How To Treat Hallux Rigidus In Runners
This study by Nawoczenski dispels previous notions about clinical evaluation of range of motion of the first MPJ. Furthermore, a new standard of “normal” range of dorsiflexion range of motion of the great toe joint should now be set at approximately 45 degrees. However, this dorsiflexion range has only been verified for walking gait, not running.
Deconstructing The Myth About Great Toe Motion In Running Gait
The assumption that running amplifies everything more than walking is somewhat true. Impact forces, muscular activation and joint moments are just a few factors that are substantially greater during running in comparison to walking. However, the assumption that all of the joints of the lower extremity go through greater range of motion during running, in comparison to walking, is simply not true.
Early on in my career, I became aware that many of my runner patients with hallux rigidus would report less symptoms during running than walking. A review of the literature has shown no valid study of measurement of range of the motion of the first MPJ during running gait. However, conversations with many respected podiatric physicians confirmed a belief that running gait would require greater range of motion of the great toe joint than would walking gait. Accordingly, one would expect that hallux rigidus symptoms would become worse during running. My experience has been just the opposite.
Mari Adad, DPM, has provided further insight with unpublished data from a study of six healthy individuals. Using the same type of electromagnetic tracking system utilized by Nawoczenski to measure range of motion of the first MPJ, Adad measured an average of 34 degrees dorsiflexion of the great toe joint during walking and only an average of 26 degrees dorsiflexion during running.
In regard to understanding the reduced dorsiflexion range of motion of the first MPJ in running in comparison to walking, Sasaki and Neptune used computer modeling to predict joint angles and forces of the lower extremity segments during running.15 This study confirmed that ground reaction forces peak earlier under the forefoot during running in comparison to walking when the ankle is in a less plantarflexed position. A reduced ankle plantarflexion angle during running, in comparison to walking, puts less dorsiflexion demand on the first MPJ during the heel rise portion of the gait cycle.
The earlier and greater peak ground reaction force in running is partly due to increased muscular activation of the ankle flexors including the flexor hallucis longus. Early and greater activity of the flexor hallucis longus will restrict dorsiflexion of the first MPJ during running in comparison to walking. In other words, runners with hallux rigidus may use greater muscle activity to restrict painful dorsiflexion of the first MPJ and minimize symptoms in comparison to walking.
Conservative Care: Can It Have An Impact For Hallux Rigidus?
When an athlete initially presents with hallux rigidus, the symptoms are usually significant as this type of patient will put off a visit to the doctor as long as possible. It is suggested that treatment of hallux rigidus on the initial visit be similar to treating any other acute injury in the athlete. One should follow the protocol of PRICE (protection, rest, ice, compression and elevation) to calm down initial symptoms. Often, a brief period of rest from running activities while substituting non-impact cardiovascular training (i.e. bike, elliptical trainer) can allow acute inflammation and swelling to subside so follow-up conservative measures have a better chance of succeeding.
As I noted previously, many running athletes can participate in their sport with significant clinical evidence of hallux rigidus but have minimal symptoms. By the time they present to the podiatric physician for treatment, their condition may have already advanced to stage III or stage IV. At this point, degenerative changes in the first MPJ are so severe that most non-operative measures will have little hope of success.