Canadian Medical Alliance for the Preservation of the Lower Extremity
Surgical Offloading of Wounds of the Great Toe
We discuss traditional, conservative, non-surgical ways to offload a wound here.
And we discuss why surgical offloading is a concept worth considering generally, even in patients who may be traditionally slow to heal here. If you haven't read that page, it might be worth starting with that page before reading this page.
Here we discuss some of the more specific ways we might wish to
surgically offload an ulcer on the great toe (or hallux, in medical terminology).
And we discuss why surgically addressing ulcers on the great toe in particular often makes a great deal of sense.
The great toe (or hallux in medical terminology) is the single
most common location for a diabetic or neuropathic wound
to form--accounting for something on the order of 1/4 to
1/3 of all such neuropathic ulcers.
Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot.
Lepr Rev 1986;57:261-7. This study found 25% of ulcers in leprosy
patients involved the hallux (N=132); 24% in diabetics (N=45)
Ambegoda, A L A M C & R Wijesekera, J & I Panditharathne,
K & Gamage, Rehan & S Mudalige, C & Piyasiri, Ruvini. (2015).
Analysis of Severity and Anatomical Distribution of Diabetic
Foot Ulcers; A Single Unit Experience 1 A L A M. International
Journal of Multidisciplinary Studies. 2. 1-10. 10.4038/ijms.v2i1.58.
This study (N=45) found 24.4% of diabetic ulcers were in the hallux
Molines-Barroso RJ, Lázaro-Martínez JL, Beneit-Montesinos
JV, Álvaro-Afonso FJ, García-Morales E, García-Álvarez Y.
Predictors of Diabetic Foot Reulceration beneath the Hallux.
J Diabetes Res. 2019 Jan 8;2019:9038171.
doi: 10.1155/2019/9038171. eCollection 2019.
This study states that one-third of all diabetic ulcers are hallux
Ledoux WR, Shofer JB, Cowley MS, Ahroni JH, Cohen V, Boyko EJ.
Diabetic foot ulcer incidence in relation to plantar pressure
magnitude and measurement location J Diabetes Complications.
This study suggests hallux ulcers make up 40.4% of diabetic ulcers
And ulcers in this location are among the most notorious in their tendency to recur. In one study, 83% of hallux ulcers were seen to return within
31.5 months of the study.
Peters EJ, Armstrong DG, Lavery LA. Risk factors for recurrent diabetic
foot ulcers: site matters. Diabetes Care. 2007 Aug;30(8):2077-9.
Epub 2007 May 16. PubMed PMID: 17507693.
Why hallux ulcers recur at so high a frequency has been a matter of
We certainly knew that there is a great deal of pressure and shear
(friction) applied to the great toe in gait, but the heel and the ball of
the foot bear a lot of force in gait, too.
The question is what specific factors are responsible for this increase
in ulceration rate in this location.
A number of possible factors have been suggested.
However, in 2019, researchers in Spain examined over two dozen
potential factors suggested as a cause of hallux re-ulceration,
including the patient’s age, blood sugar level (Hg A1c), circulation
(Ankle-Brachial Index), body-mass index, duration of diabetes, the
presence of nephropathy and retinopathy, great toe joint range of
motion, ankle range of motion, inversion and eversion ranges of
motion, and a half dozen angles of bone orientation.
In the end, the only variables found to be associated with the time
to hallux ulceration were increased body-mass index and a diminished
range of great toe joint motion.
Molines-Barroso RJ, Lázaro-Martínez JL, Beneit-Montesinos JV, Álvaro-Afonso FJ, García-Morales E, García-Álvarez Y.
Predictors of Diabetic Foot Reulceration beneath the Hallux. J Diabetes Res. 2019;2019:9038171. Published 2019 Jan 8.
This effect is demonstrated in one study of hallux ulcers, where 28 patients of 29 patients with ulcers beneath the great toe had a limitation of motion.
Boffeli TJ, Bean JK, Natwick JR. Biomechanical abnormalities and ulcers of the great toe in patients with diabetes.
J Foot Ankle Surg 2002;41:359-64
Normally we have between 60-65 degrees of motion
about the big toe joint.
To the right we see a great toe with even more range
of motion than typical.
However, sometimes people have very poor range of
motion about the big toe joint. This is known as hallux
limitus (if a mild or moderate limitation of motion exists)
or hallux rigidus (if the limitation is more severe).
To the left we see the great toe barely bends at all even when we try pushing toe. This is hallux rigidus.
The joint that is supposed to bend is known as the 1st metatarsophalangeal joint or 1st MTPJ for short.
To the right we see another example of hallux rigidus.
