Obligate Pathomechanics

Much of what we see in gait analysis is secondary to the anatomical and physiological constraints exhibited by a patient. Take a look at this gentleman running. At first glance, you may be saying “yup, crossover gait, strengthen the gluteus medius complex“.

Now let’s talk about his physical exam. He has “windswept biomechanics“, With external tibial torsion on the right and internal table torsion on the left. There is no significant difference or increase in his Q angles bilaterally. He has a forefoot supinatus on the right side (I.e his forefoot is inverted with respect to his rear foot). He has limited plantar flexion of the first Ray complex on the right.

Now watch the video again with this in mind. Can you understand that if he’s unable to get his first ray to the ground he’s going to have any sort of hike your push off, in order to get it to the Ground he’ll need to mediately rotate his lower extremity and increase the valgus angle on that side. External tibial torsion (when you drop a plum line from the tibial tuberosity, it passes medial to a line passing to the long axis of the second metatarsal) compounds this. Stand up, rotate your right foot to the outside, keep it there and walk forward. Do you see how your knee has to go to the inside to push off your big toe?

Yes, he has a crossover gait but it is obligate and a direct function of his inability to descend the first ray, at least partly due to his forefoot supinatus and his external tibial torsion on the right.

Obligate pathomechanics. Coming to a patient in your office or one of the folks you are coaching soon.

We will be talking about foot types and pathomechanics tonite, October 16th, 2019, on our 3rd Wednesday’s teleseminar on onlinece.com: Biomechanics 314

5 pacific, 6 mountain, 7 central, 8 eastern

Dr Ivo Waerlop, one of The Gait Guys

Forefoot Varus vs Forefoot Supinatus

We talked about forefoot varus, forefoot supinatus and subsequent biomechanics in a recent onlinece.com course. Here is a great commentary on a review article we discussed as well as a great explanation about thew tru differences between at forefoot varus (rare) and the more common forefoot supinatus.

Take home message? FROM THE ARTICLE:

" In summary: both look the same, but they are totally different beasts:

    a forefoot varus is bony and a forefoot supinatus is soft tissue
    a forefoot varus is a cause of ‘overpronation’ and a forefoot supinatus is the result of ‘overpronation’
    a forefoot varus is rare and a forefoot supintus is common
    a forefoot varus cannot be corrected and a forefoot supinatus can be corrected"

http://www.runresearchjunkie.com/the-effect-of-forefoot-varus-on-the-hip-and-knee-and-the-effect-of-the-hip-and-knee-on-forefoot-supinatus/

Unilateral heightened toe extensor tone.

Look at this foot. What do you see ? See the asymmetry ? This is a perfect case to prove our point, for those out there that love the short foot exercise, that insist on towel scrunches, marble pick-ups, or just mere foot rolling on the ball. These things are useless in some cases, arguably to us, much of the time actually. This is about having sufficient foot integrity, normal heel rocker, ankle rocker, forefoot rocker mechanics, and especially in this case, a NORMAL balance between the long and short flexors and extensors. These 4 must work together in harmony, and this is clearly not happening on the left foot. Head on over to this Archived blog post from 2014, and learn what is wrong here. One has to understand it, to fix it. And throwing a short foot regimen, or pilates foot work at it or even more flexor tone into this foot will not fix this. Exercise prescription is supposed to be specific, not a shot gun approach of "try this exercise", lets see if it helps. A 5th grader can give that advice, sadly it is more the industry norm at times. Yes, every exercise is a test, but do not be mistaken that every test is the exercise.

https://thegaitguys.tumblr.com/post/85726861424/unilateral-heightened-toe-extensor-tone-what-do

Unilateral heightened toe extensor tone.

What do we have here ? Well, it is obvious. The left foot is showing increased short extensor tone (EDB: extensor digitorum brevis) and heightened long flexor tone (FDL: flexor digitorum longus). This is the classic pairing for hammer toe development.  We also know from this post (link) and from this post (link) that this presentation is closely related with lumbrical weakness and distal fat pad migration.

