Let’s Talk Toes

When it comes to bunions, hammer, and mallet toes, the most common questions that I get most from athletes are how can I keep training and is surgery really my only option? Both of these are completely understandable questions, especially when you look at the typical article written about toe deformities. They offer a list of potential causes and then talk about surgical options for when “symptoms become unbearable”. Some will talk about toe spacers, pads, and taping, but most solutions are geared at symptom relief versus a long term solution. The good news? This article isn’t one of those. Instead of focusing on a list of causes, we are going to talk about toe deformities and what the different types all have in common from a biomechanics stand point.

Types of Toe Deformities

 

 

 

 

 

 

In normal anatomy, all toes are made up of little bones called phalanges. Every toe except the big toe has three of them (the big toe only has two). These phalanges create three joints called interphalangeal joints or more simply IP joints. The furthest is called the DIP (distal IP joint) and the middle is called the PIP (proximal IP joint). The closest phalange then connects to the metatarsal (long bone of the foot) at the MTP joint. Think of this one like the knuckle in the hand. Why is all of this anatomy important? Toe deformities occur when these three joints (MTP, PIP, DIP) get stuck in a position, creating inflammation and permanent changes to the bone.

Bunions – these can occur on either side of the foot although the big toe is the most common. A bunion occurs when the MTP moves away from the second toe. Over time this forces the phalanges in towards the other toes.

Hammer Toe – these are most common in the second toe (directly next to the big toe) but can happen in any of the smaller toes. This deformity occurs when the PIP joint gets stucked in a bent position. Over time this can grow to include extension at both the MTP and DIP joints.

Mallet Toe- like hammer toes, these can affect any of the smaller toes. The deformity occurs when the DIP gets stuck in a bent/flexed position.

Hallux Limitus/Rigidus (not pictured above) – this deformity affects only the big toe. The MTP joint becomes increasingly limited in motion. In the early stages this is known as hallus limitus. If this loss of motion continues, bone spurs can grow as the result of prolonged inflammation and will make the motion loss rigid as it is now blocked by bone on bone contact.

How Do They Happen?

The most important thing to realize about these types of injuries is that they all result from a progression of changes. You don’t just wake up one day with a bunion or hammer toe. These types of injuries start with a simple loss in mobility that over time results in joint breakdown and permanent bone change. Here’s a visual:

Loss of Motion > Contracture (muscle/tendon/ligaments get stuck short) > Breakdown of cartilage/bone > Bone spur/bunion formation

When you think about the different types of toe deformities in this regard, they become more like an overuse injury. Improper shoes, genetics, and prior injuries can all contribute to this type of injury by creating or exacerbating an underlying mechanical problem. This could be mobility loss in the foot, ankle or hip, decreased strength, or even coordination/muscle imbalances. Whatever the original restriction, the damage to the toes is the result of the body compensating and ultimately working in a way it isn’t designed to. Eventually, it will result in something breaking down under the strain produced by that compensation. In the case of toe deformities, the joints of the toes are what eventually breakdown.

So what can you do about it now?

While the actual changes to the bone and joint are irreversible without surgical correction, it’s important to realize that you still have a lot of control over your feet and the underlying mechanical causes. By improving mobility to the foot and ankle, you can normalize how you walk and run and take pressure off of the toes. This will allow the recurrent inflammation to calm down and help prevent further degenerative changes from happening.

In the video below, we are going to talk about some of the contributing mechanical factors at play and go through a little self test to see how your mobility stacks up:

In the self test at the end, we went through four movements. Here’s a breakdown of the test + next steps:

Self Test Walk through Result How To Fix
Toe Flexion
  1. start seated
  2. keep ankle in neutral position
  3. bend one toe at a time, joint by joint
  4. stop when you feel a pull
Ideally, you want to be able to flex (bend)your toe completely at all three joints.

If you can’t do this, the next test will help determine if the restrictions are above the ankle or below it.

  • If your toe mobility was normal? Nothing to fix!
  • If your toe was limited with just this movement? Start with the foot basics course. If you have a premium account and are looking for more, the toe deformity course will streamline this for you.
Toe Flexion with Ankle Plantarflexed
  1. start seated
  2. point ankle down (plantarflex it)
  3. bend one toe at a time, joint by joint
  4. stop when you feel a pull
How did your toe mobility change? Did it stay the same or did it get worse?

If it got worse, that likely means that you have restrictions both in the foot and up along the shin as well.

  • If your mobility was unchanged and looked normal? Perfect!
  • If your mobility got worse with this test, you will want to add in work on the shin itself where the long toe extensors are located.
  • For free users, check out the foot basics course in addition to the shin basics course. For premium users, the toe deformity course will streamline this for you.
Toe Extension
  1. start seated
  2. keep ankle in neutral
  3. pull one toe back, one joint at a time
  4. stop when you feel a pull
Ideally, you want to be able to extend (bend back) your toe completely at all three joints.

