We can breathe a little easier now that we are off the topic of broken ribs. However, we are still discussing the topic of underestimated injuries; those injuries that get written off as inconsequential, and those that are thought to pass on their own. We have to move on down the body to find our next culprit…
Hallux rigidus (which basically means a rigid first toe) is so unbelievably underestimated that often I find people don’t even have it diagnosed. Someone comes in with a significant limp, complaining of low back, hip, or knee pain and during their initial eval I will watch them walk and see that they don’t push off from their big toe. Then its time for a little face to face with some feet because I want to see if that person can move their big toe.
Guess what. They usually can’t. Hallux rigidus is primarily an inability to extend one’s great toe, making pushing off of it excruciating; and as we all know by now, pain will change the way we move. Lets go up the kinetic chain to see what happens.
Ankle: Because it’s so painful to put weight on the big toe, dorsiflexing the ankles becomes limited during the stance phase of walking( the time period when your foot is on the ground when walking). Result – shortened calves. But also to avoid having to put weight on the big toe, often excessive pronation will occur and “toe off” will occur at the base of the big toe, not the end.
Knee: Without full ankle ROM it is almost impossible to have full knee ROM, therefore knee extension becomes limited. Try this out. Put your foot on the floor, then bend your knee without bending your hip or your ankle. Aint-gonna-happen.The knee is at the mercy of the ankle and hip when it comes to motion. When one decreases, they almost all suffer.
Result – Loss of hamstring length and eccentric control of hamstrings. Also premature wearing away of the articulating surfaces of the knee(s) because we will not be completely weight-bearing on the most rich articular cartilage. In non-medical jargon, the knee will get arthritis faster.
Hip: So much can happen here. To prevent weight-bearing on the toe a “circumducted” gait pattern can occur; meaning the affected leg swings out to the side (sorta like a peg leg). Then, when the leg does weight bear, the hip drops because the knee doesn’t have complete control below it. Also, hip extension is lost, because if you put your hip through full extension in gait the big toe ends up having weight put through it.
Result – Low back pain from the circumducted pattern, as well as tight quads and hip flexors. Also, hip external rotation to make pronation in the foot easier, possibly leading to hip external rotator tightness and overuse.
So what causes this awful condition and what can we do about it?
Hallux Rigidus is caused most likely by arthritis (osteo, Rheumatoid, or even Gouty) that occurs within the joint between the foot and the big toe. Either a traumatic injury in the past, or just normal wear and tear may result in this condition.
What can I do!!? Well, first, go to your physical therapist as soon as possible. The application of joint mobilizations to increase joint mobility and re-establish full ROM is of the utmost importance. Reinforcing this ROM with closed-chain strengthening is then warranted. Stretching of the muscles in the plantar fascia and calf are also important to maintain these ROM gains. The final piece to the puzzle is a thorough gait analysis followed by gait re-patterning if the fault has been around long enough to change one’s gait pattern.
Until the pain associated with hallux rigidus subsides, exercises such as lunging and push ups should be avoided. Clearly these put a lot of weight through the big toes and will only exacerbate the pain. If think you may have hallux rigidus, or know that your big toe is causing alterations in your gait pattern, get in to see your MD, or rehab professional and get a start on regaining your mobility!
Also, if you’ve had this condition and don’t mind leaving your successes or difficulties with it, please feel free to leave your story in the comments section.