Importance of the Big Toe....I fought the Lawn and the Lawn Won!!
This case study is written with a couple of intentions in mind...
1. A reminder to be so careful when working with any machinery as accidents can and do happen in a split second. In this situation, the client sliced through his big toe with a lawnmower and although the outcome was successful, that's certainly not always the case.
2. To bring awareness to the body's incredible ability to heal itself in what is a relatively short space of time.
3. To show the importance of big toe function throughout the entire body all the way to the head. This is also applicable in cases of bunions, turf toe, broken toe etc.
This client had initially been attending another physio and after getting clearance, he returned to football training 8 weeks after the initial accident occurred. When you see the extent of wound healing in that space of time, it was a pretty remarkable.
However, a return to sport was causing stiffness and pain in and around the ankle and calf muscles, which would not be unexpected.
The gait assessment below may give a clearer picture as to why this was happening. These functional changes were achieved in two treatments - simply by focusing on what the big toe needs to do most.
- Extending as the leg swings through to the point of heel strike
- Flexing as the big toe and forefoot come into contact with the floor during pronation and single leg stance
- Extending as the foot pushes off the floor again (supination)
During the initial consultation I assessed what movement was available in the left big toe joint and sure enough it felt quite stiff and lacked extension.
In standing, I assessed what active extension (ask client to bring big toe towards ceiling) and passive extension (me repeating the movement with no assistance from client) was available.
Neither of these movements produced more than 15-20 degrees of extension, with 60 degrees being "optimal"
I then chose to assess his gait (walking) - barefoot & no treadmill!!
All of the above images are the same gait phase observed before, during and after the first treatment session.
Image (far left) - his entire body is compensating to move around his left big toe as it lacks movement, a rotation "scoop" of the left foot is evident drawing the heel towards midline.
Image (centre) - Pelvis and ribcage are now achieving better opposition in rotation, but watch what this new available movement does to his neck in right side flexion.
Image (far right) - Greater big toe extension, foot scoop towards midline lessens, pelvis begins to shift to the right, greater co-ordination in spinal opposition, neck achieves a much more centred position.
The most interesting bit for me....all of this was achieved by NOT directly treating/moving the big toe at all. Instead, I chose to look at the other movements I would like to see his body access AS the big toe would begin extending, mapping them all the way to the head.
By keeping his left foot and big toe flat on the floor (not forcing the big toe through movement) and encouraging specific AiM movement through the rest of his system, we were able to restore other length-tension relationships and allow his system to find "centre".
On repeating his active and passive big toe extension tests, his big toe extension increased by ~20 degrees. So fascinating to watch.
Follow-up treatments involved specific scar work to the left big toe, focused big toe extension (windlass mechanism) exercises and then incorporating big toe extension back into specific gait phases along with the ability to access pronation with foot flat (requiring the big toe to bear weight).