When the big toes head...East? Whats the deal?

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What is this?

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A sandal gap deformity or hallux varus creates an expanded first interspace between the hallux and the rest of the toes. It is a likened to the gap caused by wearing a sandal but is actually a normal variant. It can occasionally be developmental. In the fetus, it can be a soft marker for other fetal anomalies such as Downs syndrome, an amniotic band or ectrodactyly. It’s considered benign, however in this individual could have been developmental.

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Notice how he has external tibial torsion (when his knees are pointing forward his feet point to the outside). External tibial torsion generally, because of the orientation of the foot, causes the center of gravity to fall medially thus the need for something to push and stabilize you more laterally, such as toes two through five abducting : )

Dr Ivo Waerlop, one of The Gait Guys

#halluxvarus #strangelookingfeet #hallux #thegaitguys #sandalgapdeformity





Barp EA, Temple EW, Hall JL, Smith HL. Treatment of Hallux Varus After Traumatic Adductor Hallucis Tendon Rupture. J Foot Ankle Surg. 2018 Mar - Apr;57(2):418-420.

https://radiopedia.org/articles/sandal-gap-deformity?lang=us

Munir U, Morgan S. Hallux Varus. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.
2019 May 6.

Ryan PM, Johnston A, Gun BK. Post-traumatic dynamic hallux varus instability. J Clin Orthop Trauma. 2014 Jun;5(2):94-8. doi: 10.1016/j.jcot.2014.05.005. Epub 2014 Jun 15.

The muscle they named wrong?

Why would you name a muscle after its supposed function when its function is actually something totally different? Probably due to what made sense from how it looked, not by how it acted. Of course, we are talking about the abductor hallucis.

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Think about all the anatomy you have learned over the years. Think about all the taxonomy and how it was done: sometimes by thename of the discoverer and more often by its anatomical location. The abductor hallucis seems to be the latter. 

The abductor and adductor hallicus function from approximately midstance to pre swing (1-4) (toe off), applying equal and opposite rotational vectors of force (in an ideal world) of the proximal phalynx of the hallux. This should resolve into a purely compressive force (5). In a closed chain environment, the transverse head of the adductor hallicus should act to prevent “splay” of metatarsals, along with the lumbricals and interossei (6), providing stabilzation of the forefoot (7) and rearfoot (8) during preswing, while the oblique head serves to help maintain the medial longitudinal arch. 

The abductor hallicus is actually a misnomer, as it most cases it is not an abductor but rather a plantar flexor of the 1st ray, particularly the proximal hallux, (assisting the peroneus longus) and supinator about the oblique midtarsal joint axis (5).  In the majority of cases, there doesn’t appear to be a separate, distinct insertion of the adductor hallicus to the base of the proximal phalynx, but rather a conjoint insertion with the lateral head of the flexor hallicus bevis into the lateral sesamoid and base of the proximal phalynx (9-11), emphasizing more of its plantar flexion function and stabilizing actions, rather than abduction. 

In one EMG study of 20 people with valgus (12) they looked at activity of adductor and abductor hallucis, as well as flexor hallucis brevis and extensor hallucis longus. They found that the abductor hallucis had less activity than the adductor. No surprise here; think about reciprocal inhibition and increased activity of the adductor when the 1st ray cannot be anchoroed. They also found EMG amplitude greater in the abductor hallucis by nearly two fold in flexion. 

So, the abductor hallucis seems to be important in abduction but more important in flexion. Either way, it is a stance phase stabilizer that we are beginning to know a lot more about. As for the name? You decide...



Dr Ivo Waerlop, one of The Gait Guys



1. Basmajian JV, Deluca CJ . Muscle Alive. Their Functions Revealed by Electromyography Williams and Wilkins. Baltimore, MD 1985, 377

2. Root MC, Orien WP, Weed JH. Normal and Abnormal Function of the Foot. Clinical Biomechanics, Los Angeles, CA 1977

3. Mann RA. Biomechanics of Running. In Pack RP. d. Symposium on the foot and leg in running sports. Mosby. St Louis, MO 1982:26

4. Lyons K, Perry J, Gronley JK. Timing and relative intensity of the hip extensor and abductor muscle action during level and stair ambulation. Phys Ther 1983: 63: 1597-1605

5. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Newton MA 1993: 50-55

6. Fiolkowski P, Brunt D, Bishop et al. Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot & Ankle Surg 42(6) 327-333, 2003

7. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, Baltimore 1992; 529

8. Kalin PJ, Hirsch BE. The origin and function of the interosseous muscles of the foot. J Anat 152, 83-91; 1987

9. Owens S, Thordarson DB. The adductor hallucis revisited. Foot Ankle Int. 2001 Mar;22(3):186-91. Am J Phys Med Rehabil. 2003 May;82(5):345-9.

10. Brenner E.Insertion of the abductor hallucis muscle in feet with and without hallux valgus. Anat Rec. 1999 Mar;254(3):429-34.

11. Appel M, Gradinger R. [Morphology of the adductor hallux muscle and its significance for the surgical treatment of hallux valgus][Article in German] Orthop Ihre Grenzgeb. 1989 May-Jun;127(3):326-30.

