Surgical intervention is not always indicated or possible for patients who have first MPJ pain. Accordingly, this author discusses several non-surgical interventions, ranging from spica taping and toe separators to dancer’s padding and metatarsal doming, that one can utilize to help treat a variety of first MPJ issues.
The first MPJ is a fascinating area to treat because of all of the variables involved. As the normal stance phase of the gait cycle ends with pushing off of the hallux with first metatarsal plantarflexion, it can be challenging to treat patients who cannot execute this maneuver successfully or without pain. Patients with chronic big toe joint pain (including sesamoid problems, hallux rigidus or chronic turf toe) may need multiple treatment tactics to see improvement.
Why do orthotic devices not work for these problems at times? Varus-corrected orthotic devices work for some to shift the body’s weight more laterally but the higher the arch on the device, the more plantarflexed the first metatarsal becomes. This forces the first MPJ further into the ground, bending even further and worsening the pain. Therefore, while some custom orthotic devices (even an orthotic device made expertly for a pes cavus foot type) may work in some cases, other patients with first MPJ pain may need a flatter-arched orthotic device or no orthotic device at all.
With this in mind, let us review some key biomechanical interventions to help address subacute and chronic injuries in the first MPJ as well as options for maintenance therapy. In my experience, I commonly think of pain in the first MPJ as coming from excessive ground pressure, too much bending, malalignment with valgus forces, superficial pressure from shoe gear, compression forces across the joint or a combination of some or all of these forces. In order to address many of these causes, you have to direct treatment toward the propulsive phase of gait.
Key Considerations With Taping Techniques
Spica taping. Spica taping helps restrict first MPJ dorsiflexion. One commonly learns this technique with KT Tape® (KT Health) or RockTape® (Implus) since these taping options bend around the toe easily. If the patient needs more restriction and one has the basic skill down, Nexcare™ Absolute Waterproof Tape is an option.
Typically the provider will center one-inch wide tape, seven to eight inches long dorsally over the top of the hallux.1 First, one brings the medial leg of the tape down under the first MPJ and runs it under the first metatarsal. Then one would bring the lateral leg down under the first MPJ, parallel to the first strip of tape. At least one-half of the lateral tape leg, lengthwise, should touch the skin, and not the other portion of the tape, so the tape can last three to four days.1 Rub the finished product to activate the glue of the tape for one minute. The big toe should now rest just slightly below the second toe.
While spica taping is classically utilized for hallux rigidus and turf toe, one may employ this modality to distribute weightbearing forces away from the sesamoid for sesamoiditis or fractures as well. Be advised that spica taping can increase compressive forces across the first MPJ, which may cause pain, so this may not work for all patients.
Bunion taping. This is a similar technique to spica taping but it has a different starting point and tape leg orientation. With the same tape materials, one places the center of the tape on the lateral side of the hallux with one leg superior and one inferior.2 When applying the tape, one places the hallux in neutral and brings the plantar leg of the piece of tape under the the first MPJ to lay along the medial side of the first metatarsal. This is where you (and ultimately the patient) decide how tight to make it, balancing correction and pressure. Then one brings the superior leg across the first MPJ to lay down on the medial side of the first metatarsal with about half the tape touching skin and half the tape overlapping the other leg. This technique not only centers the joint but also restricts some joint motion. Again, one minute of massage helps activate the glue.2
Can Accessory Devices Have An Impact On First MPJ Pathology?
Toe separators/spreaders. These devices come in various shapes, sizes and materials. A medium hourglass-shaped gel toe separator is a classic conservative bunion treatment. Foam toe separators have more width and therefore work better for a lot of my patients. They can, however, be too long and cause ingrown toenails. That said, you can simply shorten them with a scissor. With overlapping toes, you either need the hourglass gel ones or a toe separator that slips over the second toe (or first and second toes), and has a separator attached medially to the second toe. It is important to ensure the toe separator does not migrate to sit under the second toe, potentially worsening a hammertoe.