If you can’t do this, the next test will help determine if the restrictions are above the ankle or below it.

  • If your toe mobility was normal? Nothing to fix!
  • If your toe was limited with just this movement? Start with the foot basics course. If you have a premium account and are looking for more, the toe deformity course is the one for you.
Toe Extension with Ankle Dorsiflexed
  1. start seated
  2. pull ankle up (dorsiflex it)
  3. pull one toe back at a time, one joint at a time
  4. stop when you feel a pull
How did your ankle mobility change? Did it get worse with the knee straight or did it stay the same?

If it got worse, that likely means that you have restrictions deeper in the calf where the long toe flexors are located.

  • If your mobility was unchanged and looked normal? Awesome!
  • If your mobility got worse with this test, you will want to add in work on the calf where the long toe flexors.
  • For free users, check out the calf basics course in addition to the foot basics course from above. For premium users, the toe deformity course will streamline this for you.

 

Stay tuned: next week we will dive into what toe deformities mean to you as an athlete in terms of shoe selection, problem areas and recovery!

Ankle Range of Motion

When it comes to overuse injuries it is really easy to see them as an isolated event. The problem, however, is that overuse injuries are not an isolated thing. In fact, overuse injuries are the result of a mechanical problem. This could be mobility loss, decreased strength, or even coordination/muscle imbalance. Whatever the restriction, the injuries that happen are a result of the body compensating and ultimately working in a way it isn’t designed to. Eventually, it will result in something breaking down under the strain produced by that compensation.

The reason I bring all of this up is to point out that a single mechanical problem can actually manifest in a number of ways. Let’s take a look at ankle dorsiflexion for example:

Ankle dorsiflexion is your ability to bring the shin/tibia over the foot. Walking around normally doesn’t doesn’t require that much, but when moving at effort, the demands increase as you load the foot and ankle in prep for more propulsion. Restrictions here will limit that load period and in some cases stop your ability to push off of the foot completely. This means your body has to find a new way to move forward or you will fall over your own two feet. Depending on how your body tries to compensate, a number of injuries are possible.

That is why I wanted to do a blog series about normal mechanics and mobility. There is a reason certain treatments are seen across multiple injuries. It’s because even though what broke is different, the mechanical problems that led to it are likely the same.

With that in mind let’s get started. Up First? The Ankle Joint

In a lot of ways the ankle is the gateway to normal walking, running, etc. Our foot is the first thing to hit the ground and the mobility our ankle provides is what allows us to move over and push off of that foot. Without it, compensation is required to keep you from falling over your own foot. Let’s take a closer look! (note: the last minute is a self test. pause as you need to!)

 

In the self test at the end, we went through three movements. Here’s a breakdown of the test + next steps:

Self Test Walk through Result How To Fix
Dorsiflexion
  1. start in half kneeling position
  2. keep heel perfectly flat on floor
  3. lunge forward so that your knee comes over your toes.
  4. stop when you feel your heel start to come up
Ideally, you want to be able to keep you heel down and move your knee comfortably over the toes.

If you can’t do this, the next two tests will help determine if the restrictions are above the ankle or below it.

  • If your ankle mobility was normal? Nothing to fix!
  • If your ankle was limited with just this movement? Start with the calf basics course.
  • If your ankle was limited in all movements? You will need to address multiple areas. Combine the calf, knee and foot basics courses. If you have a premium account, the chronic tight calves course will streamline this for you.
Dorsiflexion with toes on stretch
  1. place something under the toes. in the video I am using a massage stick. 1-2 inches of height is plenty.
  2. relax the foot and repeat the first test.
How did your ankle mobility change? Did it stay the same or did it get worse?

If it got worse, that likely means that you have restrictions in the foot itself. This can be the small muscles within the foot, the long tendons coming from the deep calf, or a combination of both.

  • If your mobility was unchanged and looked normal? Perfect!
  • If your mobility got worse with this test, you will want to add in work on the foot itself. For free users, check out the foot basics course in addition to the calf basics course from above. For premium users, the chronic tight calves course will streamline this for you.
Dorsiflexion with knee on stretch
  1. keep your heel perfectly flat
  2. straighten the knee so that it is locked straight and repeat the first test
How did your ankle mobility change? Did it get worse with the knee straight or did it stay the same?

If it got worse, that likely means that you have restrictions behind the knee where the gastroc and hamstring tendons criss cross each other.

  • If your mobility was unchanged and looked normal? Awesome!
  • If your mobility got worse with this test, you will want to add in work on the back of the knee. For free users, check out the hamstring basics course in addition to the calf basics course from above. For premium users, the chronic tight calves course will streamline this for you.