12. Arinci I, Geng H, Erdem HR, Yorgancioglu ZR Muscle imbalance in hallux valgus: an electromyographic study. Am J Phys Med Rehabil. 2003 May;82(5):345-9.


#halluxvalgus #halluxabductovalgus #bunion #footmuscleactivity #gait #thegaitguys



Keep your eyes up and your toes up...,And it doesn’t hurt to use your abs

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While out cross country skiing after a few inches of fresh fallen snow it dawned on me, especially when going uphill on my cross-country skis, lifting your toes up definitely pushes the head of the first metatarsal down and helps you to gain more purchase with the scales on the bottom of the skis. It also helps to press the center portion of the camber of the ski downward so that you can get better traction. Thinking about this further, lifting your toes up also helps you to engage your glutes to a greater degree.

Try this: stand comfortably with your knees slightly flexed. Lift up your toes leaving the balls of your feet on the ground. Do you feel the first metatarsal head going down and making better contact with the ground? Can you feel your foot tripod between the head of the first metatarsal, head of the fifth metatarsal and the calcaneus? Now let your toes go down. Squeeze your glute max muscles. You should still be able to fart so don’t squeeze the sphincter. You can palpate these muscles to see if you’re actually getting to them. You can do this by placing your hands on top of your hips with your fingers calling around forward like when your mom used to put her hands on her hips and yell at you. Now relax with your toes up again leaving the balls of your feet on the ground. Now engage your glutes. See how much easier it is?

Now stand with your feet flat on the ground and put your hands on your abs, specifically your external obliques. Now raise your right leg. Do you feel your external oblique engage? Now, lift your toes up leaving the balls of your feet on the ground. Now lift your leg. Do you feel how much more your abs engage?

Little tricks of the trade. That’s why you listen here and why your patients/clients come to see you. Now go out and do it!

Dr. Ivo, one of The Gait Guys

#gaitanalysis, #crosscountryskiing, #skiing, hallux, #engage, #abs

Two out of Three ain't Bad...But sometimes it is

image credit: https://commons.wikimedia.org/wiki/File:Meatloaf_(1).jpg

image credit: https://commons.wikimedia.org/wiki/File:Meatloaf_(1).jpg

“What do you mean my plantar fasciitis is due to my hip?”

I recently saw a 60 YO male patient with right-sided plantar fasciitis of approximately 1-1/2 months duration. It began insidiously with pain located at the medial calcaneal facet on the right hand side. He had localized tenderness in this area with some spread distally towards the metatarsal heads. He has ankle dorsiflexion was relatively symmetrical with mild impairment on the right compared to left but only approximately 2 degrees. He had hip extension is 0 degrees on the affected side and 10 degrees on the affected side. Sacroiliac pathomechanics were present as well with the loss of flexion and extension. He had a slight leg length discrepancy, short on the symptomatic side.

So what is going on?

Moving forward in the sagittal plane requires a few things:

Adequate hip extension

Adequate ankle dorsiflexion

Adequate hallux dorsiflexion with an intact Windlass mechanism

He has a diminished step length going from right to left. Because of the lack of hip extension, the motion needs to occur somewhere. His ankle dorsiflexion is almost sufficient but less sufficient on the right (symptomatic) side than it is on the left. He has adequate hallux dorsiflexion but lacks adequate hip extension. Like the song goes, begin "Two of of three ain’t bad". However in this case, it is bad. He has an intact windlass mechanism. In fact, a little too intact. This is causing a tug at the medial calcaneal facet, creating an insertional tendinitis that we know as "plantar fasciitis".

So we did we do?

  • Manipulated the right sacroiliac joint

  • Gave him lift she/spread/reach exercises

  • Gave him shuffle walk exercises

  • Worked on hip flexor lengthening

  • Treated the plantar fascial insertion locally with acupuncture and laser therapy

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis,#thegaitguys, #anklerocker#halluxdorsiflexion, #plantarfascitis

What does a pedograph of a person with hallux limitus look like?

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Take a good look at the pedographs above. Can you figure out which side has the hallux limitus from the pictures? 

You would think that with hallux limitus there would be increased printing over the distal phalanx of great toe and possibly over the distal metatarsal as seen in the print of the right foot. This would make sense as if you have limited motion here and the pressure will be more forward. However, often times Hallux limitus is painful and the patient develops a compensation to NOT load the joint, as we see on the print of the left foot. We see the lack of printing under the first metatarsal head and increased printing laterally in the foot from avoidance of that joint. Also notice a slight increased printing in the right heel teardrop (hash marks are more filled in) and slight widening of it anteriorly. He has a right sided leg length discrepancy and we would normally expect an increased amount of pronation on the longer leg side, however because of the weight shift to the left we are seeing increased pronation on the right. Now, with this valgus moment of the right foot do you understand why the printing is so heavy under the first metatarsal and distal phalanx. Note also the increased printing at the distal phalanx of toes number two, three and five on the right hand side in an attempt to stabilize as his center of gravity shifts to the right.

And now you know!

