More research on Forefoot Running: Forefoot Varus and the toe extensor muscles.

Lately we have all seen much in the news about the forefoot strike loading in runners and many of the proposals and rebuttals regarding injury rates.  Our dialogue less than 2 weeks ago on some of Lieberman’s recent comments (our blog article “Dear Dr. Lieberman”, click here) seem to be ringing true again. Here are just two more insightful and important studies when it comes to looking at some of the proposed ideas and causes of forefoot varus. Naturally, a thinking mind would wonder if some of these weaknesses in anterior and posterior tibialis muscles as well as extensor toe musculature, as proposed in just these 2 articles, are causal to the forefoot injuries that seem inevitable as Lieberman seems to suggest (again, see our blog post). Naturally, weaknesses and poor motor patterns of some or all of these muscles is going to create and insufficient and possibly inefficient and pathologic forefoot loads because of the forefoot varus foot type these muscular imbalances can functionally produce.  We have been pounding sand on this issue for years but still no one listens.  The medial research, as evidenced here is supportive of our theories and everyday clinical findings.

To summarize, ONCE AGAIN, not everyone is suited or possibly ready for forefoot load/contact/strike running.  And if you have injury or problems in doing so, don’t blame your minimalist shoe……. it is either a foot type that needs functional repair or a foot type that is fixed an must opt for midfoot strike.

There is SO MUCH MORE to this game than just strap on some minimalist shoes and start forefoot loading your way on your next run.  Buyer beware !

Shawn and Ivo…….. the gait guys……..two guys who are “Gandhi’d” regularly. 

“First they ignore you, then they laugh at you, then they fight you, then you win.”

- Mahatma Gandhi

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http://www.ncbi.nlm.nih.gov/pubmed/20307453

Foot (Edinb). 2009 Jun;19(2):69-74. Epub 2008 Dec 31.

Foot varus in stroke patients: muscular activity of extensor digitorum longus during the swing phase of gait.

Reynard F, Dériaz O, Bergeau J.

Clinique romande de réadaptation, SUVA Care, Av. Gd-Champsec 90, Sion, Switzerland. fabienne.reynard@crr-suva.ch

Abstract

CONCLUSIONS: The activity of extensor digitorum longus muscle during the swing phase of gait is important to balance the foot in the frontal plane. The activation of that muscle should be included in rehabilitation programs.

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http://www.ncbi.nlm.nih.gov/pubmed/16882899

J Bone Joint Surg Am. 2006 Aug;88(8):1764-8.

The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy.

Michlitsch MG, Rethlefsen SA, Kay RM.

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.

Abstract

RESULTS: The muscular contributor to varus deformity was the anterior tibialis in thirty feet, the posterior tibialis in twenty-nine feet, both the anterior tibialis and the posterior tibialis in twenty-seven feet, and another contributor in two feet. Seventy feet had varus deformity during both stance phase and swing phase. Of these seventy feet, twenty-five exhibited dysfunction of the anterior tibialis, twenty exhibited dysfunction of the posterior tibialis, and twenty-three exhibited dysfunction of both muscles. Therefore, the timing of varus was not predictive of the contributing muscle or muscles.

CONCLUSIONS: The current study demonstrated a higher prevalence of anterior tibialis dysfunction, both alone and in combination with posterior tibialis dysfunction, as a contributor to pes varus in patients with pes varus and cerebral palsy than had been reported previously. Dynamic electromyography provides clinically useful information for the assessment of such patients.

Dear Dr. Lieberman : Some vital facts on forefoot running are not being discussed.

A clay pot sitting in the sun will always be a clay pot. It has to go through the white heat of the furnace to become porcelain. -Mildred Wite Stouven.

Today’s blog article is likely to bring flames to our feet, but we are not afraid of the heat.  At the very least we will settle for the heat this article may bring so that our work can get the recognition we feel it deserves and so the truth can be brought to light for the good of all mankind.

“Forefoot strike causes less impact force on the body,” says co-author Daniel Lieberman, Ph.D., a professor of human evolutionary biology at Harvard and scribe of a popular barefoot running manifesto in 2010. “People forget that running is a skill, and if you don’t run properly, you’ll get injured.”

Amen to that; we have been saying that for years before this all became popular talk …

We recently read this article in Men’s Health, yet another one supportive of minimalism running. And once again some of the most important facts are being left out. We just cannot sit here and watch the inaccuracies of minimalism and forefoot running continue to root themselves without policing. So, let us once again set foot into the raging battle.

