clearly not my feet
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.
Always Evolve,
Mike
Mike Scott, DPT 
Ugh. I began developing this condition 13 years ago. There was a minor trauma to the joint that I just figured would heal. At the time, I was only 24.
Many years of living in NYC, pounding the pavement, later, I recognized the problem and still never had it looked at because I was too broke to do anything about it. When I finally got health insurance at 32, I saw a podiatrist who told me there was nothin he could do and admonished me for even asking what to do to prevent further damage. “You’ve developed arthritis. There is nothing you can do about getting old.” I was traumatized.
At 35, my knee was blown.
At 36, I finally started seeing a PT, and found some relief with joint mobilization, but honestly can’t afford weekly visits. I do the exercises on my own and my knee/hip is much better as a result. I have a number of vericose veins as a result of my altered gait, however.
I practice yoga every day and am now an avid cyclist. I’ve found that the only thing helpful is just not walking. I ride my bike everywhere now. I don’t know what more to do and am at a loss when thinking about what my body will be like to manage in another 10 or 20 years. There could be worse things to manage, but this one is pretty nefarious. I was glad to see this article address many of the problems that could surface as a result of the condition. Thanks!
Is physical therapy also helpful for hallux limitus? I have recently been diagnosed with mild hallux limitus but it doesn’t feel very mild since I’ve had pain just walking for over four months. I’ve had two podiatrists tell me that physical therapy and stretching will not help the condition and that I simply need to get custom orthotics and wear sturdy shoes. I have an appointment to get the orthotics, and have spent a lot of money on shoes with hard soles, but am looking for any/everything to do to keep this from getting worse. I want to be able to walk, jog, do yoga and salsa dance again!
PT is hogue for HR/HL. Joint mobilization (not manipulations) of the toes ankles and hips, stretching of all those as well, and pain control are very important to improved outcomes. Things even like a non-inflammatory diet can help. Rigid shoes and custom orthotics are poorly designed “bandaids” that will actually result in a likely decline of overall toe mobility. Find a reputable PT in your area and you’ll see improvements.
Mike
I thought I had a bunion!, the doctor thought it was a bunion too, that is until I saw a chiropodist who then informed me that I had been misdiagnosed and that I am suffering from HR, I’m 46 & this has only recently started to bother me, I massage the big toe and give it a wiggle, I do that funny yoga toe stretch (it freaks my husband out) & so far all is ok, I have been advised to take ibuprofen when it the joint is sore and monitor the situation, I was told that the joint will eventually fuse itself….I shall wait and see. I have been to bootcamp this morning & my right hip is sore, if this persists then I will get it sorted, I can cope with the toe pain but this is something else!
Hi, great article! I just finished reading it and it was very beneficial. I have HL and have never noticed any issues until I started working out a few months ago. It’s painful to jump rope and run and I notice I slam my heel down when I run because of HL.
I don’t know if I can afford physical therapy. Do you think it’s a complete waste of $ to buy custom orthotics? I thought this would be the best option, but from your comment above, now I don’t think so.
Any info would help! Thanks!
Custom orthotics have rarely been shown to improve any condition over out of the box orthotics. Hallux rigidus is typically conservatively treated through interventions such as joint mobilizations (from a licensed professional), some stretching, and re-education of gait patterning and lower extremity movements. In my opinion, any orthotic will not help hallux rigidus.
Thanks for reading!
Thanks for your thorough response. I have one more question for you…While orthotics will not help correct my HL, do you know if they have been shown to help with pain?
Now that I’m thinking about it I really want them to help with my knee pain, I don’t necessarily need them to help correct the root cause.
Thanks!
Any type of orthotic will unlikely help with your knee pain in this situation, however, out of the box orthotics are usually cheap enough that they may be a good place to start. People with HL have altered force acceptance in their knees, placing most of the weight in the posterior aspect of the knee vs over the entire articulate surface. This can produce unfamiliar stress levels within the tissues in this aspect of the knee. Until your gait is altered, it is unlikely that knee pain will resolve. But it could.
I have seen many podiatrist regarding my HR and they have all told me that it is very important to have orthodics because if you pronate and your arch is falling that it can defenitly make it worse can you please explaine why you think orthodics wouldnt help if you pronate or did you mean if you do not pronate they will not help. I even went to Stanford and UCSF?? To me it seems if you are not walking properly do to pronation that would definetly help. actually it has definetly helped me they even put a metal plate where my big toe is at Stanford.
Thank you 🙂
I think that seeing a good therapist who can help you gain mobility in your toe/ankle/hip as needed is a better first step. A rigid orthotic to treat a rigidity problem does not make sense. It’s like having an elbow that will not straighten but thinking the solution is putting it in a sling that keeps it bent.