Dr Ivo, one of The Gait Guys

#halluxlimitis, #gaitanalysis, #pedograph, #leglengthdiscrepancy, #LLD

A great paper on Hallux Limits

Don't let the title fool or dissuade you. 

Here is a great paper to support the post earlier this week on hallux limitus. 

Plantar pressure distribution in older people with osteoarthritis of the first metatarsophalangeal joint (hallux limitus/rigidus)

No surprise that the study found folks with osteoarthritis of the the 1st MPJ had greater maximum force and peak pressures under the hallux as well as the lesser toe than controls. 

BUT here is one of the gems from the study: " However, the plantar pressure changes observed in this study can be explained using the concept of high- and low-gear push off described by Bojson-Moller. This model suggests that there are two metatarsal axes through which propulsion may occur; a transverse axis connecting the first to second metatarsal heads, and an oblique axis connecting the second to fifth metatarsal heads. In the presence of normal first MPJ motion, a ‘‘high-gear’’ push- off occurs through the transverse metatarsal axis, resulting in an efficient transfer of bodyweight. In the presence of restricted first MPJ motion, propulsion through the transverse axis is not possible. Subsequently, a ‘‘low-gear’’ push-off occurs through the oblique axis, which subjects the lateral forefoot and toes to increased loading and results in hyperextension of the interphalangeal joint of the hallux prior to toe-off."

Zammit, G. V., Menz, H. B., Munteanu, S. E. and Landorf, K. B. (2008), Plantar pressure distribution in older people with osteoarthritis of the first metatarsophalangeal joint (hallux limitus/rigidus). J. Orthop. Res., 26: 1665–1669. doi:10.1002/jor.20700.    

link to FREE FULL TEXT: http://onlinelibrary.wiley.com/doi/10.1002/jor.20700/epdf

 

Part 2: The amputated hallux & the complex biomechanical fall-out from it.

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Last week we promised Part 2 to this case, the amputated big toe.
Here is part 2. These are the complicated biomechanical fall-outs, so grab a big mug o' coffee and have at it !

In review, this person (all photos and case premissioned in swap for insight) had the distal hallux removed because of a progressive melanoma on the big toe. Can you believe that ! This is one more reminder that the sun and regular dermatologist screenings are wise.
This person had a complaint of progressing right gluteal and QL pain, spasm, tone and some persistent pain now in the 2nd metatarsal as well as some shoe challenges. We discuss this case briefly in and upcoming podcast, #139 or #140 we believe.

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Before we add our final thoughts to this case, lets cap our post from last week.

-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- More internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will likely be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree).
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities
- These factors are likely related to his complaints in the right gluteal and low back/QL area.

Now, onto our next thoughts.

- when the hallux is incompetent, in this case absent, there are few other choices to gain forefoot purchase on the ground other than more flexion gripping of the 2nd toe (then the 3rd, then 4th). This is a progressing "searching" phenomenon for forefoot stability and without the function of the big fella, the 2nd toe will begin a hammering phenomenon, often, but not always. We would not be surprised to see hammer toe development in this case, but this person is now very aware of it, and can at least now fight that battle with increased awareness. There is some mild evidence of this on the side lateral photo.

- We are happy to see that the proximal phalange was spared. The adductor hallucis is inserted medially there, and this will help to reduce bunion generation risk (medial metatarsal drift). Comparing the photo and the radiograph is a great example of how far back/proximal the 1st MTP joint is. One could easily assume that the entire hallux was resected from the photo, but the radiograph shows otherwise.

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- Toe off is obviously going to be compromised. The patient cannot adequately stabilize the 1st metatarsal (MET) and this will mean a compromised foot tripod, medial foot/tripod splay, arch pronation control challenges but toe off stabilization is going to have to be met by the 2nd and 3rd digits, as discussed above. They are not suited to be the major players here, they are synergistic to this end. Do not be surprised to see one of 2 strategies at toe off here:

1. heavy medial foot tripod toe off, dropping into the void and this maximize the internal spin challenges and minimizing the requisite foot supination stiffness generation phase that should be normal at toe off

2. avoidance of the above, with a forced conscious forefoot lateral toe off, a supinatory strategy, to avoid internal limb spin, more toe hammering, and the lurch heavily and abruptly off of the right foot and onto the left limb.

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3. taking #2 further, any time there is perceived challenges or deficits in strength, endurance, proprioception, balance, power and the like, the brain often will create a premature departure off of said limb, creating a requisite premature loading onto the opposite limb. This can cause a phenomenon well loosely refer to "catching" in the contralateral quadriceps mechanism. These clients, with their abrupt loading pattern onto the opposite limb will most often have troubles getting into initial gluteal hip stabilization strategies, and thus default into a quadriceps strategy, that in time can lead to quad shortness and increased tone, which can cause more compression across the patellofemoral joint and cause knee pain. This is more of a compression/loading response issue rather than tracking phenomenon, which we see at the typical diagnosis. We often look for causes in the opposite limb for contralateral knee pain. IT is quite often there if you are looking hard enough for it. Fix the problem, not the symptom.
There is a long host of other things than can arise from here, including heavy contralateral (in this case left sided) foot loading challenges, often more forefoot initial loading, and all of the problems than can arise when this pattern is cyclical, but that would take this post far too deep and long. So, . . . . another time.

