The LAST word....on Lasts

The last (look inside the shoe on top of the shank) is the surface that the insole of the shoe lays on, where the sole and upper are attached).

Shoes are generally board lasted, slip lasted or combination lasted.

A board lasted shoe is very stiff and has a piece of cardboard or fiber overlying the shank and sole (sometimes the shank is incorporated into the midsole or last) . It can be effective for motion control (pronation) but can be uncomfortable for somebody who does not have this problem.

A slip lasted shoe is made like a slipper and is sewn up the middle. It allows great amounts of flexibility, which is better for people with more rigid feet.

A combination lasted shoe has a board lasted heel and slip lasted front portion, giving you the best of both worlds.

When evaluating a shoe, you want to look at the shape of the last (or sole). Bisecting the heel and drawing an imaginary line along the sole of the shoe determines the last shape. This line should pass between the second and third metatarsal. Drawing this imaginary line, you are looking for equal amounts of shoe to be on either side of this line.

Shoes have a straight, curved or semi curved last. The original idea of a curved last (banana shaped shoe) was to help with pronation. A curved last puts more motion into the foot and may force the foot through mechanics that is not accustomed to. Most people should have a straighter lasted shoe.

The shape of a last will effect the biomechanics of the foot. It should match why shape of the foot as closely as possible. Generally speaking, we recommend straighter lasts for folks that have a tendency to overpronate through the midfoot and curvier lasts for folks that have a more rigid foot.

Because the fore foot abducts during mid stance, if the last is curved, the lateral aspect of the foot can rub against the side of the shoe and create blistering of the little toe and if present long enough, a tailors bunion. A general rule of thumb is: "when in doubt, opt for a straighter one"

Dr Ivo Waerlop, one of The Gait Guys

#last #gait #foot #thegaitguys #lastshape #curvedlast #straightlast #gaitanalysis #pronation

You might think your shoe is doing more to control motion of your foot than it is actually doing.

You might think your shoe is doing more to control motion of your foot than it is actually doing.

"The measurement of rearfoot kinematics by placing reflective markers on the shoe heel assumes its motion is identical to the foot’s motion."
The results of this study revealed that "calcaneal frontal plane ROM was significantly greater than neutral and support shoe heel ROM. Calcaneus ROM was also significantly greater than shoe heel ROM in the transverse and sagittal planes. No change in tibial transverse plane ROM was observed."

It is easy to underestimate the calcaneal ROM across all planes of motion. Motion is going to occur somewhere, hopefully you can help your client control the excessive ROMs that are occurring and causing their symptoms. But just do not think that a shoe is going to markedly help, it might, but let your interventions and your client's feedback on pain lead you.

Calcaneus range of motion underestimated by markers on running shoe heel.
Ryan S. Alcantara'Correspondence information about the author Ryan S. AlcantaraEmail the author Ryan S. Alcantara
, Matthieu B. Trudeau, Eric S. Rohr
Human Performance Laboratory, Brooks Running Company, 3400 Stone Way N, Suite 500, Seattle, WA 98103 United States

The “Standing on Glass” Static Foot/Pedograph... PART 2

The “Standing on Glass” Static Foot/Pedograph... PART 2
We hope you find this case presentation dialogue interesting.

Screen Shot 2019-01-13 at 7.51.15 PM.png

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon.

Here is the case . . .

Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there.

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left. The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ? Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings. Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern.

Remember this critical fact. After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively. Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow. We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation. See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations. Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining. The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?


Pronation anyone? Coupling? Walking Speed? How do they relate?

We have talked many times here on TGG about pronation, supination, overpronation, asymmetrical pronation, and more.

When most people think of pronation, they think of midfoot pronation, or pronation about the subtalar or transverse tarsal joints. Pronation can actually occur about any articulation or bone, but with respect to the foot, we like to think of rearfoot (ie. talo-calcaneal), midfoot (talo-navicular) and forefoot (transverse tarsal). The question is why does this matter?

Pronation, with respect to the foot, is defined as a combination of eversion, abduction and dorsiflexion (see picture attached) which results in flattening of the planter vault encompassing the medial and lateral longitudinal arches. In a normal gait cycle, this begins at initial contact (heel strike) and terminates at midstance, lasting no more than 25% of the gait cycle.

