The banana hallux. When the big toe curls upward

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Note: over-extension of the hallux and over-flexion of the 2nd toe. How can they both be so different at rest ? read on

This is common, but not commonly addressed. And, it can become a cause of symptoms.
Note how curled up into extension the hallux appears. This is just a representation of hyperextension of the distal phalange at the IP joint (interphalangeal joint).
This often occurs in hallux limitus/rigidus, where there is insufficient extension through the 1st MTP joint (metatarsophalangeal joint). In that condition, they client attempts to toe off, needing extension (dorsiflexion) at that joint, and they do not have it, so the extension can be found through arch collapse (1st metatarsal dorsiflexion) or through extension at the IP joint. Over time, form follows function and you will often see this presentation.

However, we do not need to see impaired ROM function at the 1st MTP joint, as in this case. This foot had full 1st MTP ROMs.
In this case, this toe represented massive imbalance between the long and short flexors and extensors. Specifically, increased use and strength in the EHL (extensor hallucis longus) and weakness and unawareness of how to even engage the short extensor (EHB).
Similarly, the pairing met the one we always see with this, that being weak and even difficulty of awareness to engage the FHL (flexor hallucis longus) and over-activity of the FHB (short flexor-flexor hallucis brevis).
There pairings: weak: EHB and FHL & overactive: EHL and FHB over time will result in this presentation.

In gait, you will note poor compentence and purchase of the hallux on the ground and thus a sharing of that load through overflexion hammering of the 2nd digit through increased FDL activity (note the great evidence of this with the thick obvious callus at the tip of the 2nd toe).
These clients can also often have pain at the plantar aspect of the Metatarsal head because of sesamoid imbalanced loading (sesamoiditis) as well as frank pain at the MTP joint dorsally or plantarward. One will often note a medial pinch callus on these feet medial to the metatarsal head, from a rotational spin toe off. Hallux valgus and bunion formation are also not uncommmon at all in this incompetent hallux presentation.
PS: the solution is so much more complex and involved than just towel-scrunches and marble pick up games. I mean, come on, we can do better that this team !
This requires some serious reteaching of how to use the foot, arch, tripod, windlass and foot-ground engagement skills.

Shawn and Ivo, the gait guys

#gait, #gaitproblems, #gaitcompensatins, #gaitanalysis, #bunions, #halluxvalgus, #sesamoiditis, #turftoe, #halluxlimitus, #pinchcallus, #bananatoe, #metatarsalgia, #thegaitguys, #hammertoe

How does hallux valgus and bunion formation cause toe hammering?

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Photo: you need to recognize this predictable pattern.

When the hallux begins to become incompetent, from perhaps pain, hallux rigidus, hallux limitus, bunion and in this case hallux valgus with bunion (in this case rotational instability) when this incompetence kicks in, we must find stability elsewhere. One will often, unconsciously, begin to increase the flexor tone and pressure to try and find stability since one cannot get it sufficiently from the hallux anymore.

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Here you see the tenting up of the 2nd toe, from increased long flexor activity (FDL) over time.
And here is the interesting thing you will notice, over time, the 3rd toe will start the same strategy, then the 4th. We see this often. It is not set in stone, but we see it a lot.
Notice it in your clients feet. Teach them why they are getting hammer toes, flexible ones at first, and possibly rigid ones over time. Hammer toes can have many causes, this is just one.
Solution: find a way to help your client re-find better hallux and medial forefoot stability to halt the progression.

How hallux valgus and bunions can affect the shoe toe box space.

Bunions and hallux valgus can change the toe box volume and shoe choice, so be careful, don't be fooled.
This photo shoes how a change in the forefoot width and length can be a result of a bunion or hallux valgus. Notice both feet are aligned the same, but the length of the foot is different in the hallux valgus foot.

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The old Brannock device use to help us all see this more clearly. You may recall that the device measured "heel to toe" (True foot length) and ALSO "heel to ball" length (the functional length and more important one. This length measured heel to the metatarsophlanageal joint line. This concept is important to know because we want the shoe "break point" or "bend point" at the forefoot to occur where the foot bends. Not all shoes have the flex lines (the creases on the bottom of the shoe were it is most likely to bend) in the same place, there is no standard. And if your client has shorter toes, longer toes or a long or short "heel to ball" length they man needs some help from a knowledgeable person like yourself making sure that their current forefoot complaints are not from a mis-fitted shoe.
Bottom line, the "heel to ball" length of a foot is far more important than the global foot length "heel to toe". So stop judging your shoe fit by pinching the front of the shoes to "make sure you have plenty of room"! Doh ! Face palm !

Because despite what many of the "experts" online are saying, that being "shoes don't matter". The fact is "sometimes they do". Period.

WAnt to learn this stuff? Got our website and buy the National Shoe Fit program. Hours of deep shoe, anatomy and biomechanics fun with ivo and shawn, in your own home over the holidays ! Give yourself the "gift" of ivo and shawn this year ! LOL

And for all of you who joined us last night on onlineCE.com for the 55 minute condensed nuclear version of the 3+ hours shoe fit program, we hope you have recovered with a good nights sleep !

Hallux valgus can affect the entire kinetic chain(s)


Here at The Gait Guys we have been mentioning hallux valgus in many different clincial and biomechanical scenarios over the years.  Inability to stabilize this all critical joint is a severe handicap for the recipient. Not only is there a lateral drift of the hallux (big toe) which has its own challenges, but clients have a rotational stability challenge that makes anchoring the distal 1st metatarsal extremely difficult.  Often clients have few other options other than to begin strategies into lesser toe hammering and even flexion hammering of the hallux itself which does little than to further create the rotational vectors about the metatarsal head.  This is one of the most difficult problems to address let alone a remote changes of correction.  Surgery, when absolutely the last resort, has its own set of challenges to say the least.  
Impairing of the hallux-metatarsal interval makes toe off inefficient and can often lead to instability and pain that begins to impair the medial foot tripod, splay of the forefoot-rearfoot relationship, challenges the tibialis posterior and contributes to hip extension motor pattern impairment and thus gluteal function. These are all realms we have beaten into our readers heads over and over for years. 
The background of this study was "The aim of our study was to compare spatiotemporal parameters and lower limb and pelvis kinematics during the walking in patients with hallux valgus before and after surgery and in relation to a control group."
Here were their summary highlights from the study, things we have been saying for years and and could not agree with more:

Hallux valgus deformity is not only a problem of the foot's structure and function.
•Hallux valgus affects the entire lower limb and the pelvis motion during walking.
•Hallux valgus surgery itself solves only problems related with skeletal alignment.
•Hallux valgus surgery does not solve dynamic related problems that occur during walking.
•Hallux valgus surgery solves only consequences and not causes.