My mantra in bunion care is to maintain stage 2, according to the classification from Root and colleagues.3 The toe separator immediately puts the bunion, which may have started the day in stage 3 or 4, back into stage 2. As the patient walks, the forces through the first MPJ are more normal and should slow down the retrograde forces. Centering the joint will allow for normal muscle development and strengthening. This also helps to alleviate pain from lateral joint impingement. In my experience, when there is no concomitant hammertoe surgery for the second toe, toe separators can also be beneficial after bunion surgery to help maintain correction while the muscles and scar tissue transform.
Carbon plates with a Morton’s extension. This modality works well with an orthotic device on top. When using this modality to help address first MPJ pain, only the first metatarsal head and hallux will contact with the carbon plate distally.4 Ideally, a varus-based orthotic device will transfer patient weight into the middle of the foot well. However, with some severely pronated feet, this can be a great challenge. If the weight transfers more centrally, this device works well to allow normal foot motion without great toe flexion and is only appropriate on the symptomatic side.
A common problem with this design is when the hallux is too far lateral and falls off the plate. Sometimes, one must use bunion taping and/or toe separators to get the hallux evenly over the Morton’s extension. Again, if the patient pronates too severely into the Morton’s extension, the pressure can be too much and the patient may be more of a candidate for the next modality that I will discuss.
Correct Toes. Invented by Oregon podiatrist Ray McClanahan, DPM, this modality slips over each toe, gently separating them when people are walking and running. Since Correct Toes place each toe in a significantly separated position, there are only a select group of shoes that can appropriately accommodate this device. I tell my patients to look at the list on the Correct Toes company website and to start simply at first by using this device in loose slippers while walking around the house.5 When it comes to patients wearing the Correct Toes device, Altra, Keen and Lems shoes are my go-to shoes right now as they each have a wide forefoot.
Some patients have too narrow a foot for the current design of Correct Toes so I often remove the lateral aspect of the device to still allow the benefit of separation of the first through third toes. Even if the patient wears the device briefly at home, he or she will still benefit, and many describe a greater sense of power at push-off.
What Orthotic Modifications Can Be Beneficial For First MPJ Pathology?
Dancer’s padding/reverse Morton’s extension. This is a 1/8-inch or 1/4- inch pad that typically goes under the second through fifth metatarsals.6 If the fifth metatarsal has symptoms, then only place this pad under the second through fourth metatarsals. One can apply dancer’s padding/reverse Morton’s extension to any surface (orthotic device, shoe insert, sandal, ballet slipper, barefoot, etc.). If you increase the padding to 1/4 inch, make sure the patient does not feel that he or she is “falling into a hole,” which makes things worse. If you layer 1/8- inch pads like adhesive felt, you can also offset the second pad a little laterally and proximally (or distally), which helps transition the edges.
This pad typically reduces plantar pressure across the joint by 50 percent or more in my experience over the years. However, I have found that many times, one must balance the pronatory effect of the dancer’s pad by an arch support to pull the patient laterally at the midfoot. I prefer to use over-the-counter, non-plastic devices for this pursuit since the goal with the plastic-based devices is to increase first MPJ motion.
When you are in the midst of trying to offload a sore sesamoid or painful hallux rigidus, a custom plastic device may not be appropriate at this time. I recommend Dr. Jill’s Gel Dancer’s Pads (Dr. Jill’s Foot Pads) to every one of my patients with big toe joint pain. These pads come in both 1/4- and 1/8-inch thicknesses, and you can make the cut out portion bigger, depending on the nature of the patient’s problem. The pads stick on one side, which allows placement directly on skin, an orthotic device or shoe insert, primarily for sesamoid injuries. One typically only needs to use the pad on the affected side unless you are using a 1/4-inch pad. If you are using a 1/4-inch pad, you should employ a 1/8-inch pad on the contralateral side for balance.7
Cluffy Wedge®. Designed by James Clough, DPM, the Cluffy Wedge fits into the sulcus under the proximal phalanx to offload the sesamoids as your weight rolls forward.8 The 1/8-inch thick adhesive felt is usually one inch wide by one inch long or slightly smaller. This device cannot go under the distal phalanx or it will increase first MPJ dorsiflexion.8 I never used the Cluffy Wedge until 10 years ago when a patient of Dr. Clough moved to San Francisco and needed a new podiatrist. This patient faithfully and successfully wore her Cluffy Wedge as part of the treatment for a fractured sesamoid.
