One of the essential aspects of the foot that is missed during examination is the 1st toe mobility, specifically the metatarsophalangeal (MTP) joint. During healthy gait, 15 degrees of dorsiflexion (DF) is required at the talocrural joint (TC). While the joint is frequently dysfunctional, the 1st MTP joint can be limiting as well. During preswing, the 1st MTP joint can reach as much as 55 degrees of extension. Unfortunately, people are often lacking 1st MTP mobility. To assess the mobility, passively bring the joint into an extended position while stabilizing the 1st metatarsal as depicted below:
Once you've identified a joint that is limited into extension, there are several manual treatments we can perform to increase the mobility. Below you will see a mobilization and manipulation technique. With the mobilization (1st row of pictures), you stabilize the metatarsal and mobilize the phalange in a dorsal direction close to the end-range of extension. With the manipulation (2nd row of pictures), you grasp the phalange close to the MTP joint while facing the patient and perform a distraction manipulation by radially deviating your wrists from an ulnarly deviated position. The manipulation brings the joint into a flexed position with distraction performed.
While manual treatments are great for improving MTP mobility, it is essential an exercise be assigned as well to maintain the gains and continue to improve the extension ROM. Patients spend the majority of their time outside the clinic, so they will be responsible for locking in the changes with an exercise. Below you will find two pictures, for recommended exercises. First is a row of pictures of a 1st MTP extension stretch in closed kinetic chain. Stabilize the phalange on the ground and bring the same knee into flexion and ankle into plantarflexion, which results in extension of the MTP joint. Hold for a prolonged periods (at least 30 seconds). The second row of pictures is repeated flexion of the 1st MTP. Grasp the phalange and bring into end-range flexion repeatedly, holding for a second.
Hopefully, you'll find these treatment options useful for the 1st MTP joint. Make sure to be thorough with your assessments, as a limitation here can result in changes up the change. Limited extension here results in altered mobility at the talocrural joint. If the the ankle does not dorsiflex appropriately, the knee and hip do not fully extend. This can result in decreased flexibility in hip flexors which will lead to repeated extension-rotation of the lumbar spine. This is just one example of how a limitation in one spot can affect something else much farther up the chain. It doesn't hurt to be thorough in your examination.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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