According to the article (LINK) Sturtz says, “Landing on your forefoot, the way humans have run for thousands of years, produces almost zero impact on joints and bones, according to Lieberman’s 2010 study. But 75 percent of us now land heel first—cushioned running shoes made that possible (and comfortable)—which slams up to 3 times the body’s weight in impact force on your knees and legs.”

Our question is, “ Why is no one paying attention to foot types?” In every lecture we do, to clinicians or everyday runners, about “forefoot type” variants (valgus and varus to be precise) we comment that this is something that should be talked about during Running Form Clinics where forefoot landing is promoted. 

“… forefoot running is not the whole answer to injury prevention, just a component”, says Lieberman. “This is not a simple solution to a complex problem—you can’t change one thing and have everything be fine. You can still forefoot strike with poor form.”

And we would add to that quote that “you can get a resultant compensatory running form if you forefoot strike with a forefoot varus or forefoot valgus”. Not everyone has that pristine neutral forefoot bipod architecture that the internet articles are assuming exists in everyone, and thus there is no way that everyone has fully competent pristine forefoot biomechanics that will not eventually trigger injury. This is a fact, not our opinion. 

Dr Lieberman then goes on to say: “ If it ain’t broke, don’t fix it.”

We respectfully disagree. We do this on a daily basis (as do many of you).  If the check engine light on your dashboard is flashing at you every day for a week you would be remiss not to consider the repercussions.  “The car ain’t broken… YET” is a more precise comment. You would be wise not to go on a long distance car trip knowing this fact.  Translating this to forefoot load/strike running, ignoring a potential injury because of flawed forefoot anatomy and biomechanics is a recipe for injury.  Just because it isn’t broken YET doesn’t mean ignoring the issues will make them go away or make you immune. A few hundred or thousand miles on a forefoot variant can be an issue clinically and injury wise.

Just because the body isn’t broken YET doesn’t mean it cannot work better and prevent a problem down the road. Dr Lieberman then goes on to quote, “Remember, almost every distance runner gets injured".  Why is he batting from both sides of the plate here? If “Landing on your forefoot, the way humans have run for thousands of years, produces almost zero impact on joints and bones”, according to Lieberman’s 2010 study then why would he go on to say “Almost every distance runner gets injured”?  There has to be a reason !  Forefoot running is either the answer or it isn’t.  Our valid and ignored proposal above, and our repeated comments throughout our 500+ blog posts on this topic on foot types, is a valid answer to his injury assumption.  It is quite possible that these inevitable injuries occur because people take the advice of “if it ain’t broken, don’t fix it”.  It is also most likely that ignorance of the deeper facts is bliss for most people. .Had they spent the time to find out about their forefoot type and learn to modify subtle biomechanical flaws of forefoot loading strategies of their foot type, perhaps we wouldn’t hear “Remember, almost every distance runner gets injured".   Maybe that is why you SHOULD look into fixing things that are not YET broken and at the very least learn about foot types, particularly which one you have and the potential risks it exposes you to. Our blog here has done this in depth over the last year. 

“An ounce of prevention is worth a pound of cure” -Benjamin Franklin.  Anyone is medicine knows this is true (or should).

We prefer midfoot strike when possible, for many reasons but mainly because it takes into account a tripod contact loading response.  A tripod load is more stable than a rear foot unipod load and more stable than a forefoot bipod load, particularly when there are rear or forefoot variants (rearfoot valgus, rearfoot varus, forefoot valgus, forefoot varus) from the pristine normal that is always assumed in many articles.   A tripod loading response (midfoot strike) can dampen some of the mechanical flaws of either heel or forefoot strike patterns and of the foot type variants that are the norm, not the exception.

We see this stuff everyday in our practices. We are the guys that get the injury cases that are driven by the inaccuracies, or better put “overlooked facts”, of articles on the internet. To be fair, we have also written a fair number of articles for magazines and we know how they can get so chopped down that truth, honesty and full disclosure can be lost for the sake of publication limitations. None the less, our strong opinion, this article could have been far more complete had it talked about the issues we have brought to light here.  We love and respect the work of Lieberman and his colleagues.  He and his colleagues have done a huge service to the runners of the world and we have learned from them. Learning is a lifelong journey for us all and we just think that there is a huge information gap that is being missed and we feel it is time that the runners of the world hear the whole truth. We believe our work is filling that gap.