I have found anecdotally that 50 percent of patients feel the Cluffy Wedge is very helpful. So when patients present with first MPJ pain on their first visit to my office, they all leave with three recommendations for mechanical changes to begin to manipulate the symptoms: spica taping, dancer’s padding and Cluffy Wedges.
“No heel lifts.” This is a general principle in treating any metatarsal problem.9 This can be a challenge when the heel lift is for a short leg, which just happens to be on the same leg where the patient is having the great toe joint problem. One can remedy this by making the lift sulcus length with a cutout for the first MPJ (combining a lift with a dancer’s pad).
An orthotic with a rearfoot post for increased stability can also act as a heel lift. In this case, one can remove the rearfoot post and place midfoot medial and lateral supports to hold the correction. Using rubber cork from JMS Plastics, I apply 1/4 inch in the medial arch and 1/8 inch under the cuboid/fifth metatarsal base. If the heel lifts are for Achilles tendonitis, then you have to decide what the worst pain is for now and make the appropriate adjustments. Lastly, patients should of course avoid shoes that have any heel and often need to do so for longer than it takes for the first MPJ pain to resolve. In my experience, I typically have patients avoid heels for a month after their first MPJ pain resolves.
The side note to this is that flat shoes with no lift in the heel can make it harder and more stressful to push off properly at the first MPJ. Typically, the “no heel lift” rule works for those standing for long hours since the weight gets back into the heels more. However, if flat shoes are painful during push off when walking and/or running, try combining a small heel (even 1/4 inch can help) with some good forefoot cushion and flexibility.
What About Exercises And Strengthening Options For Patients?
Self-mobilization for hallux limitus. This is a gentle tool that patients can learn to use when first MPJ range of motion is limited.10 I learned about the technique of self-mobilization from Rue Tikker, DPM and Timothy Shea, DPM, and it has been a valuable part of my practice for 40 years. The principle of self-mobilization is short, quick motion in directions abnormal for the joint. Accordingly, in order to improve dorsiflexion or plantarflexion of the great toe joint and break up some scar adhesions, have the patient perform the following four motions:
1. dorsal and plantar gliding;
2. side to side rotation;
3. clockwise and counterclockwise rotation; and
4. long axis extension.10
Measuring motion before and after mobilization, I typically see a five degree gain and sometimes even a 10 degree gain. The principle of mobilization in this case is to stabilize the proximal segment (metatarsal head) and move the distal segment (proximal phalanx). Remember, this moves the proximal phalanx on the first metatarsal head in four ways in which it does not normally move. The patient must perform these motions three to four times a day to slowly gain motion. Each session only takes about 20 seconds to perform all four motions two times. For some patients, maintenance therapy may involve regularly performing these motions once a day indefinitely.11
Metatarsal doming or arcing. I find in my practice that this isometric exercise is the best way to strengthen the short flexors (hallucis brevis) along with single leg balancing. While standing or sitting, the patient first straightens all of the toes. With the patient keeping the toes reasonably straight, have him or her lift the metatarsal heads upward while keeping the tips of the toes against the ground, and count to six seconds.12 Encourage patients to try to feel the tension in the metatarsal arch and squeeze the tissue. That squeeze develops muscle bulk and tone, and patients begin to feel a difference in their feet within weeks. Metatarsal doming requires 10 repetitions performed three times a day at six seconds each with four seconds of relaxation between each repetition.12 Once patients are doing the exercise correctly and consistently, they can do so in the supermarket checkout line, etc, without having to look down.