If you pronate a lot you will definitely place increased stress on your toe. However, with stretching, strengthening, neuromuscular re-education, and mobilization, there is a chance you can treat the cause and not just the symptom.
Orthotics are relatively inexpensive so they are a decent place to start if you’re dead set on it.
Hello I was wondering about orthodics not helping.
I have been to many podiatrist in the past years regarding my HR and they all recomend orthodics to help with my HR.
To me it makes since if I have bad pronation that I would need that corrected so when my arch collapses it does not put all that pressure on my toe joint. Stanford even made an orthodic that had a metal plate in the big to so it wouldnt bend when I walk. My back, knees and definetly my toe feels better since I have been waring the orthodics. did you also feel that orthodics do not help when you have a pronation problem? Thank you Jeanine
Fix the pronation problem and the toe will feel better. Wearing an orthotic to do this will likely result in worsening pronation in the long run.
I’m a 55 year old exdancer and a yoga teacher who has probably stage 2-3 in my left foot and stage one in my right. I am very bowlegged so not sure if that affects things. My arches are good. I didn;t do pointe work but I was on the balls of my feet with dance and yoga most of my life. My left foot developed a unique form of plantar fascitis that caused severe cramping in my arch (no heel pain). I’ve had graston treatments for this and they really helped. I’ve never worn heels but use to wear flip flops and stopped that. I now wear shoes with wide toes. I like using correct toes with socks for walking around the house after work. I;ve tried my best to keep as much motion as I can but I have to really limit deep toe bending like planks and such. I am fairly hypermobile which I think contributes to this condition. I am prone to getting tight in the ankles and achilles but my hamstrings are very loose . I can do many intermediate to advanced yoga poses but have to modify basic ones like high lunges (have to keep either knee down or heel down) A podatrist wanted to do chellitemony but I want to avoid surgery. I have a fairly large spur on the left foot but the pain level is tolerable as long as I don’t walk long distances or run. Open to any suggestions to avoid surgery
Hi Tina,
It is very likely that your bowlegged-ness (genu varum) has effected your gait over your lifetime. There will be much more difficulty performing “normal” pronation through the toe off phase of walking when someone presents with this. This basically means that when you walk you will not push off your big toe, reducing the amount of extension you utilize with every step. If you don’t use something you lose it, and this goes for big toe extension. Over many years of not extending your toe, your body adapted and never found the need for it besides the occassional activity, which you likely found compensations for.
I always suggest PT first to gain mobility and reinforce with some motor control activities. Let me know how that goes for you! Also, when finding a PT, ask them what the plan is during your first visit. If it does not include exercises to improve your foot, leg, AND hip strength, I think you should look somewhere else in my opinion.
Always Evolve
Hi Mike ! I am a 24 year old grad student in New York City. Thank You so much for writing this very informative piece ! I had a minor trauma in my right toe in the beginning of February and was told that its a fracture and that I should buddy tape. 5 weeks of buddy taping later I had similar pain in my left toe at which point I visited a podiatrist who showed me that both my toes are indeed immobilized. He gave me a bunch of insoles to wear that have led to terrible knee pain. I asked him for exercises that will help regain mobility for both toes and knees and he simply said I should get better shoes. Ive gotten better shoes with good support near the big toe as he recommended, but my toes are only slightly better and my knees hurt still the same ! The problem for me getting Physio Therapy is that I need a prescription for PT for my insurance to cover it, and the podiatrist doesn’t think its necessary ! I want to make sure this doesn’t degenerate into a ridiculously chronic knee and feet problem, because I’ve been a very active recreational tennis player in the past. And I definitely agree that I don’t want to use orthotics all my life to solve this, and since I’m young I’d rather deal with the root problem. What kind of specialist would recommend me the right physio therapy ? And what is a comprehensive list of things that must be worked on at Physio Therapy ?
I’ll be writing a post that hopefully answers these questions for you! Thank you for reading and asking your question.
Chaitali, please see my post from yesterday.
I’m currently having a lot of pain in my big toe. It was in the left foot first, but as soon as that stopped, it went to the right foot. Actually, I tried stretching my big toe and after that is when the right toe started to hurt. I was diagnosed with gout, but I don’t believe that’s what it is because they didn’t check my blood for acid and my big toe is extremely stiff with a bump at the top. My question is
1. can stretching sometimes make the situation worse?
2. Should I wait to stretch until it heals?
1. Stretching can make certain situations worse. Depending on what is causing the mobility restrictions stretching may cause aggravation.
2. Definitely let is calm down prior to any other self treatments. I recommend getting in to see your local PT if you have direct access in your state, or seeing a MD if not.