You need toe extension, more than you might think.

Screen Shot 2018-07-20 at 9.24.08 AM.png

There is a major difference in these 2 photos.One foot is ready for foot loading, the other has one foot over the starting line, and is going to possibly have the risks related to inappropriate loading.

In clients with one of several possible issues related to poor control of the arch during weight bearing loading, it is not all too uncommon for us to bring to their attention that not only do they NOT utilize toe extension appropriately, and at the right time, they just simply have poor strength and endurance of the toe extensors (we will not be bringing up the complicated orchestration of the long and short toe extensors today, lets just keep it loosely as looking at them as a whole for today).

We know we say it an awful lot, that clients need more toe extension endurance and strength. But more often than not, they need more awareness of how little they are actually using their toe extensors during foot loading. This is why we despise flip flops and foot wear without a back strap on them, the flexors have to dominate to keep the footwear on the foot.  And, if you are into your toe flexors, you are definitely not into your toe extensors.

Screen Shot 2018-07-20 at 9.23.54 AM.png

You can easily see in this photo that there is a major difference in the integrity and preparation of the foot arch prior to foot loading in these 2 sample photos. One the toes are up in extension, the other the toes are lazy and neutral.  The toe up photo demonstrates well that when the toes are extended, the Windlass mechanism draws the forefoot and rearfoot together and raises the arch. Go ahead, lift your toes, it will happen on you as well (unless your arch is so collapsed that the first metatarsal actually dorsiflexes during toe extension, in this case, you are a whole different management tier). From this arch raised position, the first metatarsal is adequately plantarflexed, this means the joint complexes proximal and distal to the metatarsals are all in the right position to load and cope with loads. In the toe neutral picture, these components are not prepared, the arch is already getting ready to weight bear load from a half-baked position. One cannot expect the foot complex to load well when it is starting from a position of "half way there". One should start the loading of the foot from the starting line, not 3 steps over the line and not 3 steps before the starting line.  There is no athletic or mechanical endeavor that does well when we start the challenge too soon or too late, timing is everything.

How you choose to prep your foot for contact loading, and yes, there is some conscious choice  here, one is lazy the other is optimal, can determine to a large degree if you or your client is about to fall into the long list of problems related to poorly controlled pronation (too much, too soon, too often, too fast). Any of those bracketed problems lead to improper loading and strains during time under tension.

We will almost always start our clients on our progressing protocol of arch awareness and we will loosely say arch restoration, and attempts at better optimizing the anatomy they have, with toe up awareness.  Many clients will have poor awareness of this component issue, on top of poor endurance and frank weakness. The arch is to a great degree build from a lifting mechanical windlass effect, from the extensors and foot dorslflexors, not from the foot flexors. This is one of our primary beefs with the short foot exercise of Janda, there needs to be a toe extensor component in that exercise (search our blog for why the short foot exercise is dead). The short foot exercise is not actually dead, all exercises have some value when placed and performed properly, but the short foot exercise is based off of the toes being down and utilizing the plantar intrinsics to push the arch up and shorten the foot, this is a retrograde motion and it is not how we load the foot, but, it does have value if you understand this and place it into your clients repertoire appropriately.  This is also why we have some conceptual problems in stuffing an orthotic under someones arch to "lift it up", ie. slow its fall/pronation.  There are times for this, but why not rebuild the proper pathways, patterns and mechanics ?

Teach your clients about toe extension awareness. TEach them that they need to relearn the skill that when the toes drop down to the ground that the arch does NOT have to follow them down, that the client can relearn, "toe up, arch up . . . . . then toes down, but keep the arch up".  IT is a mantra in our office, "don't let your arch play follow the leader".  Reteach the proper neurologic disassociation between the toes and arch.

Perhaps the first place you should be starting your clients with foot and ankle issues, is regaining awareness of proper toe extension from the moment of toe off, maintaining it through swing, and then keeping it until the forefoot has purchase on the ground again, and not any time sooner than that ! If their toes are coming down prior to foot contact, it is quite likely their arch is following the leader.

So, if your client comes in with any of the following, to name just a few:  tibialis posterior tendonitis, plantar fascitis, heel pain, forefoot pain, painful bunions, arch pain, hallux limitus, turf toe, . . . . and the list goes on. Perhaps this will help you get your client to the starting line.

Shawn & Ivo, thegaitguys.com

 

Podcast 122: Achilles problems, glutes, & feet.

Key tag words:
neuroscience, elon musk, achilles, tendonitis, tendonopathy, eccentric loading, tendon loading, gluteus maximus, gmax, glutes, abductor hallucis, foot pain, hip biomechanics, navicular drop, BEAR, ACL tear, ACL reconstruction, plantar fascitis
 

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That is our website, and it is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
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Show Notes:

Stanford Develops Computer That Literally Plugs Into People's Brains

https://www.entrepreneur.com/article/289645


Elon Musk says humans must become cyborgs to stay relevant. 

https://www.theguardian.com/technology/2017/feb/15/elon-musk-cyborgs-robots-artificial-intelligence-is-he-right

1. achilles tendonopathy:

http://www.jospt.org/doi/abs/10.2519/jospt.2016.6462?platform=hootsuite&code=jospt-site

2. achilles tendinitis and tendonosis.