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4. Shoe fit, we could make the case that a shoe that nicely hugs the forefoot, as opposed to a wide toe box'ed shoe, could help fight off the risk of 1st metatarsal abduction and thus bunion formation risk. However, one cannot dismiss the wider toe box giving the remaining toes a better environment to engage without hammering with over use of long flexors. We might suggest a trial of an elastic sleeve, one often used for plantar fascitis symptom management, placing a snug one around the forefoot when ambulating. This could help keep that metatarsal snug and stop the bunion-like drift we would be watching for.

have at it gang, cases like this are far and deep and require deep understanding of normal and abnormal biomechanics, and the rabbit hole deep myriad of compensations that can be engaged.

have a great weekend !

Shawn and Ivo

Toe Break

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Here's on one of our favorite subjects: toe break:

No, this is not a post about fractures phalanges, but rather where your shoe bends, or should bend.

Toe break is where the shoe bends anteriorly. Ideally, we believe this to be at the 1st metatarsal phalangeal joint and metartarsal phalangeal articulations. This allows for the best “high gear” push off as described by Bojsen-Moller (1) High gear push off means that the pressure goes to the base of the great toe (1st MTP joint) for push off. (for an interesting post on this, see here .

If we think about rockers of the foot during the gait cycle (need a review? click here), it seems best that we accommodate each of them to the best of our abilities. Since most of us wear shoes, it would make sense that it flex in the right places. With regards to the forefoot, it should (theoretically) be under the 1st metatarsal phalangeal joint. This should provide both optimal biomechanical function (distribution of force to the 1st metatarsal phalangeal joint for push off/ terminal stance) and maximal perceived comfort (2).

If the shoe bends in the wrong place, or DOES NOT bend (ie, the last is too rigid, like a rockered hiking shoe, Dansko clog, etc), the mechanics change. This has biomechanical consequences and may result in discomfort or injury.

If the axis of motion for the 1st metatarsal phalangeal joint is moved posteriorly, to behind (rather than under) the joint, the plantar pressures increase at MTP’s 4-5 and decrease at the medial mid foot. If moved even further posteriorly, the plantar pressures, and contact time in the mid foot and hind foot (3). A rocker bottom shoe would also reduce the plantar pressures in the medial and central forefoot as well (4). It would stand to reason that this would alter gait mechanics, and decrease mechanical efficiency. That can be a good thing or a bad thing, depending on what you are trying to accomplish.

Take home messages:

    Where a shoe flexes will, in part, determine plantar pressures
    Changes in shoe flex points can alter gait mechanics
    More efficient “toe off” will come from a shoe flexing at the 1st metatarsal phalangeal joint and across the lesser metatarsal phalangeal joints
    examine the “toe break” in your clients shoes, especially of they have a foot problem

1. F Bojsen-Møller Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979 Aug; 129(Pt 1): 165–176.

2. Jordan C1, Payton C, Bartlett R Perceived comfort and pressure distribution in casual footwear. Clin Biomech (Bristol, Avon). 1997 Apr;12(3):S5.

3. van der Zwaard BC1, Vanwanseele B, Holtkamp F, van der Horst HE, Elders PJ, Menz HB Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait. J Foot Ankle Res. 2014 Mar 19;7(1):20.

4. Schaff P, Cavanagh P Shoes for the Insensitive Foot: The Effect of a “Rocker Bottom” Shoe Modification on Plantar Pressure Distribution Foot & Ankle International December 1990 vol. 11 no. 3 129-140

plantar pressure image above from : Dawber D., Bristow I. and Mooney J. (1996) “The foot: problems in podiatry and dermatology”, London Martin Dunitz Medical Pocket Books.

 

You better keep that Hallux Dorsiflexion

Geee....Looks like forefoot rocker really IS IMPORTANT, eh?

...and what have we been saying about being able to dorsiflex your big toe? Watch how well you or your client can descend the 1st ray (remember that if the head of the 1st does not go down and anchor, its axis of rotation moves dorsally and posterior, limiting dorsiflexion of the joint)

This article should make you look at the "toe break" in a shoe...

"They found that increasing bending stiffness assisted with propulsion during running, reducing the metabolic cost of running by about 1%. However, at a certain level, the increased elasticity began to interfere with the natural flexion of the first MTP joint, reducing the contribution of ankle joint torque to push-off and counteracting the metabolic benefits. Within the study population, the threshold of bending stiffness for optimal energetics varied significantly from one runner to the next, suggesting running shoe design may need to be tuned to an individual runner’s needs." 

http://lermagazine.com/news/in-the-moment-sports-medicine/stiffer-shoes-improve-running-energetics-as-long-as-first-mtp-flexion-is-preserved

One of life's great mysteries....Some folks will do what they want anyway....

The origins of the species, gravity and women...Just a few of life mysteries. Reading this article (1) made us sad in many ways. It's like smoking. You know it's bad for you but you keep doing it. Why? The mystery remains to us.

Vanity seems to often trump biomechanics, as we see in pencil skirts (see our post here), droopy pants (see here)  and high heels (here).

