Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe. 

What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head. 

This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.

So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:

  • impaired toe off
  • premature heel rise
  • watchful eye on achilles issues
  • impaired hip extension and gluteal function
  • impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)
  • impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)
  • lateral toe off which will promote ankle and foot inversion, which will challenge the peronei
  • frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function
  • possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)
  • possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading
  • impaired arm swing, more notable contralaterally

There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.

* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).

If you know the complicated things, then the simple things become … … . . simple.

Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left. 

… .  sorry for the rant, too much coffee this morning, obviously.

Shawn Allen, one of the gait guys

The Great toe’s effect on external hip rotation.

We have a simple video for you today. 

When we assess our clients for gait and locomotion we do a quick screen of all the big player joints, from the toes at least up into the thoracic spine to start. Loss of mobility/range of motion means probable functional impairment. 

In this video we display the effects of the Windlass Mechanism of the great toe. A windlass mechanism according to Wikipedia is:

a type of winch used especially on ships to hoist anchors and haul on mooring lines and, especially formerly, to lower buckets into and hoist them up from wells.

In this case, dorsiflexing the big toe spools the plantarfascia and flexor hallucis longus and brevis around the metatarsophalangeal joint (1st. MTPJ), thus pulling the heel towards the forefoot thus raising the arch. When the arch raises, the talus moves cephalad (upwards) and because of the supinatory movement orientation, it spins the tibial externally which in turn spins the femur externally. This is what you see in this video, note the blue dots being carried laterally with the limb external rotation.

The point here today, if you have loss of external hip rotation, it could be crying for you to evaluate the range of motion of the 1st MTP joint , it could be crying for you to evaluate the skill of toe extension, strength or endurance or all of the above. Impairment of the 1st MTP has great inroads into ineffective locomotion. You must have decent range of motion to effectively supinate, to effectively toe off, to externally rotate the limb, to effectively acquire hip extension to maximize gluteal use.  Thus, one could easily say that impaired hallux/great toe extension (skill, ability, endurance, strength) can impair hip extension (and clean hip extension patterning) and result in possible terminal propulsive gait extension occurring through the lumbar spine instead of through the hip joint proper.

Think of the effects of two asymmetrical great toe extensions, comparing the great toe left to right. Asymmetry in the limbs, pelvis, hip extension and perhaps worse, the lumbar spine, is a virtual guarantee.  Compare hallux extension side to side, if you can achieve symmetry through skill, endurance and strength retraining, you must do it. If you have a hallux limitus, a bunion or anything that impairs the symmetry of great toe extension side to side, you have some interesting work to do. 

You have to know what you have in your client, and know what it means to their locomotion.  Seeing or recognizing what you have must translate into understanding and action. 

Play mental games with clinical entities.  In this case, if at terminal toe off you did not have full hallux extension like in this client, and thus you did not get that last little final external rotation spin in the limb at the hip … . . what could that do to your gait ? Go tape your toe and limit terminal extension (terminal dorsiflexion) and walk around, to feel it in yourself is to get first hand experience. 

Shawn Allen, one of the gait guys

Pain at toe-off; Stopping Big Toe Impingement with the extensor hallucis capsularis.

Photo: note the AET coming off the EHL tendon in the diagram

What if there was a mechanism in place by which to pull structures out of the way of a joint moving to end range ? If you know your biomechanics, you know this is a true phenomenon on several levels. We know of one at the knee, the articularis genu has been written about having function of drawing the suprapatellar bursa and joint capsule/synovial tissue cephalad (upward) during knee extension preventing an impingement phenomenon during full quadriceps contraction in knee extension loading. 