In a perfect biomechanical world, shortly following initial contact with the ground, the calcaneus should evert 4-8 degrees, largely because the body of the calcaneus is lateral to the longitudinal axis of the tibia. This results in plantar flexion, adduction and eversion of the talus on the calcaneus, as it slides anteriorly. At this point, there should be dorsiflexion of the transverse tarsal (calcaneo-cuboid and talo-navicular joints). Due to the tight fit of the ankle mortise and its unique shape, the tibial rotates internally (medially). This translates up the kinetic chain and causes internal rotation of the femur, which causes subsequent nutation of the pelvis and extension of the lumbar spine. This should occur in the lower kinetic chain through the 1st half of stance phase. The sequence should reverse after the midpoint of midstance, causing supination and creating a rigid lever for forward propulsion.

Pronation, along with knee and hip flexion, allow for shock absorption during throughout the 1st half of stance phase. Pronation allows for the calcaneo-cuboid and talo-navicular joint axes to be parallel making the foot into a mobile adaptor so it can contour to irregular surfaces, like our hunter gatherer forefathers used to walk on before we paved the planet. Problems arise when the foot either under pronates (7 degrees valgus results in internal tibial rotation), resulting in poor shock absorption or over pronates (> 8 degrees or remains in pronation for greater than 50% of stance phase).

This paper talks about how foot and ankle pathologies have effects on other articulations in the foot. They looked at stance phase of gait in 14 people without pathology at 3 different walking speeds. they found:

coupling relationships between rear foot inversion and hallux plantar flexion and rear foot eversion with hallux dorsiflexion.... When the rear foot everts (as it does as discussed above) during pronation from initial contact to mid stance , the hallux should be extending AND when the rear foot everts, as it should from mid stance to terminal stance/pre swing, the hallux should be plantar flexing to get the 1st ray down to the ground

medial (internal) rotation of there leg was accompanied by mid foot collapse (read pronation) and lateral (external) rotation with mid foot elevation (read supination).... Because of the shape of the talar dome and shape of the talo calcaneal facet joints, the talus plantar flexes, everts and adducts from initial contact to mid stance, and dorsiflexes, inverts and adducts from mid stance to terminal stance/ pre swing

walking speed significantly influenced these coupling relationships....meaning that the faster we go, the faster these things must happen and the greater degree that the surrounding musculature and associated cortical control mechanisms must act

So, when these relationships are compromised, problems (or more often, compensations) ensue. Think about these relationships and the kinetics and kinematics the next time you are studying someones gait.

Dr Ivo Waerlop, one of The Gait Guys

Dubbeldam R1, Nester C, Nene AV, Hermens HJ, Buurke JH. Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Gait Posture. 2013 Feb;37(2):159-64. doi: 10.1016/j.gaitpost.2012.06.033. Epub 2012 Aug 27

cool video on our blog to go with this post:

https://www.thegaitguys.com/thedailyblog/2018/8/7/what-do-you-know-about-pronation-and-supination

#gaitanalysis #thegaitguys #pronation #couplingrelationshipsandgait #pronation

The loads are going to go somewhere.

You cannot change one thing, and not expect the other parts to change, have to adapt, and possibly complain at some point.
The loads are going to go somewhere.

Too much pronation means the arch may be reduced in height, but it also means that the first ray complex (the 1-2 metatarsals essentially) is dorsiflexing more than normal. This means they will not likely get to their adequate plantarflexion by the time the foot is ready to heel rise and toe off at supination. In other words, if you have pronated and dorsiflexed too long and too much, you will eat up the time you needed to plantarlfex and supinate.
This means that "Increased foot pronation may compromise ankle plantarflexion moment during the stance phase of gait, which may overload knee and hip."-Resende et al

If you cannot plantarflex the foot-ankle complex sufficiently, or in a timely manner, you should understand that you are carrying this fault forward while moving into heel rise during the forefoot rocker stance phase of gait, and you are doing it over a less stable, less rigid foot-ankle complex because it is still in relative pronation. This means you are placing higher propulsive loads over an unprepared ankle-foot complex. This means different/altered posterior compartment function, which can mean altered knee and hip function. Sagittal plane function, to name the most obvious, will have to create and endure compensatory loads. Sure, they may be fine for a time, but perhaps there will be a cost over time. Now, many might say, "if it is not a problem now, it is not a problem", let them build robustness on their chosen pattern; that can be very hopeful and shortsighted thinking in our opinion. Why not change things that are obviously aberrant and build robustness on a pattern and correction that is suspected to be more sound? This can be a cyclical argument that no one wins, EVER, we all see it all the time. After all, the arguments become silly after time, and we resist our own silly comments like "well, why change the oil in your car right now, nothing bad is happening at this time. Or, well that front right tire, though bald and nearly flat, is still rolling along so why bother changing it out?" But that stuff gets no one anywhere, other than pissed off, so we hold back. The debate never gets furthered along, because no one can see the future.

