Pain in the back? Check the big toe!

Posted: December 30, 2011 in Uncategorized

Great big toe mobility

If one link breaks,what happens to the rest?

 

As many of you know, the times of treating the site of pain are behind us (with exceptions of course). Through a paradigm shift in the rehab/training world we have come to appreciate the body as an integrated unit, where all it’s part never function in isolation but as a unified whole. This means that when a patient presents with knee pain as an example, the knee is very rarely the cause of the pain. The knee pain is simply the consequence of an issue at a joint either above or below the knee. Now that we have that out of the way….on to the topic at hand!

Low back pain (LBP) is an epidemic. We all know the stat that 80% of us will have back pain at some point in our life…I know I have! The problem then becomes an issue of treatment. Let me just say that I am not dead set in my ways and I know there are many ways to skin a cat..i.e many different treatments can fix the same problem…that’s only if the right problems are addressed. In this blog I will explain how a restriction at the big toe can ultimately lead to back pain…just something else to think about.

Hallux Rigidus can occur for many reasons. This condition presents itself as limitations in big toe extension

Heel strike, to 5th toe, to 1st toe

(dorsiflexion). Why does that really matter? Oh…it matters! Every step you take the big toe is working to create power for push off. We start off with heel strike, the subtalor joint moves us into inversion where our weight is placed on our 5th met head and then we have subtalor joint unlocking which allows the midfoot to fall into functional pronation allowing the big toe to come into contact with the ground. At this point, the big toe digs into the ground to create the push off we need to move forwards. In order for the big toe to flex into the ground to create momentum, it must first go into 45-60 degrees of extension to create the proper length tension relationship to allow the push off phase to occur. This is where problems start to set in.

If the big toe can’t dorsiflex, the body is going to compensate for that lack of movement by trying to shift the body weight medially to get that big toe to hit the ground…the body is smart and will always find a way to do things to keep moving. When we don’t get the movement from the big toe, the knee must go into valgus collapse (knock kneed) to try and get as much weight on that big toe as possible for push off. When the knee goes into medial collapse, the hip moves into internal rotation and the lower back compensates by shifting towards the side of hip internal rotation. When the low back shifts, you can get muscle shortening, facet joint impaction, degenerative changes etc…leading to back pain that started from a lack of big toe extension.

So here is the BIG question…WHY can’t the big toe extend? Arthritis is one reason but I won’t discuss that as again, I believe arthritis is just a consequence of a biomechanical imbalance elsewhere. Here is a big reason that I see clinically. If the flexor hallicus longus muscle becomes restricted, the big toe will not have the mobility to extend due to the muscle keeping it in a plantarflexed position. We sleep in a plantarflexed position so this muscle often becomes tight in some people. If the flexor hallicus longus is fine and patient still can’t dorsiflex the first ray with ambulation then I check peronius longus. Why? The peronius longus has the task of transferring weight from the 5th met head to the big toe during the gait cycle..it helps create that functional pronation I was talking about before. It also has a roll to play in plantar flexing the big toe to help with push off. So, if peronius longus is weak or tight it could be a cause of why the big toe can’t fully get the mobility it needs to create adequate push off power.

 In short, to treat this I mobilize/manipulate the first MTP using accessory and physiological glides. I do myofascial release of the flexor hallicus longus from the fibular origin to its insertion (probably getting a few other muscles at the same time…but that’s fine!). I stretch the foot into dorsiflexion, I work on peroneal strengthening (good one being heel lifts a with tennis ball squeezed between the ankles), and I of course work of glute strength…because everybody needs it! I also check the pelvis to see if there is an imbalance at the innonimate…that too can be one cause of big toe problems

Simple big toe self stretch:


Peroneal Exercise:

Are there other reasons for back pain? 100% yes without question. This article was just written to help therapists who have clients with nagging back pain to help think outside the box in terms of possible causes. I know I have been stuck with clients in my practice and have neglected to look at other factors…not so much because I didn’t want to, but more because I just didn’t know they could be issues in the first place. I guess the take away point is to be a detective with the body. Never think that a problem you see somewhere other than the site of pain is unrelated…it probably is. I’m the first to admit that I have been caught chasing symptoms to try and make the client happy. But I have found that if I take the time to explain why I’m wiggling their toe for their back pain, I gain credibility…because If I didn’t explain that, I’d be considered a voodoo therapist in their eyes hahaha

 Thanks for reading and happy new years!

