The rigid flat foot. Why an orthotic may not work well at all.

Just because the foot is flat (arch collapsed) does not mean you have a right to try and lift it !
This is a perfect example of a foot that is troubled. It is a rigid flat foot deformity. This acquired over a long period of time. Sometimes tibialis posterior insufficiency over time finally gives way to an incompetent tib posterior, with eventual arch gradual collapse into a pes planus flat deformity, and then time takes its effect to contracture and shorten tissue and arthritic change makes it permanent.
This arch will no longer lift, it is a rigid pes planus. IT will not tolerate an orthotic, SO DO NOT PRESCRIBE ONE ! Even a mild orthotic lift will feel like a golf ball under this arch.
And, to take this one step further, a rockered shoe is, in part, the right idea, but not when the foot does not sagittally toe off. This foot is permanently locked into a full limb external rotation because of hip arthritic change. The point is that his foot progression angle is 45 degrees++, and the rocker will not work if it cannot rocker in the sagittal plane.
This guy wanted an orthotic, and i would not give it to him, and you shouldn't either. He will wear it for 1 minute and throw it away.

Shawn Allen, the other gait guy

#gait, #anklerocker, #forefootrocker, #footprogression, #archcollapse

A foot bump. What might this be, and mean?

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A foot bump.
We see this kind of thing all the time. This is a fixed pes planus (flat foot). When we dorsiflex the big toe, the arch does not go up as you see in the photo. That is passive dorsiflexion, if the arch does not go up passively, there is no way you are actively going to achieve this. And, using an orthotic to "attempt" to raise this arch is not only pointless, but it is futile and it will likely cause them pain. This arch does not rise, no matter how hard you put up into it. The bump, that is the navicular bone, and its associated arthritic build up at the adjacent joints, and likely soft tissue accomodation/hypertrophy. You can't needle, ultrasound, tape, adjust or rub this bump away, so stop wasting your and your patient's time selling them that wasteful thinking. It ain't gonna happen.
This is what happens when someone earns a collapsed longitidinal arch, the 1st metatarsal no longer plantarflexes (arch up) and it becomes fixed in dorsiflexion, thus affecting the mechanics at the proximal aspect of the 1st ray complex (navicular-cuneiform-met intervals).
Why? This happened because this client has significantly compromised ankle mortise dorsiflexion, and they chose to find it at the next joint complex distally, as mentioned above. So, they are finding pseudo-ankle rocker at arch collapse? Yes, we discuss this often, more pronation will advance the tibia forward. It is not desirable, but moving forward has to occur, and some people have no choice but to find it from excessive internal rotation and pronation of the limb. And this is what happens when it happens over years. Now the deformity is painful itself in the shoe, it is a new set of problems for this client.
Can this problem occur in reverse ? Yes, a loss of hallux dorsiflexion can afford the same end result.
We have a rule, at the very VERY least, check the joint above and below the area of problem/symptom. Often you will find another piece of the puzzle causing your client's pain.

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Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

- another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. Shawn Allen, one of the gait guys

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Flat Dogs

Take a look at these pedographs. Wow!

  • No rear foot heel teardrop.
  • No midfoot arch on left foot and minimal on right.
  • An elongated 2nd metatarsal bilaterally and forces NOT getting to the base of the 1st metatarsal and stalling on the 2nd: classic sign of an uncompensated forefoot varus.
  • increased printing of the lateral foot on the right

Knowing what you know about pronation (need a review? click here) Do you think this foot is a good lever? Do you think they will be able to push off well?

What can we do?

  • foot exercises to build the intrinsic and extrinsic muscles of the foot (click here, here, here, and here for a few to get you started)
  • perhaps an orthotic to assist in decreasing the pronation while they are strengthening their foot
  • motion control shoe? Especially in the beginning as they are strengthening their feet and they fatigue rather easily

The prints do not lie. They tell the true story of how the forces are being transmitted through the foot. For more pedograph cases, click here.

The Gait Guys. Teaching you more about the feet and gait. Spreading gait literacy throughout the net! Do your part by forwarding this post to someone who needs to read it.

