Big Toe

 

Big Problems With the Big Toe

Two relatively common problems involving the "hallux", or "great toe" (big toe), can plague a runner. Both can cause pain and stiffness in the area called the "metatarsalphalangeal joint (MTPJ)". This is the first knuckle of the big toe, where the toe joins the foot. This joint is very important structurally and functionally. Most of the body weight is transferred to the ground during the "toe off" phase of gait through this area, and faster pace running requires greater range of motion at this joint. Therefore, problems with this joint and the surrounding structures can seriously hinder running ability. Three derangements of the hallux MTPJ account for much of the troubles seen in this anatomical location. These include "hallux rigidus", or arthritis, sesamoiditis, and "hallux valgus", or bunion. Bunions are a symposium in their own right, and may provide fuel for a future topic. We will look at hallux rigidus and sesamoiditis this time.

Hallux rigidus literally means "rigid big toe". This condition is caused by arthritis of this joint, which can come on insidiously, or follow an injury to the joint which occurred some time in the past. Arthritis of any joint includes thinning and loss of the low friction cartilage surfaces of the bones, formation of peripheral spurs, and thickening and inflammation of the surrounding soft tissues or joint lining. These changes contribute to the symptoms of pain and tenderness, stiffness and loss of motion, and warmth and swelling. Loss of motion at the first MTPJ limits the ability to extend or raise the great toe, as spurs on the top of the joint block movement of the toe. This is a devastating problem for any athlete, since the speed of running correlates with upward range of motion of the toe. In other words, limited extension equals limited speed, with pain as the spurs impinge.

Diagnosis is based on the findings of swelling, tenderness, palpable spurs, and reduced motion in extension (upward motion). An X-ray is confirmatory. Prior to considering surgery, treatment for the runner includes avoiding hills and inclines (uphill running demands increased toe extension), and decreasing speedwork. These modifications may be permanent. A stiffer sole shoe helps to splint the toe and reduce painful extension, and a roomy toe box keeps the pressure off this tender area. Gentle stretching can help maintain available range of motion. Ice and anti-inflammatory medication may be helpful as well. Unfortunately, as the disease progresses, running will become more limited, and surgery to remove spurs ("cheilectomy") may be necessary to allow running to continue.

There are two tiny bones, about the size of coffee beans, that rest beneath the great toe MTPJ, embedded in the tendons that flex the toe (pull the toe down). These bones are like miniature kneecaps, serving to increase the mechanical advantage of the tendons, and gliding on the overlying joint surfaces. The can become a source of irritation, called "sesamoiditis", due to overuse, injury, or arthritis. The pain is on the bottom of the MTPJ, and is typically aggravated by weight-bearing activity. As most of the body’s weight is born at the great toe MTPJ with toe-off, pain beneath this joint can be very disabling.

Sesamoiditis is usually present if there is tenderness beneath the MTPJ, and pain with direct pressure on the sesamoid bones. Extension of the toe may increase the pain. X-rays may be normal, may show a two-part bone, or even arthritis. Treatment includes reduction of mileage and intensity, or even cross-training (biking or swimming). As with hallux rigidus, uphill running usually makes things worse. I have noticed that stair climbing equipment or Nordic skiing type equipment can also aggravate this condition, and probably should also be avoided if it is to improve. Orthotic treatment can also be helpful. Cutting a depression or hole in the insole, directly beneath the tender sesamoid, can help relieve the pain while running. If ice and medication are unsuccessful, occasionally a steroid injection and/or a rest period with casting may be necessary. Surgical excision is a last resort.

                                                                                                                        Dan Wnorowski, M.D.

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