Ohberg L, Lorentzon R, Alfredson H, Maffulli N. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004;38(1):8-11. doi:10.1136/bjsm.2001.000284.

link to abstract: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724744/

3. Is Achilles tendon blood flow related to foot pronation?
 E. Wezenbeek,T. M. Willems,N. Mahieu,I. Van Caekenberghe,E. Witvrouw,D. De Clercq

http://onlinelibrary.wiley.com/doi/10.1111/sms.12834/full

4.  The effects of gluteus maximus and abductor hallucis strengthening exercises for four weeks on navicular drop and lower extremity muscle activity during gait with flatfoot

Young-Mi Goo, MS, PT,1 Tae-Ho Kim, PhD, PT,1,* and Jin-Yong Lim, MS, PT1  J Phys Ther Sci. 2016 Mar; 28(3): 911–915.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842464/

5. BEAR
https://www.youtube.com/watch?v=k3g-CagCrZM

Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) procedure uses stitches and a bridging scaffold (a sponge injected with the patient’s blood) to stimulate healing of the torn ACL eliminating the need tendon graft.

References:
Murray, M., Flutie, B., Kalish, L., Ecklund, K., Fleming, B., Proffen, B. and Micheli, L. (2016). The Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) Procedure: An Early Feasibility Cohort Study. Orthopaedic Journal of Sports Medicine, 4(11).

L. Proffen, B., S. Perrone, G., Roberts, G. and M. Murray, M. (2015). Bridge-Enhanced ACL Repair: A Review of the Science and the Pathway Through FDA Investigational Device Approval. Annals of Biomedical Engineering, 43(3), pp.805-818.

Can you guess why this person has left-sided plantar fasciitis?   This question probably seem somewhat rhetorical. Take a good look at these pedographs which provide us some excellent clues.   First of all,  note how much pressure there is over the metatarsal heads.  This is usually a clue that people are  lacking ankle rocker  and pressuring these heads as the leg cantilevers forward.  This person definitely have a difficult time getting the first metatarsal head down to the ground.   Notice the overall size of the left foot compared to the right (right one is splayed or longer).  This is due to keeping the foot and somewhat of a supinated posture to prevent excessive tension on the plantar fascia.   The increase splay of the right foot indicates more mid foot pronation  and if you look carefully there is slightly more printing at the medial longitudinal arch. This is contributing to the clawing of the second third and fourth toes on the right. Stand up, overpronate your right foot and notice how your center of gravity (and me) move medially.The toes will often clench in an attempt to create stability.   The patient’s pain is mostly at the medial and lateral calcaneal facets, and within the substance of the quadratus plantae with weakness of that muscle and the extensor digitorum longus. She has 5° ankle dorsiflexion left and 10 degrees on the right and hip extension which is similar.    The lack of ankle rocker and hip extension or causing her to pronate through her midfoot, Tensioning are plantar fascia at the insertion. The problem is worse on the left and therefore that is where the symptoms are.    Pedographs can be useful tool in the diagnostic process and provide clues as to biomechanical faults in the gait cycle.

Can you guess why this person has left-sided plantar fasciitis?

This question probably seem somewhat rhetorical. Take a good look at these pedographs which provide us some excellent clues.

First of all,  note how much pressure there is over the metatarsal heads. This is usually a clue that people are lacking ankle rocker and pressuring these heads as the leg cantilevers forward.  This person definitely have a difficult time getting the first metatarsal head down to the ground.

Notice the overall size of the left foot compared to the right (right one is splayed or longer). This is due to keeping the foot and somewhat of a supinated posture to prevent excessive tension on the plantar fascia.

The increase splay of the right foot indicates more mid foot pronation and if you look carefully there is slightly more printing at the medial longitudinal arch. This is contributing to the clawing of the second third and fourth toes on the right. Stand up, overpronate your right foot and notice how your center of gravity (and me) move medially.The toes will often clench in an attempt to create stability.

The patient’s pain is mostly at the medial and lateral calcaneal facets, and within the substance of the quadratus plantae with weakness of that muscle and the extensor digitorum longus. She has 5° ankle dorsiflexion left and 10 degrees on the right and hip extension which is similar.

The lack of ankle rocker and hip extension or causing her to pronate through her midfoot, Tensioning are plantar fascia at the insertion. The problem is worse on the left and therefore that is where the symptoms are.

Pedographs can be useful tool in the diagnostic process and provide clues as to biomechanical faults in the gait cycle.

