Over the past couple days we have been reviewing the anatomy and functional assessment for great toe mobility.   Again I am very happy by the positive response and interest by so many professionals in this topic.   It shows this increasing awareness to the importance of the foot and foot function which makes me so proud!

In Part 3 of 3 of this blog series we will begin to explore the most appropriate programming for these clients and when is surgery really the best option.

I do want to emphasize that the biggest take-away from this blog series should be that great toe mobility is not just a local issue but is globally interconnected to rear foot, core and hip stability.   As we know – everything is integrated!

Structural Limitations in Hallux Dorsiflexion

Hallux Limitus / Rigidus

One of the most important causes for limited hallux dorsiflexion is structural and progressive – arthritis     Often associated with older age great toe arthritis is actually quite common among runners, dancers, athletes or any client who has an unstable foot (over-pronation).

This loss of joint mobility is structural and cannot be corrected with functional training.   Great toe arthritis can be managed or slowed down with correctives but it cannot be reversed.  

To the left is an X-ray of a patient with structure changes to the great toe joint.   Joint space narrowing and spurring or osteophytes can be appreciated both of which greatly reduce the range of motion.

If we look at the lateral X-ray we can see that osteophyte development can become quite impressive dorsally – it’s no wonder these clients have no dorsiflexion.

I must emphasize that in these clients doing aggressive manual joint mobilization can fracture these osteophytes leading to bigger issues than they started with.

You must always know the health of the joint before you start manually manipulating a great toe joint.

So what can you do with this client?

Surgery is always an option with the ideal procedure (which of course depends on the health of the joint) is a decompression-type procedure with removal of the osteophytes.   I personally try to avoid joint fusion at all costs if possible but sometimes the condition of the joint requires fusion.

If surgery is not an option or desired by the client then I often recommend using a rocker forefoot bar or shoe.

A forefoot rocker is a graphite bar that allows the client to dorsiflex over the shoe improves function and can eliminate pain.  This type of shoe allows the client to achive proper hip extension and propulsion despite having less than 30 degrees DF.  (Think Sketcher Shape-Up shoes).

Functional Limitations in Hallux Dorsiflexion

This is the area where most of you will be able to hep your clients improve their great toe mobility.   Functional means it is driven by a loss of stability elsewehere in the foot (or body).

This type of limitation in hallux dorsiflexion will generally demonstrate good mobility open chain but then lose that range of motion as soon as they enter a closed chain environment.

Where we want to first look for instability would be the first ray.

Loss of first ray stability typically presents in those patients with decreased medial arch, excessive STJ eversion or inversion, navicular drop and under-active glutes.   For the sake of the article not all of these issues will be covered however in all EBFA Certification workshops we cover each in detail.   To find a workshop near you click – HERE

Excessive STJ Eversion 

In Part 2 we briefly demonstrated how STJ eversion can cause 1^st ray instability.   To review – this unstable STJ position puts the peroneus longus tendon on slack causing a delay in or insufficient plantarflexion of the 1^st metatarsal head realative to the base of the proxmiaml phalynx.   (If you have not read Part 1 – please click HERE)

In this client our goal is to improve STJ positning through posterior tibialis strengthening, short foot activation and glute strengthening.   One of my favorite exercises for this client is the ball between heels exercise (see picture on right).

Excessive STJ Inversion

For the client who has limited hallux dorsiflexion due to an inverted STJ and dorsiflexed 1^st metatarsal our goal is to increase foot mobility and neutralize the STJ.

For this client we want to mobilize the platnar foot, tibialis anterior and deep hip rotations.

Combination Structural & Functional Limited Dorsiflexion

Hallux Valgus

Similar to hallux limitus, the client with bunions often presents with joint space narrowing and coral spurring which can begin to block hallux dorsiflexion.

With bunions structure is not the only contributor to limited joint mobility.   Bunion formation is also greatly associated with foot type – specifically eversion / over-pronation and generalized foot instability.