Hallux valgus surgery affects kinematic parameters during gait

Jitka Klugarova
http://www.clinbiomech.com/article/S0268-0033(16)30154-1/abstract?platform=hootsuite

Toe grip strength and hallux valgus

#craigpayne over at Podiatry Arena said, "chicken or the egg", which came first ?
Weak Toe Grip Strength (TGS) correlates with hallux valgus . . . 
Do not yet take this study as "do more toe grip strength work", that is NOT what it is saying !!!!!!

We have taken note in our clinics that it "appears" that more long hallux flexor use often "seems" to accentuate a hallux valgus (HV). We continue to study this observation, but not hanging our hat on any conclusions as of yet. But, when someone with HV grips with the long toe flexor hammering down the distal toe, the valgus appears to accentuate. We shall see, its an observation. None the less, we try to get these folks into a pressing, then add the long flexor, and this seems to give adequate purchase on the ground without as much valgus posturing. Keep looking into more active toe extension, separation and hallux abduction as a means to an end. This will likely be a discussion on podcast 113, coming soon. Have you listened to podcasts 108 or 109 yet ? 109 launched Saturday. Keep up !

Weak TGS Correlates with Hallux Valgus in 10 12 Year Old Girls: A Cross- Sectional Study

https://www.researchgate.net/publication/304271421_Weak_TGS_Correlates_with_Hallux_Valgus_in_10_12_Year_Old_Girls_A_Cross-_Sectional_Study

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Simple Foot Exercises are effective!

Conclusion “These results suggest that the toe spread out (TSO) exercise can be recommended for preventing or correcting HV deformity at an early stage.”

We know and teach that foot exercises work. Here is a nice objective paper (click underlined for abstract) on two exercises we prescribe often.

Here is our variation of the TSO exercise we call the “Lift, Spread and Reach” exercise

Stand comfortably with your feet about shoulder width apart

Stand on your foot tripod with your toes extended. Concentrate on feeling pressure at the center of the calcaneus, the head of the 1st metatarsal and the head of the 5th metatarsal

Lift your toes as high as possible

Spread out (abduct) your toes as much as possible

Reach forward with your toes as far as possible

Place your toes back don on the ground as flat as possible.

repeat 10 X

You can augment the exercise with a rubber band around the toes to provide resistance after you can perform the exercise competently.

Happy exercising!

Ivo and Shawn



Kim MH1, Kwon OY, Kim SH, Jung DY.: Comparison of muscle activities of abductor hallucis and adductor hallucis between the short foot and toe-spread-out exercises in subjects with mild hallux valgus

J Back Musculoskelet Rehabil. 2013;26(2):163-8. doi: 10.3233/BMR-2012-00363.

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The partial truth about the Foot Tripod. The HEXApod.

The gait guys have talked about the foot tripod for a very long time. But the truth of the matter is that it is really a HEXApod. HEXA means 6. And when the foot is properly orientated and engaged on the ground, the 5 metatarsal heads and the heel should all be engaged with the ground, truly making it an asymmetrical hexapod. In an ideal scenario, the foot would be most stable if it looked like the strange symmetrical hexapod above with the contact points equally distributed around a center point. But that is not the human foot and this version of a hexapod is far simpler and likely inferior to the foot hexapod when human locomotion is to be attempted. The human foot is engineering marvel when it works properly.  

Perhaps the best example of what I mean by the foot being a HEXApod is in the pressure diagram above. In that first picture, on the right of that picture, we see multiple pressure points under the metatarsal heads of the right foot.  Minus the missing 1st metatarsal head pressure point (taken over by increased flexor hallucis longus activity represented by increased pressure at the big toe),  this pretty much confirms that the foot is not a tripod, rather a hexapod. The theory of the tripod, the 1st and 5th metatarsal heads and the heel, is only crudely accurate and honest. In this picture case, this person has increased lateral foot weight bearing (possibly why the 1st MET head pressure is absent) and possibly represented by pressure under the base of the 5 metatarsal. This is not normal for most people and if this person could get the 1st MET head down, they might even have a HEPTApod foot structure because of the 5th metatarsal base presentation (which sometimes represents peroneal muscle weakness). 

Where did we lead you astray after all these years of “tripod” talk ? We have always discussed the foot tripod. We have always discussed the imperative need to keep the limb’s plumb line forces within the area represented by the tripod.  If your forces fall more laterally within the tripod, as in this first discussed picture, one is at increased risk of inversion events and the myriad of compensations within the entire body that will occur to prevent that inversion. So again, why the tripod?  Well, it is easier to understand and it serves our clients well when it comes to finding active foot arch restoration as seen in this video of ours here.  But, the truth of the matter is that all of the metatarsal heads should be on the ground. The 2nd METatarsal is longer, the 3rd a little shorter, and the 4th and 5th even a little short than those. With the 1st MET shorter, these 5 form a kind of parabolic arc if you will. Each metatarsal head still should contact the ground and then each of those metatarsals should be further supported/anchored by their digits (toes) distally.  So the foot is actually more truly a HEXAPOD. Take the old TRIPOD theory we have always spoken about and extend a curved line beyond the forefoot bipod points (1st and 5th metatarsals) to incorporate contact points on the 2, 3 and 4th metatarsal heads. These metatarsals help to form the TRANSVERSE arch of the foot. It is this transverse arch that has given us the easily explainable foot TRIPOD because if a line is drawn between just the shorter 1st and 5th metatarsals, we do not see contact of the 2-4 metatarsal heads when we only look for pressure between these two bipod landmarks, but the obvious truth is that the 2-4 metatarsals are just longer and extend to the ground further out beyond this theoretical line drawn between the 1st and 5th MET heads.   

So, the foot is a HEXAPOD. Make no mistake about it. It is more stable than a tripod because there are more contact points inside the traditionally discussed foot tripod model. And frankly, the tripod theory is just a lie and just too fundamentally simple, unless you are an American 3 toed woodpecker.