Sometimes it  is  easy and straight forward.   
  HISTORY: A 56 YO 200 # male construction worker presents with pain at the bottom of his right foot, worse in the am, getting better as the day goes on till midday, then getting worse again. Better with rest and ice. More supportive shoes and a heel gel pad offer him some relief. Past history of plantar fascitis.   
  OBJECTIVE:            Tenderness at medial calcaneal facet right side;  tenderness also in the arch and over the flexor hallucis longus tendon and short flexors of the toes. Ankle dorsiflexion is less than 5 degrees on the right, and 15 on the left.  Hip extension was less than 10 degrees bilaterally. He has mild bi-lat. external tibial torsion. 
 Gait evaluation reveled an increased progression angle right greater than left.  Very limited ankle dorsiflexion noted bi-lat (decreased ankle rocker).  
 There is weakness of the short flexors (FDB) and long extensors (EDL) of the toes on the right. Poor endurance of the intrinsic musculature of the arch as well as interossei musculature during standing arch test. 
 PEDOGRAPH FINDINGS:  
  ASSESSMENT:       From history and exam, plantar fascitis.  
  PLAN:           He was given the following exercises:  lift/spread/reach, the one leg balancing, shuffle walks and toes up walking. These were filmed via ipad and sent to him.  We are going to build him a medium heel cup, full length orthotic made out of acrylic.  We will see him again later this week.  We will do some symptomatic treatment utilizing manual stimulation techniques, pulsed ultrasound and additional exercises aimed at improving dorsiflexion as well as hip extension.   
   

Sometimes it is easy and straight forward.

HISTORY: A 56 YO 200 # male construction worker presents with pain at the bottom of his right foot, worse in the am, getting better as the day goes on till midday, then getting worse again. Better with rest and ice. More supportive shoes and a heel gel pad offer him some relief. Past history of plantar fascitis. 

OBJECTIVE:           Tenderness at medial calcaneal facet right side;  tenderness also in the arch and over the flexor hallucis longus tendon and short flexors of the toes. Ankle dorsiflexion is less than 5 degrees on the right, and 15 on the left.  Hip extension was less than 10 degrees bilaterally. He has mild bi-lat. external tibial torsion.

Gait evaluation reveled an increased progression angle right greater than left.  Very limited ankle dorsiflexion noted bi-lat (decreased ankle rocker). 

There is weakness of the short flexors (FDB) and long extensors (EDL) of the toes on the right. Poor endurance of the intrinsic musculature of the arch as well as interossei musculature during standing arch test.

PEDOGRAPH FINDINGS: 

ASSESSMENT:       From history and exam, plantar fascitis.

PLAN:           He was given the following exercises:  lift/spread/reach, the one leg balancing, shuffle walks and toes up walking. These were filmed via ipad and sent to him.  We are going to build him a medium heel cup, full length orthotic made out of acrylic.  We will see him again later this week.  We will do some symptomatic treatment utilizing manual stimulation techniques, pulsed ultrasound and additional exercises aimed at improving dorsiflexion as well as hip extension. 

 

Podcast 79: Tightness vs. Shortness, Plantar Fascitis & more.

plus, pelvic asymmetry, “wearables” and cognitive choices in movement.

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D. other web based Gait Guys lectures:

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______________

Today’s Show notes:

The Brain and your choices.

http://exploringthemind.com/the-mind/brain-scans-can-reveal-your-decisions-7-seconds-before-you-decide#.VCx0P8ydUK4.facebook

 
 
Walking is the superfood of fitness, experts say
 
Hey Guys,
I have pelvis asymmetry and a snapping ankle, can you help me with … . 
 
New research on Plantar Fascitis
 
John from FB
Shortness vs tightness:
What protocol do you recommend for stretching ? I usually do static stretches1x2min. This article has the static stretch group doing 10x30sec. I’d have to set my alarm a half hour earlier! :-)

Podcast 69: Advanced Arm Swing Concepts, Compensation Patterns and more

Plus: Foot Arch Pathomechanics, Knee Pivot Shift and Sesamoiditis and more !

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______________

Today’s Show notes:

1. “Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”
What happens when we change the length of one leg? How do we compensate? Here is a look at the short term consequences of a newly acquired leg length difference.
http://www.ncbi.nlm.nih.gov/pubmed/24857934
2. Medial Longitudinal Arch Mechanics Before and After a 45 Minute Run
http://www.japmaonline.org/doi/abs/10.7547/12-106.1

3. Several months ago we talked about the pivot-shift phenomenon. It is frequently missed clinically because it can be a tricky hands on assessment of the knee joint. In this article “ACL-deficient patients adopted the … .* Remember: what you see in their gait is not their problem, it is their strategy around their problem.
http://www.clinbiomech.com/article/S0268-0033(10)00264-0/abstract

4.Do you know the difference between a forefoot supinatus and a forefoot varus?
"A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation. ”
http://www.ncbi.nlm.nih.gov/pubmed/24980930