So, at an assessment took we like to play games. Mental games to be precise. When we see something like this we immediately begin the mental gyrations of “what could have caused this, and what could this in turn be causing”. Remember, what you see is often not the problem, rather your clients compensation around the problem.  In this case, what goes through your mind ?  Without deep thought, our knee jerk thoughts are:

• possible loss of ankle rocker dorsiflexion (the increased EDB tone can be recruited to help drive more ankle dorsiflexion indirectly)
• plantar intrinsic weakness ?
• flip flops or slip on shoes where the heel is riding up and down inside the shoe/sloppy fit ?  (initiating a gripping response from the FDL)
• weak tib anterior (recruiting EDB to help)
• weak peroneus tertius (recruiting EDB again)
• Ankle /foot instability (more FDL gripping will help gain ground purchase)
• lateral ankle instablity (same thing, more gripping)
• Weak gastrosoleus (since the FDL is a posterior compartment neighbor it can kick into high gear and help with posterior comparment function, we have a whole video case based around this issue, check this out ! )
• premature departure off of the good side leg, and thus an abrupt loading response onto this affected side can challenge the frontal plane of the body and thus require more grip response at the foot level.
• how about simple weakness of the lumbricals or FDB , the short flexors. The long flexors will have to make up for it and present like this.  
• the list goes on and on … .

These are just some quick cursory thoughts, and by NO means a complete exhaustive list.  Just some quick thoughts.

But what about hip function ?  if ankle rocker is blocked in terminal stance and the FDL fire like this what will that do to hip extension ? Well, heel rise will be premature because of the limitation and thus hip extension will be abbreviated. Thus glute function will be impaired to a degree.  This can become a viscous cycle, each feeding off of each other.

This diagnostic stuff is a tricky and difficult game. If you think you can diagnose or fix a problem from just changing what you see you are mistaken, unless you like driving compensation patterns and future injuries into your clients.   There must be a hands on examination and assessment with an intact educated brain attached to the process.

Just some mental gymnastics for you today.  

Dr Shawn Allen, one of the gait guys

What do we have here and what type of shoe would be appropriate?

You are looking at a person with a fore foot varus. This means that the fore foot (ie, plane of the metatarsal heads) is inverted with respect to the rear foot (ie, the calcaneus withe the subtalar joint in neutral). Functionally translated, this means that they will have difficulties stabilizing the medial tripod (1st MET head) to the ground making the forefoot and arch unstable and likely rendering the rate and degree of pronation increased.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994), so it seems to happen happen more in males. We think this second number is inflated and those folks actually had a forefoot supinatus, which is much more common.

Fore foot varus occurs in 3 flavors:

• compensated
• uncompensated
• partially compensated

What is meant by compensated, is that the individual is able to get the head of the 1st ray to the ground completely (compensated), partially, or, when not at all, uncompensated.What this means from a gait perspective ( for partially and uncompensated conditions) is that the person will pronate through the fore foot to get the head of the 1st ray down and make the medial tripod of the foot (ie, they pronate through the subtalar joint to allow the 1st metatarsal to contact the ground). This causes the time from mid-stance to terminal stance to lengthen and will inhibit resupination of the foot. 

Today we are looking at a rigid, uncompensated forefoot varus, most likely from insufficient talar head derotation during fetal development and subsequent post natal development. They will not get to an effective foot tripod. They will collapse the whole foot medially. These people look like severely flat-footed hyperpronators.

So, what do you do and what type of shoe is appropriate? Here’s what we did:

• try and get the 1st ray to descend as much as possible with exercises for the extensor hallucis brevis and short flexors of the toes (see our videos on youtube)
• create more motion in the foot with manipulation, massage mobilization to optimize what is available
• strengthen the intrinsic muscles of the feet (particularly the interossei)
• increase strength of the gluteus maximus and posterior fibers of the gluteus medius to slow internal rotation of the leg during initial contact to midstance
• put them in a flexible shoe for the 1st part of the day, to exercise the feet and a more supportive; medially posted (ideally fore foot posted) shoe for the latter part of the day as the foot fatigues
• monitor his progress at 3-6 month intervals
• a rigid orthotic will likely not help this client and they will find it terribly uncomfortable because this is a RIGID deformity for the most part (the foot will not accommodate well to a corrective orthotic. Besides, the correction really has to be made at the forefoot anyways. 

