Bunions should change how you approach shoe fit. Bet you didn't consider this aspect.

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

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

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

The banana hallux. When the big toe curls upward

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

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

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

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

Shawn and Ivo, the gait guys

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

Do you really understand what it takes to control the 1st Metatarsal during loading ?

Do you have dorsal (top) foot pain, at the peak of the arch? Think you are tying your shoes too tightly and that is the cause? Do you have pain over the dorsal or plantar mid foot on heel rise or jumping/landing or going up stairs ?

Just because you raise your heel and load the ball of the foot does not necessarily mean you have adequately plantarflexed the 1st metatarsal and loaded it soundly/stable with the medial tarsal bone. Heel rise, and thus loading onto the medial foot tripod, must be met with ample, stable, durable, 1st metatarsal plantarflexion and the associated medial tarsal bones. Also, without this, loading of the sesamoids properly cannot occur, and pain may ensue.

The first ray complex can be delicate in people who are symptomatic. In some people who do not have a good tibialis posterior-peroneus sling mechanism working harmoniously, in conjunction with a competent arch tripod complex to achieve a compentent arch complex (ie, EDL, EHL, tib anterior and some of the other foot intrinsics) this tarsometatarsal interval can become painful and instead of the 1st ray complex being stable and plantarflexing as the heel departs and the 1st ray begins taking load, it may not do so in a stable plantarflexed posturing. In some people it can momentarily dorsiflex as the arch subtly collapses (when it should be stable and supinated in heel rise).

"Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle."-Duallert et al

Soon, I hope to show you a video of how to watch for this problem, how to train it properly, how we do it in my office.
Dr. Allen

Reference:

Clin Biomech (Bristol, Avon). 2016 May;34:7-11. doi: 10.1016/j.clinbiomech.2016.03.001. Epub 2016 Mar 10.  The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Dullaert K1, Hagen J2, Klos K3, Gueorguiev B4, Lenz M5, Richards RG6, Simons P7.

https://www.ncbi.nlm.nih.gov/pubmed/27015031

Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe.    What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head.   This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my  oral diarrhea of concerns  started.  So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:   impaired toe off   premature heel rise   watchful eye on achilles issues   impaired hip extension and gluteal function   impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)   impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)   lateral toe off which will promote ankle and foot inversion, which will challenge the peronei   frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function   possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)   possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading   impaired arm swing, more notable contralaterally    There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.  * So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).     If you know the complicated things, then the simple things become … … . . simple.     Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left.   … .  sorry for the rant, too much coffee this morning, obviously.  Shawn Allen, one of the gait guys

Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe. 

What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head. 

This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.

So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:

  • impaired toe off
  • premature heel rise
  • watchful eye on achilles issues
  • impaired hip extension and gluteal function
  • impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)
  • impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)
  • lateral toe off which will promote ankle and foot inversion, which will challenge the peronei
  • frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function
  • possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)
  • possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading
  • impaired arm swing, more notable contralaterally

There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.

* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).

If you know the complicated things, then the simple things become … … . . simple.

Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left. 

… .  sorry for the rant, too much coffee this morning, obviously.

Shawn Allen, one of the gait guys

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

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

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_70ff.mp3

Direct Download: http://thegaitguys.libsyn.com/podcast-70

Permalink: 

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

______________

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/

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

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

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

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

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

1. compensations will need to occur

2. The Windlass mechanism is insufficient

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

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

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

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

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

Shawn and Ivo … .the gait guys

Addendum for clarity:

a Facebook reader asked a question:

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

Our response:  

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

“… knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position.” - The Gait Guys  

This video is just the kind of stuff that drives us nuts.  We do not have a personal problem with the good doctor, he may know (and most likely does know) far more than he is letting on here but is merely simplifying things for some reason. We merely have a problem with the information that is missing that could make this a valuable addition, or omission, to someone’s care. There are times to simplify things, but when we put out a video on the web where the world can see it, we try to be as thorough as possible even if this means that something will come across seemingly overcomplicated. The fact of the matter is that human biomechanics are in fact complicated and simplifying something, when it is just not possible to do so, really doesn’t help anyone. People, and maybe some medical professionals, who do not know better will see this and not see what is missing, importantly so, here.