5. Pubmed abstract link: http://www.ncbi.nlm.nih.gov/pubmed/24865637
Gait Posture. 2014 Jun;40(2):321-6. Epub 2014 May 6.
Arm swing in human walking: What is their drive?
Goudriaan M, Jonkers I, van Dieen JH, Bruijn SM

6. This is Your Brain On Guitar
http://www.the-open-mind.com/this-is-your-brain-on-guitar/

Podcast 51: Bouncy Gait, Stem Cells & Plantar fasciitis,

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________________________________________

* Today’s show notes:

Neuroscience:

1. Stem cells and plantar fasciitis.
2. Study finds axon regeneration after Schwann cell graft to injured spinal cord
http://www.medicalnewstoday.com/releases/270623.php
3.Future Tiny Robots Will Communicate Using Only Molecules
http://www.fastcoexist.com/3020657/futurist-forum/future-tiny-robots-will-communicate-using-only-molecules?partner=rss
Correction:
a. I was listening to pod 49, great job. I am sending a personal message to point out an error regarding body composition. Under water weighing is considered the 2 compartment “Gold Standard” however caliper testing is used more due to cost and ability to be used in the field. Loved the learning stuff I sent some stuff similar to what you were talking about to the school administration but it went no where.
Thanks guys, Mark
b. Mark wrote: “I can see widening base of support to increase stability when one is weak but to widen base of support when one has decreased traction may increase slipping depending on width of stance couldn’t it. If decreased traction is a issue wouldn’t a better statagy”
Blog reader:
Not very infrequently the foot tripod has been discussed. Especially the importance of the medial tripod (MT) has been of great benefit to me. Some kind of a peroneus paralysis was probably the cause of weak MT of the right foot. With a weak anterior muscle group or compartment. But what about the lateral tripod, ie the 5th distal end of the fifth metatarsal. Which muscles are most responsible for the foot stability here and what kind of exercises might be of therapeutic value? Thank you.

Disclaimer
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Dear Gait Guys,                                
I’ve had a problem for a while where my lower left leg whips across the midline of my body at the start of the swing phase. This happens immediately after my left foot leaves the ground and before my right foot makes contact. My left knee seems to be angled outward, and I think this is due to some sort of external rotation of the hip or femur during the the early part of my swing phase. I attached a picture to illustrate this problem in my gait. I recently came across a blog post you guys wrote (http://thegaitguys.tumblr.com/post/14262793786/gait-problem-the-solitary-externally-rotated) and under the possibilities as to why there isn’t enough internal rotation, the second option describes exactly what happens when I run. So my question is, what can be done to correct this improper gait pattern? Thank you very much for taking the time to read this.
Sincerely,
Matthew
Between a quarter and a third of everything on the web is copied from somewhere else

 

Stretching out Plantar Fasciitis

Neuromechanics Weekly: Look to the hammy’s???

“These findings show that while we always consider the tightness of the gastrocnemius/soleus complex and the subsequent restricted ankle motion from this equinus, we also need to consider the role of the hamstrings,” said Jonathan Labovitz, DPM, lead author and associate professor at Western University of Health Sciences, Pomona, CA.

this article from Lower Extremity Review, concludes “After controlling for covariates, participants (86 of 210 feet) with hamstring tightness were 8.7 times as likely to experience plantar fasciitis (p < .0001) as participants without hamstring tightness. Patients with a BMI >35 were 2.4 times as likely as those with a BMI <35 to have plantar fasciitis.”

The question is why?

They go on to say “ If you can’t get dorsiflexion at your talo-crural joint, this often drives dorsiflexion at other joints and that is going to cause collapse of the longitudinal arch of the foot, loading the plantar fascia with increased tensile stress.”

So, loss of ankle rocker leads to increased midfoot pronation, which loads the plantar fascia. That sounds pretty logical to us. We are sure you are thinking a loss of hip extension may do the same thing. Correct. Or you may say ” The calves may be tight so the medial gastroc can invert the rearfoot to correct for too much midfoot pronation and the foot can be supinated"…and you would be correct again.

So why are the tight hammys driving the bus? Or are they?

We remember the hams are a 2 joint muscle, and with the foot in a closed chain position (ie, on the ground); they flex the thigh on the lower leg and tilt the pelvis posteriorly (ie reduce the lordosis). They are FLEXORS which are active from late swing phase, just prior to heelstrike (initial contact) and a little nudge just prior to toe off (preswing) to help extend the thigh. 

The tricep surae are FLEXORS and are supposed to be active from loading response till almost pre swing, with a burst of activity at heel lift (terminal stance). 

So they take turns, and are not firing (normally) at the same time (or maybe have a small overlap). Going from heel strike to heel strike, the hammys fire 1st.

So IF the two are related, it could be a neurological sequencing issue. How often does that happen? The literature says (and there aren’t many studies) that you can change the order of recruitment of motor units ( the nerve and the muscle fibers it innervates), but not (usually) individual muscles. So probably not.

OK, how about plan B?

