The Effect of Great Toe Amputation on Gait

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Angela LeBlanc
KIN 3514
November 18, 2013

The Effect of Great Toe Amputation on Gait

One of the greatest concerns parents may face is that their newborn child could
possess birth defects. Often times, He has ten fingers and ten toes is the first bit of
information relayed from parents to family and friends. Just how important of a role do
toes, the Great Toe in particular, play in human gait? An observational study was
conducted to determine the importance of such a small extremity. The focus of our study
was a male, fifty-six years of age, who suffered the loss of his great toe as a result of
infection caused by an untreated fracture. Some of the abnormalities observed include
over-pronation, right lateral lean, foot-slap, excessive arm swing, and forward trunk
flexion. Abnormalities either decreased or disappeared when the subject wore shoes,
which signified that he relied on his shoe as a replacement for his missing toe. Observed
abnormalities were subtle and it is important to understand that many of these
abnormalities were observed only irregularly during the subjects multiple trials and gait
cycles.

Pronation is the shift of weight to the medial line of the foot. Pronation is
considered normal in the human gait however it is possible to over-pronate. The subject
over-pronates and turns his foot out. Over-pronation is considered is a weight shift of 15-
degrees or more to the medial foot (FORM & function 2005). This can be observed in the
socks only posterior view clip. During the stance phase of his left foot, the ankle rolls
medially. This action is not as evident in the right foot. The pronation could be caused to
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the lack of support due to the missing great toe. To compensate for the inward shift of
weight for the toe-off point, the subject turns his feet out to roll off the pad where great
toe once attached.

The participant leans to the right during the toe off of the left foot. This is evident
in the posterior view of no-socks. This occurs because of the attempt to remove some of
the weight from the great toe on the left foot and transfer it to the healthy right foot. The
lateral lean shifts the center of mass to the right side of the body during the toe-off of the
left foot to allow the left foot to begin the swing phase.

The subject displays some foot slap in the left foot during the initiation of the
stance phase. Foot slap is commonly caused by weak extensors or a weak Tibialis
Anterior. It can lead to a general instability in the subject and can shorten a stride length.
Foot slap without a great toe may reduce the pressure placed on the arch because the
great toe plays a major role on arch support. When foot slap occurs, the stance time on
the effected foot is typically greater than that of a healthy foot, which signifies decreased
balance in the foot-slap foot (Jamshidi et. al. 2009). This coincides with the idea that the
lack of the great toe decreases the balance in that foot and thus the time spent in the
stance phase on the effected foot.

During toe-off of the left foot, arm swing greater than normal is evident in the
right arm during the posterior and right sagittal view in both shoe on and shoe off
observations. Arms act as a way to control upper trunk movement. An excessive arm
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swing signifies a resistance to upper trunk rotation. Because the right arm swings, it is
compensating for rightward trunk rotation. This coincides with the slight rightward lateral
lean discussed above. The arm swing may also be occurring to compensate for any
balance issues the right leg may be occurring during the stance. Due to the bodys Kinetic
Chain relationship multiple abnormalities could manifest in one display. In this case the
excessive arm swing could be caused by poor balance and an attempt to oppose trunk
rotation

Forward trunk flexion occurs from mid-stance to toe off of the left foot. This
abnormality is most evident in the right sagittal view with shoes off. When the trunk is
flexed forward, the center of mass shifts posteriorly. This weight shift slightly decreases
the Ground Reaction Forces (GRF) placed on the center of mass of the foot. Ultimately,
the posterior shift of center of mass and the GRF are directly related (Saha, Gard &
Fatone 2008). When these concepts are placed into the context of missing a great toe they
make sense. The forward flexion aims at decreasing the force placed on the great toe
during toe-off because there is no toe present to support that GRF.

Potential injuries that might arise from forward trunk flexion include a strained
hamstring and injury to the Anterior Cruciate Ligament (ACL). Forward flexion of the
trunk causes extension of the hamstring and may provoke the locking of the knee in the
stance phase. Repetitive extension greater than that of a normal gait could cause micro-
trauma to the hamstring. Additionally, the combination of the locking of the knee and an
unexpected adjustment could cause injury to the ACL (Houck, Duncan & Haven 2006).
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ACL injuries are commonly seen in sports that require sudden changes in direction (ex.
soccer and football) for athletes with a normal gait. When an individual makes a sudden
change in direction with the leg in full extension, the risk of injury increases because of
the combined tensions of the stabilizer muscles surrounding the knee and the tensions
caused from the change in direction placed on the viscoelastic ACL.

Functional limitations may include decreased reaction time when body movement
from a stop is required because trunk flexion must first occur before a movement can be
made. This includes but is not limited to balance correction and avoidance of objects. In
normal gait, an individual simply shifts the weight and steps appropriately to adjust for
balance or object avoidance but when someone who requires forward trunk flexion must
make an adjustment it requires compensatory muscles up to the abdominals and Erector
Spinae muscles to make a slight adjustment. To correct the forward flexion of the trunk,
the trunk extensors (Erector Spinae muscles) and abdominal muscles should be
strengthened. Gait training may include practicing to make toe-off occur sooner along
with earlier shifting of weight to the healthy leg.

While at first glance, one may never be able to pick someone out of a crowd with
a missing great toe. However, after closer investigation, minute abnormalities may
present themselves especially when shoes are not worn. While abnormalities occur
irregularly, a missing great toe can cause pronation, foot-slap, excessive arm swing,
lateral trunk flexion, and forward trunk flexion. It is important to remember that
inconsistencies in the appearance of these abnormalities stem from how much balance is
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required in that gait cycle. While at first adjusting to the absence of a great toe may be
challenging with time gait can be adjusted with correctional exercise and practice.





















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Resources

FORM & function. (2005). Running & FitNews, 23(2), 5-7.

Houck, J. R., Duncan, A., & Haven, K. (2006). Comparison of frontal plane trunk
kinematics and hip and knee moments during anticipated and unanticipated walking
and side step cutting tasks. Gait & Posture, 24(3), 314-322.

Jamshidi, N., Rostami, M., Najarian, S., Menhaj, M., Saadatnia, M., & Salami, F. (2009).
Assessment of Ground Reaction Forces of Steppage Gait in Comparison with
Normal gait. Journal Of Musculoskeletal Research, 12(1), 45-52.

Kuhtz-Buschbeck, J. P., & Jing, B. (2012). Activity of upper limb muscles during human
walking. Journal Of Electromyography & Kinesiology, 22(2), 199-206.

Saha, D., Gard, S., & Fatone, S. (2008). The effect of trunk flexion on able-bodied gait.
Gait & Posture, 27(4), 653-660.