A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools ¾ foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.


Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo


Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.


You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo