Painful Big Toes and Top of Active Feet.

Do you have pain on the top of your feet and big toes during and after activity? A patient came to see me with this has been experiencing increasing pain under his left big toe joint but also across the top of his left foot. This comes on 8-9 miles into a run, worse on road or harder trails and a bit easier on softer ground. Nothing has really set it off but upped training mileage as has 190 mile event coming up. No swelling and settles down quickly. Can carry on running with the pain but would like it sorting, ideally prior to the big event and also understand what is going on. They agreed for me to share this with you as it may help someone else having the same issues.

Presentation of Big Toe Joint Pain

The painful area is usually at the end of the metatarsal, the ball part of the joint that we can all feel under our foot. We push or stand on it and it is painful. This is a common presentation, not just for runners, but anyone who spends increasing amounts of time on their feet. The big toe joint does a lot of work when we are active and takes a lot of our body weight, in fact pretty much all our body weight, when we move into the push off phase of walking and running. This could be anything up to 5 times our body weight and directed with a backward force.

The big toe glides over the metatarsal head as we move into push off phase of gait but the metatarsal head takes a lot of pressure prior to us moving onto the toe. It is this repetitive loading that causes the problem. This whole area can be become inflamed and irritated with repeated loading.

There was no pain with palpation of the top of the foot but a feeling of stiffness and tension.

How Does Pain in the Top of the Foot Feel?

The pain often builds as we continue to walk or run. It can come on at anytime, gets worse the longer we are on it, or plateau out and not get any worse but reminds us if we catch a stone or sharp edge of rock. Afterwards the discomfort usually settles fairly quickly and can be uncomfortable if we are using shoes with thin soles during the day. The pain on the top of the foot is like a deep ache that can become more painful as time on feet increases.

This is what this patient presented with. Pain that came on 8-10 miles into a run, sooner with road or harder trails, longer with softer ground. Didn’t really get much worse during the next 20-30 miles but was always just niggling away. He was concerned it was going to get worse and with 190 miles coming up wanted to see what could be done. The top of the foot pain is more of an annoyance but needed to be addressed as well.

What we Found

Slight discomfort with direct pressure to metatarsal head. It has not been painful for a couple of weeks as he had reduced his running. We can also see that the metatarsal head was sitting lower than the other metatarsal heads and when I pushed it up level it did not rise above the level of the other metatarsals, so it was always sitting slightly prominent on the bottom of the foot. This was different to the right one which was slightly prominent but had enough motion to lift above the metatarsals with direct pressure.

The other point to note is that the top foot bone – talus – that glides into the ankle joint, was also sitting forward and not gliding back into the ankle joint as it should. This is a common problem following ankle sprains but can also be the natural position of the foot.

This type of presentation causes a torsion to occur across the top of the foot and can present by itself. It is a common presentation when the foot is being subjected to torsional loading, it is being twisted at the wrong time during our gait cycle.

Footscan Data Showing High Big Toe Loading

As part of the assessment we used the Footscan pressure mat to see how much pressure was being put onto the joint and the timings of this loading. As can be seen the left ball of the foot is showing a higher load than the right in gait. Also the centre of mass line is moving to the outside of the foot (laterally) and then rapidily moves over towards the big toe as he moves over his foot and this creates the torsion.

Walking Gait – Left ball of foot showing more loading than the right.

Ankle Joint Function- Related to Foot Pain

We need the ankle to work during the midstance phase so that we can use the calf muscles effectively. These will works as a shock absorber and also to provide more power into the push off phase. We can see from the Footscan data that the left heel is rising earlier in the midstance phase as the talus is blocked and not gliding back into the ankle during this phase of gait. This affects calf muscle function and also increases the forefoot loading.

Footscan data showing the left heel not in contact with the ground for as long as the right

Explanation to Why the Patient is Experiencing a Painful Foot

The main issue is that the big toe joint sits lower than the rest of the foot and is therefore being subjected to higher loads. The talus is not moving back into the ankle joint when loaded will also create a higher loading force as the foot is not able dissipate the load. This also sends body weight more lateral on the foot (as can be seen by the dotted line on the footprint) and will often result in a rotation movement when pushing off. This will also contribute to the painful area on the top of the foot as it will be subjected to loading and rotations.

Treatment Options for Foot and Big Toe Pain

There are two ways of dealing with this situation and addressing both the issues.

Firstly we can use manual therapy. The joints of the foot are mobilised so that the big toe joint sits level with the other metatarsals and moves above them when loaded and the talus is mobilised so that it glides back into the ankle when loaded. The soft tissues and fascia are also addressed during this process.

Secondly we have to maintain the position of the foot that we can achieve with manual therapy. Repeated treatment can be effective but the foot may go back into the position that caused the problem. We need to accommodate the natural bony structure both in the short and long term. The patient was keen for as quick a response as possible due to the race coming up.

This can be achieved with using orthoses.

Firstly we carried out the mobilisations and retested the function with the Footscan mat.

The patient was also keen to order the Phits orthoses which are designed with the help of the Footscan data. These will accommodate the big toe joint and allow it to sit in its natural position.

Footscan data following Manual therapy treatment

As can be seen, the loading at the painful area is reduced and the centre of pressure line is more medial than the original scan. We can also see an immediate improvement in ankle joint function following mobilisations of the foot and ankle. The heel is down for longer and the forefoot loading is reduced (blue curve).

Footscan data following manual therapy. Reduced forefoot loading and improved ankle function

Follow on Treatment

The patient came back to see me the following week and reported that he had run back to runs over the weekend with only very little discomfort in the joint on one run. This was a 10 mile road run and he would have expected more pain. His second run was a longer off road run with lots of hills and he felt no discomfort. The pain in big toes and top of feet during and after activity had definitely reduced.

I mobilised the foot again and treated the fascia. This was a lot easier this time around with less restrictions.

The next follow up was two weeks later to collect the orthoses.

Review and orthoses collection

Foot pain has been kept to a minimum with running this last week. We treated the foot again with mobilisations and we fitted the orthoses to his running shoes. Footscan data comparing shoes alone and shoes and orthoses show a decrease in forefoot loading pressures, slightly later loading and a more concave loading curve.

Comparing shoes and shoes with orthoses

As can be seen below, there is now a delay in heel lift and this means that the ankle is working more effectively and will now work better as a shock absorber and allow for better function of the calf muscles.

Data showing that the right heel is in contact with ground for longer during the midstance phase.

Summary

My explanation for this presentation of pain in big toes and top of feet during and after activity is down to overloading with increased running. The big toe joint position and ankle function were the contributing factors. Manual therapy of foot and ankle joint mobilisations and fascia release helped restore foot and ankle function in the short term. Orthoses are an option for ensuring we achieve a longer lasting response to the manual therapy treatment. We have to change function to achieve a longer lasting result. Changing function is possible with the correct manual therapy, rehabilitation and gait changes. Orthoses can help this process and these could be used for a short term or long term application.

This combined approach is often essential to ensure that injuries both resolve and stay resolved. Here is a link to our website with more information about the Footscan assessment Services – Colpod therapy (colpodtherapies.co.uk)

Here is a link to Gait and Motion UK who supply the Footscan mats with an explanation of the system and the 3D Phits orthoses we used for this patient Phits 3D Print | Gait and Motion Technology

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