What if there were a similar mechanism in the big toe ? When teaching we are sometimes asked what joint, that when it goes sour, creates more devastation to the entire biomechanical chain than any other joint. I like to choose the big toe/1st metatarsophalangeal joint because failure to fully push off the big toe at full joint range impairs hip extension, stride and step lengths, and creates compensations far and wide ipsilaterally and contralaterally in the body. Most everyone knows about bunions, turf toe, hallux valgus, sesamoiditis and the like, but there are many other things that can make this joint painful. Today we bring you another “clearing mechanism” that acts to pull synovial and capsular tissues out of a joint that is nearing end range.
As seen in the anatomy dissection photo above, the extensor hallucis capsularis (EHC) is an accessory tendon slip off of the extensor hallucis longus (EHL). Interestingly, one study found that 8% of the dissections showed the EHC came off of the tibialis anterior tendon slip. This EHC accessory slip typically originates off the long extensor tendon (EHL) and traverses medially to the dorsomedial joint capsule region. Some studies suggest it is found in 80-98% of people. We propose it is most likely present in everyone because of the critical nature of its function. We propose that perhaps it may be missed on traditional dissections because of its blending with fascial tissues and because of its sometimes trivial size and girth. Just like when we fully extend our knee we want to be sure the articularis genu will draw the synovial capsular tissue up and out of the patellar/femoral approximation, the EHC has been shown on intra-operative testing to exert a pretension on the metatarsophalangeal (MTP) joint capsule similarly pulling the synovial-capsular tissue free from the end range dorsiflexing toe. Without this function, synovial-capsular impingement can occur and create pain and an inhibitory arthrogenic reflex to the EHL, tibialis anterior or any other muscles around the joint for that matter. This can act and feel like an acute “turf toe” (hyper-dorsiflexion event) and yet, not be true turf toe osseous impingement.
So if your client has pain at the dorsal joint on end range extension of the great toe, meaning things like toe-off, doing push ups from the ball of the foot, jumping, kneeling or squatting with the hallux in forced dorsiflexion etc, this tendon slip (and its origin, the EHL muscle) should be on your mind and assessment of the anterior compartment for S.E.S. must commence (S.E.S.= skill, endurance and strength, our Gait Guys mantra). This is why you need to intimately understand this important video (link) and need to know how to do this exercise, the shuffle walks (video link) and build clean ankle rocker ranges of motion via S.E.S. of the anterior compartment.  Pulling on the great toe, twisting it like a radio knob, and forcing end range shouldn’t be the biggest guns in your arsenal, logically restoring all the dysfunctional components should be.

We wonder how many of the videos online of people demonstrating big toe mobilizations, toe distractions, fancy exercises and various toe circus tricks to regain motion and function and reduce pain actually truly know about the anatomy and function of the big toe and how ankle rocker and other things can impair its function.  We wonder about these kinds of things.  

Please just remember, the average uneducated viewer is merely looking for solutions to their painful parts. Those in the know have a responsibility to deliver as complete a package as possible, within reason. 

“With great powers (and knowledge) there must also come, great responsibility.”-Stan Lee  

Dr. Shawn Allen

the gait guys

Photo credit link:


Foot Ankle Surg. 2014 Sep;20(3):192-4. doi: 10.1016/j.fas.2014.04.001. Epub 2014 Apr 16.
The extensor hallucis capsularis tendon—a prospective study of its occurrence and function.Bayer T1, Kolodziejski N2, Flueckiger G2.

Foot Ankle Int. 2006 Mar;27(3):181-4.
Extensor hallucis capsularis: frequency and identification on MRI.
Boyd N1, Brock H, Meier A, Miller R, Mlady G, Firoozbakhsh K.

Foot Ankle Int. 2004 Jun;25(6):387-90.
The accessory extensor tendon of the first metatarsophalangeal joint.
Bibbo C1, Arangio G, Patel DV.

Foot Clearance: We don’t think about it until we are face down in the mud, and we have all been there.