Lost? Having trouble with all these terms and nomenclature? Take our national shoe fit program, available by clicking here.

The Gait Guys. Uber foot geeks. Separating the wheat from the chaff, with each and every post.

Do you know SQUAT? Have you seen SQUAT? Have patients/clients that LIKE to squat? Seen a foot that looks like this? Can you say REARFOOT VALGUS?

 "Significant changes in lower limb kinematics may be observed during bilateral squatting when rearfoot alignment is altered. Shoe pitch alone may significantly reduce peak pronation during squatting in this population, but additional reductions were not observed in the subtalar neutral position. Further research investigating the effects of footwear and the subtalar neutral position in populations with lower limb pathology is required."
 
So, what does this study tell us?

when rearfoot aliment changes, so do the kinematics (duh)
the surface (tilted into varus or inversion) or shoes (which are medially posted) can make or break the man (or women) when it comes to "peak" pronation (we knew that already; confirmation is always nice)
inverting the rearfoot can change ankle dorsiflexion (read "ankle rocker"); inverting the rearfoot seems to reduce it
inverting the rearfoot can change knee flexion; inverting the rearfoot seems to increase knee flexion
inverting the rearfoot can change hip abduction (and thus knee valgus); reducing it

Learn about the gait kinematics and clinical findings associated with this foot type, along with video clip examples and always entertaining discussion with us tomorrow night on onlinece.com: Biomechanics 308: Focus on the Rear Foot.  5PST, 6MST, 7 CST, 8EST

Power V, Clifford AM. The Effects of Rearfoot Position on Lower Limb Kinematics during Bilateral Squatting in Asymptomatic Individuals with a Pronated Foot Type. J Hum Kinet. 2012 Mar;31:5-15. doi: 10.2478/v10078-012-0001-0. Epub 2012 Apr 3.

#rearfootvalgus #squat #foottype

2012 Mar;31:5-15. doi: 10.2478/v10078-012-0001-0. Epub 2012 Apr 3.

The Effects of Rearfoot Position on Lower Limb Kinematics during Bilateral Squatting in Asymptomatic Individuals with a Pronated Foot Type.

Power V1, Clifford AM.

Author information

Abstract

Clinicians frequently assess movement performance during a bilateral squat to observe the biomechanical effects of foot orthotic prescription. However, the effects of rearfoot position on bilateral squat kinematics have not been established objectively to date. This study aims to investigate these effects in a population of healthy adults with a pronated foot type. Ten healthy participants with a pronated foot type bilaterally (defined as a navicular drop >9mm) performed three squats in each of three conditions: barefoot, standing on 10mm shoe pitch platforms and standing on the platforms with foam wedges supporting the rearfoot in subtalar neutral. Kinematic data was recorded using a 3D motion analysis system. Between-conditions changes in peak joint angles attained were analysed. Peak ankle dorsiflexion (p=0.0005) and hip abduction (p=0.024) were significantly reduced, while peak knee varus (p=0.028) and flexion (p=0.0005) were significantly increased during squatting in the subtalar neutral position compared to barefoot. Peak subtalar pronation decreased by 5.33° (SD 4.52°) when squatting on the platforms compared to barefoot (p=0.006), but no additional significant effects were noted in subtalar neutral. Significant changes in lower limb kinematics may be observed during bilateral squatting when rearfoot alignment is altered. Shoe pitch alone may significantly reduce peak pronation during squatting in this population, but additional reductions were not observed in the subtalar neutral position. Further research investigating the effects of footwear and the subtalar neutral position in populations with lower limb pathology is required.

A Child with Calcaneal Valgus...Some thoughts....

