03/18/2021    Howard Dananberg, DPM

Turf Toe (Clifford Wolf, DPM,Chris Seuferling, DPM)

Both hallux limitus (HL) and turf toe (TT) do not
necessarily have their etiology in direct joint
damage, but instead to repetitive strain
secondary to chronic inhibition of the peroneus
longus. To those who think that this is not the
case, I ask how often eccentric strength of the
peroneals is examined as part of a comprehensive
assessment of either HL or TT?

Muscles protect the joints about which they
function. Without performing an evaluation to the
muscular group known to resist 1st metatarsal
dorsiflexion during the 2nd half of the stance
phase of gait, differentiating the etiology from
symptom is simply not possible. Muscular
inhibition is a well described medical condition,
but this knowledge has unfortunately not found
its way to the 1st MTP joint.

Inhibition of the peroneus longus often follows
mild to moderate ankle sprain (hence the feeling
of walking inverted) and over time, results in a
chronically dorsiflexed 1st ray with repetitive
jamming of the MTP joint while walking. This
perpetuates the symptoms and results in a daily
inflammatory response as part of a normal repair
process.

Even in the cases where obvious DJD has
developed, management via motion enhancement vs.
motion control can succeed. Treatment involves
the use of ankle, cuboid and 1st MTP joint
manipulation. (You can search Dananberg,
Manipulation on YouTube.) As the peroneus longus
originates from the fibula, this form of
treatment re-establishes peroneal facilitation
and thus normal 1st MTP joint stabilization.
Orthotics which allow for 1st metatarsal head
plantarflexion (i.e., 1st ray cutouts) are also
important for longer term management.

The use of stiff plates to restrict motion may be
helpful in short term management for true joint
injury, but long term use will only exacerbate
the problem or shift the symptoms to the lateral
side of the foot. The article I wrote for
Podiatry Management details the evaluation and
treatment process, and there are additional
articles on this topic on the Vasyli Medical
website. Simply because this approach has not
been commonly taught in podiatry training does
not mean it does not exist. This method of care
is safe and outcomes are often rapid and
rewarding to both physician and patient.

Howard Dananberg, DPM, Stowe, VT

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