For this client we must consider both structural limitations (need X-ray) as well as our ability to slow the formation of the bunion through corrective exercises.

In addition to the foot and hip strengthieng exercises mentioned above for the STJ eversion, we also want to include a medial stretch to the great toe with either tape or a Bunion Bootie (www.bunionbootie.com).

This medial pull will mildly stretch the adductor hallucis muscle as well as position the abductor hallucis for better intrinsic activation.

Final Key Tips & Pearls

A few additional paddings and modifications to inserts and shoes which may benefit your client include:

– Reverse Morton’s Extension

– Cluffy Wedge

– LA Pad & Varus Posting

Finally my last tips of advice:

– Please know why you are doing what you are doing.   I am seeing too much of cluffy wedge for everyone! and l don’t think everyone fully understands who and when this is the most appropriate.

– Remember sometimes it’s best to refer out.

– When in doubt get a copy of your client’s X-rays

To continue exploring this topic I encourage you to check out our upcoming FREE educational webinar on Wednesday August 19th at 9pm EST.   All webinars are recorded so if you cannot tune in live you will be sent the recorded version!    Sign up HERE

And finally – as always – remember to say #barefootstrong!

Dr Emily 

I am very happy to see the overwhelming response to yesterday’s Part 1 of 3 blog posts in our Great Toe Mobility series.

Based on the responses it seems like many of you are already considering the great toe and it’s mobility during your assessments – great job!  In today’s post we are going to review some of the most functional assessment techniques for the great toe as to ensure that we are all accurately and effectively assessing hallux dorsiflexion.

If you recall in Part 1 we emphasized the interconnection between great toe mobility, 1st ray stability and STJ position.   Remember this interconnection as we go through the below assessment techniques.   If you have not read Part 1 I highly recommend you reading it before proceeding to Part 2 – even if you think you know your great toe mobility.   Part 1 is HERE

Open Chain vs. Closed Chain Assessment  

When considering hallux dorsiflexion we always want to do both an open chain and a closed chain assessment.   Reason being that in the open chain assessment we are getting an idea of the joint integrity and are able to rule out any crepitus or arthritic changes that may be present in the joint.   Meanwhile in the closed chain assessment we are now factoring in functional stability of the foot to see if it allows maximum hallux dorsiflexion.  One should not be done without the other.

Step 1 – General 1st MPJ Appearance 

Always start by looking at the 1st MPJ non-weight bearing.

Do you see a bunion?   Depending on the size of the bunion this can greatly effect the integrity of the joint as well as alter push-off position.

Do you see spurring dorsally?   In the presence of arthritis and altered joint function, the body starts to create spurs or osteophytes along the dorsal aspect of the joint.

These are easiest seen on X-ray but you can often see them or palpate them along the dorsal joint line.   Depending on the degree of osteophytes they can begin to limit hallux dorsiflexion during push-off.

Step 2 – Joint Integrity

Next you want to assess the health of the joint to determine if any arthritic changes are present.   By moving the toe up and down you are not only assessing mobility but are more so looking for the presence of crepitus or bone on bone.

In this step you also want to determine if there is limited dorsiflexion open-chain.   If there is a limitation in open chain dorsiflexion – you will surely see a limitation on closed chain!

Step 3 – Load the 1st Metatarsal

In Step 2 we are simply looking for joint integrity but not getting an accurate representation of functional hallux dorsiflexion.

If you look at the picture on the right you will see that as I am dorsiflexing the hallux the 1st metatarsal head plantar flexes greatly.    This degree of plantar flexion is not possible when standing on the ground as it would be blocked by the ground when we walk.   This means that Step 2 assessment doesn’t really translate to closed chain dorsiflexion.
To get a more accurate representation of closed chain mobility you want to load the 1st metatarsal head like I am doing in the picture to the left.   This mimics the ground when closed chain.    Now dorsiflex the hallux and determine your mobility.