How many times have you tripped over something so small and insignificant you can barely believe it ? We have all tripped over a small elevation in a cracked sidewalk or a curled up rug corner.  But sometimes we look back and there is no evidence of a culprit, not even a Hobbit or an elf.  How can this happen ?
Minimum foot clearance (MFC) is defined as the minimum vertical distance between the lowest point of the foot of the swing leg and the walking surface during the swing phase of the gait cycle. In other simpler words, the minimum height all parts of the foot need to clear the ground to progress through the swing phase of the limb without contacting the ground. One could justify that getting as close to this minimal amount without catching the foot is most mechanically advantageous.  But, how close to vulnerability are you willing to get ? And as you age, do you even want to enter the danger zone ? Obviously, insufficient clearance is linked to tripping and falling, which is most concerning in the elderly. 
Trips or falls from insufficient foot clearance can be related to insufficient hallux and toe(s) dorsiflexion (extension), ankle dorsiflexion, knee flexion and/or hip flexion, failure to maintain ipsilateral pelvis neutral ( anterior/posterior pelvis posture shifting), even insufficient hip hike generated by the contralateral hip abductors, namely the gluteus medius in most people’s minds. It can also be from an obvious failed concerted effort of all of the above. Note that some of these biomechanical events are sagittal and some are frontal plane.  However, do not ever forget that the swing leg is moving through the axial plane, supported in part by the abdominal wall, starting from a posteriorly obliqued pelvis at swing initiation into an anteriorly obliqued position at terminal swing. We would be remiss as well if we did not ask the reader to consider the “inverted pendulum theory” effect of controlling the dynamically moving torso over the fixed stance phase leg (yes, we could have said “core stability” but that is so flippantly used these days that many lose appreciation for really what is happening dynamically in human locomotion).  If each component is even slightly insufficient, a summation can lead to failed foot clearance.  This is why a total body examination is necessary, every time, and its why the exclusive use of video gait analysis alone will fail every time in finding the culprit(s). 
When we examine people we all tend to look for biomechanical issues unless one grasps the greater global picture of how the body must work as a whole. When one trips we first tend to look for an external source as the cause such as a turned up rug or an object, but there are plentiful internal causes as well. For example, we have this blog post on people tripping on subway stairs.  In this case, there was a change in the perceptual height of the stairs because of a subconscious, learned and engaged sensory-motor behavior of prior steps upward.  However, do not discount direct, peripheral and lower fields of view vision changes or challenges when it comes to trips and falls. Do not forget to consider vestibular components, illumination and gait speed variables as well.  Even the most subtle change in the environment (transitions from tile to carpet, transitions from treadmill to ground walking etc) can cause a trip or fall if it is subtle enough to avoid detection, especially if one is skirting the edge of MFC (minimal foot clearance) already. And, remember this, gait has components of both anticipatory and reactive adjustments, any sensory-motor adaptive changes that impair the speed, calculation and timely integration of these adjustments can change gait behaviors. Sometimes even perceived fall or trip risk in a client can easily slip them into a shorter step/stride length to encourage less single leg stance phase and more double support phase gait. This occurs often in the elderly. This can be met with a reduced minimal foot clearance by design which in itself can increase risk, especially at the moment of transition from a larger step length to a shorter one. Understanding all age-related and non-age related effects on lower limb trajectory variables as described above and only help the clinician become more competent in gait analysis of your client and in understanding the critical variables that are challenging them. 
Many studies indicate that variability and consistency in a motor pattern such as those necessary for foot clearance are huge keys for predictable patterns and injury prevention, and in this case a predictor for trips and falls.  Barrett’s study concluded that “greater MFC variability was observed in older compared to younger adults and older fallers compared to older non-fallers in the majority of studies. Greater MFC variability may contribute to increased risk of trips and associated falls in older compared to young adults and older fallers compared to older non-fallers.”
Once again we outline our mission, to enlighten everyone into the complexities of gait and how gait is all encompassing.  There are so many variables to gait, many of which will never be noted, detected or reflected on a gait analysis and a camera.  Don’t be a minimalist when it comes to evaluating your client’s gait, simply using a treadmill, a camera and some elaborate computer software are not often going to cut the mustard when it really counts.  A knowledgeable and engaged brain are arguably your best gait analysis tools.  
Remember, what you see in someone’s gait is not their problem, it is their adaptive strategy(s).  That is all you are seeing on your camera and computer screen, compensations, not the source of the problem(s).
Shawn and Ivo
the gait guys
References (some of them): 

1. Gait Posture. 2010 Oct;32(4):429-35. doi: 10.1016/j.gaitpost.2010.07.010. Epub 2010 Aug 7.

A systematic review of the effect of ageing and falls history on minimum foot clearance characteristics during level walking. Barrett RS1, Mills PM, Begg RK.