So, we will leave this rant with this thought, we cannot change one thing, and not expect the other parts to change, have to adapt. And adaptation can be both good OR bad. Or maybe we should say, good AND bad.
The loads are going to go somewhere. Lets leave it at that.

photo: credit pixabay.com

Gait Posture. 2018 Oct 23;68:130-135. doi: 10.1016/j.gaitpost.2018.10.025. [Epub ahead of print]
Effects of foot pronation on the lower limb sagittal plane biomechanics during gait.
Resende RA1, Pinheiro LSP2, Ocarino JM3.

"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."

We say this so often in our offices.
"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."
Translation: compromised mechanics leading to tissue overloading.
But we all have to strongly consider that injury is a result of the loading you have not trained gradually into, failure to adapt and accommodate, excessive mileage without adequate tissue recovery,

From the article:
"So Napier and co-author Richard Willy from the University of Montana reviewed the highest-quality research featuring randomized controlled trials and systematic reviews.
"What we see is that there's really no high-level evidence that any running shoe design can prevent injuries," Napier said."

Now, to be honest, in our (the gait guys) opinion, there are times we do recommend a change in the foot wear for a client, and it is often because it appears to be working against someone mechanics and is a contributory factor in their injury or complaint. And sometimes that shoe recommendation is a temporary one, and sometimes a permanent one. We can use a shoe to help us get to a better/faster end point. After all, when we sprain an ankle sometime a brace or crutches are helpful and protective, of temporary value. A wisely chosen shoe can act the same if we are dealing with an acute achilles tendinopathy or a painful bunion for example. And in those cases we might recommend a shoe that can give us an assist. Sometime, when appropriate perhaps it is a shoe with a stronger medial post, perhaps one with a higher or lower heel drop/delta, or more or less stack height, or perhaps a mid/forefoot rocker built into the shoe. The truth is, people come in with functional or "fixed" pathology and sometimes pairing up a shoe to help us around some conflicting biomechanics can be temporarily, and sometimes permanently, helpful. But, the shoe is never the only answer, a wise clinician has many things they can utilize, all the way up the kinetic chain sometimes.
The more you know, the better you can assist someone.

Shawn Allen, one of the gait guys

#Nigg, #barefoot, #shoes, #stackheight, #heeldrop, #achillestendinitis, #bunion, #pronation, #supination, #running, #gait, #thegaitguys, #gaitanalysis, #gaitproblems, #gaitcompensation

Can the design of a running shoe help prevent injury? A B.C. researcher says he has the answer

Kelly Crowe · CBC News · Posted: Dec 15, 2018 9:00 AM ET

https://www.cbc.ca/news/health/running-shoe-injury-prevention-second-opinion-1.4947408?fbclid=IwAR3XaGPdgfQ68wj2N0tHqIamDdpYuxTIIL2LeudUd-doYN8YqQrIZI9-s9E

What do you know about pronation and Supination?

We have talked many times here on TGG about pronation, supination, overpronation, asymmetrical pronation, and more. 

When most people think of pronation, they think of midfoot pronation, or pronation about the subtalar or transverse tarsal joints. Pronation can actually occur about any articulation or bone, but with respect to the foot, we like to think of rearfoot (ie. talo-calcaneal), midfoot (talo-navicular) and forefoot (transverse tarsal). The question is why does this matter?

Pronation, with respect to the foot, is defined as a combination of eversion, abduction and dorsiflexion  (see picture attached) which results in flattening of the planter vault encompassing the medial and lateral longitudinal arches. In a normal gait cycle, this begins at initial contact (heel strike) and terminates at midstance, lasting no more than 25% of the gait cycle.

