Toes Spacers, anyone?

Less pain through better mechanics?

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We have been using toe separators for various foot problems like hallux valgus, hammer toes and flexor dominance/extensor weakness. Our reasoning is that through changing the angle of attachment of the muscle, you alter the mechanical advantage of that muscle and help it to work more efficiently. This seems implied in the literature with respect to foot orthoses (1-3) but we could not find any data regarding toe separators. Toe separators DO seem to reduce pain and increase function (4-6). Perhaps this is through better biomechanics, mechanical deformation, proprioceptive changes, or most likely a combination of all these factors and more.  We think clinical results speak volumes. It is nice to see more data coming out on these easy to implement clinical tools. 

What is you clinical reasoning or rationale for using these devices? We would love to hear and if you have an article for reference you could share, that would be great. 

 

1. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

2. Halstead J, Chapman GJ, Gray JC, Grainger AJ, Brown S, Wilkins RA, Roddy E, Helliwell PS, Keenan AM, Redmond ACFoot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016 Apr;35(4):987-96. doi: 10.1007/s10067-015-2946-6. Epub 2015 Apr 28.

3. Bishop C, Arnold JB, May T. Effects of Taping and Orthoses on Foot Biomechanics in Adults with Flat-Arched Feet. Med Sci Sports Exerc. 2016 Apr;48(4):689-96. doi: 10.1249/MSS.0000000000000807.

4. Chadchavalpanichaya N, Prakotmongkol V, Polhan N, Rayothee P, Seng-Iad S. Effectiveness of the custom-mold room temperature vulcanizing silicone toe separator on hallux valgus: A prospective, randomized single-blinded controlled trial. Prosthet Orthot Int. 2017 Mar 1:309364617698518. doi: 10.1177/0309364617698518. [Epub ahead of print]

5. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008 Mar;32(1):79-83. doi: 10.1080/03093640701669074.

6. Tang SF, Chen CP, Pan JL, Chen JL, Leong CP, Chu NK. The effects of a new foot-toe orthosis in treating painful hallux valgus. Arch Phys Med Rehabil. 2002 Dec;83(12):1792-5. 

 

 

The Beef on the EDL.....

We have long been promoting appropriate function of the long extensors of the toes  here, in our practices, our lectures, on Youtube, in our book......You get the idea. Lets take a closer look at this often weakened and overlooked muscle.

We remember that the EDL lies mostly in the superior and somewhat lateral part of the anterior compartment of the lower leg, comprising approximately the upper 2/3 from under the lateral tibial plateau and fibula, and from the interosseus membrane. It lies under the tibialis anterior, and the extensor hallucis longus lies below it. Its tendons pass inferiorly and travel under the extensor retinaculum and attaches to the base of the distal phalanges of toes 2-4. These muscles act from initial contact to loading response to help eccentrically lower the foot to the ground and ensure smooth heel rocker and most likely attenuate the speed of initial pronation as the talus glides anteriorly on the calcaneal facets and again from terminal stance through initial swing to provide compression of the metatarsal phalangeal and interphalangeal joints, to offset the long flexors (which are often overactive) and create clearance for the toes during swing.  

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What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right (pair J howard r). what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has a forefoot supinatus, or possibly a forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod, possibly insufficient extensor hallucis brevis, peroneus longus, flexor digitorum brevis, or all of the above). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the supinatus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

  • Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises.
  • Make sure the articulations are mobile with joint mobilization, manipulation and massage.
  • How about dry needling and acupuncture to improve function?
  • Make sure the knee and hip are functioning appropriately.
  • Put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe).
  • As a last resort, if they cannot make an adequate tripod because of lack of motivation, anatomical constraints or both, use a foot leveling orthotic.

 

Subtle Clues to Ankle Rocker Pathology: How good are your powers of observation ?

There are clues showing you there is motor pathology to ankle dorsiflexion, if you are paying close enough attention.

When we see motor pathology in ankle dorsiflexion we immediately begin to think about impairment to hip extension range of motion, gluteal strength, motor coordination and many other issues.

Here is a simple case. Observation skills are your greatest superpower when it comes to figuring out many gait and movement problems. But, you have to know what to look for and know what they mean before you can even hope to know how to fix things.
This is a simple video. It shows active ankle dorsiflexion in supination. We asked the client (a runner with right heel and persistent sesamoid pain following a healed sesamoid fracture) to perform simple ankle dorsiflexion. This is what we saw.

