Pace Setter : May 2021

Off The Road - The Big Toe

by Russ Ebbets

Some people think the big toe developed to help humans find things in the dark. The “things” could be a bedpost, the leg of a chair or the corner of the coffee table, but in a second the realization is as sudden as the discovery was unnecessary.

The big toe is a unique appendage in the human body. First of all, it is the only toe with two joints. All the other toes have three joints. The significance of this has yet to be discovered but it will no doubt be profound.

A second unique quality is that the big toe is the furthest part of the body from the heart and brain. One may dismiss this anatomical trivia as irrelevant, but this special status can actually be used as a health indicator. Being the furthest point in the body, the blood must be pumped all the way there, turn around and eventually return to the heart where the process repeats.

The trip south is not so much a problem, as the oxygen rich blood with red blood cells, platelets and other blood particles is moving with gravity. With the return trip the process is reversed, slowed and can be almost stagnant (think of varicose veins).

The turnaround can therefore present problems, as any impurities traveling in the blood can precipitate out and get left behind. For some fast livers, the accumulation of these particles can create a locally toxic situation in the big toe called gout.

While gout is usually a self-limiting situation, resolving in about a week, there is damage done in both the short and long terms. The hot, red and swollen toe is exquisitely sensitive to the touch. Gout makes walking in general and in shoes in particular very painful. The altered gait or limp can place abnormal pressures on the ankle, knee, hip or low back that in turn may develop their own problems.

The long term problems of gout are the result of aggressive macrophages (the garbage men of the blood) doing “too good” a job cleaning up the area. The macrophages can destroy the cartilaginous caps that surround the ends of the bones of the toe. This leads to joint degeneration or osteoarthritis, commonly referred to as arthritis.

Were this process to occur in our hands, it would be minimally painful and compromise movement and grip, but the hands are not weight bearing. The fact that the foot is weight bearing and the great toe is a balance point of the foot can lead to every other step being painful, forcing one to limp, creating the problems noted above.

Long-term, the big toe may seize up, where the metatarsal phalangeal (MTP) joint becomes locked together. This condition is called hallux rigidus. While this may be a short-term solution to the painful joint, it presents with a long-term problem as the locked MTP joint makes a long lever of the foot, particularly at the toe-off, that alters one’s gait pattern, once again predisposing one to problems at the ankle, knee, hip or back as noted above.

An opposite condition is when the big toe becomes hyper-dorsiflexed and the ligaments around the MTP joint are damaged. This injury, more commonly seen in football but not unknown to runners, is called turf toe. The career of football/baseball superstar Deion Sanders was prematurely ended due to this problem. Oddly, the incidence of turf toe (along with plantar fasciitis) has spiked during the pandemic. While these foot problems had nothing to do with the disease, the fact that people were homebound, not wearing shoes and walking on hard level floors injured these poorly conditioned tissues of the foot, developing the turf toe or plantar fasciitis.

There are also variations in the length of the big toe. A short, big toe (SBT) has variously been called Morton’s Toe or the Greek Toe and has been seen as a sign of intelligence or ignorance, depending on which side of the Bosporus Strait you were born. This SBT also can alter and present problems at the second digit as that digit attempts to handle the pressures of toe-off, something it was not biomechanically designed to do.

Hallux valgus is where the big toe bends laterally and is often accompanied with the development of a bunion and arthritis at the misaligned MTP joint. While it makes sense that this misalignment would compromise force production this is not always the case. I once treated a sprinter who had won the Olympic 200m and had severe hallux valgus on both feet. While misfitting shoes can contribute to this problem, another cause is a poorly rehabbed ankle sprain. If the peroneus longus muscle loses its ability to stabilize the first metatarsal bone the bone may drift medially with the toe distal to the MTP joint drifting laterally, creating hallux valgus of the big toe.

Black toe may be the result of a one-time crush type injury (think dropping a brick on your toe). Black toe can also be the result of multiple, read that countless, micro-traumas that a marathoner or ultra-marathoner experiences with toe-off. The repeated downward pressure and pawing action of the toes can rupture the micro-circulation at the turnaround point of the toes and result in blood pooling, with the dead tissue eventually turning black. Black toe usually results in the loss of the toenail that can take as long as a year to regrow.

The in-grown toenail is a nuisance problem, usually the result of poor foot hygiene. The regard for the care of one’s feet, be it shoe selection, nail trimming or simply washing and drying the feet, can help prevent this nuisance problem. Resolution of an in-grown toenail can interrupt serious training for a month and possibly lead to other problems if one valiantly tries to limp through the problem.

At this point, it might not seem like such a stretch to see why the big toe is used in Oriental medicine for diagnosis of problems throughout the body. Whether it is due to simple or repeated traumas, gait patterns, lifestyle or neglect, the anatomy of the toe furthest from the control centers of the brain and heart can give indications of problems that may be developing elsewhere.

Some simple interventions can help maintain the health of the big toe. These suggestions begin with shoe selection. There is an old statistic that 60% of people wear shoes too small for their feet. No doubt fashion drives much of this misguided decision making. What one needs in a shoe is a roomy toe box, the front part of the shoe that allows the toes some movement. This will also alleviate the medial to lateral pressure on the big toe that creates a hallux valgus problem.

The incidence of black toe can be reduced by taking an emery board (nail file) and rubbing the nail bed crosswise 5-6 times. This thins the nail bed, however slightly, which in turn increases the pliability of the nail. By reducing the rigidness of the nail, the repeated toe-off of running reduces the chance to crush the delicate capillaries at the end of the toe.

Gout is a more serious problem. While gout can be caused by certain drug therapies, the necessity of these drugs are not typical with healthy runners (i.e. – chemotherapy, immune-suppressive drugs, drugs for tuberculosis). There may also be a genetic predisposition to gout but gout is more commonly the result of poor lifestyle choices. Repeated episodes of gout are seen as a precursor to heart disease. A critical self-analysis may be in order. In an acute episode a simple castor oil pack or coating the toe with Vaseline may reduce inflammation and increase elasticity of the skin sufficiently to relieve some of the pressure and decrease pain. If the problem continues longer than 48 hours, it is time to seek professional advice.

The MTP joint of the great toe is the second most common area in the body to develop arthritis (the fingertips are #1). This makes sense as all vertical activities involve the great toe in some manner or form. The big toe plays a critical role in running, as it is a site of force production at toe-off, a balance point and critical to symmetric gait. Despite these facts, the big toe is given little consideration on a regular basis, be it conditioning or care for this area that is necessary for a lifetime’s activity. Some simple suggestions regarding shoe selection, periodic foot inspection or maintenance can go a long way to ensure the health and integrity to the nail, bones and joints of the big toe.

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Russ Ebbets, DC is a USATF Level 3 Coach and lectures nationally on sport and health related topics. He serves as editor of  Track Coach, the technical journal for USATF. He is author of the novel Supernova on the famed running program at Villanova University and the sequel Time and Chance. His most recent book, A Runner’s Guide, a collection of training tips and running articles was a 2019 Track and Field Writers of America Book of the Year finalist. He can be contacted at spinedoctor229@hotmail.com.

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