A Study Supporting much of what we have been saying.

  • folks in the Indian population have flatter feet
  • the amount of great toe extension is important, especially as it relates to foot pain
  • foot prints can tell you a lot about a foot
  • foot exercise and footwear modifications achieved the best outcomes

Lets look at some of these points.

folks in the Indian population have flatter feet
foot morphology is not only developmental, but has a genetic component, that can differ in different populations
the amount of great toe extension is important, especially as it relates to foot pain

just how much great toe extension (or dorsiflexion as foot geeks like to say) is necessary? The great toe must extend 40 degrees to walk normally and most folks can dorsiflex 65 degrees. If this is impaired (something called “hallux limitus”) it can:
  • shorten your stride length
  • make you have difficulty with high gear push off
  • will probably give you pain at the metatarsal phalangeal junction

foot prints can tell you a lot about a foot

Gee, we have been saying this for a few years now and have been advocating the use of a pedograph as well. In fact, we wrote the ONLY book about it’s interpretation, available by clicking here.

foot exercise and footwear modifications achieved the best outcomes

We have almost a thousand posts on this blog, and nearly 100 youtube videos, many of which talk about foot exercises, their indications and how to do them

The Gait Guys. Increasing your “Foot IQ” each and every day. If you are new to us, thanks for reading and feel free to “dig in” and search this blog, as well as our youtube channel. Have a question? Want to take your learning to the next level? Consider taking the International Shoe Fit Certification Program and put yourself at the front of the line when it comes to shoe fit. email us at thegaitguys@gmail.com for more info. 

 
J Orthop Surg (Hong Kong). 2013 Apr;21(1):32-6.

Flatfoot in Indian population.

Source

Department of Orthopaedics, Moti Lal Nehru Medical College, Allahabad, India.

Abstract

PURPOSE. To compare outcomes of different conservative treatments for flatfoot using the foot print index and valgus index. METHODS. 150 symptomatic flatfoot patients and 50 controls (without any flatfoot or lower limb deformity) aged older than 8 years were evaluated. The diagnosis was based on pain during walking a distance, the great toe extension test, the valgus index, the foot print index (FPI), as well as eversion/ inversion and dorsiflexion at the ankle. The patients were unequally randomised into 4 treatment groups: (1) foot exercises (n=60), (2) use of the Thomas crooked and elongated heel with or without arch support (n=45), (3) use of the Rose Schwartz insoles (n=18), and (4) foot exercises combined with both footwear modifications (n=27). RESULTS. Of the 150 symptomatic flatfoot patients, 96 had severe flatfoot (FPI, >75) and 54 had incipient flatfoot (FPI, 45-74). The great toe extension test was positive in all 50 controls and 144 patients, and negative in 6 patients (p=0.1734, one-tailed test), which yielded a sensitivity of 96% and a positive predictive value of 74%. Symptoms correlated with the FPI (Chi squared=9.7, p=0.0213). Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index. CONCLUSION. The great toe extension test was the best screening tool. The FPI was a good tool for diagnosing and grading of flatfoot and evaluating treatment progress. Combining foot exercises and foot wear modifications achieved the best outcome.

Stage 1 of Correcting a flat foot, video demonstration.

Here is a case of a young man that was brought into us by his parents. Their concern was that their son was displaying what they thought was foot weakness. 

At the beginning of the video you can see that his foot progression angle is significant.  Certainly greater than the 10-15 degree “so called” normal range.  His arches are also somewhat collapsed. His knees were also displaying some hyperextension which is quite common with flat foot posturing.

This was his third visit into our office. He was given the corrective neuromuscular strategy that you see here and some specific exercises to help him get to this stage of correction.  The first stage of any correction is developing the awareness of what you are doing wrong (ie. become consciously aware of your incompetence). That was session one.  Session two focused on developing this corrective pattern, helping him find the skills to develop some conscious competence with a more normal foot stability skill pattern (endurance and strength still need to be added). 

Here you will see that, when queued, he immediately moves into a narrower base of stance (this will always happen when they can form a competent foot tripod, as you can see here).  In other words, the worse the foot collapse, the wider the feet will be positioned.  In his case, he now positions his feet under his hips and knees. 