It should be clear to the observer that the end of the video shows attempted right dorsiflexion pulls the 2-5 toe extensors into the pattern quite aggressively and as a dominating faction. One can see toe abduction and extension with surprisingly little help from the long hallux toe extensor (EHL).  Dorsiflexion also fatigued early on the right. There is only one reason that the lesser toe extensors (EDL & EDB) are being over recruited, it’s because the EHL and tibialis anterior are weak and/or inhibited or have been pattern corrupted for one reason or another. Depending on this smallest of anterior compartment muscles over the EHL and tib anterior will mean that ankle rocker (dorsiflexion) is impaired. It also means that abnormal forefoot valgus posturing is expected (we could make a case for valgus or varus depending on other variables present). Passive ROM assessment confirmed the impaired ankle rocker with barely greater than 90 degrees ankle dorsiflexion ROM. This impairment will possibly do many things including:

  • premature heel rise
  • premature gastrocsoleus engagement
  • accentuated rear foot eversion (Rearfoot pronation)
  • midfoot pronation
  • strain of plantar fascia
  • premature forefoot loading response (strong clue for clients sesamoid fracture and persistent pain)
  • anterior/ posterior shin splints
  • hallux VALgus /bunion formation
  • long toe flexor dominance and many other things.

This clinical find plays nicely into the clients multiple symptoms (plantar pain and sesamoid problems) and functional gait pathology.
Restoring proper motor hierarchy and synchrony to the ankle dorsiflexion team (tib anterior, peroneus tertius, EDL, EHL) will reduce the need for solitary group overuse and impart forces where they should be when they need to be present. Impair the synchrony and problems ensue.

Help your client achieve the motion at the ankle mortise and they do not have to pass the buck into the foot.  Always test for skill, endurance and strength. Endurance is the most often forgotten assessment.  If endurance is lost early, the brain will begin to block out that end range of motion because it cannot be trusted, and thus posterior compartment tightness will be detected. This is an often common source of regional achilles and para-achilles tendonopathy. If your clients symptoms take time during activity to develop looking at the endurance of motor patterns may give the clue to your solution. 

Simple case, but you have to know your normal gait parameters, know functional anatomy and know how impaired mechanics factor into injury. 

Shawn and Ivo

The gait guys

The Toe Waving Exercise, Part 2

In part one of this series, we talked about the importance of the short flexors of the toes (FDB or flexor digitorum brevis) in forming and maintaining the foot tripod. In this installment, we discuss another important muscle used in this exercise,  the extensor digitorum longus (EDL).

We have shown you time and time again, dominance of the long flexors in gait, which cause biomechanical imbalances. We remember that through reciprocal inhibition, the log flexors will reciprocally inhibit the long extensors, so increased activity in the former, means decreased activity and activation in the latter.

The balanced activity of the long flexors and long extensors helps to create harmony during gait. Working the long extensors with this exercise (along with others, like tripod standing, toes up walking and the shuffle gait exercises) helps one to achieve this balance.

The Gait Guys; promoting foot and gait competency every day here, on Youtube, Facebook, Twitter, and in our offices and yours.


all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will never have an adequate foot tripod and will have gait problems for the remainder of your days.

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The Mighty Extensor Digitorum Longus  (EDL): a pedograph case.

We have long been promoting appropriate function of the long extensors of the toes (predominantly the EDL, but also the Extensor hallucis longus) here, in our practices, our lectures, on Youtube, in our book……You get the idea. Lets tale a closer look at this muscle (picture left above)

The EDL has a proximal attachment in the lower leg up at the condyle of the tibia, proximal fibula, the interosseus membrane, and the connective tissues between the muscles. It travels down the leg, under the extensor retinaculum and attach to the base of the distal phalanges of toes 2-4. These muscles act from initial contact (to help eccentrically lower the foot to the ground), loading response (to continue to lower the foot slow or attenuate pronation), midstance and terminal stance (to provide compression of the metatarsal phalangeal and interphalangeal joints, and to offset the long flexors (which are often overactive, due to flexor dominance)).

What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right. what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has an uncompensated forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the forfoot varus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises. Make sure the articulations are mobile with joint mobilization, manipulation and massage. Make sure the knee and hip are functioning appropriately. Give the client lots of homework and put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe). As a last resort, if they cannot make an adequate tripod (because of lack of motivation or anatomical constraints), use a foot leveling orthotic.

