Metatarsalgia happens...

So a patient presents with forefoot pain, worse in the am upon awakening, with 1st weight bearing that would improve somewhat during the day, but would again get worse toward the end of the day and with increased activity. It began insidiously a few months ago (like so many problems do) and is getting progressively worse. Rest, ice and ibuprofen can offer some relief. You may see a dropped metatarsal head and puffiness and prominence in that area on the plantar surface of the foot, maybe not. Maybe you do a diagnostic ultrasound and see a lesion of the plantar plate as well? How did it get there? 

image courtesy of Tom Michaud: with permission

image courtesy of Tom Michaud: with permission

Lets look at the anatomy of the short flexors of the foot, as well as some biomechanics of the foot, ankle and hip. 

The flexor digitorum brevis (FDB) is innervated by the medial plantar nerve and arises from the medial aspect of the calcaneal tuberosity, the plantar aponeurosis (ie: plantar fascia) and the areas bewteen the plantar muscles. It travels distally, splitting at the metatarsal phalangeal articulation (this allows the long flexors to travel forward and insert on the distal phalanges); the ends come together to divide yet another time and each of the 2 portions of that tendon insert onto the middle of the middle phalanyx (1) 

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsophalangeal and proximal interphalangeal joints. In addition, it moves the axis of rotation of the metatasophalangeal joints dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly .Do you see any subtle extension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joints on your exam?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a role in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, the metatarsal heads are driven into the ground, causing irritation and pain.

If there is also a loss of ankle rocker this problem is made (much) worse. Why? Because, with the loss of one rocker, another must make up for the loss: ankle rocker decreases, forefoot rocker has to increase; this equals increased metatarsal head pressure. 

If you have been with us for any length of time, you know that ankle rocker and hip extension are intimately related, as one should equal the other, something we call “The “Z” angle”, that you have probably (hopefully?) read about here before. 

So what is the fix? Getting the FDB back on line for one. 

  • How about the toe waving exercise? 

  • How about the lift spread reach exercise? 

  • How about retraining ankle rocker and improving hip extension?

  • How about an orthotic with a metatarsal pad in the short term? 

  • How about some inflammation reducing modalities, like acupuncture, ice laser and pulsed ultrasound. 

  • Maybe some herbal or enzymatic anti inflammatories?



Dr Ivo Waerlop, one of The Gait Guys.

#gait #footpain #metatarsalgia #metatarsalpain #anklerocker #hipextension #thegaitguys



1. http://en.wikipedia.org/wiki/Flexor_digitorum_brevis_muscle

2. Tosovic D1, Ghebremedhin E, Glen C, Gorelick M, Mark Brown J.The architecture and contraction time of intrinsic foot muscles.J Electromyogr Kinesiol. 2012 Dec;22(6):930-8. doi: 10.1016/j.jelekin.2012.05.002. Epub 2012 Jun 27

3.Okai LA1, Kohn AF. Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.Motor Control. 2014 Jul 15. [Epub ahead of print]

4. Zelik KE1, La Scaleia V, Ivanenko YP, Lacquaniti F.Coordination of intrinsic and extrinsic foot muscles during walking.Eur J Appl Physiol. 2014 Nov 25. [Epub ahead of print]



Got hip extension?

Because she sure could use some...

we have see this gal before… yesterday in fact

  • left plantar plate lesion (yes, conformed on ultrasound)

  • left sided anatomical leg length discrepany

  • bilateral internal tibial torsion

  • incompetent L quadratus lumborum

  • adequate hip extension and ankle dorsiflexion available to her

  • lack of endurance in her abs

yep, lots more, but that is enough for now



note that she has plenty of ankle dorsiflexion, more on the right. this is due to her right leg being anatomically longer and has to travel through a greater range of motion

look at the knee and the hip articulations to assess hip extension. It should match ankle dorsiflexion, no?




Dr Ivo Waerlop, one of The Gait Guys




#gait #gaitguys #thegaitguys #hipextension #LLD #quadratuslumborum #internaltibialtorsion #anklerocker #ankledorsiflexion

How is your foot is connected to your butt....?

EVD-marcha-075.jpg

If you have been following us for any length of time, you have heard us talk about how the lower kinetic chain is connected, how ankle rocker effects hip extension and how important hallux (great toe) extension is. 

