When your calf is weak, things can dorsiflex too much sometimes.

When your calf is weak, things can dorsiflex too much sometimes. Maybe this is why you have Achilles tendinopathy. Maybe.

When we run, we either heel strike, midfoot strike, or forefoot strike. The literature is pretty clear on this now, that any one of them is not better than the other and there are many variables that need to be taken into consideration (even though many folks, who stopped reading the studies long after the barefoot craze began, will proclaim at the grave of their mother that rearfoot strike and anything but zero drop shoes are the root of all evil).

However, if you are a forefoot striker, the calf complex must be durable, strong and have enough endurance that when the foot strike occurs, that over time the complex does not allow the heel drop to become excessive or uncontrolled to the point that the achilles tendon proper exceeds its capacity to tolerate the drop, the stretch load capacity. It is more complex than this, because when the heel drops too much, too far, too fast and the arch is not durable enough, the metatarsals may dorsiflex too much and compromise the arch and stiffness of the midfoot, this can also have its complications. A weak calf can impact the rest of the foot. Remember, when the forefoot is engaged on the ground, and the heel drops in an uncontrolled fashion, we are increasing ankle dorsiflexion too, and this may not be welcomed during a stance phase of running where we are hoping for sufficient foot stiffness to load across it and propulse off of it.

This study showed that "analysis revealed that male recruits with lower plantar flexor strength and increased dorsiflexion excursion were at a greater risk of Achilles tendon overuse injury".

Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study.

Mahieu NN, et al. Am J Sports Med. 2006.

Do you really understand what it takes to control the 1st Metatarsal during loading ?

Do you have dorsal (top) foot pain, at the peak of the arch? Think you are tying your shoes too tightly and that is the cause? Do you have pain over the dorsal or plantar mid foot on heel rise or jumping/landing or going up stairs ?

Just because you raise your heel and load the ball of the foot does not necessarily mean you have adequately plantarflexed the 1st metatarsal and loaded it soundly/stable with the medial tarsal bone. Heel rise, and thus loading onto the medial foot tripod, must be met with ample, stable, durable, 1st metatarsal plantarflexion and the associated medial tarsal bones. Also, without this, loading of the sesamoids properly cannot occur, and pain may ensue.

The first ray complex can be delicate in people who are symptomatic. In some people who do not have a good tibialis posterior-peroneus sling mechanism working harmoniously, in conjunction with a competent arch tripod complex to achieve a compentent arch complex (ie, EDL, EHL, tib anterior and some of the other foot intrinsics) this tarsometatarsal interval can become painful and instead of the 1st ray complex being stable and plantarflexing as the heel departs and the 1st ray begins taking load, it may not do so in a stable plantarflexed posturing. In some people it can momentarily dorsiflex as the arch subtly collapses (when it should be stable and supinated in heel rise).

"Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle."-Duallert et al

Soon, I hope to show you a video of how to watch for this problem, how to train it properly, how we do it in my office.
Dr. Allen

Reference:

Clin Biomech (Bristol, Avon). 2016 May;34:7-11. doi: 10.1016/j.clinbiomech.2016.03.001. Epub 2016 Mar 10.  The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Dullaert K1, Hagen J2, Klos K3, Gueorguiev B4, Lenz M5, Richards RG6, Simons P7.

https://www.ncbi.nlm.nih.gov/pubmed/27015031

The all to common case of the Wobbling Hexapod (Tripod) : Is Your Foot hexa/Tripod Stable Enough to Walk or Run without Injury or Problem ?

Note the music we have chosen today. We tried to match the rate of the dancing tibialis anterior tendon to the tempo of the song, just for fun of course. Well, actually, for neurological reasons as well, as with a steady tempo or beat, your nervous system can learn better. Why do you think we teach kids songs to learn (or you can’t get the theme from the “Jetsons” out of your head).

This is a great video. This client has an obvious problem stabilizing the foot tripod during single leg stance as seen here.  There is also evidence of long term tripod problems by the degree of redness and size (although difficult to see on this plane of view) of the medial metatarsophalangeal (MTP) joint (the MPJ or big knuckle joint) just proximal to the big toe.  This is the area of the METatarsal head, the medial aspect of the foot tripod.

As this client moves slowly from stance into a mild single leg squat knee bend the challenges to the foot’s stability, the tripod, become obvious.  Stability is under duress. There is much frontal plane “Checking” or shifting and the tibial and body mass is rocking back and forth on a microscopic level as evidenced by the dancing tibialis tendon at the ankle level.  The medial foot tripod is loading and unloading multiple times a second. 