Ivo and Shawn. Two guys, making a difference, every day.


all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will be plagued with foot fungus and bunions for all your days.

A video case of a gait impairment. Chronic dorsal foot pain.

This client came to see us recently. They had a current (2 year) history of dorsal foot achey/burning pain and anterior ankle pain, right greater than left.  They had been just about everywhere for these complaints and were pretty much resolved that it was not fixable. They also had a chronic history of anterior shin splints.

This is a pretty simple case. It is missed alot of the time. The reason it is missed is because nothing much shows up on examination.  However, we used some tricks to bring out their symptoms.  There are also some subtle hints on the gait video above but when  you cannot pair what  you see with what you find on a clinical exam the issues can get lost in the mix, as they did in this case.  This is thus a case based much on clinical experience.  We have seen this before.  A great clinician (who’s name we have forgotten) used to have a quote that went something like this:

It is only after you have seen the beast once before that it will serve you well to be able to recognize it the next time. Having never seen the beast previously will leave you with a terrible bloody battle on how to slay it the first go-round.“

ln this video above you should basically see 2 things:

1. the easy one to see: the right foot immediately after toe off does not come forward sagitally rather it spins out into abduction in the swing phase to prepare for the next heel strike.

2. the harder one to see: both feet pronate immediately in the rear and mid foot excessively. 

This patient has some limitations in normal ankle rocker.  More simply put, they cannot get enough adequate tibial progression forward into dorsiflexion over the talar dome. The squat test was really the only positive movement assessment that was confirmatory. As they squatted the ankle met early dorsiflexion restriction and thus the foot had no choice but to pronate early and heavily thus collapsing medially and drawing the knees in medially. Normally the arch should remain unaffected and the tibia should merely pivot cleanly and effortlessly over the talus allowing the knees to come purely forward.  Not in this case.

So, we have a client that has impaired sagittal mechanics. They cannot move through ankle rocker effectively and thus they cannot pronate in a timely manner.  As the right foot leaves the ground at toe off they need to have sufficient ankle dorsiflexion to carry the foot cleanly forward to prepare for heel strike (this looks pretty good on the left in the video) but the right side is met with ankle range loss.  If they did not circumduct the right foot like you see here they would drag their toes on the ground and likely trip. So, foot abduction is the strategy to avoid this issue.  However, when you circumduct the foot you begin to lose the strength and endurance of the toe extensors and tibialis anterior.

There is it, we just gave it away.  Your question all along should have been, "but what about the dorsal foot and anterior ankle pain and chronic shin splint history?”.

After our gait assessment and history we had a strong hunch. We did our clinical exam which was unremarkable, mostly. But we saw some things that might correlate with our hunches.  So, we put the client on our Total Gym at 45 degree incline to do some partially weight bearing squats. Simple stuff. But, we put the feet in a challenged position.  We had them hold a neutral foot position on the platform (zero degree progression ankle), the foot was not allowed to spin. We told them they had to keep the toes up at all times and directed them to not let the arch drop or heel spin (these are all compensations to get around impaired ankle rocker in gait, and we see them in her gait video). It seemed simple to them so they began to squat repeatedly, slowly with good form. At about 2 minutes into the movement challenge there began some burning and achey pain reproduction at the dorsal foot from the toes to the anterior ankle. Then it started up their shins. The knees began to hurt. Their toes began to lose their earlier extension/lift. They then started to avoid the depth of the initial first squats so we made them aware and insisted they challenge the initial ranges.  After about another 30 seconds the anterior ankle pain began.  Our exam was pretty much done. We went back into the room, their pain had stopped. On the exam table it was clear that they now had more toe extension and ankle dorsiflexion range but had no strength in this new range.  You see, they initially tested strong in these ranges, but they were strong only in the limited range available to them. On our exam we felt that the ranges were a bit meager, but for some people that is just their anatomy. But we had to be sure, so we gently drove some of those old lost ranges and our examination was concluded.

So, it turns out that this patient had enough weakness in the tibialis anterior and long toe extensors (EDL) sufficient enough to lose ankle rocker ranges over time. When you lose ankle rocker range you meet resistance early. This means you will begin pronation in the foot earlier than normal and begin one or several compensations:

  1. arch collapse
  2. heel abduction twist
  3. increased foot splay (progression angle)
  4. external limb rotation (paired usu. with #3)
  5. foot circumduction
  6. medial knee collapse
  7. just to name a few…… knee hyperextension etc

Chronic fatiguing and weakness of the toe extensors and tibialis anterior are frequent findings in many people. Sometimes they are subtle and you have to tease them out.

