Neuroma! Triple Threat....

Can you guess why this patient is developing a neuroma on the left foot, between the 3rd and 4th metatarsals?

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This gal presented to the office with pain in the left foot, in the area she points to as being between the 3rd and 4th metatarsals. It has been coming on over time and has become much worse this spring with hiking long distances, especially in narrower shoes. It is relieved by rest and made worse with activity.

Note the following:

  • She has an anatomical short leg on the left (tibial)

  • internal tibial torsion on the left

  • left forefoot adductus (see the post link below if you need a refresher)

Lets think about this.

The anatomical short leg on the left is causing this foot to remain in relative supination compared the right and causes her to bear weight laterally on the foot.

The internal tibial torsion has a similar effect, decreasing the progression angle and again causing her to bear weight laterally on the foot, compressing the metatarsals together.

We have discussed forefoot adductus before here on the blog. Again, because of the metararsal varus angle, it alters the forces traveling through the foot, pushing the metatarsals together and irritating the nerve root sheath, causing hypertrophy of the epineurium and the beginnings of a neuroma.

In this patients case, these things are additive, causing what I like to a call the “triple threat”.

So, what do we do?

  • give her shoes/sandals with a wider toe box

  • work on foot mobility, especially in descending the 1st ray on the left

  • work on foot intrinsic strength, particularly the long extensors

  • treat the area of inflammation with acupuncture

Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #metatarsusadductus #neuroma #gaitanalysis #thegaitguys #internaltibialtorsion

1st MTP Pain? The Biomechanics of the Big Toe...

Remember the rockers? We have done a series on this in the past. Remember there are three: heel, ankle and forefoot. We are going to concentrate on the forefoot today.

As a reminder, forefoot rocker occurs at the 1st metatarsal phalangeal joint (big toe knuckle) as the tibia progresses over the forefoot during forward movement. You NEED 50 degrees to do this competently; you SHOULD have 65 degrees. When you don’t, you have a condition called hallux limitus. This could be from a number of reasons, from overpronation in the mid foot, to a bunion, to faulty firing patterns of the muscles which help to descend the 1st ray (the extensor hallucinations brevis, the peroneus longs and the short flexors off the toes). Pretty much, ANYTHING that causes a dorsal and posterior shift of the 1st MTP axis will cause limited forefoot rocker.

So, the question is, “Do you know where 1st 1st MTP pain may be coming from? How familiar are you with the mechanics of that joint?”

Take a few minutes to review it in this video with Dr Ivo Waerlop of The Gait Guys.

#gait, #gaitanalysis, #1stmtp, #forefootrocker, #thegaitguys,

The Power of the 1st Ray?

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Does the 1st ray complex have super powers? Perhaps Marvel should consider a new superhero “Ray”? We are not sure but here is a story that gets us one step closer to the answer. 

While teaching a course this past weekend and doing a teaching case, we examined one of the participants who had high arches, a rigid rearfoot varus, internal tibial torsion, R > L, and foot pain R>L and a dorsal exostosis (growth of extra bone from stress at the base of her 1st metatarsal) where it articulated with the  1st cunieform on the right. No surprisingly, she also had a partially compensated forefoot supinatus on the right. She had increased wear on the lateral aspect of her shoes and a walking strategy which involved hiking the right side of the pelvis during stance phase on the left, and a pelvic shift to the right during stance phase on the right, as well as an inability to get the head of either 1st ray complex to the ground, R > L. It was also determined she had, not surprisingly, locking of the 1st metatarsal cunieform joint on the right and a loss of anterior and posterior shear at the superior tib fib articulation on the right, as well as hypomobility of the right sacoiliac joint. There was weakness of the abdominal external obliques bilaterally and posterior fibers of the left gluteus medius, along with the long toe extensors on the left and short toe flexors, a pattern that we often see clinically.

We then proceeded to treat her tib posterior, peroneus longus and flexor digitorum on the right, all of which have an effect on descending the 1st ray, along with the long extensors on the right, which would effectively raise the distal aspect of the 1st ray, but we thought may provide better eccentric control of the foot from initial contact to loading response, and again from the end of terminal stance and through swing phase.  We then mobilized the 1st met cunieform articulation only. Ideally, we should have reassessed after we made EACH change, but due to time constraints, AFTER we had done ALL these things. 