Is it any shock to you that this person has chronic foot problems which are exacerbated by running ?  Every time this foot hits the ground the foot is trying to find stability. The medial tripod fails and the big knuckle joint (the 1st MPJ or big toe joint) is enlarging from inflammation, uncontrolled loading through the joint, and early cartilage wear and decay, not to mention the knee falling medially to the foot line as well.  Hallux limitus (turf toe) is subclinical at this time, but it is on the menu for a later date. A dorsal crown of osteophytes (the turf toe ridge on the top of the foot) is developing steadily, soon to block out the range necessary for adequate toe off in this client.  And that means a limitation in  hip extension sometime down the road (and premature heel rise……. did you read Wednesday’s blog post on that topic ?).

*addendum:

Take the time to develop the skill. We ask our clients to work on standing with the toes up to find a clean tripod and do some shallow squats working on holding the tripod quietly. Be sure your glutes are in charge, spin of the limb is in part controlled at the core-hip level so that can a primary location to hunt as well. Eventually work into toes pressed flat but be sure the tripod is still valid, esp the medial tripod. Don’t be what Dr. Allen refers to as a “knuckle popper”. No toe curling/hammering either. Keep that glute on. Move the swing leg forward during a lunge, and then behind you during a squat (mimicking early and late midstance phases of gait/running). This will help your brain realize when it needs this stability and it will also act to press you off balance and will make the foot check and challenge. Do this until you feel the foot fatigue on the bottom. Then Stop. Repeat later. If the medial tripod collapses, the knee will drop inwards and excess pronation is inevitable. We modified this with our prescription of the “100 ups”…..combine the two !

Shawn and Ivo … .  comfortably numb.

Once you have been to the Dark Side of the Moon  (and hopefully you didn’t have any Brain Damage) you will know it well and know what to expect when you return again.  Meaning, when you have seen these issues over and over again, hopefully in your daily work if not regularly here at The Gait Guys, you will quickly know what things to assess and look for in your athletes.  And you might just turn into a Pink Floyd fan at the same time, or at least crave some Figgy Pudding (but you have to eat yer’ meat! How can you have any pudding if you don’t eat  yer’ meat?).

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Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction.     Rabbito M, Pohl MB, Humble N, Ferber R.

CONCLUSION:

The increased foot pronation is hypothesized to place greater strain on the posterior tibialis muscle, which may partially explain the progressive nature of this condition. J Orthop Sports Phys Ther, Epub 12 July 2011. doi:10.2519/jospt.2011.3545.

 

What the Gait Guys say about this article:

Do these results really surprise us? The Tibialis posterior (TP) is one of the more important extrinsic arch stabilizing muscles. It is a stance phase muscle that fires from the loading response through terminal stance. It ‘s proximal attachments are from the posterior aspect of the tibia, fibula and interosseous membrane and its distal attachments are the undersurface of all the tarsal’s except the talus and the bases of all the metatarsals except the first.

Since the foot is usually planted when it fires, we must look at its closed chain function (how does it function when the foot/insertion is fixed on the ground), which is predominantly maintenance of the medial longitudinal arch, with minor contributions to the transverse metatarsal and lateral longitudinal arches; flexion and adduction of the tarsal’s and metatarsals, eccentric slowing of anterior translation of the tibia during ankle rocker. It is also an external rotator of the lower leg and is the prime muscle which decelerates internal rotation of the tibia and pronation. As the origin and insertion are concentrically brought towards each other during early passive heel lift it becomes a powerful plantarflexor and inverter of the rearfoot.  There is also a  component of ankle stabilization via posterior compression of the tarsal’s and adduction of the tibia and fibula.

Alas, there is soooo much more than the typical open chain function of plantar flexion, adduction and inversion. Perhaps it is some of these other, closed chain functions, that cause the “progressive nature of the condition”?

We remain…The Gait Guys…Going above and beyond basic function and biomechanics.


Passive Arch Stability Anatomy Review

Anatomy review: No matter how good the shoe choice is for a client’s/patient’s foot type……if muscular weakness has persisted long enough to compromise one of the big 6 (plantar aponeurosis, long-short plantar ligaments, plantar calcaneonavicular ligament (spring ligament), medial talocalcaneal ligament, talocalcaneal interosseous ligament, and tibionavicular portion of the deltoid ligament) there is likely to be recurrent foot problems.

Foot Ankle Int. 1997 Oct;18(10):644-8.

Stability of the arch of the foot.

Kitaoka HB, Ahn TK, Luo ZP, An KN.

Source

Department of Orthopedics, Mayo Clinic, Rochester, Minnesota 55905, USA.