Dr. Shawn Allen,     www.doctorallen.co

one of the gait guys

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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/

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Spanking the orthotic: The effects of hallux limitus on the foot’s longitudinal arch.

But the issues do not stop at the arch. If you have been with us long enough, you will have read about the effects of the anterior compartment (namely the tibialis anterior, extensor digitorum and hallucis and peroneus tertius muscles) strength and endurance on the arch.

Here we have a very troubled foot. This foot has undergone numerous procedures, sadly. Today we will not talk about the hallux varus you see here, a virtual unicorn in practice  (and acquired in this case) nor do we want to discuss the phalangeal varus drift. We want to draw your attention to the obvious impairment of the 1st MTP (metatarsophalangeal joint) dorsiflexion range.  You can see the large dorsal crown of osteophytes, a dorsal buttress to any hallux dorsiflexion.  There is under 10 degrees of dorsiflexion here, not even enough worth mentioning.  We have said it many times before, if you lose a range at one joint usually that range has to be accommodated for proximal or distal to the impaired joint. This is a compensation pattern and you can see it here in the hallux joints themselves.

Here you can see that some of the dorsiflexion range has been acquired in the proximal phalangeal joint.  We like to call this “banana toe” when explaining it to patients, it is a highly technical term but you are welcome to borrow it. This occurred because the joint was constantly seeing the limitation of dorsiflexion of the 1st MTP joint and seeing, and accommodating to, the demands of the need for more dorsiflexion at toe off. 

But, here is the kicker. You have likely seen this video of ours on Youtube on how to acquire a foot tripod from using the toe extensors to raise the arch.  Video link here  and here.  Well, in his patient’s case today, they have a limitation of 1st MTP dorsiflexion, so the ability to maximally raise the arch is impaired. The Windlass mechanism is broken; “winding” of the plantar fascia around the !st MTP mechanism is not sufficiently present. Any limitations in toe extension (ie dorsiflexion) or ankle dorsiflexion will mean that :

1. compensations will need to occur

2. The Windlass mechanism is insufficient

3. gait is impaired at distal swing phase and toe off phases

4. the anterior compartment competence will drop (Skill, endurance, strength) and thus injury can be more easily brought to the table.

In this patient’s case, they came in complaining of burning at the top of the foot and stiffness in the anterior ankle mortise area.  This would only come on after a long brisk walk.  If the walk was brisk yet short, no problems. If the walk was long and slow, no problems.  They clearly had an endurance problem and an endurance challenge in the office showed an immediate failure in under 30 seconds (we will try to shoot a quick video so show our little assessment so be patient with us). The point here today is that if there is a joint limitation, there will be a limitation in skill, strength or endurance and very likely a combination of the 3. If you cannot get to a range, then any skill, endurance or strength beyond that limitation will be lost and require a compensation pattern to occur.  This patient’s arch cannot be restored via the methods we describe here on our blog and it cannot be restored by an orthotic. The orthotic will likely further change, likely in a negative manner, the already limited function of the 1st MPJ. In other words, if you raise the arch, you will shorten the plantar fascia and draw the 1st MET  head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … .  but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ……..yes, exactly !  So use your head  (and spank the orthotic when you see it used in this manner.  ”Bad orthotic, bad orthotic !”)

So think of all of this the next time you see a turf toe / hallux rigidus/ hallux limitus. Rattles your brain huh !?

This is not stuff for the feint of heart. You gotta know your biomechanics.

Shawn and Ivo … .the gait guys

Addendum for clarity:

a Facebook reader asked a question:

From your post: “if you raise the arch, you will shorten the plantar fascia and draw the 1st MET head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … . but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ” I always thought when the plantar fascia is shortened, it plantar flexes the 1st metatarsal (1st ray) and extends (dorsiflexes) the 1st MTP joint….

Our response:  

We should have been more clear, our apologies dear reader.  Here is what we should have said , ” The plantar fascia is non-contractile, so it does not shorten. We meant conceptually shorten. When in late stance phase, particularly at toe off when the heel has raised and forefoot loading is occurring, the Windlass mechanism around the 1st MET head (as the hallux is dorsiflexing) is drawing the foot into supination and thus the heel towards the forefoot (ie passive arch lift). This action is driving the 1st MET into plantarflexion in the NORMAL foot.  This will NORMALLy help with increasing hallux dorsiflexion. In this case above, there is a rigid 1st MTP  joint.  So this mechanism cannot occur at all. In this case the plantar fascia will over time retract to the only length it does experience. So, if an orthotic is used, it will press up into the fascia and also plantarflex the 1st MET, which will carry the rigid toe into plantar flexion with it, IN THIS CASE.”

Hallux Varus: The anti-bunion. Thinking of bunion surgery ? This could be a complication if things go sour. 
  Hallux varus, when the big toe drifts medially, is a real problem. It is typically an acquired problem from a hallux valgus/bunion surgery gone awry.  (This post will not delve into some of the suspected culprits of this problem including   Mc Bride, Scarf, Chevron or Akin osteotomy etc but that would be some of the reader’s next steps into diving deeper into this problem. Surgical procedures to the 1st ray was one of the gait guys senior orthopedic residency thesis topics, hence we now hate this topic !).     
  This deformity can be rigid or flexible.  This case seen in the photo walked into our office recently.  These are not all that common and you won’t see many of them, but you do need to know they exist and where they can come from, how to cope with them and what issues you will need to understand (ie. footwear, talked about below) to assist your client.   
  Hallux varus can be painful, uncomfortable and even debilitating in some cases.  Sometimes they necessitate fixation to realign the hallux bone along a more reasonable alignment with the shaft of the 1st metatarsal.   
     
  Early correction seems critical because the linear and rotational forces at work generating the deformity can eventually lead to a further progressing deformity that can be even more problematic. When left unaddressed more drastic and radical corrective interventions seem necessary, including but not limited to,   resection of the base of the proximal phalanx, fusions and tendon transfers. However, newer surgical procedures are coming along proposing things like   reconstruction of the lateral stabilising components of the first metatarsophalangeal (MTP) joint.   
     