Now, remember the initial pain quality ? Achey burning pain.  Now, lets review last weeks pain posts. 

Remember the Krebs cycle? How about glycolysis? What was one of the end products of glycolysis? Lactic acid. Your ability to recycle it and make it into oxaloacetic acid and stuff it back into the Krebs cycle determines your aerobic capacity. When lactic acid builds up, we get muscular inefficiency due to the drop in pH (initially this helps, but too much of a good thing creates a problem), The result? Burning pain. Burning pain is the burn of glycolysis, or muscular overuse.

Aching/ throbbing pain is that deep, boring pain, like a toothache in a bone. It is the pain of the mesoderm, or what is often called sclerotogenous pain. Aching/Throbbing pain is the pain of connective tissue dysfunction (remember that connective tissue is bone, cartilage and collagenous structures like ligaments and tendons). Throbbing pain can sometimes be vascular in origin, as the connective tissue elements of the vessels (the tunica adventitia to be exact) is stretched (which contains a perineural plexus; think about the pain of a migraine headache).

This client had fatigue weakness. This is a physiologic energy production issue. Thus the BURNING pain in the toe extensor muscles. They also had the chronic achey pain of sclerotogenous referral from connective (mesoderm) tissue challenges.

See how this all comes together ?! Putting the pieces together is not hard once you know what the pieces are supposed to do and what their limitations are. Then you have to listen to them and hear what they are telling you.

This was a case that did not have to go on for 2+ years. This client did not need to suffer and become a shoe and orthotic obsessed fanatic (searching for answers on their own). Their body was screaming for someone to just listen and look at its communications. 

We started them with our famous Shuffle Walks to drive toe extension, ankle rocker/tibialis anterior strength and then showed them how to use more of both during normal gait.  As with most of the cases like this. We will let them go for 2-3 weeks to improve these SKILL and ENDURANCE components of the movement pattern.  We bet this one will take 2-3 visits to resolve. As endurance builds and then as STRENGTH (the last component) builds they will own the changes and be pain free.  And then return to then normal shoe shopping habits like the rest of the world.

We are The Gait Guys……..saving humanity from the scourge of gait related pain, one lovely person at a time.

Shawn and Ivo

When the Short Toe Extensors Try to Rule the World !   
  A case of a runner with forefoot pain.   
 This is a runner of ours, one of the fastest young men in the state  of illinois, top 10 in the country in mid-distance, top 20 in the USA in  cross country. 
 He came in with left forefoot plantar pain.  He explained (in a  matter of words) that he was having pain at full forefoot loading at  heel rise /push off. 
 We watched him walk, saw this visual problem present itself in  dynamic motion (yup, no stop frame video on this one, not when you see  it about 10 times a month !) and noted a subtle left lateral hip/pelvis  shift past what would be considered normal for frontal plane mechanics. 
 On the table this is a photo of his feet.  What do you see ? 
 We see a suspected (which you will try to confirm on examination)  increase in short extensor (EDB, extensor digitorum brevis) muscle  tone.  Increased long extensor (EDL, extensor dig. longus muscle) tone  would have  represented itself with the distal toes also extended but here we see a  relative dominance of the long flexors (FDL, Flexor dig. longus) with  the heightened short flexor increase. 
 We also see more confirmation of heightened long flexor tone (FDL) by  the degree of heavy callus formation on the very tip of the 2nd toe (it  was on all 4 lateral toes but the photo is not clear enough to  demonstrate).  You can also see supporting evidence of heightened long  flexor dominance by the subungual hematoma (bleeding under the 2nd toe  nail). (How does this correlate ? Well, in most runners with excessive  long flexor tone/use not only do they flex and claw so much in the shoes  that the callus is on the tip of the toes but the nail also begins to  lift as the  nail is caught on the sock liner of the shoe as the toe  flexes, slowly, mile by mile pulling the toe nail from the nail bed thus  bleeding underneath it).  Yes, it is NOT from the toes hitting the  front end of the shoe ! 
 Our examination confirmed weakness of all lumbrical muscles and of  the flexor digitorum brevis and lateral quadratus plantae.  The patient  could feel the strength/engagement difference as compared to testing on  the right foot of the same muscle groups (we always compare side to  side, for us and for the patient’s awareness).  The extensor digitorum  brevis muscle mass on the lateral dorsum of the foot was tender as were  the tendons along their course.  There was also weakness higher up in  the kinetic chain at the lower division of the transversus abdominus and  internal abdominal oblique, and frontal plane hip stabilizers (gluteus  medius; anterior-middle-and posterior divisions).The 2nd and 3rd  metatarsal heads were remarkably tender to palpation and it was obvious  that the metatarsal fat pads had migrated distally from the lumbrical  muscle weakness. 
 Sometimes a grasp response by the long flexors can represent a  propioceptive /balance deficit during single leg stance phase so be sure  to test those centers as well (cerebellar, vision, joint position  sense, inner ear-vestibular apparatus).  
 So, what is the take away for the non-medical person, the runner next  door if you will ?  Lets just say, symmetry wins and when asymmetry is  apparent, bring it up to the people that do your body work.  Hopefully,  what you and they see will be assessed in a clinical light, and as a  team you can get to the bottom of what is not working…….and in this  case…..what was causing not only the plantar foot pain, but the left  lateral hip sway outside the frontal plane. 
 ———we are, The Gait Guys……Shawn and Ivo