“First they ignore you, then they laugh at you, then they fight you, then you win.”

- Mahatma Gandhi

For the past year, we have been feeling a bit like Gandhi must have felt. We realize that some of our work is complicated, difficult to understand, and tough to digest. We know we are laughed at by some who prefer to seek the safety of ignorance. And yes, despite 600 blog posts on these very topics (yes, we have one of the most informative blogs and YouTube Channels on the web for runners and athletes looking for answers) we feel somewhat ignored. None the less, we continue to stick our necks out far and long to set the record straight to make sure that everyone knows the facts they deserve to know.   We hope you will forward, link, Facebook and tweet the hell out of our blog post today, for the good of every runner and athlete you know and for the whole of mankind.  We are in this for the long haul. Stick and stones … .       - Drs. Shawn and Ivo …  The Gait Guys

here is the article that spurred our post:

http://news.menshealth.com/fix-your-running-form/2012/01/24/

The Importance of the foot function and posturing at terminal swing in a great and talented runner. Part 2 of the Toe Extensor Dialogue.

* This is a follow up from yesterday’s video blog post. Lets review once again and then dive in, layering some deeper principles onto yesterday’s dialogue.

Stand up. Both feet on the floor. Close your eyes and raise your toes up off the floor, just the toes, and then let them fall. Pay great attention to what happens to your arch height as you raise and lower the toes. Yes, do this now. Then come sit down again and read some more. Go !

Ok, now you are back.

Do you think that toe extension ability (range, skill, endurance AND STRENGTH) will play a significant part in achieving adequate successful arch height and thus treating plantar foot pain syndromes (plantar fascitis to name the most obvious and simple nemesis)? You better believe it, we showed it in yesterday’s blog post ! * For a great little video sample of a young boy with flat feet using our queue’s to restore tripod positioning and arch height along with a more normal foot progression angle, see yesterday’s blog post or click here.

So, if toe extension is critical for arch height, both in preparation for foot strike/contact and in arch height and control should you ever try to consciously limit this natural phenomenon ?

In the video above the author and runner (Jordan McGowan) at 1:07 discusses his concern that the left foot is coming across in too much toe extension (ie. ankle dorsiflexion as well) in preparation for contact phase and that his right foot is coming across less extended/dorsiflexed, something we sometimes call shallow dorsiflexion. He indicates that he likes the appearance of the right foot pre-contact approach but he feels that he wants to relax the toe up/dorsiflexion exaggeration on the left. We do not necessarily agree based on the principles discussed above and yesterday because arch height preparation will be reduced (again, see yesterday’s blog post and video). However, Jordan is not wrong either. Read on !

Now, although Jordan himself does not discuss any deeper concerns we could imagine that some less skilled runners in this scenario might worry that if the toe extension is too excessive that it will pre-position the foot for a heel strike phenomenon. This does seem very reasonable thinking, but it is not necessarily so. Heel strike is a conscious choice. If this is your concern, it can easily be overcome; you will just have to do one of two things to avoid heel strike (ie. get to mid foot strike, which Jordan does very well on both sides, even the left, despite its increased toe extension/ankle dorsiflexion).

To overcome the concerns of heel striking with high toe extension pre-contact:

1. One will have to lean forward more to offset the possible early heel strike. Leaning forward more (as is done in natural/chi running form) will make it harder to heel strike because the foot will land even further under the body. Whenever the foot reaches out in front, the opportunity for heel strike increases. Make no mistake however, there is a difference between heel strike and heel contact. A skilled walker or runner can heel contact and quickly transition to midfoot load and get the same effect as a more pure midfoot strike. The difference is whether you LOAD the heel contact or quickly transition to the midfoot. Any skilled runner can do this and feel this. When done skillfully, a mere kissing of the heel, a mere light brushing with the ground, before the midfoot loading occurs is completely fine just do not load the heel otherwise a deceleration event is going to occur and that is a definite “no no”. This is a problem with amateur gait analysts and runners, and proves once again that what you see is not always what you get. We demo this illusion all the time with our runners and without a skilled eye they cannot see the difference, but they can feel the difference when asked to focus on the skill difference. To reiterate, for MOST runners there should be little if any rearfoot loading response, it is a mere zone of transition. This topic is absolutely no comment here on Jordan, he has superb midfoot contact.

