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Inside-Out Paradigm

By Dale G. Alexander, LMT, MA, PhD

About the Columnist
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Prevention vs. Intervention

Why intervention can be the quality of life choice.

Pain is one way we learn. Most recently, the pain of my wife's fractured big toe led us to seek out a foot doctor. During conversation with him, I learned that the progression of immobility within the first MTP (metatarsophalangeal joint) can be a significant contributor leading toward an eventual knee replacement.1 This was a new awareness. As my newest course that I am now teaching is the Aspiration to Prevent Hip, Knee, and Shoulder Replacements, his clinical statement intrigued me. Also, one of the themes of this column continues to be: Our profession has the ability and skills to function as an early detection team for our clients; so I requested Dr. Bradley J. Makimaa DPM, FACFAS, to guide my understanding in preparing this article.2

Sadly, many of our clients live with chronic foot pain when an ounce of prevention could make a huge difference in their comfort level with skilled attention and care by a good foot and ankle specialist. And at other times, our clients present to us with problems that require a true pound of cure but don't know what their options are or from whom to seek qualified help. Clients do listen to our encouragements to seek proper medical care when we have an informed opinion. That's the purpose of this article, to contribute to you developing an informed opinion.

Prevention vs. Intervention - Copyright – Stock Photo / Register Mark For many of our clients, stiffness and pain in their feet progressively emerges as they walk, dance, or run over the years. The foot joint being highlighted in this article is the condyloid synovial joint at the base of the big toe, the metatarsophalangeal joint. The early stages of this progressive degeneration is known as halux limitus. As the problem progresses toward joint immobility, it's latter stages are diagnosed as halux rigidus. This progression toward immobility is considered to be a form of degenerative arthritis.1 A history of having fractured or having severely "stubbed" the same big toe is a common human experience and is a question to ask of our clients.

As bodyworkers and massage therapists, we can easily feel the stiffness and the calcium deposits around this joint when it is progressing toward degeneration. A simple distraction and mobilization technique that I use is to traction the joint to the first barrier to motion, lifting the toe slightly, then request the client to push their big toe downward. Most often, the joint will slide and the active plantar flexion movement will reduce its compression. If, on the other hand, this produces quite a bit of discomfort or pain, and has a very limited range of motion, then the client is probably into the halux limitus territory and needs to be referred to a foot and ankle specialist. This is the ounce of prevention indicator.

In contrast, all of us have experienced clients presenting with a big toe that doesn't move at all. Sometimes it will be swollen and painful and sometimes it will be so stiff that palpation doesn't hurt in the least. Sadly, this means that the joint is frozen and that halux rigiditus is probably the more appropriate assessment. Occasionally, these symptoms will indicate a chronic gout condition. Again, an encouraging referral is in order. This is the pound of cure territory.

Let's now consider Dr. Makima's clinical experience on how this eventually contributes to knee deterioration, interventional surgeries, and possibly even knee replacement. "When patients have this ongoing limitation at the base of their big toe, their foot must invert to continue through the push-off phase of gait. It is the easiest compensation and closest in proximity to the motion. It really comes down to gait and having watched thousands of patients with this condition. They all invert their foot, i.e., tilt the sole of the foot toward the midline, to continue the push off phase of gait and continue the natural motion they used to have, only now all joint dorsiflexion and plantarflexion is done with the MTP's of the 2nd through 5th toes. This late phase inversion causes a closed chain external rotation of the leg and the knee and thus an exaggerated overloaded varus position of the knee at toe off."2

Varus, means bow-legged which adds compression and directs the force of each heel strike moving through primarily the medial compartment of the knee instead of being distributed between the medial, center, and lateral compartments of the knee.3 "Further, this results in a wiggle-waggle hip motion attempting to bring the foot back to a neutral position during the acceleration phase. Many of the patients I have seen with this gait have had one or several knee surgeries. Some led to knee replacements. I always ask if they have ever had the big toe addressed by the orthopedic surgeon or foot and ankle specialist (as they had an obvious giant bone spur formation and reported pain). The answer almost unanimously is "we will deal with the knee first" or, "no it has never been addressed."

I have had several patients cancel knee surgery after having a first MTP implant. I can't speak as to the long-term knee follow-up and previous damage but the correct gait with appropriate rehabilitation follow-up after surgery, definitely removed their knee pain."2

Having an implant done for the first MTP is the pound of cure approach that many of our clients may need, as it will allow them to continue a more active lifestyle and thus maintain their quality of life. Our collective desire as a profession to prevent physical deterioration can only assist those whose degradation hasn't spiraled downward to the point where medical intervention does need to be considered. Being alert to the conditions and symptoms which may indicate that such interventions are a possible necessity is a very significant service to our clients.

Dr. Makima states that overpronation, eversion during the push off phase, is the root of most foot pain and dysfunction and that orthotic support will always be helpful if that is part of the underlying cause. Taping procedures can be helpful to those whose big toe limitations and pain have not progressed beyond such conservative measures.

Additional red flags for when to refer clients to a foot and ankle specialist include:

  • Any altered gait, of any sort.
  • When going downstairs is painful.
  • When a person states: "I gave up walking or jogging." "I only have a few comfortable pairs of shoes." "I can no longer wear high heels." "I only took a tiny step and it sent me to the ground in pain."2

The many additional foot and ankle problems that our clients may experience are beyond the scope of this article. However, the next time someone's big toe doesn't move with ease or is painful to palpation, do encourage them to see a foot and ankle specialist, their physician, or an orthopedist. Be a part of your clients' early detection team.

References:

  1. www.foothealthfacts.org/footankleinfo/hallux-rigidus.htm
  2. Dr. Bradley J. Makimaa DPM, FACFAS, Board certified by American Board of Foot and Ankle Surgery, President, Southernmost Foot and Ankle Specialists
    2407 N. Roosevelt Blvd. (primary office), Key West, FL 33040
    (305) 294-5553 (office phone) sfakeywest@gmail.com or www.urgentfootcare.com
  3. https://www.verywell.com/what-is-varus-or-valgus-knee-deformity-2552048
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