 Jesse Awenus B.A (Hons) Kin, MSc.PT
Registered Physiotherapist

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Comments
  1. Excellent article my friend. Nicely written. The big toe is a critical part of the movement puzzle. Liked the highlighted relationship to the peroneals. Gotta think globally. Thanks for posting. This will help someone and that is what it’s all about. I see this all the time in clinical practice.

  2. […] Pain in the back? Check the big toe! (jessephysio.wordpress.com) […]

  3. Thanks, well written, will pay more attention to my clients’ big toes now!

  4. Jesse A says:

    Thanks Vicky! Just something else to consider 🙂

    Glad you enjoyed it

  5. I had no idea that this could make a difference. I’m going to look into this as soon as I can. Thank you for sharing!

  6. jessephysio says:

    1st MTP extension is a big player in foot, knee and back pain…it’s a quick check.to see if they have that 50-60 degrees of extension. Check contralateral side for east comparison.
    Thanks for reading the blog Amber!!

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  8. Thanks a lot for this interesting share about the relation of low back and the big toe. I am pleased to read this stuff and hope to get more.

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  32. Jesse, I need you’re help.A bone spur developed on my left big toe joint about 6 years ago and I went to the FOOT DR right away. She said I had started developing Hallux Limitus. She didn’t recommend surgery at the time, so for the last 6 years, I played it safe, gave up high heels and got inserts made for my running shoes. For a few years, this worked! Over the past 2 years, I’ve developed ITBS, hip and lower back pain on the left side. I’ve read certain articles and they say that having Hallux Limitus or Rigidus can over time change your GAIT and cause pain in other areas because the BIG TOE push off when walking/running is very important. So I had my PT do a GAIT Analysis on me, he confirmed that i’m internally rotating my leg to avoid putting weight on the big toe. He said that I’m not suspanating and I’m doing a kind of swing motion where after toe off I my left heel points out, then swings my leg back to the front again. Its funny when I see it on a video.

    He suggests that I have the bone spur removed even though he said that my range of motion of my left Big Toe isn’t that bad when I dorseflexes it. But the fact that I’ve changed my gait is a concern to him. He had me do some Big toe joint exercises and tests. I had a very hard time doing, and when I did do them my toe joint started hurting so I would allow my leg to collapse in. Or when I stood on my tippy toes my ankle would stick out to support the weight. PT said I also do this collapse of the left leg when I’m squatting or doing one legged leg lifts, my left leg goes in to compensate. So now I’ve been having hip and groin pain and lower back pain and some doctors are saying I have a hip impingement but say I don’t show all the symptoms of a classic hip impingement. My PT said that even if I have a FAI and I had surgery, it still would fix my gait or that fix that i’m not pushing off my big toe properly, and thats why he suggests I get the bone spur out.

    I went back to my Foot Dr and she agreed to do a “cheilectomy” on my left toe. She’s not a runner and so when I talk to her about gait and anything else she just doesn’t get it. But she is one of the BEST Orth Surgeon’s in the area.

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  35. Cary brief says:

    Hello, thanks for your article. I am trying to find a dr to deal with my big toe problem. I have a fused lumbar l4l5s1. (1999). Still have low back pain, bad leg pain, foot pain. Thing is my big toe has no strength for push off, it bends all the way back and hurts like it is broken sometimes. Went to foot dr and he blamed fusion and gave me narcotic topical (didn’t take). My pain dr says nothing. Since I do. Don’t know what the toe problem is called it makes it hard to get it taken care of, any suggestions? Thanks again. Cary in miami

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