In this video there is no regard to the pre-positioning of the metatarsal to that big toe. This is a very unique joint, it has an eccentric axis that changes with metatarsal plantarflexion and dorsiflexion. This eccentric axis is shifted by the shifting position of the relationship of the metatarsal head with the base of the hallux. Here, at this joint, we have a concave-convex joint interface which with all said joint types, has a roll-glide biomechanical rule.  This rule at this joint is unique in that the axis of roll-glide is eccentric meaning that the joint has a shifting axis during the motion of dorsi and plantarflexion.  This is dictated and dependent upon the posturing of the sesamoid bones properly beneath the metatarsal head.  You can hear more about this premise here, in a video we did a few years ago. It is long, but it is all encompassing.  What is important, that which is not noted here, is that with more metatarsal plantarflexion there is opportunistically more dorsiflexion at the joint.  (This is precisely the joint range loss that occurs in “turf toe”, hallux limitus.)  Thus, in the above video, to properly mobilize the big toe into dorsiflexion, the foot must be taken into full metatarsal plantarflexion (pointing the foot) where greater amounts of joint dorsiflexion will be found (because of the eccentric axis shift) and the joint should be also mobilized in full ankle and metatarsal dorsiflexion, but the therapy giver must know, and be expected to find, that less toe/joint dorsiflexion will ALWAYS be found in this position.  Knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position.   

* Here is a little experiment you can do to teach yourself this principle. It should also help you to realize the gait cycle.

Sit in a chair, cross one ankle over the opposite knee and see what happens to the joint ranges as you proceed.  

  • dorsiflex the ankle and big toe. With your muscles only, not your hands, actively pull back the ankle and toe striving to get the most amount possible of dorsiflexion at both joints.  You should see that there is some toe dorsiflexion of the big toe.  
  • now keeping that big toe dorsiflexed as strongly as possible, begin to plantarflex the foot, thus moving the 1st metatarsal into plantarflexion as well. You should note that the relative amount of toe-metatarsal dorsiflexion DRAMATICALLY increases !
  • you can also do this passively. This time start at full foot plantarflexion (foot pointed) and passively pull that big toe back into dorsiflexion.  A huge range is likely to be found if you have a cleanly functioning foot.  Now, try to hold that significant range while you push the ankle into dorsifleixon.  At the end of the metatarsal and ankle dorsiflexion range you should feel the big toe start to resist this range you are trying to maintain, the big toe will forcibly start to  unwind the dorsiflexion. This is because of the eccentric shift of the joint and tension building in the passive tissues in the bottom of the foot. 
  • You want, and need, these relationships to occur properly and timely in the gait cycle and there are milliseconds to get it right and that means the entire kinetic chain must be clean of flaws, otherwise compensation will occur. (Note: Blocking or trying to control these issues with a foot bed, shoe type or orthotic can either be helpful therapeutically, or harmful to the chain.)

This is precisely what happens in the gait cycle. During swing phase the foot/ankle is in dorsiflexion to create foot clearance and to prepare the foot tripod for the contact phase with the ground.  There is some big toe (hallux) dorsiflexion represented in this swing phase, but it is not a significant amount you likely learned from your own self-demo above, mainly because it is not possible, nor warranted.  But, once the foot is on the ground and moving through the late stance phase of gait into heel rise, the ankle is plantarflexing. Thus, the metatarsals are plantarflexing, and this is causing the slide and climb of the metatarsal head up onto the sesamoids.  This causes the requisite shift of the axis of the 1st MTP joint (metatarsophalangeal) and affording the greater degree of toe dorsiflexion to occur to allow full foot supination, foot rigidity to sustain propulsive loading and also, never to forget, sufficient hip extension for gluteal propulsion. At this point, the range of the big toe in dorsiflexion is far greater than the dorsiflexion of the joint at ankle dorsiflexion. Impairment of this series of events is what leads to turf toe, hallux limitus as it is called. And when that becomes more permanent, even mobilizing the joint, as seen in the video above or otherwise, is not likely to get you or your client very far in terms of normal gait restoration.  And forcing it, won’t made it so either.