Dr Ivo discusses a pediatric case and some treatment modalities

Forefoot valgus: A fixed structural defect in which the plantar aspect of the forefoot is everted on the frontal plane relative to the plantar aspect of the rearfoot; the calcaneum is vertical, the mid tarsal joints are locked and fully pronated

Want to know more? Join us Wednesday evening: 5 PST, 6 MST, 7 CST, 8 EST for Biomechanics 309: Focus on the forefoot on onlinece.com.

McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Video case: The King’s Preference: Short and Sweet. A quick and easy case demonstrating the patellar tracking struggles with external tibial torsion.

Our favorite functional evaluation piece of equipment as well as our favorite piece of therapy equipment is the Total Gym.  Here we clearly demonstrate, to us and the client, in partial weight bearing load, the effects of external tibial torsion.  

Remember, the knee is sort of the King of all joints when it comes to the lower extremity.  The knee is a sagittal plane hinge, and so all it wants to do is hinge forward, freely without binding from deficits at the hip or knee. But we cannot ignore the simple fact that pre-pubescent kids the long bone derotation process is still undergoing, and in adults the process may have been corrupted or insufficient.  

In this case it should be obvious that the knee is sagittal and free to hinge when the foot is at a large foot progression angle.  This allows the knee to hinge cleanly. But when the foot is corrected to the sagittal plane, as you see in the second half of the video, the knee tracks inward and this can cause patellofemoral pain syndromes, swelling, challenges to the menisci (and possible eventual tears) and challenges to the ACL and other accessory restraints.  Additionally, this medial drift is a longer and more difficult challenge to the eccentric phase external rotators such as the gluteus maximius not to mention many of the other muscles and their optimal function.  

So, the next time you see a large foot progression angle in a client or in their walk (duck footed if you will) try to resist the natural urge to tell them to corrrect the foot angle. They are likely doing it to keep the King happy.  And furthermore, be careful on your coaching recommendations during squats, olympic lifts, lunges and running.  Just because you do not like the way the foot looks doesn’t mean you should antagonize the King of joints.  

External tibial torsion, its not something you want to see, but when you do see it, you have to know its degree, its effects at the knee, hip and foot as well as how it might impact hip extension, pelvic neutrality, foot strike, foot type, toe off and so many other aspects.

Whoever said gait analysis was easy was a liar. And if all they use is a video camera and fancy analysis software they have show up with only part of the team. And if they said they were an expert  in gait only a few years into practice, you had better also look for a jester’s hat somewhere hiding in the corner. After all, the King would want to know !

Shawn and Ivo, your court jesters for the last 3+ years.  Maybe we will get a promotion from the King someday soon !

Can you see the problem in this runner’s gait ?

You should be able see that they are heel impacting heavy on the outside of the rear foot, and that they are doing so far laterally, more than what is considered normal.  

This is a video of someone with a rear foot varus deformity.

These folks typically have a high arched foot, typically more rigid than flexible, and they are often paired with a forefoot valgus.  

Q: Do you think it might be important as a shoe fitter to know this foot type ?

A: Yes

Q.Should they be put in a shoe with a soft lateral crash zone at the heel ? 

A: No, absolutely not. Why would you want to keep this person deeper and more entrenched on the lateral heel/foot ?!

This foot type has a difficult time progressing off of the lateral foot. The lateral strike pattern and the tendency for the varus rear-foot (inverted)  keeps this person on the lateral aspect of the foot long into midstance.  This eats up time when they should be gradually progressing over to the medial forefoot so that they can get to an effective and efficient medial (big toe) toe off.  This gait type is typically apropulsive, they are not big speed demons and short bursts of acceleration are difficult for these folks much of the time. Combine this person with some torsional issues in  the tibia or femur and you have problems to deal with, including probably challenges for the glutes and patellar tracking dysfunction. What to see some hard, tight IT Bands ?These folks are often the poster child for it. Good luck foam rolling with these clients, they will hate you for recommending it !

They are typically poor pronators so they do not accommodate to uneven terrain well.  Because they are more on the outside of the foot, they may have a greater incidence or risk for inversion sprains. You may choose to add the exercise we presented on Monday (link  here) to help them as best as possible train some improved strength, awareness and motor patterns into their system. In some cases, but only when appropriate, a rear foot post can be used to help them progress more efficiently and safely. 

