When trail runners discuss their aching bodies, they typically talk about IT-band tendinitis, runner's knee or a sprained ankle. Seldom do you hear the "A" word uttered, but at some point most people will develop arthritis, a disease characterized by inflammation of a joint or joints.
Osteoarthritis of the big toe joint is the type that most often afflicts trail runners, and can severely limit an athlete's performance. It results from simple wear and tear, and is the most common form of arthritis. Various other conditions can also cause arthritis, the most prevalent being Gout and rheumatic diseases, but we'll stick to osteoarthritis of the great toe joint here.
Developing Situation
The joint in question is at the base of the big toe, or ball of your foot, and called the metatarsophalangeal joint or MPJ. When arthritis begins to affect the motion of the MPJ, it is termed Hallux limitus (limited motion of the great toe joint). As the condition progresses, the joint will become increasingly rigid. This condition can also be associated with a bunion-an abnormal enlargement of the joint.
Early symptoms of this condition include morning stiffness and aching pain. As the arthritis advances, there is progressive loss of motion, bony enlargement, swelling and more pain. Sometimes the overlying skin can get irritated. Since arthritic symptoms can overlap with other problems (see sidebar), you should see a specialist for diagnosis.
As osteoarthritis advances the cartlidge breaks down and the joint space decreases, which can lead to bone rubbing against bone. As the joint continues to jam, excessive bone begins to form around the joint (bone spurs) and can begin to break loose causing bone fragments. When you can feel a crackling sensation as you move the joint, it is a sign that the arthritis is severe.
Arthritis can progress very slowly or rapidly depending on your activities and footwear. High-impact activities such as trail running place significantly greater reactive forces on the foot, leading to more stress on the big toe joint. Ill-fitting shoes can also exaggerate symptoms. Any trauma to the joint can initiate arthritis. Genetics also play a role. You inherit a foot type or skeletal structure, and the shape of your metatarsals, motion of your foot and arch height may predispose you to arthritis.
Prevention
Prevention begins with proper footwear. Most good trail shoes will have good cushioning, but cushioning is not the most critical factor; stability is more important, because it helps reduce stress on the joint. Replace shoes as they wear down.
If you begin to experience pain in the joint, see a foot specialist. If you are diagnosed with arthritis, you need to be more specific with your shoe selection. Purchase a shoe with a stiff midsole, i.e. one with little or no bend. The forefoot should also be relatively stiff and bend no more than 30 degrees. These recommendations apply to any shoe; also buy firm-soled house shoes. Do not walk around barefoot, as this will continue to stress the joint. The shoe should have a wide toe box with no irritating seam against the joint.
To find a shoe that matches your foot type, go to a reputable running shoe store to be fitted. Look for a stable, firm heel counter, and a rocker sole can help reduce pressure on the ball of the foot.
If you have an abnormal foot type or a high-arched or flat foot, you may need a prescription orthotic device, which can help redistribute weight away from the big toe joint. An orthotic device will add volume to the shoe, so purchase shoes after getting an orthotic device for the best fit. If you have a more neutral foot type, there are various over-the-counter inserts that can help (see Trail Tested, September 2004, No. 29). Focus on inserts that give firm support as compared to the cushion-y insoles.
Other treatments to alleviate pain:
-Strapping the great toe joint with one-inch cloth tape can help protect the joint by reducing motion;
-A cortisone injection can provide temporary relief to the joint (but is generally not recommended);
-Glucosamine sulfate supplements might help regenerate cartilage;
-Ibuprofen or aspirin may relieve symptoms;
-Icing after activity
More Toe Woes
-Sesamoiditis: Inflammation of two pebble-sized bones on the bottom of the big toe joint.
-Acute Capsulitis: Inflammation of the big-toe-joint capsule due to overuse.
-Tendinitis: Inflammation of the tendons crossing the big toe joint.
Acute Inflammatory
-Arthritis: Gout is the most common form. Sudden redness, excessive swelling and significant pain of the great toe joint without any history of injury.
-Bunion and Hallux Abductovalgus Deformity: Bony enlargement of the great toe joint on the side of the joint with drifting/angling of the big toe toward the lesser toes.
Others:
-Peroneal tendinitis: Pain on the outside of the ankle.
-Posterior tibial tendinitis: Pain on inside of the ankle and arch areas.
-Plantar Fasciitis (heel-spur syndrome): Aching pain in the heel.
-Neuroma: Pain in the ball of the foot and lesser toes.
-Ingrowing Nail: Pain along the nail border.
UNDER THE KNIFE
If, despite conservative treatment efforts, pain persists and the condition limits your activities, you may want to consider surgery. There are numerous surgical procedures; none, however, are curative.
For more severe arthritis, a joint implant or joint fusion may be needed. Big-toe-joint hemi (partial) implants have proven successful in maintaining some motion and relieving pain. For long-term relief, fusing the big toe joint can be quite effective in relieving pain and maintaining a stable foot.
Yvonne Weber is a Doctor of Podiatric Medicine and board-certified in foot surgery, has practiced in Boulder, Colorado, for 10 years, and runs trails around her home.
This article appeared in Trail Runner magazine, issue #30 (NOVEMBER 2004). Order your back issue now!
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