Ask the Experts: Big toe getting in the way of dancing or sports?

Anaheim Hills pediatric and sports medicine specialist Dr. Chris Koutures provides information and advice so you don’t let this small joint cause big problems:

Many dancers I have seen in my practice have taught me that the root cause of foot, ankle, knee or even hip pain often starts with abnormal motion of the big toe.

How does the Big Toe work in dance or sports?

Some may question why this small joint (aka 1 st MTP joint) may cause such a great list of problems. Well, let’s review why optimal big toe function is so essential for healthy dance performance. In many dance positions and movements, including demi-pointe or releve, the ideal dancer should have full big toe dorsiflexion.

DORSIFLEXION: Movement of the big toe towards the shin

Dorsiflexion.jpg

Any running on toes or approach, especially barefoot, also needs solid dorsiflexion.
Limitations in big toe dorsiflexion, known as hallux rigidus, lead to painful changes at several joints such as:

  1. Rolling the foot outward (aka sickling) which puts more pressure on the middle or
    outside of the foot and ankle. This not only doesn’t look great, but also increases risk of ankle sprains and damage to the bones on the outside of the foot
  2. Forcing the knees into a more forward position (can’t see toes when in squatting
    position) that can place abnormal stresses on the front of the knee
  3. Increasing the need to bend the hips, placing an unusual demand on these joint

What Causes Big Toe Limitations?

OSTEOPHYTES

Deposits of extra bone growth in the joint that are one cause of big toe limited range of motion. Surgical removal of the extra bone growth may be necessary and many a career has been shortened due to such destructive joint breakdown.

FLEXOR HALLICUS LONGUS TENDON DYSFUNCTION

The Flexor Hallicus Longus (FHL) tendon follows a course along the inside of the foot, travels underneath the 1 st MTP joint and attaches to the bones at the tip of the big toe. Restriction of the FHL is a more common cause of limited big toe motion, especially in school-age dancers, and routinely occurs in three spots:

1. Tarsal Tunnel at inside of ankle (STAR)

2. Intersection of FHL with neighboring Flexor Digitorum Longus tendon (TRIANGLE)

3. Attachment of FHL to the first bone (proximal phalange) of the big toe (SQUARE)

HOW CAN A DANCER TREAT BIG TOE LIMITATIONS AND FHL PROBLEMS?

Start with aggressive stretching the FHL combined with intense friction massage at those
three points. The best results tend to come after working with a trained medical professional. Self or home-based massage items include tennis balls, golf balls, and ice blocks (paper ice cups are a favorite).

Bigtoeproblems.jpg

HOW AGGRESSIVE AND INTENSE DOES THIS TREATMENT NEED TO BE?

Let’s just say that the stretching and massage can be uncomfortable, bordering on painful. Bruising of the foot is not uncommon with properly aggressive intensity. Being prepared for the potential pain and bruising helps increases chances of continuing with treatment.

DON’T WAIT FOR HIP, KNEE OR ANKLE PROBLEMS TO OCCUR

All dancers can check out big toe motion by standing in parallel and either pulling up on the big toes or having someone else lift up the big toes. If one toe moves less than the other, or it there is any pain or tightness, then consider doing the above exercises or seek a dance medicine specialist for more advice. Paying attention to big toe motion can pay off big dividends for dancers of all ages!

TarsalTunnel(STAR)

 

About Dr. Chris Koutures

Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA. He is a team physician for USA Volleyball (including participating in the 2008 Beijing Olympics), the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton Intercollegiate Athletics, Chapman University Dance Department, and Orange Lutheran High School. He offers a comprehensive blend of general pediatric and sport medicine care with an individualized approach to each patient and family. Visit activekidmd.com or follow him on twitter
(@dockoutures).

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