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