  So here at The Gait Guys we like to ask the big, and sometimes obvious, questions.  What is toe off in walking and running gait going to look like in this hallux varus case ?  Well, one has to consider that the normal linear and rotational forces are now changed.  This means that the normal eccentric axis of the 1st MPT joint involved is going to very likely be changed. This means that the clearance of the base of the phalanx could be impaired and lead to painful binding, grinding or locking of the toe prior to reaching the adequate range of dorsiflexion for normal toe off. Additionally, the toe may act functionally unstable as the rotational forces remain unchecked leading to joint instability. Naturally, the medial foot tripod will be impaired and since the big toe acts in part like a kickstand to help support and fixate the 1st metatarsal (medial tripod), pronation forces can remain unchecked and beyond normal.  Naturally the foot will attempt to shift the tripod stability elsewhere and often this goes to the 2nd metatarsal commonly found with hammering of the digit in an attempt to help with stability through increased long flexor tone (FDL). Pain with a hallux varus can be a bigger complaint than the unsightly surgical outcome.  
     
  There is so much more to this topic. We could go on for at least another 50 pages on this topic (as our thesis reminds us) but volume is not the point of today’s task. It was to bring something new to light for our brethren here at The Gait Guys.  In the photo above, you see drift of the lesser toes, seemingly to follow the big toe. What you need to know is that this is not typical, however not impossible one could propose. This client had some other forefoot procedures done that were largely, although not exclusively, related to that lesser digit drift. Regardless, this is a client that is in some amount of foot trouble. They had good mobility of the 1st MTP joint, so full toe off was possible but because of the instability and uncontrollable rotational forces the joint was painful. A simple intervention made her life infinitely more comfortable, moving her into rigid rocker bottomed shoes.  Dansko clogs for work, and ROCS shoes for walking.  This left us with a very happy client. Not bad, all things considered.  In the mean time we will watch for deformity progression even though the patient could not be urged to have another surgery probably even if their life depended upon it.   
     
  In summary, being a patient can be difficult. These days, more than ever it seems, one needs to do their homework and be their own advocate.  Prior to surgery several consults should have taken place, risk and rewards should have been discussed, realistic outcomes dialogued and perhaps most of all questioning whether surgery needed to be on the table in the first place. Remember, surgery is most wisely selected in cases of neurologic decline and excessively painful and further detrimental biomechanics (ie. unaddressed ACL deficiency eventually promoting secondary instability with time). If there are ways around either, they should be explored. Cosmetic correction should never be on the table, and in the case of the foot, nor should poor shoe choices that promote problems.

Hallux Varus: The anti-bunion. Thinking of bunion surgery ? This could be a complication if things go sour.

Hallux varus, when the big toe drifts medially, is a real problem. It is typically an acquired problem from a hallux valgus/bunion surgery gone awry.  (This post will not delve into some of the suspected culprits of this problem including Mc Bride, Scarf, Chevron or Akin osteotomy etc but that would be some of the reader’s next steps into diving deeper into this problem. Surgical procedures to the 1st ray was one of the gait guys senior orthopedic residency thesis topics, hence we now hate this topic !). 
This deformity can be rigid or flexible.  This case seen in the photo walked into our office recently.  These are not all that common and you won’t see many of them, but you do need to know they exist and where they can come from, how to cope with them and what issues you will need to understand (ie. footwear, talked about below) to assist your client. 
Hallux varus can be painful, uncomfortable and even debilitating in some cases.  Sometimes they necessitate fixation to realign the hallux bone along a more reasonable alignment with the shaft of the 1st metatarsal. 
 
Early correction seems critical because the linear and rotational forces at work generating the deformity can eventually lead to a further progressing deformity that can be even more problematic. When left unaddressed more drastic and radical corrective interventions seem necessary, including but not limited to, resection of the base of the proximal phalanx, fusions and tendon transfers. However, newer surgical procedures are coming along proposing things like reconstruction of the lateral stabilising components of the first metatarsophalangeal (MTP) joint. 
 
So here at The Gait Guys we like to ask the big, and sometimes obvious, questions.  What is toe off in walking and running gait going to look like in this hallux varus case ?  Well, one has to consider that the normal linear and rotational forces are now changed.  This means that the normal eccentric axis of the 1st MPT joint involved is going to very likely be changed. This means that the clearance of the base of the phalanx could be impaired and lead to painful binding, grinding or locking of the toe prior to reaching the adequate range of dorsiflexion for normal toe off. Additionally, the toe may act functionally unstable as the rotational forces remain unchecked leading to joint instability. Naturally, the medial foot tripod will be impaired and since the big toe acts in part like a kickstand to help support and fixate the 1st metatarsal (medial tripod), pronation forces can remain unchecked and beyond normal.  Naturally the foot will attempt to shift the tripod stability elsewhere and often this goes to the 2nd metatarsal commonly found with hammering of the digit in an attempt to help with stability through increased long flexor tone (FDL). Pain with a hallux varus can be a bigger complaint than the unsightly surgical outcome.
 
There is so much more to this topic. We could go on for at least another 50 pages on this topic (as our thesis reminds us) but volume is not the point of today’s task. It was to bring something new to light for our brethren here at The Gait Guys.  In the photo above, you see drift of the lesser toes, seemingly to follow the big toe. What you need to know is that this is not typical, however not impossible one could propose. This client had some other forefoot procedures done that were largely, although not exclusively, related to that lesser digit drift. Regardless, this is a client that is in some amount of foot trouble. They had good mobility of the 1st MTP joint, so full toe off was possible but because of the instability and uncontrollable rotational forces the joint was painful. A simple intervention made her life infinitely more comfortable, moving her into rigid rocker bottomed shoes.  Dansko clogs for work, and ROCS shoes for walking.  This left us with a very happy client. Not bad, all things considered.  In the mean time we will watch for deformity progression even though the patient could not be urged to have another surgery probably even if their life depended upon it. 
 
