Let’s Talk Toes

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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!

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