Question
I am just over 50.

My big toe is starting to turn inward (away from center towards the other toes) -- but only slightly at this point.

My dad is 84 -- and his big toe is crossed over the toe next to it and I would like to avoid this happening to me as years go by.

I've been researching on the net and can't really find much information on how to prevent this.  Most of the internet info concerns bunions that form as a result of hallux valgus.

I've seen the suggestion that tight fitting shoes cause this.  But I am at home most of the time and we leave our shoes at the door.  Even so, my shoes are "earth variety" shoes with extra room across the toes.  

I've been reading on nutrition and experimenting with different supplements over the years and have recently added glucosamine/chondroitin -- this seems to have a positive effect on the big toe effect -- but since my condition is NOT severe or overly noticeable, it's hard to tell if this could be helpful in preventing the toe from gradually turning.  Glucosamine/chondrotin supplementation, you might know, is thought to be useful in keeping arthritic swelling down because it keeps joints from abrasion that can cause build up.

While some supplements might be useful in helping preventing, my question is not really only about supplements but also about ANY general preventative measures that might be taken in order to prevent the big toe from changing its orientation in relation to the rest of the foot.

Thanks if you can help here or if you would suggest any sites where I mught research for some clues to this question.  So far I've had no luck coming up with internet information.

Some years ago, I had a deep scar removed by a podiatrist.  I am thinking of making an appointment for a consultation -- but this would be just for prevention -- there is currently no condition on my foot that could be treated.  Plus, a visit would be expensive.  Since there's no reason for a visit, I'd like to find some info on my own.

Thanks again,

Jerry in Pennsylvania  

Answer
Hi Jerry,

Certainly, good nutrition and proper footwear can help maintain joint health, but if you have a progressive deformity, the only way to address it is to find the cause.  Often, there is some type of arthritic condition involved in situations like yours; sometimes, there are more simple mechanical problems such as the tendon having some fibrous changes and not being able to glide smoothly/even getting stuck which lead the toe to turn.  Another possibility is a problem with the stability of the foot--are the muscles supporting the arch correctly?  are the bones in proper alignment or have they shifted, causing the toe(s) to shift as well?  is there a problem with the gait (walking) pattern that is shifting the toe inward? Those are some questions an examiner would ask.

Since your father had a similar event, it wouldn't be a stretch to assume the cause of his toe dysfunction might be the cause of yours.  

Prevention wise, if there is a mechanical force directing the toe inward, I don't know of any exercise or nutritional program that will stop that from happening.  There may be some splinting techniques that could slow the process or perhaps some orthotics to help correct any mal-alignment. Also, surgical correction can be done to stop the progression and even reverse it.  Furthermore, if it is systemic in nature (arthritis, for example), only early intervention and medications can help prevent or slow this type of deformity.

Long story short, I think it is worth it to get it looked at by a professional.  Starting with your primary care physician wouldn't be inappropriate (and would probably be less expensive).  He/She could give you a better idea what the cause is and what the expected progression is, and that would let you know whether to make an appointment with the podiatrist or any other type of specialist.  

I'm sorry I don't have a simpler answer for you, but since we don't know the cause, it makes it difficult to narrow down a solution.  I found a few good websites.  Here is a quote from one of the best with my comments in CAPs-- The entire page there is very good, and it goes into detail on the treatment options as well.  http://www.emedicine.com/orthoped/topic126.htm

"Hallux valgus is known to have numerous etiologies, including biomechanical, traumatic, and metabolic factors.

Etiologies of hallux valgus include the following:

   * Biomechanical instability
--MEANING THE SMALL ROCK LIKE BONES IN THE FOOT MAY BE MIS-ALIGNED, OVERLY STIFF, OR OVERLY MOBILE, CAUSING THE TOE TO "TAKE UP THE SLACK" WHILE YOU WALK--
         o The most common yet most difficult to understand etiology is biomechanical instability. Contributing factors, if present, include gastrocnemius or gastrocsoleus equinus, flexible or rigid pes plano valgus, rigid or flexible forefoot varus, dorsiflexed first ray, hypermobility, or short first metatarsal. Most often, excessive pronation at the midtarsal and subtalar joints compensates for these factors throughout the gait cycle.

         o Some pronation must occur in gait to absorb ground-reactive forces. However, excessive pronation produces too much midfoot mobility, which decreases stability and prevents resupination and creation of a rigid lever arm; these effects make propulsion difficult.