In summary, being a patient can be difficult. These days, more than ever it seems, one needs to do their homework and be their own advocate.  Prior to surgery several consults should have taken place, risk and rewards should have been discussed, realistic outcomes dialogued and perhaps most of all questioning whether surgery needed to be on the table in the first place. Remember, surgery is most wisely selected in cases of neurologic decline and excessively painful and further detrimental biomechanics (ie. unaddressed ACL deficiency eventually promoting secondary instability with time). If there are ways around either, they should be explored. Cosmetic correction should never be on the table, and in the case of the foot, nor should poor shoe choices that promote problems.
Does this foot look like your foot ?  
 There are a few subtle issues here. At first glance this foot looks half-way decent but upon further observation you should note the subtle drift of all of the toes.  In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit is the reference digit.   
 In this foot, look at the shape of the 2nd and even the 3rd digit, they have a curve to them. Remember, form follows function and the dead give away here is that the hallux (the big toe) is drifting into adduction towards the 2nd digit. This is referred to as early hallux valgus and it is accompanied by early evidence of a bunion at the medial foot at the metatarsophalangeal joint.  When the shaft of the hallux is not in line with the shaft of the metatarsal long bone we get the angulation between the two causing the hallux valgus.  This is often from excessive pronation (either rearfoot, midfoot and/or forefoot) that collapses the tripod, splays the distal MET head via its dorsiflexion, and the development of complicated long and short hallux flexor muscle dysfunction as well as abductor hallucis (transverse and oblique head) disfunction further driving the hallux pull medially.  When the distal toes are engaged on the ground and there is still forefoot pronation occurring through the medial tripod support, the toes will be forced into a twist or spin, and in time you will get toes that appear drifted or windswept like these toes appear.  A similar phenomenon occurs at the lateral foot and a Tailor’s bunion begins to occur there as the forefoot begins to widen as the MET heads separate and the toes funnel medially (often provoked to do so by pointed footwear).   
 We can also see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL).  See this post here  for an explanation of this phenomenon.   
 This is a fairly typical foot that we see in our practices.  This is not a far-gone foot but one has to catch this foot at this stage or it is rather difficult to resuscitate back to a healthy foot. Like a spinal scoliosis, once a bunion and  hallux valgus gets too far, it becomes an issue of symptom management rather than repair.  Hallux abduction must be retaught, tripod skills must be retaught, intrinsic foot muscle strength must be regained as well as strength and endurance of the tibialis anterior and toe extensors to help raise the arch again and control pronation. Sometimes a temporary orthotic can help the person to passively regain some degree of competent tripod while homework earns the changes. In some cases, an orthotic needs to be a permanent intervention if tripod stability cannot be adequately achieved.  But, we never give up and neither should you or your client, amazing things can happen over long periods of time when correction is forced. 
 There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box.  Support the midfoot with an orthotic or built up foot bed, if necessary, but don’t leave it there. It is a crutch, and even crutches are intended to be put aside at some point.  
 Shawn and Ivo, The gait guys

Does this foot look like your foot ? 

There are a few subtle issues here. At first glance this foot looks half-way decent but upon further observation you should note the subtle drift of all of the toes.  In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit is the reference digit.  

In this foot, look at the shape of the 2nd and even the 3rd digit, they have a curve to them. Remember, form follows function and the dead give away here is that the hallux (the big toe) is drifting into adduction towards the 2nd digit. This is referred to as early hallux valgus and it is accompanied by early evidence of a bunion at the medial foot at the metatarsophalangeal joint.  When the shaft of the hallux is not in line with the shaft of the metatarsal long bone we get the angulation between the two causing the hallux valgus.  This is often from excessive pronation (either rearfoot, midfoot and/or forefoot) that collapses the tripod, splays the distal MET head via its dorsiflexion, and the development of complicated long and short hallux flexor muscle dysfunction as well as abductor hallucis (transverse and oblique head) disfunction further driving the hallux pull medially.  When the distal toes are engaged on the ground and there is still forefoot pronation occurring through the medial tripod support, the toes will be forced into a twist or spin, and in time you will get toes that appear drifted or windswept like these toes appear.  A similar phenomenon occurs at the lateral foot and a Tailor’s bunion begins to occur there as the forefoot begins to widen as the MET heads separate and the toes funnel medially (often provoked to do so by pointed footwear).  

We can also see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL). See this post here for an explanation of this phenomenon.  

This is a fairly typical foot that we see in our practices.  This is not a far-gone foot but one has to catch this foot at this stage or it is rather difficult to resuscitate back to a healthy foot. Like a spinal scoliosis, once a bunion and  hallux valgus gets too far, it becomes an issue of symptom management rather than repair.  Hallux abduction must be retaught, tripod skills must be retaught, intrinsic foot muscle strength must be regained as well as strength and endurance of the tibialis anterior and toe extensors to help raise the arch again and control pronation. Sometimes a temporary orthotic can help the person to passively regain some degree of competent tripod while homework earns the changes. In some cases, an orthotic needs to be a permanent intervention if tripod stability cannot be adequately achieved.  But, we never give up and neither should you or your client, amazing things can happen over long periods of time when correction is forced.

There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box.  Support the midfoot with an orthotic or built up foot bed, if necessary, but don’t leave it there. It is a crutch, and even crutches are intended to be put aside at some point. 

Shawn and Ivo, The gait guys

Lebron James and his funky toes. We have the scoop as to what is going on.

http://bleacherreport.com/articles/1757693-everybody-look-at-lebron-james-toesimage

This is what happens when you get too much short extensor tone and/or strength in the digits of the foot.  Now this is his trailing foot and he has moved into toe off so he should be activating his toe extensors and the tibialis anterior (ie. the anterior compartment) to create clearance for that foot so that he doesn’t catch the toes on the swing through phase of gait.  In this case we do not see alot of ankle dorsiflexion (which we should see at this point) so we are  seeing a compensation of perhaps increased short extensor (of the toes) activity.  

We also see what appears to be a drifting of the big toe (the hallux) underneath the 2nd toe. This often happens when a bunion or hallux valgus is present.  Now we do not see a bunion present here but the viewing angle is not optimal however it does appear that there is a slight drift of the hallux big toe towards the lesser toes . We are not sure if we would qualify this as hallux valgus, and if so it is mild, but none the less we see a slight lateral drift. What is interesting is that despite the obvious activity of the lesser toes short extensor muscle (EDB) we do not see a simultaneous activity of the short extensor of the hallux (EHB, extensor hallucis brevis). Does he need to do our exercise ? See video link here ! 

And so, when the lesser toes are in extension as we see here and the big toe is not moving into extension, and when that is simultaneously combined with even a little hallux valgus tendency, the big toe will drift underneath the lesser toes as we see here, even appearing to push the 2nd toe further into extension.  

As for his little toe, well, Dr. Allen  has one just like it so perhaps he missed his calling in the NBA. Some folks just do not have as plantarward orientation of the 5th toe and so it migrates upward (dorsally) a little. This can be from birth but it can also come from trauma. But in time because the toe is not more plantar oriented, the dorsal muscles (the extensors) become more dominant and the toe just starts to take on this kind of appearance and orientation. It will reduce significantly when the foot is on the ground and the extensors are turned off, but it looks more shocking during the swing phase because of the extensor dominance in that phase.

