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Fact or Fiction?: No Big Toe, No Go

A missing toe will keep you out of the armed services, but will it keep you off your feet?
feet
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© ISTOCKPHOTO.COM/XAVI ARNAU
During the Vietnam War, young men considered drastic measures to dodge the draft: flee the country, fake an asthma attack or shoot off a big toe. An amputee, according to legionnaire's legend, would be unfit to trudge across rice paddies or move fast to escape enemy fire.

Even today, missing a big toe will disqualify an eager enlistee from the armed forces. The Department of Defense's medical standards require rejecting anyone with a "current absence of a foot or any portion thereof." Yet, doctors consider having nine toes a minor impairment that does little to keep soldiers, runners or walkers off their feet.

"If you have your toe amputated, it doesn't mean you'll never run again," says Sheila Dugan, a physiatrist at Rush University Medical Center in Chicago. In fact, with no toes or other bones below the knee, South African sprinter Oscar Pistorius is only a second away from qualifying for the 2008 Olympics in Beijing on his carbon fiber prosthetics. Granted, Dugan says, most runners perform best when their bodies are fully intact: A foot and all of its parts is sturdy enough to absorb the high impact of landing on the ground. The big toe carries the most weight of all the toes, bearing about 40 percent of the load. The big toe is also the last part of the foot to push off the ground before taking the next step.

A nine-toed gait is less efficient, slower and shorter, but no less effective. "You're going to look choppier," Dugan says. Although running on fewer toes takes some getting used to, people can modify their style, train their muscles and practice balance exercises to compensate for a lost toe.

From a functional standpoint, amputating a big toe results in little or no disability, according to a study published in Clinical Orthopaedics and Related Research and conducted by Roger Mann, past president of the American Orthopaedic Foot and Ankle Society. Mann observed a slight thickening of the skin on the second and third toes of the impaired foot, and the patients wore down their shoes on that side more.

Regardless, the big toe myth has legs. Patients who arrive in foot and ankle surgeon Robert K. Lee's office with horrible infections are less preoccupied with the mundane consequences of thick toes and worn shoes than with their concern that, without a toe, they'll be confined to a wheelchair. Most of his patients have diabetes—the number one cause for lower extremity amputation in the U.S.—and removing an infected toe ensures their safety. "Their biggest fear is that they are not going to walk again," the University of California, Los Angeles, specialist says.

Customizing shoes to fit oddly numbered toes helps patients adjust to their imperfect gait and quickly get back on their feet. "We have several patients who have had all toes amputated and they walk fine," Lee says. "You lose some balance, strength and ability to propulse in gait, but they walk fine as long as they are in appropriate shoes with customized inserts and toe fillers." Except for aesthetic reasons, Lee does not prescribe prosthetic toes. (One patient requested a prosthetic so she could wear open-toed shoes and not have people stare at her feet.)

Although they are unnecessary, prosthetics for big toes have been around for quite a while. An Egyptian woman was outfitted with a wooden toe prosthesis in approximately 1000 B.C., says Andreas Nerlich, a pathologist at Ludwig Maximilians University of Munich. The wooden toe, described in The Lancet in 2000, is the world's oldest example of a prosthetic limb replacement. Scratch marks on its sole, Nerlich says, are evidence that she wore the toe during her lifetime and, unlike other early prosthetics, it was not popped on in preparation for the afterlife. At any rate, she could have run just as well without it.

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