The hams and tricep surae are all flexors, correct? What is the innervation to the hamstrings and tricep surae? Hmm….Hamstrings, mostly tibial branch of the sciatic nerve, short head of biceps femoris is the common peroneal: L5-S2. How about the tricep surae? Tibial nerve, mostly S1-S2. I think I see a trend here. Common neurological overlap of FLEXOR muscles.

So are the hams driving the bus? Probably not, but neither are the gastroc/ soleus. The FLEXORS are driving the bus, and excitation of that common neuronal pool is probably causing the tightness

Ivo and Shawn….Uber footgeeks of the web. Dicing and slicing through the literature so you don’t have to.

Athlete with Plantar Fascitis

Gentlemen,
 
I have enjoyed your blog tremendously.  My inner mechanics geek motivated me to read all the blog posts, and go through the Youtube videos as well.  Fascinating stuff.
 
My reason for writing, however is more desperate.
 
I have an athlete with a problem, and hope you might provide some guidance.  She is experiencing what has been diagnosed as plantar fasciitis, with her pain on the medial side of her calcaneus - roughly 2 inches forward of her achilles, and about a half inch up.  MRI was negative for a calcaneal fracture.   She’s taken several months off, and had the site injected, but any return to running brings her pain back.  It’s her mechanics that might catch your interest;  she has what a doctor once referred to as ‘an Equinus Deformity", essentially running completely on her forefoot.  She had heel contact when walking, but is completely on the balls of her feet when racing or training.  Her injury history to this point has been minimal, with only a minor adductor issue for a day or two in her background.  She has been told her options are injection (tried, helps for only a short time) or surgery.  Humbly, is there anything we can do to help her overcome this?  I am convinced there is an underlying mechanical issue, but her somewhat nontraditional running style leaves me with few ideas.  Any suggestions would be worth their weight in gold.  
 
 
Sincerely,
  
Girls XC/track coach
 
Dear Track Coach
Thank you for the Kudos and we are glad you have an “inner mechanics” geek as well .
We are sorry to hear about your athletes recalcitrant problem. It was astute observation on your part regarding her gait. Given the history you have provided, what has already been done, and the description of what you see, please understand that our opinion is limited, without the opportunity to examine her (which we would be glad to do; we have offices in the Chicago, IL suburbs and West of Denver, CO). Video would be helpful in the future as well, as we are not sure she has a true talipes equino varus foot or it is merely describing the attitude of the foot while running.
It sounds like she may have a rigid foot and a forefoot varus deformity. This would parlay with the “equinis” description.
A forefoot varus is when the forefoot to rearfoot relationship is such that the forefoot is inverted with respect to the rearfoot. This causes increased torque on the plantar fascia, as the forefoot lands on the outside of the foot and the medial side of the foot immediately descends: this must be controlled some how: either through flexion (downward motion) of the 1st metatarsal and cunieform (ie 1st Ray complex) provided adequate range of motion is available; the other scenario is that there IS NOT adequate range of motion of the 1st ray available and the knee collapses medially to bring the 1st ray down to the ground. A third possibility (most likely) is that it is a combination of the two.
The fix lies in the etiology: follow the mantra: skill, endurance, strength. Insuring the foot has adequate range of motion and is able to control it (skill), the appropriate endurance of the muscles to carry out the job (endurance) and the foot intrinsics have the cross sectional area needed to do the job (strength).
1. Does the athlete have a adequate foot tripod and are they able to keep all 3 legs of the tripod on the ground with the knee comfortably over the 2nd metatarsal? see a video here
2. does the athlete have enough muscular control of the lower extremity to ensure proper mechanics (foot intrinsics, knee motion, hip motion) ?
3. Is their running gait appropriate for their anatomy and any physical limitations? we have numerous posts covering many different gait scenarios on the blog, as well as on our youtube channel.
Again, without an exam, pictures or video, the exact diagnosis and fix is difficult. Thanks for the opportunity to respond.
The Gait Guys

Foot Strength: Some Clinical Q & A.

A Few question (and answers) about Foot Problems, from our Blog.

Dr. Ivo Waerlop and Dr. Shawn Allen,

I have had the pleasure of reading much of the content of your website and I have gained many valuable insights into the fascinating world of gait. I have a number of questions that I would love to get your perspective on though. First question: What exercises or techniques do you use to strengthen the intrinsic foot musculature? I gleaned that you are not particularly fond of flexor dominant exercises like towel scrunches so how do you functionally improve the strength, muscular balance and neuromuscular control over those little muscles? Second question: What strategies do you use when treating runners with plantar fasciitis? Would you move them into a less supportive or minimalist shoe or would you bump them up temporarily into a stiffer shoe or use a rigid orthotic?

I would like to also take the time to thank you guys for posting volumes of valuable information on your website. I have found that your website has a remarkable amount of solid, scientifically based information on topics that typically are rife with misinformation when discussed on other websites. Keep up the excellent work and I greatly look forwards to hearing your response to my questions.