Yet, here is yet another study about women, heels and bunion surgery. 

"Almost two thirds (31) of the 50 patients who said they wanted to go back to wearing heels after surgery did so, and 24 of these women said their postoperative use equaled or exceeded the frequency of their preoperative wear. There were no differences between pre- and postoperative heel heights.

In the study, women older than 65 years were more likely than younger women to report high-heel use prior to hallux valgus surgery.

However, 58.5% of study participants reported difficulty with heel wear, and 13.9% said they had significant restriction, and couldn’t wear anything without pain but custom orthopedic shoes or slippers. Most women (86%) were able to return to comfortable shoes after surgery with minimal or no discomfort; 27.7% said their footwear choice was unrestricted, meaning they could wear both comfortable shoes and heels with minimal discomfort. The 23 women older than 65 years were twice as likely to report significant restriction as those in the younger cohort; compared by operative type, patients who had the most extensive procedures had the highest rates of restriction. The findings were published in June by the World Journal of Methodology. (2)"

Bunions are believed to be caused by an inability to anchor the 1st ray and the untoward action of the adductor hallucis, acting from the transverse and oblique insertions more proximally on the foot, make the hallux head west. This is under the purview of the peroneus longus, extensor hallucis brevis as well as the short flexors of the lesser toes (see here).

The components of supination are plantar flexion, inversion and adduction. Why would you continue to wear a shoe with a narrow toe box that forces the big toe medially and that puts you in plantar flexion? We won't even begin to talk about the loss of ankle rocker.....

We guess folks will continue to do what they will do....

 

1. Robinson C, Bhosale A, Pillai A. Footwear modification following hallux valgus surgery: The all-or-none phenomenon. World J Methodol 2016;6(2):171-180.

2. http://lerfoothealth.com/archives/2016/most-women-who-want-to-wear-heels-after-bunion-surgery-do-so/

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Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

The Great toe’s effect on external hip rotation.

We have a simple video for you today. 

When we assess our clients for gait and locomotion we do a quick screen of all the big player joints, from the toes at least up into the thoracic spine to start. Loss of mobility/range of motion means probable functional impairment. 

In this video we display the effects of the Windlass Mechanism of the great toe. A windlass mechanism according to Wikipedia is:

a type of winch used especially on ships to hoist anchors and haul on mooring lines and, especially formerly, to lower buckets into and hoist them up from wells.

In this case, dorsiflexing the big toe spools the plantarfascia and flexor hallucis longus and brevis around the metatarsophalangeal joint (1st. MTPJ), thus pulling the heel towards the forefoot thus raising the arch. When the arch raises, the talus moves cephalad (upwards) and because of the supinatory movement orientation, it spins the tibial externally which in turn spins the femur externally. This is what you see in this video, note the blue dots being carried laterally with the limb external rotation.

The point here today, if you have loss of external hip rotation, it could be crying for you to evaluate the range of motion of the 1st MTP joint , it could be crying for you to evaluate the skill of toe extension, strength or endurance or all of the above. Impairment of the 1st MTP has great inroads into ineffective locomotion. You must have decent range of motion to effectively supinate, to effectively toe off, to externally rotate the limb, to effectively acquire hip extension to maximize gluteal use.  Thus, one could easily say that impaired hallux/great toe extension (skill, ability, endurance, strength) can impair hip extension (and clean hip extension patterning) and result in possible terminal propulsive gait extension occurring through the lumbar spine instead of through the hip joint proper.

Think of the effects of two asymmetrical great toe extensions, comparing the great toe left to right. Asymmetry in the limbs, pelvis, hip extension and perhaps worse, the lumbar spine, is a virtual guarantee.  Compare hallux extension side to side, if you can achieve symmetry through skill, endurance and strength retraining, you must do it. If you have a hallux limitus, a bunion or anything that impairs the symmetry of great toe extension side to side, you have some interesting work to do. 

You have to know what you have in your client, and know what it means to their locomotion.  Seeing or recognizing what you have must translate into understanding and action. 

Play mental games with clinical entities.  In this case, if at terminal toe off you did not have full hallux extension like in this client, and thus you did not get that last little final external rotation spin in the limb at the hip … . . what could that do to your gait ? Go tape your toe and limit terminal extension (terminal dorsiflexion) and walk around, to feel it in yourself is to get first hand experience. 