Rexamination had better 1st ray motion, restoration of tib fib motion and restoration of R sided SI mechanics. Her 1st ray descended much better, tib fib motion was normalized, L sided hip hiking strategy and R sided pelvic shift were greatly improved. For the 1st time in 10 years, the participant had no foot pain. Coincidence? Perhaps. Placebo? Maybe. You decide. 

Sometimes, doing a little of the right thing can be a good thing. Sometimes we overdo. I have to admit, because I am a chiropractor, I would have started with manipulation 1st of all 3 articulations with a recheck immediately post treatment AND THEN treated the other dysfunctions. For those of you who are manual therapists, I am sure you see miraculous things happen when we cavitate joints and change their instantaneous axes of rotation. I can thank Dr Ted Carrick and my good friend and colleague, Dr Paul Chille, for teaching me that. The students, in this case, were driving the bus and I went along with it.  I was surprised (though I shouldn’t have been) to see the pathomechanics resolve WITHOUT manipulation, but it got me thinking I should consider treating the muscular dysfunctions 1st, and then recheck and manipulate later. It makes sense that the receptor density of the lower extremity musculature has a much larger population of muscle mechanoreceptors, especially in the foot, since it has a greater cortical representation than the joint mechanoreceptors.

My students never cease to teach me something new...

Lets take another look at the tibialis posterior

As cinincians , we often needle and treat the tibialis posterior for posterior tibial tendon dysfunction, platar fasicits, patellofemoral joint pain, and a host of other conditions. Lets take a look at some of the anatomy and see why it is a big player in these conditions. 

The tibialis posterior takes its origin from the proximal posterior tibia, fibula and interosseous membrane. It is deep to the tricep surae and more superior than the flexors hallucis and didgitorum longus. The tendon descends medially, travels around the medial malleolus and divides into 3 portions: plantar, main and recurrent components. It inserts into all the tarsals and metatarsals 2-4.(1) Note that it DOES NOT insert into the 1st metatarsal. There must be a good reason for this, no?

The tibialis posterior acts to plantar flex and invert the foot as well as help eccentrically control eversion of the foot. It fires from initial conact to almost terminal swing. This assists in plantart flexion of the foot from initial contact to loading response, eccentric slowing of the foot during pronation from loading response to misdstance and concentric contraction to assist in and speed up supination from midstance to terminal stance.  When you look at the EMG studies for walking (2,3) , you will see that it starts ramping down activity just after midstance as the peroneus longus starts to ramp up more (firing from just after loading response to pre swing, with a bust of activity from midstance on). 

So, with all this talk, there has to be a reason, right? Think about this. In order to move forward in the gravitational plane and have high gear push off (ie, pushing off the base of the hallux), the 1st ray needs to descend to gain purchase on the ground (2,4, 5) . This is largely through the actions of the peroneus longus, extensor hallucis brevis and flexor digitorum brevis (6,7). The function of the peroneus longus should be obvious with its attachment to the base of the 1st metatarsal. The extensor hallucis brevis moves the axis of the 1st MTP downward when it contracts, as discussed here and here (8, 9). The flexor digitorum brevis moves the axis of metatarsalphalangeal joints 2-5 dorsally and posterior which effectively moves the axis of the head of the 1st metatarsal phalangeal joint ventral and anteriorly. This is requisite for you to have adequate hallux dorsiflexion of about 60 degrees to toe off normally. 

OK, so what about the tibialis posterior? 

Remember that the tib posterior attaches to most of the proximal bottom of the foot with the exception of the 1st metatarsal base? In the area of the 1st ray, the tib posterior attaches to the navicular. When it contracts, it will pull the navicular posterior and inferior, effectively rasing the base of (and lowering the head of) the 1st metatrsal. If it attached to the 1st metatarsal, its base would be pulled posterior and inferior which would raise the head of the 1st ray, exactly what we are trying NOT TO DO

Armed with this clinical tidbit, can you see how posterior tibial tendon dysfunction can be involved with so many foot and therefore lower kinetic chain problems? If you can’t descend the 1st ray, the foot will need to toe off its lateral aspect, with less effectiveness of the calcaneocuboid locking mechanism (more on that here (10) and here (11)), so problems with propulsion off of an “unlocked” foot. Can you see how the forefoot may be somewhat more everted in this situation? Can you see how this would contribute to more calcaneal eversion and sustained midfoot pronation from midstance through the rest of the gait cycle?  What muscle is sitauted to help maintain the arch as well as decelerate pronation? Tibialis posterior. What muscle will be called into play to assist the gastroc/soleus to help propel you forward? Tibialis posterior. You get the picture.