The great toe joint doesn't bend at all at the base of
the toe (1st MTPJ).
As a result, you can see excessive motion at the next
joint, the joint between the toe bones. This joint is
called the interphalangeal joint or IPJ.
The result of the hyperextending IPJ is more pressure
on the bottom of the toe. This has resulted in early
callus development at the bottom of the toe.
A callus like this is the first step towards ulcer
Why Does Great Toe Joint Motion Become Limited?
Limitation of motion of the great toe joint commonly originates with a biomechanical abnormality resulting
in elevation of the first metatarsal bone--the bone to
which the great toe attaches to the foot.
A variety of biomechanical issues can cause this. A
longer-than-normal first metatarsal is one example.
An excessively mobile first metatarsal is another.
But the most common cause of limited motion in a great toe joint is a foot that excessively pronates or flattens in stance--as seen to the left.
We mentioned above how body weight was also related to ulcer recurrence in this location. Extra weight not only increase pressure directly, but it also causes the foot to
When the foot rolls in like this, there is more pressure on that side of the foot and the 1st metatarsal tends to elevate.
A great toe joint is often normal in appearance and in motion when the patient is not bearing weight, but when it elevates in stance, it makes it more difficult for the great toe to get up and around the first metatarsal in order to bend.
A limitation in motion about the great toe joint that is seen only in gait, but has no structural limitation of motion (like arthritis or a bony blockage), is called functional hallux limitus or FHL. FHL is extremely common, and a major factor in the formation of hallux ulcers.
M. K. Allen, T. J. Cuddeford, W. M. Glasoe et al., “Relationship between static mobility of the first
ray and first ray, midfoot, and hindfoot motion during gait,” Foot & Ankle International, vol. 25,
no. 6, pp. 391–396, 2004.
E. Maceira and M. Monteagudo, “Functional hallux rigidus and the Achilles-calcaneus-plantar system,”
Foot and Ankle Clinics, vol. 19, no. 4, pp. 669–699, 2014.
You can see an elevated first metatarsal in the
standing x-ray to the right. Note how the bone
is elevated, but there are no arthritic changes.
If a great toe tries to bend, it is blocked by the
first metatarsal, and cannot bend upwards.
This can cause extra pressure to built up on the
great toe, creating a callus or an ulcer.
At this early stage, with little to no arthritic
change seen in the joint, a specialized orthotic
can be made to allow the 1st metatarsal to
drop, thereby increasing great toe joint motion.
And surgeries to shorten, drop or decompress
the great toe joint may be considered in healthy
patients. These can restore range of motion in
the great toe joint and resolve ulcers under the
Eventually, as the base of the big toe continually
bangs nto the elevated metatarsal, we begin
to see bone changes--enlargements of bone
(known as spurs) that develop on the top of
the joint, as seen to the right.
This bony build up further blocks the 1st MTPJ
movement, increasing pressure on the bottom
of the big toe, leading to ulceration.
When a bony build up is physically blocking great toe joint motion, this is known as a structural or bony hallux limitus.
Surgeries at this stage involve removing the bony spur, possibly with other procedures. Removing a bump like this is not overly invasive as a procedure, and can be performed under local anesthetic. The patient may walk immediately afterward. However, arthritic changes soon develop in the joint, and this may limit motion even if the spur is removed.
Over time, the spur on top of the joint enlarges, you may see flattening of the joint surfaces and loose fragments of bone in the joint space, something known as a joint mouse (left). These changes act like a door jam, further blocking movement.
As the edges of the joint degenerate, the joint space
between the great toe and the first metatarsal becomes
narrowed and irregular. This is because the joint surfaces
are covered with cartilage, something invisible on x-ray.
As the cartilage wears down, there is less separating the
bones, and they get closer and closer to each other.
Eventually the bones are close enough to touch.
This is arthritis. And the motion about the joint will be
In severe cases, there may be complete obliteration
of the joint space. In severe cases of arthritis like this, there will be little to no motion about the great toe joint.
This is hallux rigidus.
Ulcers of the big toe are often found directly beneath the big toe, as seen in the three images below. This location is common when the lack of great toe joint motion causes direct pressure under the great toe.
Other times, ulcers are seen more on the side of the big toe (as seen below). When ulcers are seen a bit off to the side of the great toe, as seen in the photos below, it means friction or shear is part of the cause.
Shear or friction that causes an
ulcer to form on the side of the big
toe may arise from a great toe that
is turned on its side, in what is known
as a valgus position. We see this in
the examples on the left and right.
Note how the nails of the big toes
are turned on their side. This shows
the degree of rotation present.