What can we conclude from this study?

toe spreading exercises are important for reducing navicular drop (and thus mid foot pronation, at least statically)
In addition to increased abductor hallucis recruitment in ascending and descending stairs, when hip external rotation exercises were added along with toe spreading exercises folks had more recruitment of the vastus medialis (a closed chain external rotator of the leg and thigh)
 
Keep in mind:

the exercises given were all non weight bearing and open chain for the external rotators. Imagine what might have happened if they were both closed chain AND weight bearing!
They concentrated on the effects of toe spreading (AKA  lift/spread/reach) on the abductor hallucis. It also has far reaching effects on the dorsal interossei, long and short extensors of the toes. 

Abstract: The purpose of the present study was to examine the effects of toe-spread (TS) exercises and hip external rotator strengthening exercises for pronated feet on lower extremity muscle activities during stair-walking. [Subjects and Methods] The participants were 20 healthy adults with no present or previous pain, no past history of surgery on the foot or the ankle, and no foot deformities. Ten subjects performed hip external rotator strengthening exercises and TS exercises and the remaining ten subjects performed only TS exercises five times per week for four weeks. [Results] Less change in navicular drop height occurred in the group that performed hip external rotator exercises than in the group that performed only TS exercises. The group that performed only TS exercises showed increased abductor hallucis muscle activity during both stair-climbing and -descending, and the group that performed hip external rotator exercises showed increased muscle activities of the vastus medialis and abductor hallucis during stair-climbing and increased muscle activity of only the abductor hallucis during stair-descending after exercise. [Conclusion] Stair-walking can be more effectively performed if the hip external rotator muscle is strengthened when TS exercises are performed for the pronated foot.

Goo YM, Kim DY, Kim TH. The effects of hip external rotator exercises and toe-spread exercises on lower extremity muscle activities during stair-walking in subjects with pronated foot. J Phys Ther Sci. 2016 Mar;28(3):816-9. doi: 10.1589/jpts.28.816. Epub 2016 Mar 31. 
link to  FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842445/

The Gluteus Medius: Its not just for abduction anymore...

It would logically follow that the gluteus medius is important for generating both forward progression and support, especially during single-limb stance suggesting that walking dynamics are influenced by non-sagittal muscles, such as the gluteus medius, even though walking is primarily a sagittal-plane task. After midstance, but before contralateral preswing, support is generated primarily by gluteus maximus, vasti, and posterior gluteus medius/minimus; these muscles are responsible for the first peak seen in the vertical ground-reaction force. The majority of support in midstance was provided by gluteus medius/minimus (NOT the maximus), with gravity assisting significantly as well. The gluteus medius has also been highlighted as an abductor of the pelvis, working in concert with the contralateral quadratus lumborum (2), involved with keeping the pelvis level and abducting the pelvis on the stance leg side, such as when ascending stairs. 

Albinus_rear-2.jpg

Seemingly, the gluteals appear important for extension of the thigh during gait. One of the most common scenarios appears to be a loss of ankle rocker and resultant weakness of the gluteals (personal observations). Lets look at an example. 

Have you ever sat at the airport and watched people walk? I travel a great deal and often find myself passing the time by observing others gait. It provides clues to a plethora of biomechanical faults in the lower kinetic chain, like a loss of ankle rocker with people who wear flip flops or any other open backed shoes.

What is ankle rocker, anyway? According to Jaqueline Perry (THE Matriarch of Gait Analysis) during normal gait, the stance phase (weight bearing) foot depends on 3 functional rockers (pivots or fulcrums) for forward progression (3).

  • heel rocker: at heel strike, the calacaneus acts as the fulcrum as the foot rolls about the heel into plantar flexion of about 10 degrees . The pretibial muscles must contract eccentrically to slowly lower the foot and help, along with forward momentum, pull the tibia forward
  • ankle rocker: next, the ankle acts as at fulcrum and the tibia rolls forward due to forwardmomentum, with a maximum excursion of approximately 15 degrees. The gastroc and soleus should eccentrically contract to decelerate the forward progression of the lower leg.
  • forefoot rocker: the metatarso-phalangeal joints act at the finalfulcrum in the stance phase of gait. Note that the 1st metatrso-phalangeal joint must dorsiflex65 degrees for normal forward progression, otherwise the individual will usually roll off he inside of the great toe. Tibial progression continues forward and the gastroc/soleus groups concentrically contract to decelerate the rate of forward limb movement. This, along with passive tension in the posterior compartment muscles, forward momentum , and the windlass effect of the plantar fascia result in heel lift.

