Why Many Shoes Cause Big Toe Joint Pain

Lots of pumps and flats hurt over the big toe joint. One of the causes is wrong toe box and topline shape. Read on to find out how to tell the good ones from the bad.

Tell me if your feet ever look like this (or feel like they do!) after a long day in your heels:

Women's shoes damage feet
Hope you weren’t about to go have lunch. Oh, you were? Sorry about that.

If you’ve experienced this, you are not alone – this is extremely common. I’ve seen people with thick, scaly callouses over that area from years of abuse. Sometimes it’s due to wearing the wrong size, or the foot sliding forward in the shoe because the heel cup is shaped incorrectly. The third major culprit of big toe joint pain are shoes that ignore the simple fact that our toes have tendons, and those tendons need room.

Our toes have tendons?

They do, and lots of them. For the purpose of this article, I’ll focus on the two tendons running along the top of the big toe. The other toes also have their tendons and do some of the work of propelling you from foot to foot, but the big toe does the lion’s share of the work, and its tendons are the biggest:

  1. Extensor hallusis brevis: this tendon connects the “mainland” of your foot to the very base of your big toe.
  2. Extensor hallusis longus:  this tendon runs from your foot to the knuckle of your big toe.
Two foot tendons labeled drawing and photo
There’s lots more going on than just two measly tendons. We’ll ignore all that for now.

These two work in tandem with the corresponding set of tendons that connect the big toe to the foot from below like two sets of rubber bands: when one stretches, the other contracts. This stretching and contracting is what enables you to push off your foot and, you know. Walk.

What happens to your big toe tendons in heels?

When you go up on your tiptoe, the tendons that connect your toes to the foot from above contract. That includes all of them, but for the sake of this discussion the big toe ones are the most important ones because they are the biggest.

When a given amount of material is squeezed to occupy a shorter length, it has to go somewhere. For our toe tendons, that “somewhere” is up.

Here’s what happens:

Big toe joint height difference between heels and flats
My big toe joint is about 0.5 cm taller on tiptoe than flat on the ground.

When my foot is flat on the ground, the big toe joint is about 3 cm tall. The two tendons that run across is stretch out over about an inch and lie nice and flat. When it’s in a heel, it’s about 3.5 cm because that same amount of tendon is now squeezed into about 3/4 of an inch in length.

The “up” doesn’t happen uniformly. The tendons get really bunched up over the big toe joint, where they are forced to work with the foot at a 90 degree angle. This produces a dramatic curve in that spot, and the base of that curve happens to coincide with the opening of many women’s shoes, because putting the opening there gives the perfect amount of toe cleavage.

The big toe gets thicker too, because Extensor hallusis longus gets bunched up all the way to the knuckle. The effect is not as pronounced as it is over the big toe joint, but it’s there. Since women’s shoes fit very closely to the foot, it’s an important difference.

It’s called “big” toe for a reason

It IS much bigger than the other ones. Most importantly, it’s much taller, especially at the joint. It’s not something most people notice about their feet because people usually look at their own feet from above, which flattens out the height difference. The height difference is pretty dramatic. My foot is about 3.5 cm tall at the big toe joint in heels, then drops drastically to 2.5 cm at the second toe joint and gradually tapers to about 2 cm tall at the pinkie toe joint.

These may not sound like big differences, but in shoemaking, a few missing millimeters can spell agony for the wearer. Remember, half a size is just 1/6 of an inch, or about 0.42 cm. The whole centimeter of height difference between the big toe and the rest of them is a big deal and a properly made shoe will reflect that.

So what does all this mean for shoes?

In order to accommodate your tendons bunching upwards, the toe box of your high heel shoe has to do two things:

1. It has to be fairly tall over the big toe from the opening to the knuckle.

2. It has to curve quite a bit right at the opening, unless it’s a very, very open style, giving LOTS of toe cleavage. In that case, it can curve just a bit, but it still has to curve.

If your shoe does not do those two things, it WILL cut into the top tendons of your big toe. This means more than just a bit of discomfort. Over time, the constant cutting into your tendons will lead to actual tendon damage. These shoes are literally cutting away at your ability to walk.

In addition, to properly fit all of your toes, the shoe must be substantially taller over the big toe than the rest. If it does not, it will either gape over the small toes, or cut into the big toe. Usually, fashion footwear errs on the side of the latter.

We have to suffer for beauty, then?

Nope. Lots of gorgeous shoes give good heel without chewing at your tendons.


Examples of shoes with uppers curving at the opening
Curves are good. I drew the toe box shape a little bit above each shoe so you can see the curve better.

These toe boxes are appropriately tall AND they curve at the opening. It’s subtle and hard to see in a little photo, but you can see that they all curve upwards at the opening – some more, some less, but they are all trying. These shoes may still have other issues, but they are all doing right by our Extensor hallusis friends. They avoid looking clunky by slimming the toe box height a bit from the knuckle down, and then trimming it to nothing once they get past toe-space into shape-space. Just because a toe box must be tall in the first 1/2 an inch, doesn’t mean it has to stay that way the rest of the way.

On the other hand:

Shoes with too-low uppers that don't curve
I drew the toe box shape again. This was much easier to draw because it’s all just straight lines.

The first two don’t curve at the opening AND are much too low. The third gives a little bit more vertical room than the others, but the shape is still wrong. All of these will cut into the tendons instead of accommodating them and it won’t be because there’s something wrong with your feet.

The shoes simply weren’t made for human anatomy.