In a perfect biomechanical world, shortly following initial contact with the ground, the calcaneus should evert 4-8 degrees, largely because the body of the calcaneus is lateral to the longitudinal axis of the tibia. This results in plantar flexion, adduction and eversion of the talus on the calcaneus, as it slides anteriorly. At this point, there should be dorsiflexion of the transverse tarsal (calcaneo-cuboid and talo-navicular joints). Due to the tight fit of the ankle mortise and its unique shape, the tibial rotates internally (medially). This translates up the kinetic chain and causes internal rotation of the femur, which causes subsequent nutation of the pelvis and extension of the lumbar spine.  This should occur in the lower kinetic chain through the 1st half of stance phase. The sequence should reverse after the midpoint of midstance, causing supination and creating a rigid lever for forward propulsion.

Pronation, along with knee and hip flexion, allow for shock absorption during throughout the 1st half of stance phase. Pronation allows for the calcaneo-cuboid and talo-navicular joint axes to be parallel making the foot into a mobile adaptor so it can contour to irregular surfaces, like our hunter gatherer forefathers used to walk on before we paved the planet. Problems arise when the foot either under pronates (7 degrees valgus results in internal tibial rotation), resulting in poor shock absorption or over pronates (> 8 degrees or remains in pronation for greater than  50% of stance phase).

This paper talks about how foot and ankle pathologies have effects on other articulations in the foot. They looked at stance phase of gait in 14 people without pathology at 3 different walking speeds. they found

  • coupling relationships between rear foot inversion and hallux plantar flexion and rear foot eversion with hallux dorsiflexion

When the rear foot everts (as it does as discussed above) during pronation from initial contact to mid stance , the hallux should be extending AND when the rear foot everts, as it should from mid stance to terminal stance/pre swing, the hallux should be plantar flexing to get the 1st ray down to the ground

  • medial (internal) rotation of there leg was accompanied by mid foot collapse (read pronation) and lateral (external) rotation with mid foot elevation (read supination)

Because of the shape of the talar dome and shape of the talo calcaneal facet joints, the talus plantar flexes, everts and adducts from initial contact to mid stance, and dorsiflexes, inverts and adducts from mid stance to terminal stance/ pre swing

  • walking speed significantly influenced these coupling relationships

meaning that the faster we go, the faster these things must happen and the greater degree that the surrounding musculature and associated cortical control mechanisms must act

 So, when these relationships are compromised, problems (or more often, compensations) ensue. Think about these relationships and the kinetics and kinematics the next time you are studying someones gait. 

Here is a fun video talking about some of these relationships. 

 

Dubbeldam R1, Nester CNene AVHermens HJBuurke JH. Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Gait Posture. 2013 Feb;37(2):159-64. doi: 10.1016/j.gaitpost.2012.06.033. Epub 2012 Aug 27.

 

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

 

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

Trying again here. VIDEO CASE: Is this lateral compartment weakness ?

Quite simply, there are too many people playing doctor out there that do not have the ability to examine their clients appropriately. Here is another case of just that.
It is clear that this client has left lateral compartment deficits. Or is it too much medial compartment tone ? Your screens and loading tests will not likely show you this specifically, this client may merely present, as they did in this case of left frontal plane hip-pelvis drift and a right cross over step. If you have been with us for awhile, you know these 2 match up when it comes to locomotion. But one must solve the "Why" for the "how" to be accurate (how to fix it).
But, if you are looking for weakness, you will find it here, yes, peronei and lateral gastroc are weak. But is it inhibition or neurologic or frank weakness ? It is because of heightened medial compartment tone ? It could be, thus making one think of possible centrally mediated processes.
And, is the ankle the source or the frontal plane drift (glute weakness) the source ? Cart or the horse ? Chicken or the egg ? You have to examine your clients, on and off their feet, shoes off, socks off (yes, i took the socks off afterwards). Screens are not enough if you are trying to solve problems. Fixing how your client's improper loading is not a fix always, it could merely be teaching a compensation over a compensation to a problem. Be smarter than the rest, get the knowledge to examine your clients deeper , and more specific, function. Then, how they are moving, and the movements that you see that you do not like, will make more sense.
in this case, if you do not address the foot and the hip abductors and pelvis stabilizers, you lose, and so does your client as you build more strength into their asymmetry . . . . eventually leading, possibly, to complaints.

What’s up, Doc?

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

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

Let’s start at the rear foot:

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

Now let’s look at the mid foot:

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

Now how about the fore foot?

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

 Figure it out?

What would cause increased supination on the L?

