When the Big Toe Says “Enough”: Understanding Osteoarthritis in Dancers | Dinah Hampson, BA. BScPT. FCAMPT. RISPT

When the Big Toe Says “Enough”: Understanding Osteoarthritis in Dancers

By Dinah Hampson, BA. BScPT. FCAMPT. RISPT

Registered Physiotherapist, Founder of Pivot Dancer & Former Ballet Dancer

My Story

As a ballet dancer, demi-pointe seemed to be a regular position of my feet. Every rise, every jump, every push-off depended on the strength and mobility of my feet and, in particular, the big toe joint — the first metatarsophalangeal (MTP) joint. Years later, now a physiotherapist, that same joint has become an osteoarthritic challenge for me.  I wonder if you have experienced something similar and will find this article interesting.

I began noticing stiffness and discomfort in my big toe, especially when pushing off in walking or during exercise. My toe would feel “stuck” and would click dramatically to restore movement. I was experiencing worsening pain and stiffness, so I started investigating what was happening. When I finally had weight-bearing x-rays taken, the images showed early osteoarthritis: mild joint space narrowing, small bone spurs (osteophytes), and even a small cyst in the head of my first metatarsal bone.  I opted to change my footwear, teach my 4 Pointe classes in running shoes, and have had injections of corticosteroids and hyaluronic acid.  My joint range is about 50% of what it was but I can do everything I need to do with good running shoes and a little modification.

I feel like this experience is a chance to reflect on what this means for dancers everywhere — and I would like to share how to stay strong, mobile, and empowered even with arthritis.  What better place to talk about feet than the Apolla Performance Blog!

What Is Osteoarthritis in the Big Toe?

Osteoarthritis (OA) is a degenerative joint condition where cartilage gradually thins and bone reacts by forming osteophytes, cysts, and sclerosis. In the big toe joint, this process is often called:

• Hallux Limitus: limited motion, especially dorsiflexion (extension of the big toe).

• Hallux Rigidus: more advanced stiffness, with very little motion left.

On x-ray, OA looks like:

• Joint space narrowing (loss of cartilage)

• Bone spurs (osteophytes)

• Subchondral cysts or sclerosis (bone changes beneath the joint)

Why Dancers Are at Risk

Demi-pointe, relevé, pointe work, and repeated push-off movements place increased loads on the 1st MTP joint. Ballet requires not only extreme ranges of toe joint movement but can involve increased compressive load if the dancer is working en pointe.

Studies have shown:

• Ballet dancers often demonstrate early radiographic signs of arthritis in the big toe (osteophytes, cysts) even if not always symptomatic.

• Former female ballet dancers had a higher prevalence of arthritis in the 1st MTP joint compared with non-dancers.

• Yet, not all dancers develop painful arthritis, reminding us that individual anatomy, mechanics, and training load matter.

Signs & Symptoms Dancers Should take Notice of

• Stiffness in the big toe

• New clicking or snapping noises with movement

• Pain when rising onto demi-pointe or pushing off

• Bony bumps on the top or sides of the joint (osteophytes)

• Reduced “spring” when walking or dancing

• Callus formation under other toes (from compensating)

• Shoes (especially pointe shoes) feeling tighter or more uncomfortable

What My X-Rays Show

• Joint narrowing: less space between bones means cartilage is wearing away.

• Osteophytes: small bone spurs that can impinge and cause pain in relevé.

• Cyst: a hollow area in the metatarsal head from stress inside the bone.

You can see all of these changes on my x-rays!  If you are having x-rays taken, ask for them to be done weight bearing so that your physical therapist can also see your weight placement and arch. Even mild findings like these can affect performance if ignored — which is why awareness is so important.

Managing Big Toe Arthritis: Options for Dancers

✅ Conservative Care

• Education & load management: respect pain thresholds, don’t push into forced relevé.

• Footwear & supports: stiff-soled shoes, rocker-bottom sneakers, or carbon-fiber insoles reduce stress on the big toe. Pointe shoe modifications may help.

• Manual therapy: gentle joint mobilizations, distraction, and soft tissue release.

• Strengthening: intrinsic foot muscles, toe flexors/extensors, balance training.

• Stretching: calf/Achilles stretching reduces demand on the toe during push-off.  A useful tool is a dorsal night splint so you can stretch while you sleep. (not the most attractive device but definitely useful)

• Modalities: ice for flare-ups, short courses of anti-inflammatories (with MD guidance).

🩺 Medical Options

• Injections: corticosteroid or viscosupplement injections for persistent pain.  I did both of these.  My advice is to plan for a little down time.  It’s a very small joint and fitting more than 1-1.5cc into the joint is difficult.  Also, I didn’t take enough down time and my joint capsule became quite inflamed.  Viscosupplimentation can be quite expensive but it is worth asking if there is a discounted program available.  I used Durolane and I know they have an application for financial discount. (I have no financial or professional relationship with Durolane – I’m just telling you what I used.) 

• Surgery (if conservative care fails):

• Cheilectomy: removal of bone spurs.

• Moberg osteotomy: increases dorsiflexion capacity.

• Arthrodesis (fusion): reliable pain relief but eliminates motion.

For dancers (and anyone), surgery should be a last resort, and recovery requires patience.  As my surgeon friends say “it could always get worse with surgery and staying away from the people carrying sharp knives is usually a good idea ☺”

What Dancers Can Do Right Now

• Warm up your feet thoroughly before class. Have you seen the Pivot Dancer “Prepare your feet” videos? Module 1 is available on the Pivot Dancer Ytube channel and the others are included in their on-line memberships.

• Strengthen intrinsic foot muscles daily.

• Modify pointe or demi-pointe work if your toe feels painful.

• Rotate footwear to avoid repetitive stress.

• Don’t ignore stiffness — early intervention matters.

• Work closely with a physiotherapist or dance-medicine provider.

A Note of Encouragement

Arthritis in the big toe doesn’t have to end your dancing. With smart load management, consistent maintenance, and supportive care, many dancers continue to move beautifully. I’m walking this path myself — literally and figuratively — and I can tell you: your artistry and strength are not defined by one joint.

References

• Patel J, Swords M. Hallux Rigidus. StatPearls. NCBI Bookshelf, 2023.

• Angioi M, et al. Early signs of osteoarthritis in professional ballet dancers. J Dance Med Sci. 2014;18(1):23–28.

• Valderrabano V, et al. Osteoarthritis of the first metatarsophalangeal joint in ballet dancers. Clin Orthop Relat Res. 1995; (317):235–242.

• Werber B. Dance Medicine of the Foot and Ankle: A Review. Clin Podiatr Med Surg. 2010.

• Aggarwal A, et al. Therapeutic Management of the Hallux Rigidus. Foot Ankle Clin. 2012.

• “Big Toe Got You Down? It May Be Hallux Rigidus.” Harvard Health Publishing.