Remember this, the kinetic chain exists and functions in both directions. If you are starting with a hip problem that limits hip extension, and thus full range toe off during gait, in time you will lose the end range of the toe-off dorsiflexion range. And any attempts to try and regain it at the foot will fail long term if you do not remedy the hip.  "If you don’t use it, you will lose it". So to gain it back actively, sometimes you have to restore all of the functional losses of the entire kinetic chain to get what you are hoping for.  And for all you people doing “activation” to the glutes on your athletes, finding you are having to do it over and over and over again…….day after day after day, well … . . we hope you take this blog article to heart and put this thought process into action.

Remember, if you do not have the requisite strength, skill and endurance of the 2 toe extensors and 2 toe flexors as well as sufficient strength of the tibialis anterior (as well as many other components) you are likely to see impairment of this joint.  In this environment, do not expect joint mobilizations to offer you anything functionally lasting.  

We are not saying that joint mobilizations are useless and unnecessary, not by any means.  We are saying that you have to know what you are doing when you do them, so you can get the results you desire or, to realize why you are not getting the results you desire.  

Treat your clients with clear biomechanical knowledge and you will get the results you desire. If you go in with limited knowledge, results may speak for themselves. 

Gait analysis and understanding movement of the human body is a difficult task. It takes many years to learn the fundamental parameters and then many decades to implement the understanding wisely and with effectiveness.  Here at the gait guys, we hope to someday get to this point. We too, are students of gait and gait pathology. It is a journey.

“Once you understand the way broadly, you can see it in all things.”  -Miyamoto Musashi

 

Shawn and Ivo, The Gait Guys

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.


What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
- a rigid high arched cavus foot
- perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
- a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
- weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
- contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
- presence of a rigid forefoot valgus
- avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop

Podcast #28: Nanotech, Athletes & Barefoot ?


podcast link: 

http://thegaitguys.libsyn.com/podcast-28-nanotechnology-athletes-minimalism

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


Today’s show notes:

1. Neuroscience Pieces:

Technology is advancing so quickly that it won’t be long before the era of performance-enhancing drugs seems like the athletic Stone Age. Injecting or ingesting chemicals will be considered primitive when athletes will have the ability to have robotic cells powered by software coursing through their veins.

Russian Billionaire Wants to Create Cyborgs for Real

http://mashable.com/2013/04/01/avatar-project/


2.
Barefoot Running Can Cause Injuries, Too

By GRETCHEN REYNOLDS


http://well.blogs.nytimes.com/2013/03/06/barefoot-running-can-cause-injuries-too/
http://www.ncbi.nlm.nih.gov/pubmed/23439417

3. Running with sesamoiditis: How I resolved a 10 year injury by ditching my traditional running shoes. | Dr. Nick’s Running Blog
http://drnicksrunningblog.com/2013/04/04/running-with-sesamoiditis-how-i-resolved-a-10-year-injury-by-ditching-my-traditional-running-shoes/


4. Case
I have a question about peroneus longus in relation to “morton’s toe”. I did a very deep deep massage for an extended length of time and found that when I put my foot on the floor afterwards, the first metatarsal head was no longer raised!! Can you advise what may cause the peroneus longus to become tight, and if there any good stretches for it?
Thank you,Tracy



5. Do orthopedic shoes really help?
http://www.ncbi.nlm.nih.gov/pubmed/23496924

Well, they do seem to assist in foot placement and can enhance proprioception, so in the right circumstances, they can be an excellent adjunct to exercise and rehabilitation.

“Footwear adaptation led to pain relief and to improved foot & ankle proprioception. It is likely that that enhancement allows patients to better control foot placement. As a result, higher dynamic stability has been observed. LDS seems therefore a valuable index that could be used in early evaluation of footwear outcome in clinical settings.”


6. Shoes and Performance. Does it surprise you that it affects adolescents too? It shouldn’t:

http://www.sciencedaily.com/releases/2013/03/130319091420.htm