These foot types typically have dysfunction of the peronei (amongst other things). A weak peroneus longus can lead to a more dorsiflexed first metatarsal compromising the medial foot tripod stability and efficiency during propulsion while also risking compromise to the first metatarsaophalangeal (1st MTP) joint and thus hallux complications.  Additionally, a weak peroneus brevis can enable the rear foot to remain more varus. This muscle helps to invert the rearfoot and subtalar joints. This weakness can play out at terminal swing because the rear foot will not be brought into a more neutral posture prior to the moment of heel/foot strike (it will be left more varus) and then it can also impair mid-to-late midstance when it fires to help evert the lateral column of the foot helping to force the foot roll through to the big toe propulsive phase of terminal stance.  (* children who have these peroneal issues left unaddressed into skeletal maturity are more likely to have these rearfoot varus problems develop into anatomic fixed issues…… form follows function.)

You can see in the video the failed attempt to become propulsive. The client speeds over to the medial foot/big toe at the very last minute but it is largely too late. Sudden and all out pronation at the last minute is also fraught with biomechanical complications.

One must know their foot types. If you do not know what it is you are seeing, AND know how to confirm it on examination you will not get your client in the right shoe or give them the right homework.

* caveat: the mention of Monday’s exercise for this foot type for everyone with Rearfoot varus is not a treatment recommendation for everyone with the foot type. For some people this is the WRONG exercise or it might need modifications. Every case is different. The biomechanics all the way up need to be considered. Medicine is not a compartmentalized art or science. 

Shawn and Ivo, The Gait Guys

How good is your tripod? Looks can be deceiving

You have heard us here on the blog talking about the foot tripod. For those of you who may not remember; click here and here for a refresher.

In the right foot (far left image) pedograph, you notice increased ink under the three points of the tripod (pass your mouse or click on the image to enlarge): The center of the calcaneus, the head of the 1st metatarsal and the head of the 5th metatarsal. Looks pretty good, correct ? The left one (center image) shows more weight on the lateral aspect of the foot.

Note now the picture of the feet that go with this tripod (far right). Pretty scary, huh ? Their left foot actually looks like a better tripod, especially the medial tripod.  So, what does that tell you? It tells you that from the pedograph print (remember the person is walking across the pedograph), they are able to compensate better on the right than on the left.  Remember what we always say, what you see is not what is wrong or what is actually truthfully going on.

So, what do you do?

consider exercises to increase the foot tripod (tripod standing, the Extensor hallucis brevis exercise,  lift spread reach ) and try and make the weight distribution equal from side to side.

The Gait Guys. Making sure you are firing on all your cylinders (or walking on all 3 points of the tripod). 

Want to know more? Consider taking the 3 part National Shoe Fit Program. Email us at thegaitguys@gmail.com for more details. 

Lateral Forefoot loading. Why do we see so many runners laterally strike on the forefoot ?

This was from a reader on our Facebook PAGE. It was a great observation and a great topic to continue on our dialogue here on the blog and on our last 2 podcasts. We discussed this on the last podcast but we feel that there needs to be further clarification. (FB link) and (Pod link)

I think Runblogger or someone like that showed video clips of footstrike at an elite (or pro) level race…virtually all the elites (or pros) were first contacting the ground on the outside of their forefoot and rolling to the inside.

The Gait Guys response:

For some people, their anatomy “works” or can tolerate the forefoot contact better than others. Remember, the natural walking gait foot progression is heel, lateral forefoot, medial forefoot. The natural running foot strike is under greater debate as you all know if you have been following the materials here on our blog, facebook, twitter and podcasts. Our last two podcasts (#19 and #20) have gone into this in greater depth.

What you likely are seeing (the more lateral forefoot loading pattern) for these elite pro runners in the video you spoke of is normal clean biomechanics (for them), but for many people, you are not seeing that (by the way, we saw plenty of nice squared off forefoot loading responses as well in other pics and videos); rather you are seeing a coping compensation or just simply poor biomechanics that will lead them to injury. The question is when does it become excessive for a person via poor running form choice, forefoot varus foot type or internal tibial torsion etc ? Perhaps a more important question is whether the person has a flexible mid foot and fore foot that will allow the drop of the first metatarsal (medial tripod) to the ground to complete the foot tripod without having to over pronate through the midfoot or forefoot ? That is the key ! 