The tibialis posterior. An important player in the gait game. A great muscle to needle thatpays clinical dividends in more ways than you can imagine. 


1. Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior Tibial Tendon Dysfunction: An Overlooked Cause of Foot Deformity. Journal of Family Medicine and Primary Care. 2015;4(1):26-29. doi:10.4103/2249-4863.152245.

 2. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Thomas Michaud Newton, MA 1993

3. ValmasseyR. Clinical Biomechanics of the lower extremities. Mosby, St Louis, Philadelphia. 101-107: 1996

4. Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore, Williams and Wilkins, 1981

5. Scranton PE, et al. Support phase kinematics of the foot.  In Bateman JE, Trott AW (eds). The Foot and Ankle. New York, Thieme-Stratton, 1980

6. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack 1992

7. The Pathokinesiology Service and the Physical Therapy Department. Observational Gait Analysis. Rancho Los Amigos National Rehabilitation Center Downey, CA 2001

8. https://tmblr.co/ZrRYjxFOn2hk

9. https://tmblr.co/ZrRYjxFSJ4Yz

10. https://tmblr.co/ZrRYjx1MjeIVN

11. https://tmblr.co/ZrRYjxToM8SI

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1st met pain in an orthotic?

This patient came in with pain at the base of the first metatarsal that she believed was related to her orthotic. The first picture shows the foots relationship to the orthotic. Notice how the sesamoid bones and distal aspect of the first metatarsal under lap the orthotic shell. In other words, the shell is longer than her foot. When she dorsiflexes her big toe, she’s hitting the distal of the orthotic.

The next view shows the orthotic with a typical first ray cutout. Notice how far forward the shell of the orthotic goes (next picture). I have placed a pen pointing to the area where the orthotic shell is too long.

In addition to reviewing her first ray descending exercises, a simple fix was to grind back the orthotic shell and be careful to bevel the edge so that it was not hitting the sesamoids and it did not impinge upon the descending first ray. I have placed a pen where the cut out now is (pre and post gluing in the pictures). The cork underlying the base of the first ray was also ground away (last picture)

A simple fix for a common problem. Make sure that your orthotic shell lengths fall just short of the 1st ray and not impinge on the sesamoids!

One way to correct an dysfunctional Extensor Hallucis Brevis

The Extensor Hallicus Brevis, or EHB  (beautifully pictured above causing the  extension (dorsiflexion) of the proximal big to is an important muscle for descending the distal aspect of the 1st ray complex (1st metatarsal and medial cunieform) as well as extending the 1st metatarsophalangeal joint.

Since this muscle is frequently dysfunctional, and is one of THE muscles than can lower the head of the 1st metatarsal, along with the peroneus longus and most likely the tibialis posterior (through its attachment to the 1st or medial cunieform), needling can often assist in normalizing function and works especially well, when coupled with an appropriate rehab program. Here is one way to needle it effectively. 

1st MTP Pain?

It may not be a trigger point. In this capsule summary, Dr Ivo discusses an interesting and perhaps revolutionary, theory on trigger point pain that refers to the 1st metatarsal phalangeal articulation. The anatomy of the joint and responsible muscles are also discussed

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All about 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.

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The case of the dropped (plantarflexed) metatarsal head. Or, “How metatarsalgia can happen”.

This gentleman came in with fore foot pain (3rd metatarsal head specifically), worse in the AM upon awakening, with first weight bearing that would improve somewhat during the day, but would again get worse at the end of the day and with increased activity. The began insidiously a few months ago (like so many problems do) and is getting progressively worse.

Rest and ice offer mild respite, as does ibuprofen. You can see his foot above. please note the “dropped” 3rd metatarsal head (or as we prefer to more accurately say, “plantarflexed 3rd metatarsal head”) and puffiness and prominence in that area on the plantar surface of the foot. 

To fully appreciate what is going on, we need to look at the anatomy of the short flexors of the foot. 

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

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsal phalangeal joint, and proximal interphalangeal joint (although this second action is difficult to isolate. try it and you will see what we mean). In addition, it moves the axis of rotation of the metatasal phalangeal joint dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly (much like the function of the extensor hallucis brevis above in the drawing from Dr Michauds book, yes, we are aware this is a picture of the 1st MTP).