Shawn Allen, one of the gait guys

Big Toe Woes: One way to learn to load the head of the 1st metatarsal   On Thursday morning, while sprinting up a hill on the latter part of a run, I had the fortuosity of catching my big toe on what I beleive was an exposed root and fell sudddenly. Instinctively I rolled to protect my back (as you often do if you have had any history of back injuries). After a few expletives and a bruised ego, I took inventory of my body: back was fine, an abrasion and contusion on my left elbow and a really sore big toe. I got up and decided to run home as I was less than a mile from there.   I immediately noticed that my gait would need to be altered if I was going to make it home. I had injured the distal interphalangeal joint and distal phalanyx from the best I could tell; loading them in any way brought excruciating pain, so I was forced into one of my mantra’s: “Keep your toes up”*. I did this for the rest of my run and noticed, probably more than ever, how much this simple technique shifts the weight to the head of the 1st metatarsal and sesamoids. It also made me make my gait more “circular” (rather than pendular, another thing we teach in gait retraining).   I made it home and promptly iced. After getting to the office, an X ray confirmed my suspicion of a fracture in the proximal portion of the distal phalanyx. A day later and from my distal to my 1st metatarsal phalangeal joint is sausage like and a beautiful violet color. I am grateful I did not seem to injure the MTP…Oh well, I will either have to run carefully or switch to mountain biking for the next few weeks. Some ipriflavone (to assist in calcium absorption), cucumin and essentail oils (for inflammation) and I was good to go. Yes it throbs a bit, but it is a reminder that I need to push off through the head of the 1st : )  Try “toes up”with your peeps and let us know how it goes.   TGG  * “Toes up” technique involves conciously firing the anterior compartment muscles, particularly the extensor digitorum longus. It fires more into the extensor pool and assists in firing ALL your extensors through spacial and temporal summation and also heps to shut down flexor tone through reciprocal inhibition. It will also help you to rocker through your stance phase and get more into your hip extensors.

Big Toe Woes: One way to learn to load the head of the 1st metatarsal

On Thursday morning, while sprinting up a hill on the latter part of a run, I had the fortuosity of catching my big toe on what I beleive was an exposed root and fell sudddenly. Instinctively I rolled to protect my back (as you often do if you have had any history of back injuries). After a few expletives and a bruised ego, I took inventory of my body: back was fine, an abrasion and contusion on my left elbow and a really sore big toe. I got up and decided to run home as I was less than a mile from there.

I immediately noticed that my gait would need to be altered if I was going to make it home. I had injured the distal interphalangeal joint and distal phalanyx from the best I could tell; loading them in any way brought excruciating pain, so I was forced into one of my mantra’s: “Keep your toes up”*. I did this for the rest of my run and noticed, probably more than ever, how much this simple technique shifts the weight to the head of the 1st metatarsal and sesamoids. It also made me make my gait more “circular” (rather than pendular, another thing we teach in gait retraining).

I made it home and promptly iced. After getting to the office, an X ray confirmed my suspicion of a fracture in the proximal portion of the distal phalanyx. A day later and from my distal to my 1st metatarsal phalangeal joint is sausage like and a beautiful violet color. I am grateful I did not seem to injure the MTP…Oh well, I will either have to run carefully or switch to mountain biking for the next few weeks. Some ipriflavone (to assist in calcium absorption), cucumin and essentail oils (for inflammation) and I was good to go. Yes it throbs a bit, but it is a reminder that I need to push off through the head of the 1st : )

Try “toes up”with your peeps and let us know how it goes.

TGG

* “Toes up” technique involves conciously firing the anterior compartment muscles, particularly the extensor digitorum longus. It fires more into the extensor pool and assists in firing ALL your extensors through spacial and temporal summation and also heps to shut down flexor tone through reciprocal inhibition. It will also help you to rocker through your stance phase and get more into your hip extensors.

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Keeping it Objective.

For clinicians and some die hard foot geeks, we often like to keep things objective. What could be more objective than an angular measurement? A few important measurements when examining or radiographing feet can give us information about clinical decision making (not that we suggest radiographs for mensuration purposes unless you are a surgeon, but when they are already available, why not put them to good use ?). When things fall outside the accepted range, or appear to be heading that way, these numbers can help guide us when to intervene. 

Hallux valgus refers to the big toe headed west (or east, depending on the foot and your GPS). In other words, the proximal and distal phalanyx of the great toe (hallux) have an angle with the 1st metatarsal shaft of typically > 15 degrees. This angle, called the Hallux Valgus Angle (HVA above) is used to judge severity, often for surgical intervention purposes but can guide conservative management as well. 

Metatarsus Primus Varus (literally, varus deformity of the 1st metatarsal) often accompanies Hallux Valgus. It describes medial deviation of the 1st metatarsal shaft, greater than 9 degrees. This angle is called the intermetatarsal angle and is measured by the angle formed by lines drawn parallel along the long axis of the 1st and 2nd metatarsal shafts. 

One other measurement is the Distal Metatarsal Articular Angle, which measures the angle between the metatarsal shaft and the base of the distal articular cap (ie, where the cartilage is) of the 1st metatarsal. This typically should be less than 10 degrees, preferably less than 6 degrees. Remember, these are static angles, things can change with movement, engagement, weight bearing strategies and shoes. What you see statically does not always predict dynamic angles and joint relationship.s

Are you doing surgery? Perhaps, as a last resort. Hallux valgus and metatarsus primus varus can be treated conservatively.

How do you do that?

The answer is both simple and complex.

