretching and strengthening exercises.

A 2005 paper by Doctors James Michaelson and Laura Dunn suggest three specific stretching exercises for the FHL to be done several times daily for ten seconds each. These three stretches, all variants of ordinary calf stretches, are designed to put controlled tension on the FHL.

The authors report good outcomes in a large number of patients from this routine alone, though some did need surgery.⁶

A 2015 paper by researchers in Japan and California suggests adding calf raises with the toes hanging off a step as a rehab exercise.

The goal here is not to strengthen the FHL; rather, the goal is to take stress off it by training the body to use other muscles to plantarflex the ankle.⁷

No specifics are given by the authors, but a good place to start would be 15 single leg calf raises with the toes off a step every day, increasing over time to three sets of 15.

How To Diagnose And Treat A Big Toe Injury

Since there are so many possible causes of big toe pain in runners, and because some of the causes demand a lot of time off, your number one priority should be figuring out the cause of your pain.

Hallux rigidus, hallux valgus, turf toe, sesamoiditis or sesamoid stress fracture, and flexor hallucis longus tendonitis are all candidates.

It may not be easy to pinpoint the problem. If this is the case, see a trusted doctor, because you might need X-rays or, more rarely, an MRI, to definitely diagnose the problem.

The correct treatment is going to largely depend on what the problem is. Unfortunately, most big toe injuries need a lot of time off from running, and may even need to be immobilized in a cast to heal properly.

Shoe modifications or custom orthotics can be helpful when the goal is reducing pressure on a certain area of the foot, as is the case with a bunion (hallux valgus) or sesamoiditis. Please read Do You Really Need Custom Made Orthotics For Running? to learn more.

In all cases of big toe injury, the primary solutions are to 1) allow the damaged area to heal or allow inflammation to subside and 2) reduce stress on the big toe.

Cross Training While Injured and During Recovery

Cross training is recommended while you're injured and as you slowly return to running.

The best form of cross training for this injury is Aqua Jogging. Studies have shown that aqua jogging can enable a well-trained runner to maintain running fitness for up to 4-6 weeks.

Aqua jogging is a form of deep water running that closely mimics the actual running movement.  Your feet don’t actually touch the bottom of the pool, so it is zero impact and safe for almost any type of injury. In my experience, the only time to avoid aqua jogging is when you have a hip flexor injury, which can be aggravated by the increased resistance of the water as you bring your leg up. Because aqua jogging closely mimics natural running form, it provides a neuromuscular workout that, in addition to aerobic benefits, helps keep the running specific muscles active. The same can’t be said for biking and swimming. The only downside to aqua jogging is that you need a pool that is deep enough to run in without touching the bottom. If you’re lucky enough to have access to a pool of this size, aqua jogging should be your first cross training choice.

In one study, a group of ten runners trained exclusively with deep water running for four weeks and compared 5km race times pre deep water running and post deep water running.

The researchers found no statistical difference in 5k time or other markers for performance, such as submaximal oxygen consumption or lactate threshold.

In a second study, researchers measured the effects of aqua jogging over a six week period.

This time, 16 runners were separated into two groups – one who did aqua jogging workouts and the other who did over land running.

Using the same training intensities and durations, the researchers found no difference between the groups in maximal blood glucose, blood lactate, and body composition.

It get’s better:

Research has also demonstrated that aqua jogging can be used as a recovery tool to facilitate the repair of damaged muscles after hard workouts.

These findings make aqua jogging an important recovery tool in addition to being the best cross training method for injuries.

Need one more reason?

The calories burned aqua jogging are even higher than running on land, so if you want to avoid weight gain while you take time off from running, this is definitely the exercise for you!

Aqua Jogging Workouts For Runners

If you're interested in aqua jogging to rehab your injury, then the absolute best way is to use one of my favorite programs, Fluid Running.

First, it comes with an aqua jogging belt and waterpoof bluetooth headphones so you have everything you need to aqua jog effectively.

Second, they have an app that pairs with the headphones so you can get workouts, guided instructions on how to aqua jog properly, and motivation while you're actually pool running.

This has been an absolute game changer for me when I am injured.

I used to dread aqua jogging workouts because they were so boring and it took all my mental energy to stay consistent.