Can you see the subtle extension of the metatarsal phalangeal joint and flexion of the proximal interphalangeal joint in the picture?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a tole in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, especially if there is a concomitant loss of ankle rocker, the metatarsal heads are driven into the ground (plantarflexion), causing irritation and pain. Metatarsalgia is born….

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

  • How about the toe waving exercise? 
  • How about the lift spread reach exercise? 
  • How about retraining ankle rocker and improving hip extension?
  • How about an orthotic with a metatarsal pad in the short term? 
  • How about some inflammation reducing modalities, like ice and pulsed ultrasound. Maybe some herbal or enzymatic anti inflammatories?

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

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

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

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

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

What’s up, Doc?  
 Nothing like a little Monday morning brain stretching and a little Pedograph action. 
 This person had 2nd metatarsal head pain on the left. Can you figure out why? 
  Let’s start at the rear foot:  
  limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here. 
 note the increased pressure at the  medial calcaneal facets on each side with the increased printing 
 very little fat pad displacement overall 
   Now let’s look at the mid foot:  
  decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch 
   Now how about the fore foot?  
  increased printing under the met heads bilaterally; L >> R 
 increased printing of 1st met head L >> R 
 increased printing at medial proximal phalynx of hallux  L >> R 
 increased printing of distal phalanges of all toes L >> R 
     Figure it out?   
 What would cause increased supination on the L? 
  short leg on L 
 more rigid foot on L 
 increased pronation on the R 
  Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot? 
 Here is what is going on: 
  there is no appreciable leg length deformity, functional or anatomical 
 The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot 
    do this:   stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice? 
  Can you feel how when your foot is supinated 
 can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction 
 Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left? 
 now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux) 
   Wow, does that make sense now?  

   What’s the fix?   
   create a more supple foot with manipulation, massage, muscle work  
  increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)  
  have them walk with their toes slightly elevated  
  we are sure you can think of more ways as well!  
 
   The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, tell others and spread the word. If you didn’t like this post, tell us! We value your constructive feedback.

What’s up, Doc?

Nothing like a little Monday morning brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let’s start at the rear foot:

  • limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.
  • note the increased pressure at the  medial calcaneal facets on each side with the increased printing
  • very little fat pad displacement overall

Now let’s look at the mid foot:

  • decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

  • increased printing under the met heads bilaterally; L >> R
  • increased printing of 1st met head L >> R
  • increased printing at medial proximal phalynx of hallux  L >> R
  • increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

  • short leg on L
  • more rigid foot on L
  • increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot?

Here is what is going on:

  • there is no appreciable leg length deformity, functional or anatomical
  • The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

  • Can you feel how when your foot is supinated
  • can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction
  • Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?
  • now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What’s the fix?

  • create a more supple foot with manipulation, massage, muscle work
  • increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)
  • have them walk with their toes slightly elevated
  • we are sure you can think of more ways as well!

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, tell others and spread the word. If you didn’t like this post, tell us! We value your constructive feedback.

Podcast 32: "Shorts"- Stress Fracture Buddies

Today we have a 4 minute short clinical story on a case we saw in the recent weeks. We have searched the medical literature and have not found a study on what we attempted, but we hope that one of our listeners will have found one or had similar experiences and be willing to share their story or a client’s story.

This is a story of a high school middle distance runner who cut her toe, and ended up developing a stress fracture in her metatarsal.  And … . what we attempted to offer immediate change, some theories as to how it worked and how we saved her season (we hope).

Enjoy our short story. 

Imagine, think, ponder, explore and experiment.  Sometimes, you might be surprised what you can come up with, even when it is as simple as something as reaching for a roll of tape.

The Gait Guys

_____________________

podcast link:

http://thegaitguys.libsyn.com/podcast-32-shorts-stress-fracture-buddies

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

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

Rothbart's Foot Type: A Case discussion

We received a case question from a field doctor today.

Q: I have a pt. that demonstrates pretty classic Rothbart foot  with forefoot compensated varus - sesamoid pain of digit 1. She is a dancer as well which obviously complicates things. Would you generally post under the first MT and try to bring her more medial on her foot with a lateral heel post or just post the first MT in her day shoes?