A great toe rolling on its side like this
is common with bunion formation--
an enlarged great toe joint with a
crooked great toe (left and right).
And it's common in very pronated
feet (where the foot is rolling inwards
and the arch is collapsing, as seen
to the right.
Ulcers forming on the inside edge of the great toe
are common, too, in out-toed feet.
With an out-toed gait, the great toe may be straight compared to the foot, but the whole foot is pointed away from the centre-line of the body. And as the body moves forward, weight is transferred off the side of the big toe.
This creates friction or shear on the side of the big toe--forces that can create an ulcer in that location.
So a variety of mechanical forces can cause an ulcer to form on the big toe. Some of the most common causes are a stiff great toe joint, a foot that is too pronated (one that rolls in too much), a bunion deformity with a crooked big toe, and an out-toed gait.
So Why Do Ulcers On The Big Toe Frequently Need Surgical Intervention?
As discussed on the top of this page, ulcers of the great toe joint are the most common site of ulcer formation, and ulcers of the great toe have an extremely high recurrence rate (over 80% within three years).
The danger is that about a third of ulcers become infected within 12 weeks of formation, and eventually more than half become infected.
Lavery LA, Fulmer J, Shebetka KA, Regulski M, Vayser D, Fried D, Kashefsky H,
Owings TM, Nadarajah J; Grafix Diabetic Foot Ulcer Study Group. The efficacy and
safety of Grafix(®) for the treatment of chronic diabetic foot ulcers: results of
a multi-centre, controlled, randomised, blinded, clinical trial. Int Wound J.
2014 Oct;11(5):554-60. doi: 10.1111/iwj.12329. Epub 2014 Jul 21. PubMed PMID:
Marston WA, Hanft J, Norwood P, Pollak R; Dermagraft Diabetic Foot Ulcer Study
Group. The efficacy and safety of Dermagraft in improving the healing of chronic
diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care.
2003 Jun;26(6):1701-5. PubMed PMID: 12766097.
Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic Foot Ulcer
Study. Graftskin, a human skin equivalent, is effective in the management of
noninfected neuropathic diabetic foot ulcers: a prospective randomized
multicenter clinical trial. Diabetes Care. 2001 Feb;24(2):290-5. PubMed PMID:
Prompers L, Huijberts M, Apelqvist J, et al. Optimal organization of health care in diabetic
foot disease: introduction to the Eurodiale study. Int J Low Extrem Wounds 2007;6:11-7.
Each infection puts the patient at risk for amputation, with the risk becoming greater as the patient ages and the patient's health declines. And amputations tend to lead to a domino effect of more ulcers and more amputations.
The high recurrence rate, the high tendency for infection, the rising risk of amputation over time mean that surgical intervention to correct the cause of the ulceration is often indicated.
Surgery of the Great Toe Joint
In patients with ulcers, what is commonly indicated is a simple surgery to resolve
arthritis and increase range of motion of the great toe joint--yet a procedure that
allows for speedy healing and weight bearing.
Often the procedure indicated in cases of hallux limitus or rigidus is a 1st
metatarsophalangeal joint arthroplasty or Keller procedure. First described in
1904 by Colonel William Lordan Keller (1874-1959), the Keller arthroplasty involves
removing the base of the great toe joint.
Keller WL.The surgical treatment of bunions and hallux valgus. New York Medical Journal.
For a biographical background on Dr. Keller, and the origin of this image, visit
Below left you can see an example of a patient with significant arthritis of the great toe joint. To the right you can see a red, transverse line drawn where the bone may be cut.
When the bone cut is made and the fragment is removed,
as with the example to the right, we create a space
between the two remaining bone fragments.
To keep the edges of the remaining bones from grinding
together, the soft tissues surrounding the joint are placed
between the bones, acting as a cushion.
There's no more arthritis blocking motion. The remaining
bones are separated and cushioned. And the
procedure decompresses the joint, also addressing the
limitation of motion caused by functional hallux limitus.
Removing part of the great toe joint may sound like a big procedure, and it certainly needs to be carefully considered, particularly when attempts at conservative, non-surgical offloading methods have failed.
But this surgery can be done under local anesthetic, even in a specialized office setting. And the patient may usually walk out of the operatory theater.
To the left is a patient who had been treated surgically by the author over ten years earlier. It's difficult to see the scar on the top of the great toe joint. The toe now bends, and, most importantly, there has been no ulcer in the past ten years since the surgery.
Isn't surgery like this risky for diabetic and neuropathic patients?
There are risks to surgery. The patient may get an infection. The patient may not heal well. Surgery could lead to amputation.
But this all true of ulcers as well. A third of ulcers become infected within 12 weeks of forming. And many ulcers never manage to heal.