This kind of presentation if left unchecked can lead to hammer toes, plantar fat pad migration distally exposing the metatarsal heads to more plantar forces without protection and a host of other problems.  Lebron needs to do our Shuffle Walk Exercise to get more ankle rocker (dorsiflexion) and also work to increase his long toe extensors (EDL) and lumbricals.  This will flatten his toes and improve mechanical leverage.  Remember, if you gait better foot function with increased ankle dorsiflexion you will get more hip extension and more glute function.  But does the big fella really need to jump any higher? We are sure he would accept being faster though … .  who wouldn’t ?

Fee for today’s long distance consult: …  Lebron, lets say 10,000$ and we will call it even.  Sound good ?  But a lifetime of prettier, stronger and more functional toes……priceless. Have  your people contact our people.  (Ok, we don’t have people, but we do have an email address here on our blog !).

Shawn and Ivo, The Gait Guys.  Even helping the elite, little by little.


Why alignment of the big toe is so critical to gait, posture, stabilization motor patterns and running.

There are two ways of thinking about the arch of the foot when it comes to competent height.  One perspective is to passively jack up the arch with a device such as an orthotic, a choice that we propose should always be your last option, or better yet to access the extrinsic and intrinsic muscles of the foot (as shown in this video) to compress the legs of the foot tripod and lift the arch dynamically.  Here today we DO NOT discuss the absolute critical second strategy of lifting the arch via the extensors as you have seen in our “tripod exercise video” (link here) but we assure you that regaining extensor skill is an absolute critical skill for normal arch integrity and function.  We like to say that there are two scenarios going on to regain a normal competent arch (and that does not necessarily mean a high arch, a low arch can also be competent….. it is about function and less about form): one scenario is to hydraulically lift the arch from below and the other scenario is to utilize a crane-like effect to lift the arch from above. When you combine the two, you restore the arch function.  In those with a flat flexible incompetent foot you can often regain normal alignment and function.  But remember, you have to get to the client before the deforming forces are significant enough and have been present long enough that the normal anatomical alignments are no longer possible. For example, a hallux valgus with a large bunion (this person will never get to the abductor hallucis sufficiently) or a progressively collapsed arch that is progressively becoming rigid or semi-rigid.

Think about these concepts today as you watch your clients walk, run or exercise.  And then consider this study below on the critical importance of the abductor hallucis muscle after watching our old video of Dr. Allen’s competent foot.  

CONCLUSIONS AND CLINICAL RELEVANCE:

The abductor hallucis muscle acts as a dynamic elevator of the arch. This muscle is often overlooked, poorly understood, and most certainly rarely addressed. Understanding this muscle and its mechanics may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and many other issues that lead to a challenge of the arch, effective and efficient gait. Furthermore, its dysfunction and lead to many aberrant movement and stabilization strategies more proximally into the kinetic chains.

*From the article referenced below,  “Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait.“

We hope that this article, and the video above, will bring your focus back to the foot and to gait for when the foot and gait are aberrant most proximal dynamic stabilization patterns of the body are merely strategic compensations.

Study RESULTS:

All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted ‘V’ shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch.

http://www.ncbi.nlm.nih.gov/pubmed/17559771

Foot Ankle Int. 2007 May;28(5):617-20.

Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study.

Wong YS. Island Sports Medicine & Surgery, Island Orthopaedic Group, #02-16 Gleneagles Medical Centre, 6 Napier Road, Singapore, 258499, Singapore. 

Podcast 34: Chimp feet, Marathon Monks & Statin drugs

podcast link:

http://thegaitguys.libsyn.com/podcast-34-chimp-feet-marathon-monks-statin-drugs

iTunes link:

http://thegaitguys.libsyn.com/podcast-33-heart-beats-toe-walking-crawling

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen  Biomechanics

Today’s show notes:

 1.Did Rock Climbing Help Us Start Walking Upright?   By Shaunacy Ferro A new theory suggests humans became bipedal so that we could scramble up rugged terrain.
http://www.popsci.com/science/article/2013-05/did-rock-climbing-help-us-start-walking-upright?src=SOC&dom=tw


2. http://en.wikipedia.org/wiki/Kaih%C5%8Dgy%C5%8D

The Running Marathon monks of Mt. Hiei

The Kaihōgyō is a set of the ascetic physical endurance trainings for which the Japanese “marathon monks” of Mt. Hiei are known. These Japanese monks are from the Shugendō and the Tendai school of Buddhism, a denomination brought to Japan by the monk Saichō in 806 from China.


3. http://www.runnersworld.com/general-interest/do-you-have-chimpanzee-feet

Do you have Chimpanzee feet ?

About 8% of people tested by Boston University researchers had midfoot flexibility of the sort that apes use to climb trees, according to a study published in the American Journal of Physical Anthropolgy.

4. Statins Linked With Risk of Musculoskeletal Injury

Michael O'Riordan

http://www.medscape.com/viewarticle/805369?src=wnl_edit_medn_wir&spon=34

http://archinte.jamanetwork.com/article.aspx?articleid=1691918

Can Statins Cut the Benefits of Exercise?

By GRETCHEN REYNOLDS

http://well.blogs.nytimes.com/2013/05/22/can-statins-curb-the-benefits-of-exercise/

http://www.ncbi.nlm.nih.gov/pubmed/23583255

5. Shoes: The Primal Professional.com

http://theprimalprofessional.com/products/pre-order-the-primal-professional

http://well.bradrourke.com/2013/05/my-new-primal-dress-shoes/

6. Hallux valgus and lesser toe deformities are highly heritable in adult men and women: The Framingham foot study

Marian T. Hannan
http://onlinelibrary.wiley.com/doi/10.1002/acr.22040/abstract;jsessionid=99975015C3EE5678E6351273C2CD42A0.d02t04

7. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers

Kulmala, Juha-Pekka; Avela, Janne; Pasanen, Kati; Parkkari, Jari

http://journals.lww.com/acsm-msse/Abstract/publishahead/Forefoot_strikers_exhibit_lower_running_induced.98324.aspx

8. Why Where You Land On Your Foot Isn’t That Important

http://www.kinetic-revolution.com/why-where-you-land-on-your-foot-isnt-that-important/

Is Your Foot Tripod Stable Enough to Walk or Run without Injury or Problem ?