2. Gait Posture. 2007 Feb;25(2):191-8. Epub 2006 May 4. Minimum foot clearance during walking: strategies for the minimisation of trip-related falls. Begg R1, Best R, Dell’Oro L, Taylor S.

3. Clin Biomech (Bristol, Avon). 2011 Nov;26(9):962-8. doi: 10.1016/j.clinbiomech.2011.05.013. Epub 2011 Jun 29. Ageing and limb dominance effects on foot-ground clearance during treadmill and overground walking. Nagano H1, Begg RK, Sparrow WA, Taylor S.

4. Acta Bioeng Biomech. 2014;16(1):3-9. Differences in gait pattern between the elderly and the young during level walking under low illumination. Choi JS, Kang DW, Shin YH, Tack GR.

The Abductor Heel Twist: Look carefully, it is here in this video.

This should be a simple “piece it together” video case study for you all by this point. This young lad came into our office with left insertional achilles pain of two weeks duration after starting some middle distance running.

What do you see here ? It is evident on both the right and the left, but it is a little more obvious on the left and can be seen on the left when he is walking back toward the camera as well.  You should see rearfoot eversion, it is excessive, and a small rearfoot adductor twist. Meaning, the heel pivots medially towards the midline of his body.  Some sources (Michaud) call this an Abductory Twist, but the reference there is typically the forefoot.  Regardless, to help our patients, we sometimes refer to this is “cigarette butt” foot. It is like stepping on a lit cigarette to put it out via twisting/grinding it into the ground. 

So, now that you can see this, what causes it? 

The answer is broad but in this case he had a loss of ankle dorsiflexion range.  The ankle mortise clearly did not have enough of ankle rocker range during midstance so as that limitation was met, the heel raised up prematurely during the moments when the opposite leg is in full swing imparting an external rotation on the stance limb (hence the external foot spin (adducting heel/abducting foot……depending on your visual reference)). There is a bit more to it than that, but that will suffice for now because it is not the central focus of our lesson today.

What can cause this ? As we said, a broad range of things:

  • hallux limitus
  • flexion contracture of the knee (swelling, pain, joint replacement etc)
  • short calf-achilles complex
  • weak tib anterior and extensor toe muscles
  • Foot Baller’s ankle
  • limited/impaired hip extension
  • weak glute (minimizing hip extension range)
  • sway back (lower crossed syndrome-type biomechanics)
  • short quadriceps (similarly impairing hip extension)
  • flip flop excessive use (or any other motor strategy that imparts more flexor compartment dominance (read: calf-achilles, FDL)
  • excessive pronation
  • impaired foot tripod mechanics
  • etc

The point is that anything impairing TIMELY (the key word is timely) forward sagittal gait mechanics can, and very likely will, impair ankle rocker.  Even the wrong shoe choice can do this (ie. someone who suddenly drops from a 12 mm heel ramped shoe into a 0-4mm ramped heel shoe and who thus may not have earned the length of the calf-achilles complex as of yet).

The abductor-adductor twist phenomenon is not a normal visual gait observation. It is a softly seen, but screaming loud, pathologic gait motor pattern that must be recognized.  But, more importantly, the source of the problem must be found, confirmed and resolved.  In this fella’s case, he has some weakness of the tib anterior and extensor toe muscles that has lead to compensatory tightness of the calf complex. There was no impairment of the glutes or hip extension, as this was just 2 weeks old or so, but if left unaddressed much longer the CNS would have likely begun to dump out of hip extension and gluteal function to protect……another compensation pattern. Remember, ankle rocker and hip extension have a close eye on each other during gait.

Clinical pearl for the true gait geeks…… if you see someone with a vertically bouncy forefoot-type gait (you know, those people that bounce up and down the hallway at work or school) you can usually suspect impaired ankle rocker and if you look closely, you will usually see a quick abductor-adductor twist.

Shawn and Ivo

the gait guys

Spanking the orthotic: The effects of hallux limitus on the foot’s longitudinal arch.

But the issues do not stop at the arch. If you have been with us long enough, you will have read about the effects of the anterior compartment (namely the tibialis anterior, extensor digitorum and hallucis and peroneus tertius muscles) strength and endurance on the arch.