But, with workouts directly in my ear, it's changed the whole experience and I actually look forward to the workouts. So much so that I now use aqua jogging as a cross training activity in the summer, even when I am not injured.

Fluid running is an awesome deal when you consider it comes with the belt (highly recommended for better form), the waterproof headphones (game changer for making pool workouts fun), a tether (to add variety to the workouts you can do) and the guided workout app (to make your cross training structure and a whole lot more interesting).

That's why we've partnered with them to give you 2 additional running-specific workouts you can load into the app when you use the code RTTT .

Check out the product here and then on the checkout page, add the code RTTT in the coupon field and the workouts will be added to your order for free.

If you'd rather do the aqua jogging workouts on your own, here are some great ideas to get you started!

Medium Effort Workouts

The Pyramid

10 minutes easy warm up - 1:00 hard, 30 seconds easy - 1:30 hard, 30 seconds easy - 2:00 hard, 30 seconds easy - 2:30 hard, 30 seconds easy, go to 5:00 in 30 second intervals and then come back down the pyramid (4:30 hard, 30 easy, 4:00 hard, 30 easy etc). Finish with 10 minutes easy cool down.

Wave your hands in the air like you just don’t care

10 minutes easy warm up, 1 minute medium (87-92% of maximum heart rate or what feels like tempo effort), 1 minute sprint (95-100% of maximum heart rate or all out sprint), 30 seconds hands in air (keep moving your legs in the running motion, but put your hand above your head), 1 minute rest, Repeat 10-15 times. 10 minutes easy cool down.

Hard Workouts

One of the difficulties of cross training is replicating those truly lung-busting, difficult workouts.

So, if you’re going to be pool running quite a bit due to injury or limited training volume, invest in a bungee cord designed for sprinters.

Tie one end of the resistance band to a sturdy object (pole, lifeguard stand, pool ladder) and bring the other into the water with you.

Put the strap around your waist and begin aqua jog away from your starting point.

You’ll begin to notice the bungee tighten and resist against you (depending on the length of your pool, you may need to wrap the bungee around the supporting object or tie it in knots to make it shorter to feel resistance).

Spend a few moments testing yourself to see how far you can pull the bungee.

This is a great challenge and a fun way to compete with yourself during an otherwise boring cross training activity.

Now for the hard part:

Pick a point on the pool wall or side of the pool that you feel stretches the bungee to a very hard sprint that you could maintain for 60-90 seconds.

This will be your “sprint” marker that you’ll use on sprint intervals (95-100% of maximum heart rate or all out sprint).

Now:

Find a point that feels like the end of a hard tempo run.

Mark this spot as your “medium” interval distance.

When you complete the hard workouts, you can use these reference points to ensure that you maintain a very hard effort.

The springboard

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 2 minute medium, 1 minute sprint, 1 min rest (let the bungee pull you back – this is kind of fun). Repeat 10 times. 10 minutes easy cool down.

The race simulation

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 5 minutes medium (focus and concentrate, just like during the hard part of a race), 30 seconds sprint, 2 minutes rest. Repeat 4 times. 10 minutes easy col down

The lactic acid

10 minutes easy warm up, 90 seconds easy (slowly moving out and stretching the bungee), 2 minutes sprint, 90 seconds rest. Repeat 12 times, 10 minutes easy cool down.

I guarantee that with the bungee, you’ll get your heart rate through the roof.

You can challenge yourself and make aqua jogging more fun by seeing how long you can stay at your maximum stretched distance or seeing how far you can push it.

Likewise, if you have a friend who is injured (or someone willing to be a good sport) you can try pulling each other across the pool for some competitive fun.

Cross training can be tough, especially when you’re injured or want to be increasing your volume faster.

However, I hope that providing a variety of workouts, either through the Fluid Running app (which also makes it easier to keep track of the workout while in the water) or on your own can add a fun challenge in the pool and you can emerge from your injury with minimal fitness loss.

Return to Running

Return to running is also going to depend somewhat on the specific injury that’s causing your big toe pain, but sadly, most require several weeks or even months off from running.

Check with a doctor or physical therapist if you’re unsure about whether you’re ready to run again, because some big toe injuries, like turf toe and sesamoid stress fractures, need to be totally healed before you try to run on them again.