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.
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