The simple answer is: anchor the head of the 1st ray and normalize foot function. This could be accomplished by:

  • EHB exercises to descend the head of the 1st metatarsal
  • exercise the peroneus longus, to assist in descending the head of the 1st metatarsal
  • short flexor exercises, such as toe waving, to raise the heads of the lesser metatarsals relative to the 1st
  • work the long extensors, particularly of the lesser metatarsals to create balance between the flexors and extensors
  • consider using a product like “Correct Toes” to normalize the pull of the muscles and physically move the proximal and distal phalanyx of the hallux
  • wear shoes with wide toe boxes, to allow the foot to physically splay
  • consider using an orthotic with a 1st ray cut out, to help descend the head of the 1st metatarsal

This is by no means an exhaustive list and you probably have some ideas of your own. 

The complex answer is that in the above example, we have only included conservative interventions for the foot and have not moved further up the kinetic (or neurological chain). Could improving ankle rocker help create more normal mechanics? Would you accomplish this by working the anterior leg muscles, the hip extensors, or both? Could a weak abdominal external oblique be contributing? How about a faulty activation pattern of the gluteus medius? Could a congenital defect or genetic be playing a role? We have not asked “What caused this to occur in the 1st place?”

Examine your patients and clients. Understand the biomechanics of what is happening. Design a rehab program based on your findings. Try new ideas and therapies. it is only through our failures that we can truly learn.

The Gait Guys

references used:

http://www.bjjprocs.boneandjoint.org.uk/content/90-B/SUPP_II/228.3

http://www.slideshare.net/ANALISIS/hallux-valgus-2008-pp-tshare

http://www.orthobullets.com/foot-and-ankle/7008/hallux-valgus

http://www.slideshare.net/bahetisidharth/hallux-valgus-31768699?related=1

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When the big guy heads medially….Game Changer

Lately we have been seeing a lot of bunions (hallux valgus). While doing some research on intermetatarsal angles (that’s for another post) we came across the nifty diagram you see above. 

Regardless of the cause, as the 1st metatarsal moves medially, there are biomechanical consequences. Lets look at each in turn. 

  • the EHB (extensor hallucis brevis) axis shifts medially. this muscle, normally an extensor of the proximal phalanyx, now becomes more of an abductor of the hallux. It’s secondary action of assisting the descent of the head of the 1st metatarsal no longer happens and it actually moves the base of the proximal phalanyx posteriorly, altering the axis of centration of the joint, contributing to a lack of dorsiflexion of the joint and a hallux limitus
  • Abductor hallucis becomes more of a flexor, as it moves to the plantar surface of the foot. Remember, a large percentage of people already have this muscle inserting more on the plantar surface of the foot (along with the medial aspect of the flexor hallucis brevis), so in these folks, it moves even more laterally, distorting the proximal phalanx along its long axis (ie medially) see this post here for more info
  • Flexor hallucis brevis moves more laterally. Remember this muscle houses the sesamoid bones before inserting onto the base of the proximal phalannx; the medial blending with the abductor hallucis and the lateral with the adductor hallucis. Because the sesamoid bones have moved laterally, they no longer afford this muscle the mechanical advantage they did previously and the axis of motion of the 1st metatarsal phalangeal joint moves dorsally and posterior, contributing to limited dorsiflexion of that joint and a resultant hallux limitis. The lateral movement of the sesamoids also tips the long axis of the 1st metatarsal and proximal phalanyx into eversion. In addition, the metatarsal head is exposed and is subject to the ground reactive forces normally tranmittted through the sesamoids; often leading to metatarsalgia. 
  • Adductor hallucis: this muscle now has a greater mechanical advantage  and because the head of the 1st ray is not anchored, acts to abduct the hallux to a greater degree. The now everted position of the hallux contributes to this as well

As you can see, there is more to the whole than the sum of the parts. Bunions have many biomechanical consequences, and these are only a small part of the big picture. Take you time, learn your anatomy and examine everything that has a foot!

See you in the shoe isle…

Ivo and Shawn

pictures from: http://www.orthobullets.com/foot-and-ankle/7008/hallux-valgus and http://www.stepbystepfootcare.com/faqs/nakedfeet/

How much does your Hallux Extend?

Last week, on Mondays post, we introduced potential areas for power leaks.

The common areas for leaks are:

  • great toe dorsiflexion
  • loss of ankle rocker
  • loss of knee flexion/extension
  • loss of hip extension
  • loss of balance/ proprioception


let’s take a look at a video of the 1st one:

Power leak 1: Great Toe Dorsiflexion

The big toe needs to extend AT LEAST 40 degrees and CLOSER TO 60 degrees for normal walking and running gait. If you do not have that available range of motion, then you will need to “borrow” it from somewhere else.

Common compensations include:

  • externally rotating the foot and coming off the inside of the great toe. this often causes a callus at the medial aspect of the toe. This places the foot in more pronation (plantar flexion, eversion and abduction) so it is a poorer lever.
  • internally rotating the foot and coming off the outside of the foot. This places the foot in more supination ( dorsiflexion, inversion and adduction) and it is therefore a more rigid lever. This often causes tripping or stumbling because of a lack of adequate dorsiflexion of the foot.
  • lifting the foot off the ground and avoiding toe off at terminal stance phase
  • abbreviating the step length to accommodate the amount of available great toe dorsiflexion.

Are YOU losing power? Tune in here for more tips on this series in the coming weeks!

The Gait Guys. Increasing your gait literacy with each and every post.