Thanks,

JD

____________________

The Gait Guys Response:

JD:

Thanks for the support and the kudos. In answer to your inquiries:

“First question: What exercises or techniques do you use to strengthen the intrinsic foot musculature? I gleaned that you are not particularly fond of flexor dominant exercises like towel scrunches so how do you functionally improve the strength, muscular balance and neuromuscular control over those little muscles?”

Exercises are prescribed very specific to muscle weakness. There are no “swiss army knife” exercises. Each case is on an individual basis, based on physical exam and muscle testing. For the most part, there are really no bad exercises just bad choices for a specific case and poor execution (although one can easily find on YouTube a plethora of ridiculous examples of foolishness worthy of only The Darwin Award).

The small, intrinsic muscles of the foot have many functions, but flexion of the distal toes is not one of them (this is all afforded via the long flexors, FDL). Proprioception from the feet is very important and information from these muscles, as well as the articulations they traverse, provide the brain with much information about the environment, as well as the landscape they are traversing. Increasing proprioception from the feet (through gradual introduction of more minimalistic footwear and going barefoot) is as paramount, if not more important, as increasing strength. Skill, endurance, strength (S.E.S.) in that order (larger diameter, medium diameter and smaller diameter neurons respectively) is the rule for progressing exercise.    S.E.S. is an abbreviation we coined, but it is based purely on neurophysiology principles …  all of our information is science based. You will find no ‘internet forum’ assumptions here, as  you have so accurately gleaned. As for an example of some of our exercises, we are currently trying to find time to create some new videos of our current exercise protocols. As we mentioned however, it is a difficult projected since each case has different needs and differing orders of protocol. None the less, here is an “oldie but a goodie” from two years ago. Click here.

“Second question: What strategies do you use when treating runners with plantar fasciitis? Would you move them into a less supportive or minimalist shoe or would you bump them up temporarily into a stiffer shoe or use a rigid orthotic?”


A: The causes of plantar fascitis are multifactorial, but I think we all agree that overpronation of the rearfoot, midfoot, forefoot (or a combination) all play a frequent role. Following that assumption as a possible cause, the question is, What is causing the overpronation? Is it due to muscular incompetence? Is it due to loss of ankle rocker? Is it due to a loss of hip extension? Is it due to….. (fill in the blank).

The treatment depends on the etiology. As we just eluded, the cause is not always a foot issue, there can be top-down kinetic chain causes. Progressing them to more minimalistic footwear is a great idea (provided they have earned their right to be in it and have muscular competency and appropriate foot structure). The problem is that not everyone does have the necessary structure to drop into minimalism, some never and some need help with a logical progression.  Modalities like acupuncture, ultrasound and EMS, to reduce inflammation certainly help in pain management and can expedite the healing process. At times, if the case calls for it, using an orthotic to temporarily give them the mechanics they do not have, and relieve some of the tension of the fascia is appropriate. Sometimes the orthotic makes things worse (too much support, not enough support). Sometimes, albeit rare, the orthotic is suspect as the causal mechanism.  The root cause needs to be identified and then the appropriate therapy can be initiated.

We get questions like these all the time. They are great questions but they are often fraught with so many open ended subsequent questions and parameters that we often feel our answers are never good enough.  But, if solving things like plantar fascitis were easy in every case, we would not see clients in our practices who arrive with a bag of orthotics, a long  history of therapy, and multiple failed interventions. There are no easy answers or magic bullets. If there were, there would be no need for The Gait Guys.

Providing answers to difficult questions.