Here we have a very troubled foot. This foot has undergone numerous procedures, sadly. Today we will not talk about the hallux varus you see here, a virtual unicorn in practice  (and acquired in this case) nor do we want to discuss the phalangeal varus drift. We want to draw your attention to the obvious impairment of the 1st MTP (metatarsophalangeal joint) dorsiflexion range.  You can see the large dorsal crown of osteophytes, a dorsal buttress to any hallux dorsiflexion.  There is under 10 degrees of dorsiflexion here, not even enough worth mentioning.  We have said it many times before, if you lose a range at one joint usually that range has to be accommodated for proximal or distal to the impaired joint. This is a compensation pattern and you can see it here in the hallux joints themselves.

Here you can see that some of the dorsiflexion range has been acquired in the proximal phalangeal joint.  We like to call this “banana toe” when explaining it to patients, it is a highly technical term but you are welcome to borrow it. This occurred because the joint was constantly seeing the limitation of dorsiflexion of the 1st MTP joint and seeing, and accommodating to, the demands of the need for more dorsiflexion at toe off. 

But, here is the kicker. You have likely seen this video of ours on Youtube on how to acquire a foot tripod from using the toe extensors to raise the arch.  Video link here  and here.  Well, in his patient’s case today, they have a limitation of 1st MTP dorsiflexion, so the ability to maximally raise the arch is impaired. The Windlass mechanism is broken; “winding” of the plantar fascia around the !st MTP mechanism is not sufficiently present. Any limitations in toe extension (ie dorsiflexion) or ankle dorsiflexion will mean that :

1. compensations will need to occur

2. The Windlass mechanism is insufficient

3. gait is impaired at distal swing phase and toe off phases

4. the anterior compartment competence will drop (Skill, endurance, strength) and thus injury can be more easily brought to the table.

In this patient’s case, they came in complaining of burning at the top of the foot and stiffness in the anterior ankle mortise area.  This would only come on after a long brisk walk.  If the walk was brisk yet short, no problems. If the walk was long and slow, no problems.  They clearly had an endurance problem and an endurance challenge in the office showed an immediate failure in under 30 seconds (we will try to shoot a quick video so show our little assessment so be patient with us). The point here today is that if there is a joint limitation, there will be a limitation in skill, strength or endurance and very likely a combination of the 3. If you cannot get to a range, then any skill, endurance or strength beyond that limitation will be lost and require a compensation pattern to occur.  This patient’s arch cannot be restored via the methods we describe here on our blog and it cannot be restored by an orthotic. The orthotic will likely further change, likely in a negative manner, the already limited function of the 1st MPJ. In other words, if you raise the arch, you will shorten the plantar fascia and draw the 1st MET  head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … .  but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ……..yes, exactly !  So use your head  (and spank the orthotic when you see it used in this manner.  ”Bad orthotic, bad orthotic !”)

So think of all of this the next time you see a turf toe / hallux rigidus/ hallux limitus. Rattles your brain huh !?

This is not stuff for the feint of heart. You gotta know your biomechanics.

Shawn and Ivo … .the gait guys

Addendum for clarity:

a Facebook reader asked a question:

From your post: “if you raise the arch, you will shorten the plantar fascia and draw the 1st MET head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … . but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ” I always thought when the plantar fascia is shortened, it plantar flexes the 1st metatarsal (1st ray) and extends (dorsiflexes) the 1st MTP joint….

Our response:  

We should have been more clear, our apologies dear reader.  Here is what we should have said , ” The plantar fascia is non-contractile, so it does not shorten. We meant conceptually shorten. When in late stance phase, particularly at toe off when the heel has raised and forefoot loading is occurring, the Windlass mechanism around the 1st MET head (as the hallux is dorsiflexing) is drawing the foot into supination and thus the heel towards the forefoot (ie passive arch lift). This action is driving the 1st MET into plantarflexion in the NORMAL foot.  This will NORMALLy help with increasing hallux dorsiflexion. In this case above, there is a rigid 1st MTP  joint.  So this mechanism cannot occur at all. In this case the plantar fascia will over time retract to the only length it does experience. So, if an orthotic is used, it will press up into the fascia and also plantarflex the 1st MET, which will carry the rigid toe into plantar flexion with it, IN THIS CASE.”