Now watch someone walking in flip flops or open back shoes. There is no pivot past 90 degrees at the ankle (i.e. the tibia never goes beyond 90 degrees vertical). At this point the heel comes up (premature heel rise) and the motion must occur at the metatarso-phalalgeal joint. The only problem is that this joint usually has a maximum of 65 degrees extension, with 50 degrees needed for "normal" ambulation. Since more is now needed, the body borrows from an adjacent joints, namely the knee (which increases flexion) and the interphalangeal joints (which should be remaining flat and now must claw to “create” more available extension at the middle joint, as the proximal is nearly fully extended, through overactivity of the flexor digitorum longus. The tibialis posterior, flexor hallicus longus, and gastroc soleus groups also contract in an attempt to help stabilize the foot . Overactivity of these groups causes reciprocal inhibition of the long toe extensors and ankle dorsiflexors (tibialis anterior for example), causing the toes to buckle further and a loss of ankle dorsiflexion; in short, diminished ankle rocker function.

So there you have it. Glutes. They are a beautiful thing! Now get out there and improve their function!

 

1. Presswood L, Cronin J, Keogh J, Whatman C (2008). Gluteus Medius: Applied Anatomy, Dysfunction, Assessment, and Progressive Strengthening. Strength and Conditioning Journal, 30 (5), 41-53

2. J. Porterfield, C. DeRosa (Eds.) Mechanical low back pain. 2nd ed. WB Saunders, Philadelphia; 1991

3. Perry J, Burnfield JM, eds. Gait Analysis: Normal and Pathological Function. Journal of Sports Science & Medicine. 2010;9(2):353.

 

What’s wrong with this picture? (Besides the fact that you probably shouldn’t run with your dog on asphalt)    There’s been a lot of incongruency in the media as of late. This particular gal, with your head rotation to the right is going against the harmony of neurology and physiology. Let me explain…   This particular gal, with her rotated to the right is going against the way the nervous system is designed to work.  In a post  in the last week or so (the massage cream one and  incongruent movement) we talked about tonic neck responses. When the head is rotated to one side, that upper and lower extremity should extend while the contralateral side should flex. This poor gal is fighting her own neurology!     Also note that she really doesn’t have that much hip extension on the right and increases her lumbar lordosis to compensate. Gee whizz. You’d a thought they would have done better…   So much for the photo op : -) 

What’s wrong with this picture? (Besides the fact that you probably shouldn’t run with your dog on asphalt) 

There’s been a lot of incongruency in the media as of late. This particular gal, with your head rotation to the right is going against the harmony of neurology and physiology. Let me explain…

 This particular gal, with her rotated to the right is going against the way the nervous system is designed to work.

In a post  in the last week or so (the massage cream one and  incongruent movement) we talked about tonic neck responses. When the head is rotated to one side, that upper and lower extremity should extend while the contralateral side should flex. This poor gal is fighting her own neurology! 

 Also note that she really doesn’t have that much hip extension on the right and increases her lumbar lordosis to compensate. Gee whizz. You’d a thought they would have done better…

 So much for the photo op : -) 

A profound loss of hip extension…

While sitting on the beach, our mind never rests. Even when on vacation we continue to watch how people move.

Luckily today, I had the gait cam (Dr Allen is holding down the Gait Guys Fort), so live from Sunset Beach, it’s Sunday night. See of you can see what I saw.

Sitting with my wife and watching the kids dig in the sand, this gal with the flexed posture caught my eye.

Why is she so flexed forward? The profound loss of hip extension made it impossible for her to stand up straight! It was difficult to say if she has bilateral hip osteoarthritis, or possible bilateral THR’s (total hip replacements), maybe just really tight hip flexors, painful bunions that do not like toe off, or even all of the above. She may have a leg length discrepancy, as she leans to the left on left stance phase; of course she could have weak hip abductors on the left. It does not appear she has good control of her core.

What do we see?

  • flexion at the waist
  • loss of hip extension
  • body lean to left at left midstance
  • shortened step length
  • loss of ankle rocker
  • premature heel rise
  • decreased arm swing (she is carrying something in her left hand)

No one is safe from the gait cam! Stay tuned for more beach footage this week!

We remain, The Gait Guys, even on vacation.

Heads up! 
 