Ivo and Shawn

Defective Running Shoes as a contributing Factor in Plantar Fascitis in a Triathlete  
  Wilk B, Fisher K, Guitierrez W: JOSPT 2000;30(1):21-31  
   http://www.jospt.org/issues/articleID.407/article_detail.asp    
  Overview:  Case study of 40 yo male triathlete who developed R sided plantar fascitis after completing a half ironman (2K swim, 90K bike, 21K run). The study describes the factors contributing to the injury, the rehab process, and shoe construction along with the symptoms of plantar fascitis. 
  Authors Conclusion:  A running shoe manufacturing defect was found that possibly contributed to the development of plantar fascitis. Assessing athletic shoe construction may prevent lower extremity overuse syndromes. 
  What The Gait Guys Say  :  Plantar fascitis is something we see clinically many times in our practices. It is often due to overpronation of the midtarsal joint (talo-navicular and calcaneo-cuboid) in midstance, with insufficient supination from late midstance through preswing.  Thus, this over pronation causing overloading of the plantar fascia and windlass mechanism, resulting in increased torsional forces and micro-tearing at it’s proximal calcaneal (and sometimes distal) attachments. This causes local pain, swelling and inflammation, particularly at the calcaneal attachment site, which is alleviated by rest, ice and analgesics. As we have shared many times now, this over pronation does not have to be a local cause, it could be necessary from insufficient internal rotation of the hip or from other factors. 
 In this study, the Right shoe upper was canted medially on the midsoles, believed due to it not being glued perpendicularly (as we often see inspecting a shoe from behind, especially Asics Kayano’s in our experience). The authors state they felt this contributed to excessive inward rolling of the right foot, contributing to overpronation. 
 The authors make the following recommendations about shoe inspection: 
  The shoe should be glued together securely 
 The upper should be glued straight (perpendicular)      onto the midsole. The shoe, viewed from behind should have a horizontal      heel counter and vertical upper 
 The sole of the shoe should be level to the surface      on which it is resting (ie no medial to lateral motion should be present)      You can test this by attempting to “rock” the shoe from side to side 
 The shoes should not roll excessively inward or      outward when resting on a level surface (ie when rolling from P to A) You      can test this by rocking the shoe from A to P 
 Air and gel pockets should be inflated evenly. This      can be tested manually by pressing into them and checking for uniformity.  
  A nice rehab protocol is also outlined over a 4 week period. 
  Bottom Line:  It pays to be shoe nerd. Shoes can help or hurt. We see manufacturers defects in shoes every day and tell clients to return the shoe; in fact some we collect  to use to show people. A rearfoot varus in a shoe will help to slow pronation. This may actually be beneficial for overpronators but detrimental for supinators. Some defects can be helpful but try and find defect free shoes. Stay away from “2nds” at cheapie stores and online specials. There is usually a reason they are being sold so cheaply. EVA’s have a shelf life and will break down over time. You must be able to not only recommend the appropriate shoe for your patient, based on their evaluation and gait analysis, but you need to inspect their footwear carefully and teach them to do the same. 
 The   original   shoe nerds&hellip;.Shawn and Ivo

Defective Running Shoes as a contributing Factor in Plantar Fascitis in a Triathlete

Wilk B, Fisher K, Guitierrez W: JOSPT 2000;30(1):21-31

http://www.jospt.org/issues/articleID.407/article_detail.asp

Overview: Case study of 40 yo male triathlete who developed R sided plantar fascitis after completing a half ironman (2K swim, 90K bike, 21K run). The study describes the factors contributing to the injury, the rehab process, and shoe construction along with the symptoms of plantar fascitis.

Authors Conclusion: A running shoe manufacturing defect was found that possibly contributed to the development of plantar fascitis. Assessing athletic shoe construction may prevent lower extremity overuse syndromes.

What The Gait Guys Say: Plantar fascitis is something we see clinically many times in our practices. It is often due to overpronation of the midtarsal joint (talo-navicular and calcaneo-cuboid) in midstance, with insufficient supination from late midstance through preswing.  Thus, this over pronation causing overloading of the plantar fascia and windlass mechanism, resulting in increased torsional forces and micro-tearing at it’s proximal calcaneal (and sometimes distal) attachments. This causes local pain, swelling and inflammation, particularly at the calcaneal attachment site, which is alleviated by rest, ice and analgesics. As we have shared many times now, this over pronation does not have to be a local cause, it could be necessary from insufficient internal rotation of the hip or from other factors.

In this study, the Right shoe upper was canted medially on the midsoles, believed due to it not being glued perpendicularly (as we often see inspecting a shoe from behind, especially Asics Kayano’s in our experience). The authors state they felt this contributed to excessive inward rolling of the right foot, contributing to overpronation.

The authors make the following recommendations about shoe inspection:

  • The shoe should be glued together securely
  • The upper should be glued straight (perpendicular) onto the midsole. The shoe, viewed from behind should have a horizontal heel counter and vertical upper
  • The sole of the shoe should be level to the surface on which it is resting (ie no medial to lateral motion should be present) You can test this by attempting to “rock” the shoe from side to side
  • The shoes should not roll excessively inward or outward when resting on a level surface (ie when rolling from P to A) You can test this by rocking the shoe from A to P
  • Air and gel pockets should be inflated evenly. This can be tested manually by pressing into them and checking for uniformity.

A nice rehab protocol is also outlined over a 4 week period.

Bottom Line: It pays to be shoe nerd. Shoes can help or hurt. We see manufacturers defects in shoes every day and tell clients to return the shoe; in fact some we collect  to use to show people. A rearfoot varus in a shoe will help to slow pronation. This may actually be beneficial for overpronators but detrimental for supinators. Some defects can be helpful but try and find defect free shoes. Stay away from “2nds” at cheapie stores and online specials. There is usually a reason they are being sold so cheaply. EVA’s have a shelf life and will break down over time. You must be able to not only recommend the appropriate shoe for your patient, based on their evaluation and gait analysis, but you need to inspect their footwear carefully and teach them to do the same.

The original shoe nerds….Shawn and Ivo

Stage 1 of Correcting a flat foot, video demonstration.

Here is a case of a young man that was brought into us by his parents. Their concern was that their son was displaying what they thought was foot weakness. 