Hallux Varus: The anti-bunion. Thinking of bunion surgery ? This could be a complication if things go sour.

Hallux varus, when the big toe drifts medially, is a real problem. It is typically an acquired problem from a hallux valgus/bunion surgery gone awry.  (This post will not delve into some of the suspected culprits of this problem including Mc Bride, Scarf, Chevron or Akin osteotomy etc but that would be some of the reader’s next steps into diving deeper into this problem. Surgical procedures to the 1st ray was one of the gait guys senior orthopedic residency thesis topics, hence we now hate this topic !). 
This deformity can be rigid or flexible.  This case seen in the photo walked into our office recently.  These are not all that common and you won’t see many of them, but you do need to know they exist and where they can come from, how to cope with them and what issues you will need to understand (ie. footwear, talked about below) to assist your client. 
Hallux varus can be painful, uncomfortable and even debilitating in some cases.  Sometimes they necessitate fixation to realign the hallux bone along a more reasonable alignment with the shaft of the 1st metatarsal. 
Early correction seems critical because the linear and rotational forces at work generating the deformity can eventually lead to a further progressing deformity that can be even more problematic. When left unaddressed more drastic and radical corrective interventions seem necessary, including but not limited to, resection of the base of the proximal phalanx, fusions and tendon transfers. However, newer surgical procedures are coming along proposing things like reconstruction of the lateral stabilising components of the first metatarsophalangeal (MTP) joint. 
So here at The Gait Guys we like to ask the big, and sometimes obvious, questions.  What is toe off in walking and running gait going to look like in this hallux varus case ?  Well, one has to consider that the normal linear and rotational forces are now changed.  This means that the normal eccentric axis of the 1st MPT joint involved is going to very likely be changed. This means that the clearance of the base of the phalanx could be impaired and lead to painful binding, grinding or locking of the toe prior to reaching the adequate range of dorsiflexion for normal toe off. Additionally, the toe may act functionally unstable as the rotational forces remain unchecked leading to joint instability. Naturally, the medial foot tripod will be impaired and since the big toe acts in part like a kickstand to help support and fixate the 1st metatarsal (medial tripod), pronation forces can remain unchecked and beyond normal.  Naturally the foot will attempt to shift the tripod stability elsewhere and often this goes to the 2nd metatarsal commonly found with hammering of the digit in an attempt to help with stability through increased long flexor tone (FDL). Pain with a hallux varus can be a bigger complaint than the unsightly surgical outcome.
There is so much more to this topic. We could go on for at least another 50 pages on this topic (as our thesis reminds us) but volume is not the point of today’s task. It was to bring something new to light for our brethren here at The Gait Guys.  In the photo above, you see drift of the lesser toes, seemingly to follow the big toe. What you need to know is that this is not typical, however not impossible one could propose. This client had some other forefoot procedures done that were largely, although not exclusively, related to that lesser digit drift. Regardless, this is a client that is in some amount of foot trouble. They had good mobility of the 1st MTP joint, so full toe off was possible but because of the instability and uncontrollable rotational forces the joint was painful. A simple intervention made her life infinitely more comfortable, moving her into rigid rocker bottomed shoes.  Dansko clogs for work, and ROCS shoes for walking.  This left us with a very happy client. Not bad, all things considered.  In the mean time we will watch for deformity progression even though the patient could not be urged to have another surgery probably even if their life depended upon it. 
In summary, being a patient can be difficult. These days, more than ever it seems, one needs to do their homework and be their own advocate.  Prior to surgery several consults should have taken place, risk and rewards should have been discussed, realistic outcomes dialogued and perhaps most of all questioning whether surgery needed to be on the table in the first place. Remember, surgery is most wisely selected in cases of neurologic decline and excessively painful and further detrimental biomechanics (ie. unaddressed ACL deficiency eventually promoting secondary instability with time). If there are ways around either, they should be explored. Cosmetic correction should never be on the table, and in the case of the foot, nor should poor shoe choices that promote problems.