And these are valid concerns. Many of people have this, the elites you saw obviously have tolerant anatomy and tolerant biomechanics, for them. For them, they orchestrate all of the parts, perfect or imperfect, into a symphony. This is not as common as many of us would wish. Sure a more (not 100%) squared off forefoot strike is more perfect but not many people have perfect anatomy, in fact we are taught in med school that anatomic variance is the norm. And besides, what is perfect for any given person ?  Perfect and clean biomechanics for a given person could arguably be debated as that which enables them to be most efficient without injury long term. Meaning that which may not look pristine but that which acts as such over the long term.

Classically, a brief, controlled, and non-excessive lateral strike may be  normal, and with a normal and progressive transition to the medial side of the foot however, many people have a rigidity-flexibility issue between the forefoot and rearfoot (ie. rigid or uncompensated forefoot varus for example) and these people often become patients as runners.  This was what we were referring to in podcast #20 which spurred the readers inquiry.  These folks cannot adequately, safely and efficiently drop the medial tripod down (1st metatarsal head) without having to so much of the movement more grossly through the midfoot and excessive pronation.  Many people try to fix this with shoes or orthotics but it is a bit more complicated than that, although on the surface it seems logical and simple.

Obviously those pros that were viewed do not have these issues, hence why they are pros, meaning optimal mechanics, rarely injured for long combined and with gifted cardio fitness. To be a pro you need all of the pieces, just wanting to run fast or simply training hard is often just not enough to become elite. The pros are a small percent of the population. Many others are not in that category and thus remain at risk injury or become statistics. We have had plenty of elite runners in our offices who had the cardio and the will but not the anatomy and biomechanics to stay out of our offices long term (injury free) to compound the necessary training.  Many of these folks were converted to triathletes and have been able to compete at world class levels because we found a way for them to dampen the impact miles on tortured running anatomy. 

Sometimes a person’s will is not enough, sometimes you have to have the complete package. And that means competent anatomy and a tolerance system to aberrant biomechanics.  In our opinion our dialogue here is critical in runners, unfortunately there are some big gaps from the medical and biomechanics side in  many of the dialogues on the internet.  But that is were we find our niche, and it is where we are best positioned to help the masses. 

Join us weekly on our podcasts,  here on our blog, or our other social media sites. Join the Gait Guys brethren !
Shawn and Ivo

The Gait Guys

all material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our stuff!

Podcast #16: Monkeys, Newton Shoes & Gait Vision

Gait, running, Newton Shoes, Forefoot Strike, Gait Software, limb torsion problems, foot tripod and lots more !

LINK: http://thegaitguys.libsyn.com/podcast-16-monkeys-newtons-gait-vision

Join us today for the following topic list and show note links:

Links to DVD’s & e-downloads: http://store.payloadz.com/results/results.asp?m=80204

1- scars of evolution:

Bigfoot blog post:    http://thegaitguys.tumblr.com/day/2011/11/05

Why gait must be taught slowly. Even running gait must be taught slowly.

2- email from a reader

wondering if you had any internal femoral torsion videos? I have been looking online and noticed most of the articles were on children with IFT. I have internal femoral rotation, a “winking patella” and I believe an externally rotated tibia? I am a runner and I am trying to find some more info on my awesome gait:) As you can imagine, I have had my fair share of injuries from running (hip, knee, and foot) and I have tried foam rolling but I am hoping you have some other recommendations

3- The Almighty Foot Tripod exercise - good for pronation of the foot

4- DISCLAIMER: We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors

5- Blog post we liked recently:  Perception/vision and Gait analysis software.

http://thegaitguys.tumblr.com/search/vision

2 blog posts here…….review them before the pod

The Observation Effect:   http://www.sciencedaily.com/releases/1998/02/980227055013.htm

6- SHOE TALK:   Skora Shoes
7- Our dvd’s and efile downloads
Are all on payloadz. Link is in the show notes.
Link: http://store.payloadz.com/results/results.asp?m=80204

READY

The Gait Guys Case of the week: What do you see?