The all to common case of the Wobbling Tripod.

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

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

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

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

*addendum:

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

Shawn and Ivo … .  comfortably numb.

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

Part 2 of the EHB: Bringing the Extensor Hallucis Brevis of the Foot Back to Life.

Today we show you a proprietary exercise we developed here at The Gait Guys. It was developed out of necessity for those clients who are too EHL dominant (long big toe extensor muscle) and big toe short flexor dominant (FHB). These two muscles are what we call a foot functional pair.  Big toes like these will be dysfunctional and will not be able to gain sufficient purchase on the ground to produce stability and power without impacting the joint (1st metatarsophalangeal joint).  Imbalances like these lead to altered joint loading responses and can be a possible predictor for premature damage to the joint over time. These imbalances are also what lead to injuries to the big toe, the arch and other areas of the foot. After all, when the big is weak or dysfunctional gait will be compensated.  When imbalance at this joint occurs because of EHB weakness the medial tripod anchor (the head of the 1st metatarsal) is compromised possibly transmitting stress into the foot, arch and medial stabilizers such as the tibialis posterior for example.

This exercise is to be weaned back to less and less yellow band resistance until the EHB can be engaged on its own. Then the gait retraining must begin. Simply reactivating and strengthening the skill and muscle is not enough. The pattern must be then taken to the floor and learned how to be used in the gait cycle.

Do we need to mention the critical function this muscle plays in extension of the 1st MPJ, of its importance in hallux rigidus/limitus, in bunions, hallux valgus, toe off function, arch height and function ? We hope not.

It is a process restoring gait. All too often the “Devil is in the Details”.
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Shawn and Ivo
The Gait Guys

all material copyright 2012 The Gait Guys/ The Homunculus Group: all rights reserved.

Curse of the Bunion

Hi Dr. Allen,

My husband was able to stop using his orthotics by utilizing the exercises he learned from The Gait Guys on YouTube so I thought I would send you an email to ask your opinion about my daughter’s foot issues. She is 14 years old and a serious dancer (eight hours of class per week plus up to eight hours of rehearsal). She has developed a bunion which is starting to cause her significant pain in the joint of her big toe. We took her to an Orthopedist who gave her a Cortizone shot in her joint and suggested she will need surgery. Considering she is only 14 and surgery would take her out of dance for at least 3-4 months, we do not view it as a viable option. Is it possible to fix a bunion without surgery and is that something you have had success doing? I know she is not currently a patient of yours but I would be interested to hear your opinion on the issue.
Thanks,  PG
___________________________________
Dear PG
Wow, that is great news for your husband ! Although we do not recommend taking our information as medical advice it is always nice to hear that by simply using our stuff to self educate oneself that people are fixing what therapy was unable to achieve.
I used to treat many in the dance company at the Chicago Joffrey Ballet along side a few other brilliant doctors (who are Gait Guys followers as well !) and we always cringed when a nasty bunion would walk and and cry for help.
Bunions are developmental for the most part. They are found paired with Hallux Valgus. This journal article has a real nice verbiage that we like:
“The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments, and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its alignment. In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers that disrupts this muscle balance.  Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these associations are incomplete and nonlinear. In any patient, a number of factors have to come together to cause the hallux valgus.”
In working with dancers we found plenty that did not have bunions or hallux valgus.  So it is not always the dancing that is the culprit. But it can be a factor if the osseous alignment is suboptimal (the joint line architecture at the metatarsophalangeal joint at the big toe is angled to allow for lateral hallux drift or the intermetatarsal angle is predisposed (wider than optimal)).  
The main problem however in dancers is multifactorial:
  • the “turn out” predisposes the foot to more pronation which can easily destabilize the medial foot tripod anchoring of the 1st metatarsal to the ground.  This will change the pull of the adductor hallucis causing the hallux to drift laterally and the 1st metatarsal to drift medially widening the gap between the 1st and 2nd metatarsals (ie. the intermetatarsal angle).
  • dancers also axially load the hallux. This is called “en pointe”.  Please read our prior blog post on “en pointe” (click here). As you can see in the video above, the angle at the big toe (the 1st metatarsophalangeal joint) immediately begins to drift into hallux valgus.  Continuing to do this will render this poor gal a nasty bunion in time we highly suspect.  These are the challenges that dancers put into the foot. Once the hallux drifts laterally the first metatarsal loses more anchoring capacity at the medial foot tripod and the viscous cycle continues. 
  • Remember, a bunion is a soft tissue adventitious mal-development.  It is often erroneously confused as a bony proliferation at the medial joint, the knuckle area.  This is not the case.  Hallux valgus drives the metatarsal head medially and exposes the head of the bone medially giving the appearance of a bump (the “bunion”). In fact, the bunion is an inflamed or adventitious bursal sac combined with the prominence of the MET head and angry inflammed skin, ligaments, joint capsule etc
To “fix the bunion” is a loaded issue.  Once these begin to develop they frequently progress in degree and pain.  They are very hard to correct conservatively but you have to give it a chance, surgery has to be the last road. Unfortunately if this is going to happen it must be determined if dance is a provoking factor, which is very likely.  Being in En Pointe will make this a quick trip into a nasty bunion we fear.  Use caution and logic on this one PG.  Your daughter has to live with these feet for many decades at the very least, and there is nothing like walking on painful incompetent feet for the rest of your life.  Further correction possibilities may come from determining if she can adequately form a good foot tripod and achieve competent strength in the muscles that stabilize the joint (FHL, FHB, EHL, EHB, ABD H., ADD H., tib posterior and anterior …… to name most of them).  A strong competent foot with excellent medial tripod anchoring ability will rarely develop into a bunion or hallux valgus. But you have to catch the incompetencies early and correct them before things get out of  hand. 
Good luck to you and  your daughter PG.  Find someone good at these things.  Find your local “Gait Guy or Gait Gal” and you will be in good hands (or should we say “good feet”).
The government needs to start a “Just say no to bunions” grassroots program. Although on second thought, maybe that is not a good idea. It would only get caught up in congress and the senate for years.
Warm regards,
Shawn and Ivo

A case of severe mechanical gait challenges.