You will also see the early success (after just 2 visits !) of a critical neuromuscular pattern.  He is showing some competence in holding the arch up and letting the toes move into flexion onto the ground.  Most flat footed children cannot separate “maintaining arch up, and moving into toes down”, rather they are into the pattern of “when the toes drop to the floor, the arch drops as well”.  This is a critical pattern (ability to hold arch up) to recognize and develop.  The child must develop the ability to independently flex and extend the toes on a static arch, while holding tripod,  before gait retraining can ensue.  This is mainly because the speed of gait and difficulty of single leg stance while displaying the correct pattern is just too much of a skill mastery issue. Often these pupils do not have enough hip frontal plane stability nor pelvic stability as well.

Also, note that he uses the skill of toe extension to help with arch height determination.  This goes right back to our blog posts last week on the Windlass Mechanism.  He is using the power of the windlass effect (toe extension) to take up the slack in the plantar fascial around the great toe metatarsal joint and thus pull the rear foot towards the forefoot (ie. raising the arch via this mechanism ! ).  Without a competent windlass a competent arch cannot be obtained (thus the ridiculousness of plantar fascial release surgery !).  Additionally, understanding the windlass and the effects of this simple video should give you insight into our success in quickly treating plantar fascitis. 

(addendum: also note at the end of the video that i ask him to collapse into his old pattern, this was after 30 minutes of corrective motor pattern exercises.  I laugh because in a solid posture that he shows at the end of the video, plus 30 minutes of new patterning, he found it difficult to find his old collapsed pattern.  This is a frequent occurance ! It gives you and the patient confidence that headway is being made.)

You must develop isometric, eccentric and concentric strength of the plantar intrinsic muscles that stabilize, raise, and control the lowering of the arch (as well as the arch controlling extrinsic muscles such as tibialis anterior and posterior among others) if you are going to make a difference in someones foot mechanics.  Just putting someone into a pair of ANY minimalist shoe (let alone barefoot) doesn’t guarantee strengthening of the foot or a remedy for a pair of feet like in this video. The process is a little more complicated than slipping on a pair of low ramp angle “shoes” and wearing them all day long…….in these types of cases all it does is raise their risk of injury or further foot incompetence down the road. 

For our fellow clinicians out there who are following us and trying to learn more about this kind of stuff……. wouldn’t your clinical world be nice if just prescribing a minimalist shoe would strengthen the foot in the correct pattern !?  We argue that, as in this kids foot, they would strengthen his foot in his poor postured patterns. So, we guess these companies are not lying when they say their shoes “strengthen” your feet, they just leave out the word “correctly”.

So, we do not argue with the point that going minimalist will strengthen your foot…… the question is “do you want to strengthen the correct pattern or a compensated one?”. 

here at The Gait Guys…….we know which pattern we want to strengthen.

We remain strong advocates that not all feet belong in minimalist shoes…… at least not initially, and some, never.  It would be nice if just slipping on a shoe could fix all of your foot problems, but it just isn’t that easy.  This is the topic no one is talking about, except The Gait Guys ……… because it doesn’t sell shoes.

There is much more to it than this video shows……. but we have to start somewhere.  Educating you with the issues we feel passionate about is the first step sometimes.

We remain…….obviously passionate………..

Shawn and Ivo….. The Gait Guys

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe

As promised. We fixed the volume.  Less hiss next time. Enjoy

Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch. Muscle specifically discussed are a team: FHB (flexor hallucis brevis), AbDuctor hallucis, and tibialis posterior. He discusses the functional anatomy, normal and pathologic movement patterns of the arch and first ray complex and big toe (hallux). His foot’s ability to show the optimal patterns for the arch and hallux are excellent examples. Follow up videos and DVDs will show more details you need to know, and some of the exercises he and Dr. Ivo Waerlop use to restore a foot that has lost these abilities. The DVDs are in the works. Take their lectures and CME on www.onlineCE.com. Visit them at www.thegaitguys.com and on their facebook PAGE & Twitter of the same name for daily feeds of unique things.