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

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

Here is what is going on:

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

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

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

Wow, does that make sense now?

What’s the fix?

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

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

Supination, anyone?

Pronation gets all the press; but what about its counterpart, supination? There could not be one without the other. If anything, supination is at least as, if not more important to create propulsion.

Pronation is dorsiflexion, eversion and abduction of the foot. It provides shock absorption. Supination is plantar flexion, inversion and adduction. It helps the foot become a rigid lever so we can GO (Like in Theo Selig’s “Go Dig Go” ).

external leg rotation supination.gif

Locking of the lateral column of the foot (4th and 5th metatarsal, cuboid and calcaneus) is a necessary prerequisite for normal force transmission through the foot and ultimately placing weight on the head of the 1st metatarsal for proper (high gear) toe off . Locking of the lateral column minimizes muscular strain as the musculature (soleus, peroneus longus and brevis, EHL, EDL, FDL and FHL) is usually not strong enough to perform the job on its own.

external rotary moment.gif

This process is initiated by the opposite leg going into swing phase, which initiates dorsiflexion, inversion and abduction of the talus

The peroneus longus tendon aids this process by wrapping around the cuboid (the brevis attaches to the base of the 1st metatarsal) on its way to insert onto the base of the 1st metatarsal. When the peoneus longus contracts, it dorsiflexes and everts the cuboid, which, along with the soleus (which plantar flexes and inverts the subtalar joint) allows dorsiflexion of 4th and 5th metatarsals and “locks” the lateral column. Without this mechanism, there is no locking. Without locking, there is no supination. Without supination, there is little rigidity and inefficient propulsion.

The calcaneo cuboid locking mechanism. Another cool thing you learned about gait today from The Gait Guys.

Inverted ? Cross over gait? How we do all things ?

How we do one thing, is how we do all things.

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I was sitting having my morning coffee earlier than normal this morning, which left me time to ponder some things.
Look at this picture, is this not a magnification of the "cross over gait" x100 ? Thus, is that planted foot not inverted ? Yes, it has to be, to a degree, a high degree. There is a reason why soccer players have a great affinity for ankle sprains.
When we have a narrow based gait, we are most likely going to strike more laterally on the foot, more supinated, if you will. If you widen step width, less inversion, less lateral forces (typically) and less supination (typically) compared to a narrow based gait. 
If we descend stairs with our feet in a more narrow based gait, we are not only going to be inverted more, but striking at the ball of the foot, thus, more on the lateral foot tripod. This is the typical inversion sprain injury position. 
When we jump, we should be trying to land with our feet more abducted, certainly not narrow based, because if we are too narrow we are at more risk for the same lateral forefoot landing and thus ankle inversion event. Just like descending stairs.

We see plenty of ankle inversion events. Why? 
Because most people do not have enough hip abduction or peroneal skill, strength, endurance and they are unaware of their weak gait patterns or their ankle spatial awareness. Many have lazy narrow based gaits and insufficient proprioceptive awareness. And, they carry these things over into running, walking, jump landing (ie. volleyball, basketball, etc), and descending stairs, just to name a few.

How we do one thing, is how we do all things (mostly).

-Dr. Allen

Addendum:

Rickie Lovell : As he struck the ball it would been everted. The momentum of the follow through will have off loaded the everted foot as the energy moves in a similar line to that of the ball. It is extremely rare for a footballer to get a sprain from this, I certainly didn't see over several years working in professional football. 
On a side note, find some footage of David Beckham taking free kicks - the mechanics are astounding!

The Gait Guys: possibly everted, but no guarantee.It still looks pretty inverted to me.But we see your point, and is a real good one, real good. Super good. We will check our the bender-man thanks for chiming in with such great insight !

The Gait Guys:  yes, the momentum of the leg kicking across the body would externally spin the stance leg. The picture is likely showing the offloading phase, not the loading. Bueno !