Step 4 – Heel Rise Assessment

Next we want to have our client stand up and begin to compare the above findings with closed chain function.    The first assessment we want to look at is a heel rise.

Not only is this a great assessment for determining the foot’s ability to lock and become a rigid lever – but it also allows us to look at the client’s forefoot lever.

When coming up to a heel rise you are looking for the height the client is able to lift – as well as the ability to stay even across all 5 metatarsal heads of MPJs.

On the picture above I’d like to see this client stay a little more medial on the hallux during her heel rise.   This assessment finding will be compared to the gait assessment and walking push-off position below.

Step 5 – Walking Push-Off Position 

Walking push-off position and hallux dorsiflexion is probably the most important assessment you can do for the great toe.   If a client has great hallux dorsiflexion in all other assessments but then doesn’t push-off properly – all other assessments are irrelevant.

Remember our goal is to optimize function – not just seeing if our client’s pass static assessments.

When walking we need a minimum of 30 degrees of hallux dorsiflexion.   If there is less than 30 degrees dorsiflexion – or the dorsiflexion isn’t occurring at the right time during the gait cycle – then compensation results.    The most common compensation is that we will see our client’s begin to assume what is called a low gear push-off position.

A low gear push-off position looks like the image to the right and is associated with an unlocked and unstable foot.   If you recall during push-off we need maximum foot rigidity to allow power output.   In Part 3 of 3 of this blog series we will be focusing on the low gear push-off.

Step 6 – Finger Under Toe / STJ Assessment 

I’m sure I could come up with a more technical name for this assessment but I think the “finger under the toe” is easiest to remember!   In this assessment I like to demonstrate to clients and professionals the impact that the STJ has on 1st ray stability and hallux dorsiflexion.

In the above client we saw through the different assessments that she had good dorsiflexion open chain with good joint integrity (no crepitus).    When we had her stand up though and do a heel rise we begin to see a deviation off of the body weight away from the hallux.   In addition during gait she assumed a low gear push-off position – all indicating a compromise in functional hallux dorsiflexion.

The next assessment we want to do as to determine if the limitation in hallux dorsiflexion is driven by a lack of 1st ray stability would be the finger under the toe test.    

Have the client stand with the feet in a relaxed calcaneal position.   In the case of our above client you can see that she is mildly pronating or in an unlocked position.   Remember that we ideally want to assess STJ position from behind – not anteriorly like in the picture to the right.

When the client is in this unlocked, relaxed position we then want to assess the hallux dorsiflexion by trying to put our finger under the great toe.   Advise the client to stay relaxed and to not fight or assist you in any way.

In the picture to the left you can see I can barely get my finger under her big toe.   This is an insufficient amount of hallux dorsiflexion.   We should be able to get the entire finger under the toe.

What you want to do next is put the foot in a neutral position.   This neutral STJ position will shift the 1st ray into a stable position and engages the peroneus longus or spiral line which we learned in Part 1.

From here you want to re-assess the hallux dorsiflexion with the finger under the toe test.

 You can see in the picture to the left that stabilizing the STJ and 1st ray led to a large improvement in hallux dorsiflexion.

This assessment begins to guide my approach to this client.

My focus must go back to STJ stability and function if I ever want to optimize her hallux dorsiflexion during closed chain movements.

In Part 3 we will begin to explore the most effective programming to improve client hallux dorsiflexion.   Please remember that the above assessment techniques are designed to get your thinking.   They are not intended to be a be all end all to diagnosis of great toe dysfunction.    A complete great toe assessment would also include images such as X-rays so that we can get a true perspective on joint health.

To prepare for tomorrow’s Part 3 of 3 blog post you may view a recent video I created where I begin to discuss high gear vs low gear push-off positions seen below – as well as sign up for a FREE educational webinar I am doing on Weds August 19th at 9pm EST available – HERE