 Remember that song “Hold Your Head Up” by the British  band “Argent” in 1972? Ok, maybe not, but the principle is very important to runners and sprinters, so lets talk about it a bit.    We are wired to maintain our visual axes parallel to the horizon. This involves a series of joint and muscle mechanoreceptors in the neck (for a review of joint mechanoreceptors, click here, muscle mechanoreceptors, click here). These muscle and joint mecanoreceptors receptors, through connections in the midbrain (or mesencephalon as we neuro geeks like to call it) and pons, interact with the vestibular system to keep our head (and our bodies) upright, by firing our extensor muscles.   
 Berta Bobath, physiotherapist, wrote a great book in 1965 entitled “Abnormal Postural Reflex Activity Caused By Brain Lesions”. In it she describes, among many things, reflexes involving the cervical spine and correlating them to motor function. One of these is the cervical extensor reflex.   To explain this reflex, think of a dog sitting to get a treat. As he looks up while sitting down he has to extend his head, extend his front legs and fires all the axial extensor muscles associated with performing this action. The opposite would also happen, but with the flexors, if he were to bend forward to take a drink; fire front flexors and rear extensors to bend down. There are many more reflexes (tonic neck, cervcio ocular, etc) that could be the subject of another post. 
 
 As we have learned from the principle of facilitation (see recent post here), when we fire pur extensors, we fire into the extensor pool, and as a result, ALL extensors get to benefit. The advantage of the receptors in the cervial spine is that the upper four fire DIRECTLY into the flocculo nodular lobe of the cerebellum, and thus have a PROFOUND EFFECT on extensor tone in general. 
  
 So, if you want to go faster, why not hold your head up and FIRE YOUR EXTENSORS MORE? Hmmm….Where have you heard this before?   
 Another magic bullet, courtesy of your built in neurology, we are sharing with you so you and your clients, patients and friends can be better at what they do 
 The Gait Guys. Stretching your neurology on a daily basis.

Heads up!

Remember that song “Hold Your Head Up” by the British  band “Argent” in 1972? Ok, maybe not, but the principle is very important to runners and sprinters, so lets talk about it a bit. 

We are wired to maintain our visual axes parallel to the horizon. This involves a series of joint and muscle mechanoreceptors in the neck (for a review of joint mechanoreceptors, click here, muscle mechanoreceptors, click here). These muscle and joint mecanoreceptors receptors, through connections in the midbrain (or mesencephalon as we neuro geeks like to call it) and pons, interact with the vestibular system to keep our head (and our bodies) upright, by firing our extensor muscles.

Berta Bobath, physiotherapist, wrote a great book in 1965 entitled “Abnormal Postural Reflex Activity Caused By Brain Lesions”. In it she describes, among many things, reflexes involving the cervical spine and correlating them to motor function. One of these is the cervical extensor reflex.

To explain this reflex, think of a dog sitting to get a treat. As he looks up while sitting down he has to extend his head, extend his front legs and fires all the axial extensor muscles associated with performing this action. The opposite would also happen, but with the flexors, if he were to bend forward to take a drink; fire front flexors and rear extensors to bend down. There are many more reflexes (tonic neck, cervcio ocular, etc) that could be the subject of another post.

As we have learned from the principle of facilitation (see recent post here), when we fire pur extensors, we fire into the extensor pool, and as a result, ALL extensors get to benefit. The advantage of the receptors in the cervial spine is that the upper four fire DIRECTLY into the flocculo nodular lobe of the cerebellum, and thus have a PROFOUND EFFECT on extensor tone in general.

So, if you want to go faster, why not hold your head up and FIRE YOUR EXTENSORS MORE? Hmmm….Where have you heard this before?

Another magic bullet, courtesy of your built in neurology, we are sharing with you so you and your clients, patients and friends can be better at what they do

The Gait Guys. Stretching your neurology on a daily basis.

Being a gait geek offers you a unique perspective in many situations.

Perhaps you have been with us for some time now and would like to check your gait acumen. If you are new, or these terms are foreign to you; search here on our blog through hundreds of posts to become more comfortable with some of the vocabulary.

Watch this video a few times (we slowed it down for you) and write down what you see.

Did you see all of these in this brief video?

  • bilateral loss of hip extension
  • bilateral loss of ankle rocker
  • less ankle rocker on right
  • bilateral increased progression angle  
  • dip in right pelvis at right heel strike
  • arm swing increased on R

The Gait Guys. Increasing your gait competency each and every day.

special thanks to NL for allowing us to use this video footage.