So it could be argued that in many cases it may be safer to perform a one-time surgery when the patient is younger and the circulation and overall health will never be better, than it is to allow ulcerations to recur, half of which may become infected, and a fifth of which may end up, at some point in time, with an amputation.
The medical literature appears to support this view. For example, in a 2003 study of ulcers under the great toe, those treated with a Keller arthroplasty were compared to those who received conservative, non-surgical treatment. Those treated with surgery healed at 24.2 days. Patients treated with non-surgical care took 67.1 days, 2.8 times longer. Those treated with surgery had a re-ulceration rate of 4.8% within 6 months of follow up. Those who were treated non-surgically had a 35% re-ulceration rate in the first 6 months after closure, 7.3 times higher. Those treated with surgery had an amputation rate of 4.8%. Those treated with non-surgical care had a 10% amputation rate--twice as high. Infection rates were similar (40% vs 38.1%, respectively).
Armstrong DG, Lavery LA, Vazquez JR, Short B, Kimbriel HR, Nixon BP, Boulton AJ. Clinical efficacy
of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal
joint wounds in patients with diabetes. Diabetes Care. 2003 Dec;26(12):3284-7.
In another study (N=14), a Keller arthroplasty provided wound healing in 14-23 days versus an average of 47 days with total contact cast, and the re-ulceration rate was 0% with surgery vs 19% with total contact casting.
Lin SS, Bono CM, Lee TH. Total contact casting and Keller arthoplasty for diabetic great toe ulceration
under the interphalangeal joint. Foot Ankle Int. 2000 Jul;21(7):588-93. PubMed PMID: 10919626.
An Israeli study of 28 procedures, ulcers treated with a Keller procedure healed in just 3.1 weeks. Complications of infection and slow wound closure occurred in six procedures (21%). The rest returned to normal activity by 4 weeks. At 26 months, 78% had no ulcer recurrence.
Tamir E, Tamir J, Beer Y, Kosashvili Y, Finestone AS. Resection Arthroplasty for Resistant Ulcers
Underlying the Hallux in Insensate Diabetics. Foot Ankle Int. 2015 Aug;36(8):969-75.
doi: 10.1177/1071100715577952. Epub 2015 Mar 25. PubMed PMID: 25810459.
Other Great Toe Procedures
In the case to the below, the ulcer on the bottom of the great toe was not caused by a toe that bent poorly at its attachment to the foot.
Rather, the last toe bone was dislocated and situated above the first toe bone. This resulted in the first toe bone being pushed down into the ground, creating a pressure spot (arrow below) that created an ulcer at the bottom of the great toe joint.
In this case, the fragment removed was not the base of the great toe, but the portion of bone being pushed into the ground, as marked with the arrow. Below you can see the bone being pressed into the ground is bone. And so is the ulcer.
Ulcers at the tip of the great toe are quite common
as well. These are usually caused by a contracture of
the great toe, (below left) that causes the tip of the
toe to bear weight (below right).
In simple cases with no arthritis, a flexor tenotomy
can be considered. In some cases this would require
no more than a single stitch
If arthritis is present in the contracted joint, a portion
of bone can be removed as seen in the case above.
On somewhat rare occasions, an ulcer may be caused
by an extra bone on the bottom of the great toe.
This is known as an interphalangeal joint sesamoid,
and it may also cause enough pressure to create an ulcer.
Surgical correction of this problem involves the removal
of the sesamoid.
Some patients will develop ulcers as a
result of a misaligned great toe, where
it leans in so severely that the bones of
the first and second toes begin to rub
This can be corrected by filing any bony
prominences through a very small (1-2
stitch) incision, or surgically straightening
the great toe, such as through the Keller
procedure described above.
Sometimes ulcers are created as the great toe sits beneath the 2nd toe. In the example to the below right, the pressure caused by an overlapping great toe resulted in gangrenous changes.
These, too, can be corrected surgically to prevent the recurrence of ulcers.
We discuss ways to surgically offload the lesser toes here.
First metatarsal elevating relative
to the other metatarsals.
"If you have spent two years in bed trying to wiggle your big toe, everything else seems easy."
--Franklin Delano Roosevelt
No motion at the 1st MTPJ or
1st metatarsophalangeal joint
1st metatarsophalangeal joint
To return to the top of this page, click on the leaf to the right.
This page written by Dr. S A Schumacher
Surrey, British Columbia Canada
All clinical photographs are owned and provided
by Dr. S A Schumacher. They may be reproduced
for educational purposes with attribution to:
Dr. S A Schumacher, Surrey, BC Canada