This individual presents with Right achilles tendonitis, bilateral foot pain and a history of plantar fascitis. What do you think?

Take a look at his foot type, particularly the forefoot to rearfoot orientation. Hmmm….Asymmetrical. Notice the dropped 1^st metatarsal on the left that is not present on the right. He has a forefoot valgus on the left with a quasi flexible 1^st ray (1^st ray = medial cuneiform, 1^st metatarsal and associated phalanges) which is dropped and an uncompensated forefoot valgus on the right, with an inflexible 1^st ray.

He has bilateral external tibial torsion (which you cannot see in these pictures) right greater than left (OK, you can see that), as well as a Left anatomically short leg (tibial) of approximately 7mm.

Now look at the pedographs. BIG difference from left to right. Good tripod on right with clear markings over the calcaneus, the head of 5^th metetarsal and the head of 1^st metatarsals.  But I thought you said he had an UNCOMPENSATED forefoot valgus ?  Look at the shape of the forefoot print. It is very different from right to left. Remember, with a forefoot valgus, the medial side of the foot hits the ground before the lateral side most of the time,

How about the left? Look at all that metatarsal pressure. Looks like a loss of ankle rocker. Think that might be causing some of that left sided foot pain? Notice the print under the 1^st metatarsal is even greater; and look at all that printing of the 5^th metatarsal head. Remember, this is the shorter leg side, so this foot will have a tendency to supinate more, thus he increased pressures laterally.

Achilles tendonitis?  Stand on one leg on your foot tripod and rock between the head of your 1^st metatrsal and head of the 5^th.  Where do you feel the strain? The gastroc/soleus and peroneals. Now put all your weight on the lead of the 1^st metatarsal. What do you notice? The foot is everted. What everts the foot? The peroneals. So, if the foot is everted (like in the forefoot valgus), what muscle is left to shoulder the load? Remember also, that the gatroc/soleus group contracts from mid to late stance phase to invert the heel and assist with supination of the foot.

The Gait Guys. Your guiding light to gait literacy and competency.

Want to know more about pedographs? Get a copy of our book here.

All material copyright 2012 The Gait Guys/The Homunculus Group.

What’s your foot type: Part 4

Forefoot valgus.

In this foot type, the fore foot is everted with respect to the rear foot and the little toe side of the tripod cannot gain purchase on the ground. This foot is a poor lever. The problem here is that in normal ambulation we progress our body mass lateral to medial, which engages normal biomechanics.  In this foot, the body moves from medial to lateral, so we are unable to toe off  from the bog toe side of the tripod. Lack of optimal toe off means poor propulsion strategies from the calf and gluteals. Consequently, patellar tracking is challenged, the limb is in a more relative external rotation, and the peroneal muscles are typically overburdened in an attempt to stabilize the lateral ankle area.

Missing something? Check out the last 3 weeks posts on foot types. Our shoe fit program is launching soon. You too can become certified and become “all that you can be” in shoe fitting.

Ivo and Shawn: Bald…Middle aged…Geeky…Good Looking….promoting foot and gait literacy here on a daily basis

What’s your foot type? : Part 3 of a 5 part series

Forefoot varus.

Here the forefoot is inverted (twisted inward about its long axis) with respect to the rear foot and the big toe side of one of the front legs of the tripod is able to touch the ground without compromising normal mechanics and collapsing medially to bring the foot to the ground.  In doing so, this foot like the rearfoot valgus foot, has to rotate internally more dramatically, forcing pronation (dorsiflexion, eversion and adduction) to occur more violently and for a longer period of time.  This action drags the knee medially and leads to the same hip and pelvic stability and external rotation challenges we discussed in the rearfoot valgus, as well as patellofemoral tracking syndromes.