No Achilles tightness. This is a very important aspect of first MPJ treatment.13 A tight Achilles tendon drives a tremendous force downward into the metatarsals, which the ground reactive forces have to match. That is why Achilles flexibility is a vital measurement for patients with first MPJ pain. When the ankle cannot bend past 90 degrees at the middle of midstance, as the body weight continues to move forward, the heel lifts early, the midfoot collapses or the foot abducts. This all drives abnormal pressure into the forefoot.12
When the patient stretches the Achilles tendon, both with straight-knee and bent-knee positions, it can put a lot of pressure on the great toe joint. Instead, one can hang the first MPJ off the end of a thick book so as you stretch, no weight goes into that joint. You can also take four 1/2-inch thick magazines and arrange them so they overlap in a square with a hole in the middle. You can then allow the patient to stand on the magazines with the injured first MPJ complex in the hole. This will accommodate weightbearing exercises while offloading the joint. Purchasing a cheap but thick sandal, and having a shoe cobbler cut out the big toe area can help patients avoid irritating the joint while stretching, etc.13
I hope that the aforementioned conservative biomechanical interventions will help you think outside your normal treatment routine in reducing first MPJ pain in your patients and ensuring a stable joint.
Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a Past President of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby. com.
Dr. Blake acknowledges the assistance of Megan E. Hom, DPM in the preparation of this article.
Editor’s note: For an online-exclusive sidebar to this article, read “A Closer Look At Rocker Shoes, Bike Shoes With Cleats And Skip Lacing” by clicking here.
1. Blake R. Hallux rigidus spica taping (that one can) also (use) for hallux limitus, bunions, (and) turf toes. Available at: https://youtu. be/l_4HESXCG40 . Published September 16, 2010. Accessed January 6, 2021.
2. Blake R. Taping for bunions. Available at: https://youtu.be/l_4HESXCG40 . Published May 18, 2011. Accessed January 6, 2021.
3. Root M, Orien W, Weed J. Normal and abnormal function of the foot. Vol. 2. Los Angeles: Clinical Biomechanics Corporation; 1977.
3. NRG plates. JMS Plastics Supply. Available at: https://jmsplastics.com/product/nrg-plates/ . Accessed January 7, 2021.
4. Correct Toes. Shoe list. Available at: https:// www.correcttoes.com/foot-help/shoe-list/ . Accessed January 7, 2021.
5. Cohen BE. Hallux sesamoid disorders. Foot Ankle Clin. 2009;14(1):91-104.
6. Blake R. Dancer’s pad for sesamoid or big toe joint problems. Available at: https://youtu.be/ GG-mSjtSwj8 . Published July 31, 2016. Accessed January 7, 2021.
7. Clough JG. Functional hallux limitus and lesser-metatarsal overload. J Am Podiatr Med Assoc. 2005;95(6):593-601.
8. Zhang X, Li B. Influence of in-shoe heel lifts on plantar pressure and center of pressure in the medial-lateral direction during walking. Gait Posture. 2014;39(4):1012-1016.
9. Brantingham JW, Wood TG. Hallux rigidus. J Chiropr Med. 2002;1(1):31-37.
10. Blake R. Hallux rigidus/hallux limitus: self joint mobilization. Available at: https://youtu. be/FBTeWbdGrzs . Published September 10, 2010. Accessed January 7, 2021.
11. Blake R. Metatarsal arcing or doming: foot intrinsic muscle strengthening. Available at: https://youtu.be/GY-mJjXmeIc . Published November 13, 2010. Accessed January 7, 2021.
12. Cazeau C, Stiglitz Y. Effects of gastrocnemius tightness on forefoot in gait. Foot Ankle Clin. 2014;19(4):649-657.
13. Blake R. How to stretching for plantar fasciitis and Achilles tendonitis. Available at: https://youtu.be/0eAqJ4-oKTM . Published August 20, 2010. Accessed January 7, 2021.