A year ago we produced this  short video (link)  on how to bring back the EHB (extensor hallucis Brevis muscle). Well, it continues to do its magic on a regular basis. Here is a patient’s foot with clear demonstration of unassisted success of isolated engagement of the EHB while simultaneous release of the EHL (ext. Hallucis long us) while engaging the FHL (flexor hallucis long us).  This patient could not isolate any of the long or short hallux muscles on his own. “I can’t find it, my brain doesn’t know what it is supposed to do or how to do it ! (paraphrased)  But after just 24 hours consisting of a few sessions of the exercise here is the result in the photo above.  Success !  And here were his comments:  
 
 Doc, you were right - the brain is an amazingly plastic thing!  I’ll keep working on it, but happy to see such quick progress! 
 
 The client’s problem was some medial mid-rear foot pain from the resultant excessive increased pronation because of a forefoot varus.  Well, it is a bit more complicated than that to be precise. There was some true clinical ankle and rearfoot instability because of a lifetime of ankle sprains as well as some highly suspect lower syndesmosis hypermobility from probable distal anterior tib-femoral ligamentous attenuation/tears but the main point is that these were clinically manifesting themselves because of the apparent forefoot varus and the resultant pronatory foot mechanics to get the 1st metatarsal head (medial tripod) to the ground; a typical phenomenon .  Here is the kicker, he did  not have a fixed forefoot varus, it was a mirage, it was functional.  What he had was an inability to descend the first metatarsal (plantarflex the Metatarsal) / medial tripod of the foot.  He could not do this because he could not separate ankle dorsiflexion and hallux dorsiflexion.  There was essentially no hallux dorsiflexion at all because he could not descend the 1st MET (head).  So, we knew it was time to break out the nuclear EBH exercise in the video above !  Big problems require big guns ! 
 The rest is history. We fully expect to see a virtual disappearance of the “so called” forefoot varus (because it was never present in the first place).  
 
 “If you have never seen the beast, you will not recognize it when you see it.”-unknown

A year ago we produced this short video (link) on how to bring back the EHB (extensor hallucis Brevis muscle). Well, it continues to do its magic on a regular basis. Here is a patient’s foot with clear demonstration of unassisted success of isolated engagement of the EHB while simultaneous release of the EHL (ext. Hallucis long us) while engaging the FHL (flexor hallucis long us).  This patient could not isolate any of the long or short hallux muscles on his own. “I can’t find it, my brain doesn’t know what it is supposed to do or how to do it ! (paraphrased)  But after just 24 hours consisting of a few sessions of the exercise here is the result in the photo above.  Success !  And here were his comments: 

Doc, you were right - the brain is an amazingly plastic thing!

I’ll keep working on it, but happy to see such quick progress!

The client’s problem was some medial mid-rear foot pain from the resultant excessive increased pronation because of a forefoot varus.  Well, it is a bit more complicated than that to be precise. There was some true clinical ankle and rearfoot instability because of a lifetime of ankle sprains as well as some highly suspect lower syndesmosis hypermobility from probable distal anterior tib-femoral ligamentous attenuation/tears but the main point is that these were clinically manifesting themselves because of the apparent forefoot varus and the resultant pronatory foot mechanics to get the 1st metatarsal head (medial tripod) to the ground; a typical phenomenon .  Here is the kicker, he did  not have a fixed forefoot varus, it was a mirage, it was functional. What he had was an inability to descend the first metatarsal (plantarflex the Metatarsal) / medial tripod of the foot.  He could not do this because he could not separate ankle dorsiflexion and hallux dorsiflexion.  There was essentially no hallux dorsiflexion at all because he could not descend the 1st MET (head).  So, we knew it was time to break out the nuclear EBH exercise in the video above !  Big problems require big guns !

The rest is history. We fully expect to see a virtual disappearance of the “so called” forefoot varus (because it was never present in the first place). 

“If you have never seen the beast, you will not recognize it when you see it.”-unknown

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And what have we here?

The above is a pedograph, a simple, effective pressure map of the foot as someone is walking across an inked grid. For more info on pedographs, click here.

Did you note the increased ink present under the great toe bilaterally? What could be causing this? If you look carefully, you will note that it is at the base of the proximal phalynx of the great toe. This could be none other than the tendon of the flexor hallucis brevis!

This bad boy arises from the medial part of the under surface of the cuoid and the adjacent 3rd cunieform, with a small slip from the tendon of the tibialis posterior. As it travels forward it splits into two parts, which are inserted into the medial and lateral sides of the base of the proximal phalanyx of the great toe. There is a sesamoid bone present in each tendon, which offers the FHB a mechanical advantage when flexing the toe.  The medial portion is blends with the abductor hallucis and the lateral portion blends with the adductor hallucis.

Had the increased printing on the pedograph been more distal, it most likely would have been due to increased action of the flexor hallucis longus.   Had it been more proximal (under the head of the 1st metatarsal) it would have been due to the peroneus longus.

Cool, eh?

Reading pedographs and making you a sharper clinician/coach/trainer/sales person is just one of the many skills we try to teach here on the blog. Keep up the great work!

The Gait Guys