All right. Welcome everyone to the next episode of the Redefining Physical Therapy podcast. I’m your host, Dr. Gray. Happy Wednesday, everyone.

And so today, I want to talk a little bit more about the first ray and the first MTP joint.

So obviously, this is a very important point that I think sometimes gets overlooked, or maybe it’s kind of misconstrued in the way that it gets extension functionally.

And so up to this point, over the last few weeks, I’ve really talked about how the rearfoot and the ankle joint and just different ways of mobilizing them, but then I’m going to talk a little bit more about how that impacts the first MTP.

And so I’ve been seeing quite a few patients coming in with hallux rigidus and limitus, where they just don’t have any real big toe extension. And so, as we propel off and gate that big toe is important because all the weight goes through that big toe to propel off towards the end, the terminal stance, and heel lift.

As we’ve reviewed in other podcast episodes, which I would highly recommend, you need a normal reaction at the subtalar joint and ankle and even up at the hip to get the mechanics right, and so for the MTP to function the way it needs to. And so let’s break that down step by step.

As I step in the gate and as I go heel contact, the foot’s relatively inverted, but then my foot, as I step, my foot wants to get its flat onto the ground.

So it’s going to want to go through pronation at the rear foot, and that’s going to go faster relative to the forefoot. And so relatively speaking, the forefoot and midfoot are going to go through inversion.

Now, all of this changes as I step through with my opposite foot.

So my rear foot then is going to go through supination and I’m going to get a pronation twist at the forefoot midfoot complex, because my rear foot is going faster, so it’s a relative.

And so to keep my foot flat on the ground, I need pronation at my forefoot midfoot complex.

And this is so important because what that does is allows that first TMT joint to glide plantarly so that it then clears the first MTP, the phalanx there to get big toe extension.

Now, it’s necessary to have ankle dorsiflexion in terminal stance, hip extension in terminal stance, and also rearfoot inversion because then you’re not going to get that relative pronation twist at the forefoot midfoot.

And so therefore over time, you’re jamming up that joint and not going through the full range of motion of it. And so eventually, you can get this hallux rigidus and limitus to the big toe joint.

And so basically in a nutshell, if your rear foot and your ankle isn’t functioning, you’re going to overtime never be able to go through and propel off your first ray because the biomechanics are all thrown off.

And so basically what you need to do is A, make sure that you’ve got enough rearfoot inversion mobility and strength to supinate.

You also need to make sure that you have enough calf sensibility.

You also need to know that you’re going to post your glide of that tailless.

You might need some adequate joint play of the syndesmosis between the tib fib complex, but another part of it is adequate hip extension.

So if I don’t have an adequate hip extension, I’m never going to get full ankle dorsiflexion. And if I don’t have full ankle dorsiflexion, I’m not going to get my rear foot to invert.

And so then, I’m not going to get that pronation twist at the forefoot and midfoot, and eventually, I’m going to wear out my MTP joint.

So I know that was a lot, but if you do apply those mechanics and understand what drives that joint and how it really does extend itself.

I think you’ll have better clinical outcomes in treating this joint because anyone can mobilize that joint and sure, there’s time and place just to give that joint some love and distract and get that mobility back.

But at the end of the day, you got to get this stuff more proximal working right to help that distal joint.

So apply that with your patients, leave any comments in the feed, and I’ll be glad to answer any questions that you may have.