This is a unique case. This is a complicated case, there is so much going on. If your eye is getting good at this gait analysis stuff you will know that just from the first pass this gait is very troubled.

This young middle distance runner who came to see us with complaints of chronic anterior and posterior shin splints. This is unusual because usually only one of the lower limb compartments are strained, either the anterior (tibialis anterior mostly) or the posterior compartment (tibialis posterior mostly). Admittedly this is not a fast runner but they love to run none the less, so you do what you can to help.

Please watch this video again and note the following:

  1. crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs)
  2. slightly wider based gait compared to knee postioning but neutral compared to hip spacing
  3. client starts heavily on the outer edge of the feet and moves medially
  4. client over strides (step length is increased) which is particularly evident when they are walking towards the camera
  5. early bunion formation and troubles engaging the big toe during stance phase
  6. the knees / patella also appear medially positioned in an environment of a neutral foot progression angle
  7. if you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height.

Wow ! So much going on ! This is a gait from hell in some respects. So, what is driving so much of the terrible gait mechanics ? The answer is a congenital loss of ankle rocker (dorsiflexion) bilaterally. This client can barely squat because the ankles just do not dorsiflex. There was clear osseous lock at barely 90 degrees.

Lets break each one down.

  1. Crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs). * This is occuring due to some genu valgum of the knees (slightly “knock-knee”). When the knees are valgum they are at risk for brushing together during gait. The client has no choice but to circumduct the limbs to avoid this behavior. Unfortunately they cannot abduct the thighs far enough during many of the gait cycles and so a “Scissored” appearance occurs where the thighs brush and cross over in appearance.
  2. Slightly wider based gait compared to knee positioning but neutral compared to hip spacing. * This is closely related to our answer in #1. Valgus knees will widen the foot spacing side to side because the feet are not under the knee joints. Then couple this with the necessity to circumduct to avoid knees from contacting and the foot posturing is that of an even wider based gait. This can also occur from many hip problems. However as in this case with a congenital loss of ankle rocker, the client uses more foot pronation to progress the tibia over the talus (allowing the tibia to get past 90degrees) and allow them to move forward. This added pronation does magnify and likely progress the knee valgum but there are few other options for this client. This is often a destructive vicious cycle with few good outcomes decades down the road.
  3. Client starts heavily on the outer edge of the feet and moves medially. *This may be to avoid the immediate rear foot pronation that is seen here.
  4. Client over strides (step length is increased) which is particularly evident when they are walking towards the camera. * This may be a conscious attempt to lengthen the shortened stride that occurs because of the limited ankle dorsiflexion ranges. It appears at many moments however to be a result of the extra effort to circumduct the legs sufficiently. A longer stride does play into #3 above, a larger stride usually leads to a heavier lateral heel strike but it also means that the rearfoot pronation will be more aggressive, this is a negative resultant outcome.
  5. Early bunion formation and troubles engaging the big toe during stance phase. *We are not surprised here. Whenever pronation is excessive the first metatarsal (medial foot tripod) is unstable and this changes the mechanics of the hallux muscles to pull towards the 5th metatarsal anchor generating the bunion. Look at the origin and insertion of the adductor hallucis muscle particularly the transverse head, if the 1st MET is anchored the 5th MET is pulled to the 1st and the transverse arch is formed. However, if the 1st MET is unstable and the 5th is the only anchor, the adductor hallucis will pull the toe laterally and form a bunion and hallux valgus and compromise the transverse arch. (particularly look at the left big toe at the :09 to :11 second mark, the big toe and first MET are clearly not anchored to the ground).
  6. The knees / patella also appear medially positioned in an environment of a neutral foot progression angle. * Answers for #1-#5 clearly will medial patellar deviation and drive patellar tracking problems.
  7. If you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height, but remember, that does not mean that pronation is not occurring. * This is a result of the loss of ankle rocker mechanics. If they start pronation early at the rear foot it will drive more pronation. When pronation is driven excessively the arch can drop, and with more arch height drop the tibial will pitch forward past the magical 90 degree mark and allow forward motion to occur.

So, how can they run with all this going on ? Well, the answer is quite simple. They avoid most of these issues as best they can. How you ask ? Forefoot strike; they run avoiding heel strike and midfoot strike. By staying on the forefoot all of these rear and midfoot mechanical limitations as well as ankle rocker loss can be avoided by remaining on the forefoot. This makes distance running difficult but anything below the two mile mark is tolerable and the 100-800 distances are probably best suited for their feet. Incidentally they enjoy the 400 the best, no wonder. Also, moving at increased speed will necessitate a forward lean, and a forward lean makes the tibia progression over the talus easier taking out some of the ankle rocker limitations.

This is a foot type, with complications, that is really beyond much of what anyone can do conservatively. We would even argue that surgery is not an option, just a change in activity choice. This is simply a client that should not run beyond distances where they can stay on the forefoot. The foot, ankle and lower limb mechanics just suffer far to much from having to compensate (as discussed in #1-7) to enable pain and problem free running with anything other than forefoot loading. This means that walking is going to be difficult and problematic, as you can see from this video above.

Our only solution in this case ? ……… utilizing a rocker based footwear. Easy Spirit Get UP and Go (link) was our recommendation and it worked very well for this client for walking. Here is a link to this shoe and pictures of the huge forefoot rocker that helps (somewhat) to dampen the mid-forefoot rocker issues but there is not much that can be done for the rear foot rocker issues as discussed. If you use an orthotic to block the rearfoot valgus motion and rearfoot pronation you will pass more challenges to the midfoot-arch and forefoot. Sadly.

This was a very tough case. Getting every aspect of the case in your head during an evaluation is sometimes a challenge. Sometimes you need to see them a 2nd or 3rd time to digest it all. But be patient with yourself, it takes time to get decent at this stuff. This is a perfect case for “getting a feeling and flow” of the persons gait, at their speed. A case evaluation like this on a treadmill or via video analysis can make things tougher because the treadmill can change the dynamics (did you read our Treadmill article in last months Triathlete magazine ? It was linked on the blog 2 weeks ago) and make the client move at its speed and not their speed inhibiting and promoting different mechanics. There are times for a treadmill and times to avoid them. This is an art, in time you will know when to use and when not to use.

Happy Monday Gait Gang………. welcome to The Gaits of Hell !

Shawn and Ivo ……….two gnarly lookin dudes with pitchforks and a toothy grin.