A little lost? We were too. That’s why we have this blog and have come up with a the only of it’s kind “Shoe Fit Program” . Launching soon with the new website. The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail.

WE ARE The Gait Guys: foot and gait literacy for everyone! 

What’s your Foot Type? : Part 2

Welcome to Monday! Here is the next in the series…

Rearfoot valgus.

Remember the foot tripod? It consists of the the 3 points: the base of the 1st metatarsal (under the sesamoids), the base of the 5th metatarsal, and the calcaneus. In this foot type the rear leg of the tripod is compromised as the rear foot collapses medially (the heel or calcaneus,  everts or moves laterally) causing subsequent collapse of the arch and midfoot.

This foot type causes an excessive internal rotation strain on the lower kinetic chain, often with collapse of the knees inward (genu valgum or “knock knees”). Due to the midfoot collapse, the deep calf muscles are typically overused and strained leading to medial ankle region tendonopathies, as they attempt to slow the rate of pronation and arch collapse.

This foot type has a difficult time going from pronation to supination to prepare for a rigid foot push off in the propulsive phase. Because the lower limb is internally rotated so much, the external rotators are over burdened leading to fatigue and weakness of the glutes and shortening of the TFL, leading to the chronic IT Band syndromes. Low back pain is common because of forward tip of the pelvis.

2 down, 3 to go!

Confused between the ear?

Have no fear. Shed no tear.

Our shoe fit program is almost here!     (Everyone has a little Dr. Seuss in them)

The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail.

The Gait Guys: promoting foot and gait competency everywhere!

What’s your Foot Type?: Part 1

Ready for Monday Morning? This is the 1st of a 5 part series to get your week going and help get you in a “Gait Guys” frame of mind

Rearfoot varus

What if many of your nagging and seemingly un resolvable injuries as an athlete were from an undiagnosed foot type? What if every shoe, insert and orthotic you implemented in an attempt to help manage these problems was not the solution, but rather a means of “band aiding” the problem because your anatomy was compromised from the start? 

Wouldn’t it be nice to have some answers to all the questions you have as to why your interventions were less than optimal? Wouldn’t life be better if you knew that your anatomy was slightly left of center and that this was the true cause?  Life as an athlete sure would be more tolerable and perhaps, just perhaps, a life with fewer nagging injuries.

The main issue is that the majority of humans have less than perfect feet. The “perfect” neutral foot is one in which the rearfoot and the forefoot lie on the same plane, meaning that the forefoot and the rearfoot lie square on the ground when ankle and subtalar joint mechanics are neutral.  This insures the tripod of the foot (the base of the big toe, the base of the little toe and the center of the heel) remain on equal footing, creating a balance of power between the muscles and articulations.

There are many reasons at to why we do not all have perfect feet with pristine mechanics to run and walk on.  Some are genetic, some congenital, and some developmental. Regardless, as the saying goes “You have what you have, so why not make the best of it?”

In a nutshell, there are 5 basic foot types; two involving challenges to the forefoot, and two challenging the rear foot. These can be rigid and non adapting, flexible and adapting, or somewhere in between. The fifth type is the ideal of what we all hope to have. This 5 part series will help you to understand each and the biomechanics associated with the anatomical variant.

Rearfoot varus.

The rear foot varus is a foot that has the heel inverted, almost appearing as though the ankle is about to roll, like a common ankle sprain. Here the rear of the tripod is compromised. Because of this lateral shift of weight through the contact phase of walking or running, the foot is over supinated  (plantar flexed, inverted and adducted) at toe off.  The owner of this foot type usually has excessive use of the peroneal muscle group to fight this supinated tendency and prevent ankle sprains.  The 4^th and 5th metatarsals typically take on more stress, and are often painful. Loading the lateral aspect of the limb shifts the center of gravity and challenges stability in the frontal plane, often leading to hip problems, such as trochanteric bursitits and IT band friction type syndromes and knee/patellar tracking issues.

Confused? Have no fear. Our shoe fit program is almost here! The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail. Watch here on Mondays for a different foot type each week!

The Gait Guys: promoting foot and gait competency everywhere!