         o During normal propulsion, approximately 65?of dorsiflexion is necessary at the first metatarsophalangeal joint, yet only 20-30?is available from hallux dorsiflexion. Therefore, the first metatarsal must plantarflex at the sesamoid complex to gain the additional 40?of motion needed. Failure to attain the full 65?because of jamming of the joint during pronation subjects the first metatarsophalangeal to intense forces from which hallux valgus develops.

         o If the foot is sufficiently hypermobile as a result of excessive pronation, the metatarsal tends to drift medially and the hallux drifts laterally, producing hallux valgus. If no hypermobility is present, hallux rigidus develops instead.

   * Arthritic/metabolic conditions (see Images 1-2)
--MEANING THESE CONDITIONS HAVE BEEN KNOWN TO CAUSE THE BIG TOE TO TURN INWARDS...THIS DOES NOT MEAN YOU HAVE THESE CONDITIONS, BUT IT DOES SUGGEST IT WOULD BE WISE TO HAVE YOUR PRIMARY CARE PHYSICIAN LOOK YOU OVER--
         o Gouty arthritis

         o Rheumatoid arthritis

         o Psoriatic arthritis
--THESE CONDITIONS BELOW ARE VERY RARE AND IT IS HIGHLY UNLIKELY YOU WOULD HAVE THEM AND NOT ALREADY KNOW IT--
         o Connective tissue disorders such as Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome, and ligamentous laxity

   * Neuromuscular disease

         o Multiple sclerosis

         o Charcot-Marie-Tooth disease

         o Cerebral palsy
--PREVIOUS INJURIES IN THE FOOT OR LEG CAUSING IMBALANCES THAT RESULT IN ABNORMAL STRESS ON THE TOE--
   * Traumatic compromise

         o Malunions

         o Intra-articular damage

         o Soft tissue sprains

         o Dislocations

   * Structural deformity
--OF THE BONES IN THE FOOT--
         o Malalignment of articular surface or metatarsal shaft

         o Abnormal metatarsal length

         o Metatarsus primus elevatus
--...OF THE CALF AND UPPER LEG BONES--
         o External tibial torsion

         o Genu varum or valgum

         o Femoral retrotorsion
--
Pathophysiology: During the gait cycle, the hallux --BIG TOE--and digits generally remain parallel to the long axis of the foot, regardless of the degree of forefoot abduction (or pronation) occurring --ABDUCTION=SPLAYING, PRONATION=TURNING UNDER--(see Image 3). This is because of the pull of the conjoined adductor tendon, extensor hallucis longus, and flexor hallucis longus tendons. The tendons gain greater mechanical advantage the further displaced the joint becomes, with tension created for the medial aspect of the joint and compression laterally.

Medial tension causes the medial collateral ligaments to pull on the dorsomedial aspect of the first metatarsal head, causing the bone to proliferate. Lateral tension causes the sesamoid apparatus to fixate in a laterally dislocated position. Remodeling also occurs laterally in addition to medially, as evidenced by the increase of the proximal articular set angle or structural remodeling of the cartilage. Therefore, without correction of the biomechanical etiology, excessive pronation continues, with propagation of the deformity. "--IN OTHER WORDS, THE TENDONS ON THE INWARD SIDE GET AN ADVANTAGE BECAUSE THE TOE IS LEANING TOWARDS THEM, SO THEY SHORTEN AND PULL HARDER; THIS CAUSES THE TENDONS ON THE OUTWARD SIDE TO STRETCH OUT, CAUSING THE JOINT TO BEND AWKWARDLY; THERE ARE VERY SMALL ROCK-LIKE BONES CALLED SESMOID BONES AND IF THE BEND CONTINUES, THEY GET DISPLACED/DISLOCATED AND GET STUCK OVER ON THE OUTSIDE OF THE TOE.  CHANGES IN THE CARTILAGE START TO OCCUR DUE TO ABNORMAL WEARING, AND THIS WEAR, JUST LIKE ON YOUR TIRES, WILL CAUSE THE TOE TO GLIDE UNEVENLY, WHICH STARTS THE CYCLE ALL OVER AGAIN WITH THE TENDONS ON THE INSIDE SHORTENING FURTHER--

I hope this has been helpful to you.  Please don't hesitate to write back if you have other questions.

Best wishes,

Jen