At the beginning of the video you can see that his foot progression angle is significant.  Certainly greater than the 10-15 degree “so called” normal range.  His arches are also somewhat collapsed. His knees were also displaying some hyperextension which is quite common with flat foot posturing.

This was his third visit into our office. He was given the corrective neuromuscular strategy that you see here and some specific exercises to help him get to this stage of correction.  The first stage of any correction is developing the awareness of what you are doing wrong (ie. become consciously aware of your incompetence). That was session one.  Session two focused on developing this corrective pattern, helping him find the skills to develop some conscious competence with a more normal foot stability skill pattern (endurance and strength still need to be added). 

Here you will see that, when queued, he immediately moves into a narrower base of stance (this will always happen when they can form a competent foot tripod, as you can see here).  In other words, the worse the foot collapse, the wider the feet will be positioned.  In his case, he now positions his feet under his hips and knees. 

You will also see the early success (after just 2 visits !) of a critical neuromuscular pattern.  He is showing some competence in holding the arch up and letting the toes move into flexion onto the ground.  Most flat footed children cannot separate “maintaining arch up, and moving into toes down”, rather they are into the pattern of “when the toes drop to the floor, the arch drops as well”.  This is a critical pattern (ability to hold arch up) to recognize and develop.  The child must develop the ability to independently flex and extend the toes on a static arch, while holding tripod,  before gait retraining can ensue.  This is mainly because the speed of gait and difficulty of single leg stance while displaying the correct pattern is just too much of a skill mastery issue. Often these pupils do not have enough hip frontal plane stability nor pelvic stability as well.

Also, note that he uses the skill of toe extension to help with arch height determination.  This goes right back to our blog posts last week on the Windlass Mechanism.  He is using the power of the windlass effect (toe extension) to take up the slack in the plantar fascial around the great toe metatarsal joint and thus pull the rear foot towards the forefoot (ie. raising the arch via this mechanism ! ).  Without a competent windlass a competent arch cannot be obtained (thus the ridiculousness of plantar fascial release surgery !).  Additionally, understanding the windlass and the effects of this simple video should give you insight into our success in quickly treating plantar fascitis. 

(addendum: also note at the end of the video that i ask him to collapse into his old pattern, this was after 30 minutes of corrective motor pattern exercises.  I laugh because in a solid posture that he shows at the end of the video, plus 30 minutes of new patterning, he found it difficult to find his old collapsed pattern.  This is a frequent occurance ! It gives you and the patient confidence that headway is being made.)

You must develop isometric, eccentric and concentric strength of the plantar intrinsic muscles that stabilize, raise, and control the lowering of the arch (as well as the arch controlling extrinsic muscles such as tibialis anterior and posterior among others) if you are going to make a difference in someones foot mechanics.  Just putting someone into a pair of ANY minimalist shoe (let alone barefoot) doesn’t guarantee strengthening of the foot or a remedy for a pair of feet like in this video. The process is a little more complicated than slipping on a pair of low ramp angle “shoes” and wearing them all day long…….in these types of cases all it does is raise their risk of injury or further foot incompetence down the road. 

For our fellow clinicians out there who are following us and trying to learn more about this kind of stuff……. wouldn’t your clinical world be nice if just prescribing a minimalist shoe would strengthen the foot in the correct pattern !?  We argue that, as in this kids foot, they would strengthen his foot in his poor postured patterns. So, we guess these companies are not lying when they say their shoes “strengthen” your feet, they just leave out the word “correctly”.

So, we do not argue with the point that going minimalist will strengthen your foot…… the question is “do you want to strengthen the correct pattern or a compensated one?”. 

here at The Gait Guys…….we know which pattern we want to strengthen.

We remain strong advocates that not all feet belong in minimalist shoes…… at least not initially, and some, never.  It would be nice if just slipping on a shoe could fix all of your foot problems, but it just isn’t that easy.  This is the topic no one is talking about, except The Gait Guys ……… because it doesn’t sell shoes.

There is much more to it than this video shows……. but we have to start somewhere.  Educating you with the issues we feel passionate about is the first step sometimes.

We remain…….obviously passionate………..

Shawn and Ivo….. The Gait Guys

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe

As promised. We fixed the volume.  Less hiss next time. Enjoy

Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch. Muscle specifically discussed are a team: FHB (flexor hallucis brevis), AbDuctor hallucis, and tibialis posterior. He discusses the functional anatomy, normal and pathologic movement patterns of the arch and first ray complex and big toe (hallux). His foot’s ability to show the optimal patterns for the arch and hallux are excellent examples. Follow up videos and DVDs will show more details you need to know, and some of the exercises he and Dr. Ivo Waerlop use to restore a foot that has lost these abilities. The DVDs are in the works. Take their lectures and CME on www.onlineCE.com. Visit them at www.thegaitguys.com and on their facebook PAGE & Twitter of the same name for daily feeds of unique things.