When the Short Toe Extensors Try to Rule the World !

A case of a runner with forefoot pain.

This is a runner of ours, one of the fastest young men in the state of illinois, top 10 in the country in mid-distance, top 20 in the USA in cross country.

He came in with left forefoot plantar pain.  He explained (in a matter of words) that he was having pain at full forefoot loading at heel rise /push off.

We watched him walk, saw this visual problem present itself in dynamic motion (yup, no stop frame video on this one, not when you see it about 10 times a month !) and noted a subtle left lateral hip/pelvis shift past what would be considered normal for frontal plane mechanics.

On the table this is a photo of his feet.  What do you see ?

We see a suspected (which you will try to confirm on examination) increase in short extensor (EDB, extensor digitorum brevis) muscle tone.  Increased long extensor (EDL, extensor dig. longus muscle) tone would have represented itself with the distal toes also extended but here we see a relative dominance of the long flexors (FDL, Flexor dig. longus) with the heightened short flexor increase.

We also see more confirmation of heightened long flexor tone (FDL) by the degree of heavy callus formation on the very tip of the 2nd toe (it was on all 4 lateral toes but the photo is not clear enough to demonstrate).  You can also see supporting evidence of heightened long flexor dominance by the subungual hematoma (bleeding under the 2nd toe nail). (How does this correlate ? Well, in most runners with excessive long flexor tone/use not only do they flex and claw so much in the shoes that the callus is on the tip of the toes but the nail also begins to lift as the  nail is caught on the sock liner of the shoe as the toe flexes, slowly, mile by mile pulling the toe nail from the nail bed thus bleeding underneath it).  Yes, it is NOT from the toes hitting the front end of the shoe !

Our examination confirmed weakness of all lumbrical muscles and of the flexor digitorum brevis and lateral quadratus plantae.  The patient could feel the strength/engagement difference as compared to testing on the right foot of the same muscle groups (we always compare side to side, for us and for the patient’s awareness).  The extensor digitorum brevis muscle mass on the lateral dorsum of the foot was tender as were the tendons along their course.  There was also weakness higher up in the kinetic chain at the lower division of the transversus abdominus and internal abdominal oblique, and frontal plane hip stabilizers (gluteus medius; anterior-middle-and posterior divisions).The 2nd and 3rd metatarsal heads were remarkably tender to palpation and it was obvious that the metatarsal fat pads had migrated distally from the lumbrical muscle weakness.

Sometimes a grasp response by the long flexors can represent a propioceptive /balance deficit during single leg stance phase so be sure to test those centers as well (cerebellar, vision, joint position sense, inner ear-vestibular apparatus). 

So, what is the take away for the non-medical person, the runner next door if you will ?  Lets just say, symmetry wins and when asymmetry is apparent, bring it up to the people that do your body work.  Hopefully, what you and they see will be assessed in a clinical light, and as a team you can get to the bottom of what is not working…….and in this case…..what was causing not only the plantar foot pain, but the left lateral hip sway outside the frontal plane.

———we are, The Gait Guys……Shawn and Ivo