A painful toe: Osteoarthritis of the big toe joint
with intraining Podiatrist, Steve Manning
Osteoarthritis (OA) also known as degenerative arthritis is very common in people over 50 at around 17% prevalence . The Clinical Assessment Study of the Foot, identified that almost half of the symptomatic OA in the foot that can be confirmed in X-rays is in the big toe joint. (1)
When running and walking all of the body weight may be focused on this joint while it is flexing in propulsion. This may create excessive forces in the joint that can lead to:
degeneration of the joint;
spurring around the joint causing a bunion; and
deviation of the joint causing a condition called HAV.
It has been known for a long time that dysfunction in this joint can lead to changes in the forces and movement up the kinetic chain. (2) When walking the big toe joint requires around 60 degrees of available flexion or else gait compensation may be required that could lead to a secondary injury. This can be significantly reduced when running depending on the person.
Mechanism of action
The mechanism of action when this occurs is that in some people the joint is locked when trying to toe off. This happens because the force from the ground slides the joint slightly causing it to lock. These forces on the bones over time will lead to the spurring around the margin of the joint and eventually fusion of the joint.
The compensation for what is called a sagittal plane block can be flexing off at the joint in the toe, Twisting action of the foot in propulsion, or extra flexion at the ankle, knee or hip. All of these motions can stress weaker structures in ways that they can not cope, again leading to injury.
Conservative Treatment: Orthotics or Footwear?
Intervention with orthotics or footwear may slow the progression of the degeneration of this joint. If there is still function left in this joint then shifting ground reaction force from this joint to the other toes may allow initiation of flexion and prevent it locking.
If there is significant reduction in the range of motion at this joint when not weightbearing, or there is significant deviation of the joint then improving its function may not be successful. In that case we will attempt to stop flexion so as to reduce pain. However the compensatory gait will then need to take the load. In severe cases surgery may be the best option but initially the goal of treatment should be to prevent or delay future surgery.
Unfortunately the evidence for orthotic intervention has not yet been established. (3) Part of the problem is that there are many different types of orthotic prescriptions used and some may only be effective in certain individuals. This may require trialling different orthotic modifications until the best result is achieved.
Footwear intervention has shown more promise to reduce symptoms. (4) Carbon plated super shoes reduce the loads on this joint by preventing flexion and creating a rocker effect in propulsion. These shoes do not work for every runner but there is now a variety of supershoes to select from.
Managing the pain
The pain in these joints may only occur in bouts as the joint is degenerating then stabilising. However, often the pain is caused by an inflammed bursa that occurs after the increased joint size gets extra pressure from the shoe. This can be alleviated by choosing a shoe that puts no pressure on the joint or modifying the shoe with a small cut over the joint. Orthotics may also be effective in reducing pressure on this joint from the shoe.
We have successfully treated many people with problems in this joint at the clinic. If you are experiencing pain in this joint, or just want to have it checked out, then book in to see Steve, Doug or Margot at the intraining Running Injury Clinic, Toowong Ph.3367 3088.
Steve Manning – intraining Podiatrist & Level 4 running Coach
Steve Manning has worked since the 1980s to create opportunities for runners of all abilities to pursue their running goals, to establish and maintain a healthy balance of sport, health and work in their lifestyle and to connect with other like-minded and supportive runners. He has done this by creating a community of runners, coaches, sporting podiatrists, physiotherapists and a retail team with a large focus on inclusion and collaboration. He loves runners and what running can bring to people’s lives. Steve is the owner of the intraining Running Centre, a podiatrist, Associate Lecturer QUT, marathoner, Level 4 Running coach, member of the Queensland Sports Medicine board, and doting dad.