* The Gait Guys response:

Rothbart’s foot is a difficult foot type. We would consider it an underdevelopment issue. The first metatarsal is typically short, elevated (referred to as metatarsus primus elevatus) and supinated (if you are looking down at your own right foot, it is spun clockwise).  This, as you can see all 3 components in the picture, leaves a very incompentent first toe.  Many times, if the ankle and subtalar joints are in neutral positioning the first metatarsal (MET) head doesn’t even touch the ground. The problem is that the foot does not work well that way !  So, the owner will typically spin the foot  outward into external rotation ( we will show this in a video we will attach later tonight that will help the understanding of this issue, it is important) in order to shift the tripod to help find grounding of the first MET onto the ground. The problem is that in this foot type, the grounding is not entirely complete. 

Thus, what Rothbart did, wisely, was devise a Rothbart wedge. This wedge slid in from the medial side and basically brought the ground up to the elevated and spun metatarsal. 

Background info: Under the 1st MET are 2 sesamoids, like tiny patellae, that improve mechancial advantage to the first metatarsophalangeal joint (MTPJ). The short flexor to the big toe , the flexor hallucis brevis (FHB) has these 2 sesamoids embedded within its tendon, and when paired with a well orchestrated movement pattern between the long big toe flexor (FHL) and FBH as well as the long and short extensors (extensor hallucis longus and brevis, EHL, EHB) and some assistive means from the abductor and adductor hallucis muscles the 1st MTPJ joint can adequately dorsiflex (extend) the big toe to its necessary range of 40+ degrees so we can toe off properly from this medial aspect of the toe. 

In a Rothbart foot type scenario, this neuromechanical phenomenon is impaired, because the medial aspect of the foot and big toe are not grounded.  The wedge, when slipped underneath the 1st MET, improves this dramatically.  It brings the sloped edge of the wedge up to the elevated and spun toe and attempts to restore equal weight bearing on both sesamoids. It likely also reduces the postural slump phenomenon (often referred to as bio implosion) that we will not discuss here at this time (the postural collapse comes from first a collapse of the medial foot, then genu valgum, then hip internal spin, pelvic unlevelling and then increases in lumbar lordosis, thoracic kyphois and cervical lordosis. Orthotic companies base much of their purpose on this principle, and it does have some merrits, but the question remains…….must we support the deformity forever, or can something functionally be done to improve it.)

In  your case Doc (assuming this is yet another foot from the Joffrey Ballet Dance company that we worked for) placing a wedge under the first MET is not possible in dance slippers.  IT will help him/her in their daily shoes but as you know we are merely supporting the deformity.  What we would suggest is making every attempt, in addition to the supportive help at this time, to improve their ability to plantarflex the first metatarsal.

How do you do this ?  This works well on Forefoot varus feet that are flexible and have some skills left in their playbook.  Increasing the  skill, endurance and strength (our 3 tenants, S.E.S.) of the extensors (both short and long, EHL & EHB) will help to drop the first metatarsal into plantarflexion.  So will improving the pull up on the other end of the metatarsal base, ie. tibialis anterior, posterior etc. Many insufficient feet do not have adequate extensor strength to the toes. This creates many anterior compartment syndromes (shin splints etc).

In this case, you could try to improve extensor strength but you will have to make sure  they can get adequate function of the short hallux flexor (FHB) to help anchor the sesamoids if they can get them more purchase on the ground.  We would use our therapy approach. Treat the wedge as an orthotic (for the big toe!).  Place the wedge sufficient in size to reduce their medial foot collapse.  Initiate the protocol above, and as improvements are noted in S.E.S. then begin to reduce the degree and amount of the wedge correction.  We use a grinder in our offices, but sandpaper or a nail file will do the job, it is why we use a cork-type product.

Supporting this foot type with a high arch bearing device will artificially help reduce the bio-implosion issue to the body posture, but those supportive structures would do well with improved S.E.S. as well.  The problem with a high orthotic is that it will  maintain the metatarsus primus elevatus issue (raise 1st MET) and they will have to pronate even harder through the forefoot. This will not be good.  In some cases we will implement a custom rearfoot varus wedge ground in our office to be precise, to help reduce the rearfoot pronation that may be employed by the client to help the medial foot on the ground. But, from what we are imagining here in our heads, we think the forefoot implementation and homework is the first way to go.  Placing a thin sheet of EVA foam under the MET head might also soften the blow on that inflammed sesamoid in the mean time.  

The Gait Guys hope this helps a bit, perhaps opening some other thoughts for treatment on your end or more pointed future questions on this case.  Tune in again in case we hear back.

We will see if we can put a little video together that will support this dialogue, it makes it so much easier to digest.