2. Back to overcoming heel loading……. one will also have to better eccentrically control the descent of the forefoot to the ground. This is a normal biomechanical event. Yes, you can reduce this need if you bring the foot through shallowly as Jordan explained regarding his right foot, but at the possible consequences of entering the pronation phase with a partially unprepared arch and subtalar joint configuration (if the subtalar joint is starting its loading at the mid or anterior facet joint pronatory unlocking of the midfoot will occur too soon). A runner with a highly competent and strong foot can get away with cheating this mechanical event, and it is quite (very) possible that Jordan has such a foot with all his running experience. On the other hand, a more amateur runner could be loading a bullet into the pronation gun. Now, back to the eccentric loading of the anterior compartment muscles. Too slow an ankle dorsiflexion posture release and the heel will strike first, too fast and the forefoot could slap on the ground. One will thus need to get the proverbial porridge just right (not too hot, not too cold…..rather just right). Most skilled runners will be able to get this skill down within just one workout and then master it over the next 12 weeks (the time we find necessary to engrain a new motor pattern in the cerebellum and parabrachial nucleus, the primary pattern generators). And with more skill and foot strength a more risky shallow posturing can be taken with success. And, this may very well be the case with Jordan. He may be there and be correct in his evaluation. We just wanted to share both sides.

Understanding the end-phase swing foot and toe function is important. Understanding what your foot is doing is paramount. We wanted to share both sides of the coin because we would hate for amateur runners to see this and try to reduce their proper and necessary toe extension/ankle dorsiflexion and mimic a shallow late swing phase foot posture. This is where running moves from science to an art. Guys like Jordan can play with this stuff safely, but not everyone else can or should. For many, better preparation of the foot for the contact phase in a solid tripod will reduce excessive and possibly deformative pronatory forces. Presenting the foot to the ground with a less than optimal arch, via a conscious reduction in toe extension, will increase risk for the deformative pronatory forces to have a better chance of creating tissue pathology (ie. plantar fascitis etc).

Here is one of the reasons we recommend even our elite runners from time to time to exaggerate the toe extension-ankle dorsiflexion range off and on during runs. If you never use the FULL range Tib Anterior and extensor digitorum longus muscles (as in the shallow end swing foot posturing), you will begin to lose their strength at the end ranges. We often lose end range strength first. And in time that can trickle down those weaknesses into the ranges where more of the strength is truly needed. This is the “gosh, my pain just started out of the blue phenomenon !” Truth is, it did not, you just finally found yourself without that necessary extra little bit necessary to adequately protect a joint for the load at hand. And perhaps this is the take home point here. We all need to be sure that we still have what is necessary for optimal joint complex protection from time to time. It is why many athletes come to see us a few weeks before big events, for assessment to be sure that they are not trickling down into that risk zone as they peak their training and then taper.

In another post, we will discuss Jordan’s frontal view issues. He wisely has detected his foot pronation issues and we couldn’t agree more about his mention of the gluteal control and an important factor. So we will once again review our Cross over gait pathologic movement pattern which is somewhat evident here and part of the foot posturing, but we will also discuss the abductory twist phenomenon of his left foot, which is truly what is going on at the foot level (don’t get us wrong, the glute is part of the deal, but it is not the entire deal).

From the start our mission has never been to strike at the moral fiber of someones good intent. Rather, our mission has always been to dispel the myths and state the facts. This was a great assessment by Jordan, we just wanted to point out a few possible misconceptions and explain some of the differences between a skilled runner and what they are working on and what an amateur runner should be aware of mainly so that the masses of runners who will see this great video will get the honest facts and not start to, or too early, consciously change normal behaviors and start to generate compensations.

We spoke to Jordan about this blog post before we ran it and he was a champion about it. It opened some productive dialogue on both ends, that’s the way it should always work. Jordan was all for stating the truth and facts from all angles.

We are Jordan and Newton fans. We thank Jordan for his input, his feedback and for sharing his nearly flawless running form in his Newton’s. This is a form everyone should take note of and try to strive for.

The Gait Guys

Shawn and Ivo

Good Form video from Newton

Great little video from Danny at Newton…….it doesnt matter what shoe you have if your technique is crummy. Here he demonstrates very well what good contact form is……..we like to say…..“land so subtle on the forefoot that it is a hair distance to kiss your heel to the ground before you push off…..if you remain high on your forefoot at contact you lose your shock absorption because the foot mechanics are more close to supination.”