Looking for the subtle clues will help you. You should have hypotheses and work to prove or disprove them.      “Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”     We used to call this a “windswept” presentation. It is not that it is incorrect, but it is so vague.    Look at these fippy floppers. Look closely at the dark areas, where foot oils and whatnot have played their changes in the leather upper of the flops. The right f.flop displays more lateral heel loading, rear foot inversion if you will. You can even see that there is less big toe pressure on this right side and even some increased lateral forefoot loading. This client appears to be more supinated clearly. You can even see there is more lightness to the arch leather on the right, again, more supination is suggested.  The left f.flop suggests the opposite. More medial heel pressures and more over the medial forefoot and arch.   Now this clients f.flops tell a story.  So, this client is being windswept to the right we used to say, appearing to pronate more on the left and supinating more on the right.  Why are they doing this? Is the left leg functionally longer and by pronating they reduce the functional length of the leg (yet, increase internal spin of the limb and the host of naughty things that come with that). Is the right leg shorter, and by supinating they are raising the ankle mortise and arch which helps reduce the length differential ?  MAybe a bit of both, finding common ground for a more symmetrical pelvis ?  Who knows. This is where you need your physical exam, but, now you have some hypotheses to prove or disprove.      “Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”     Is there some right hip pain from the right frontal pelvis drift creating some aberrant loading on the greater trochanter from ITB tension ? Perhaps a painful right hallux big toe, and they are unloading it to avoid pain? Maybe some knee pain or low back pain ? Who knows? Take your history and start putting the pieces together, it is your job. Just don’t screen them and throw corrective exercises at them, you owe it to them to examine them, take their history, watch them walk, teach them about what you see, and then sit down, spread the puzzle pieces out, look for the straight edges and corner pieces, and begin to build their puzzle.   Clues, they are everywhere, if you look for them.  Dr. Shawn Allen, one of the gait guys

Looking for the subtle clues will help you. You should have hypotheses and work to prove or disprove them. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

We used to call this a “windswept” presentation. It is not that it is incorrect, but it is so vague.  

Look at these fippy floppers. Look closely at the dark areas, where foot oils and whatnot have played their changes in the leather upper of the flops. The right f.flop displays more lateral heel loading, rear foot inversion if you will. You can even see that there is less big toe pressure on this right side and even some increased lateral forefoot loading. This client appears to be more supinated clearly. You can even see there is more lightness to the arch leather on the right, again, more supination is suggested.

The left f.flop suggests the opposite. More medial heel pressures and more over the medial forefoot and arch. 

Now this clients f.flops tell a story.  So, this client is being windswept to the right we used to say, appearing to pronate more on the left and supinating more on the right.  Why are they doing this? Is the left leg functionally longer and by pronating they reduce the functional length of the leg (yet, increase internal spin of the limb and the host of naughty things that come with that). Is the right leg shorter, and by supinating they are raising the ankle mortise and arch which helps reduce the length differential ?  MAybe a bit of both, finding common ground for a more symmetrical pelvis ?  Who knows. This is where you need your physical exam, but, now you have some hypotheses to prove or disprove. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

Is there some right hip pain from the right frontal pelvis drift creating some aberrant loading on the greater trochanter from ITB tension ? Perhaps a painful right hallux big toe, and they are unloading it to avoid pain? Maybe some knee pain or low back pain ? Who knows? Take your history and start putting the pieces together, it is your job. Just don’t screen them and throw corrective exercises at them, you owe it to them to examine them, take their history, watch them walk, teach them about what you see, and then sit down, spread the puzzle pieces out, look for the straight edges and corner pieces, and begin to build their puzzle. 

Clues, they are everywhere, if you look for them.

Dr. Shawn Allen, one of the gait guys

A test question from Dr. Allen, see how you do with this photo critical thinking.  When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface.   Here is the game …  to keep the pelvis level on the horizon, one would have to:  a. shorten the water side leg  b. lengthen the water side leg  c. pronate the water side leg  d. supinate the water side leg  e. lengthen the beach side leg  f. shorten the beach side leg  g. pronate the beach side leg  h. supinate the beach side leg  i. externally rotate the water side leg  j. internally rotate the water side leg  k. externally rotate the beach side leg  l. internally rotate the beach side leg  m. flex the water side hip  n. extend the water side hip  o. flex the beach side hip  p. extend the beach side hip   ******Ok, Stop scrolling right now !!!!!       List all the letters that apply first.    You should have many letters.  ***  And here is the kicker for bonus points , the letters can be unscrambled to spell the name of one of  the most popular of the Beatles . Name that Beatle.  .  .  .  don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.  .  .  .  .  .  .     Answer: B, D, F , G, I ,L , N, O  * now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.  ok, we were messing with ya on the Beatles thing. Sorry.  Dr. Shawn Allen

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

.

.

.

don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

.

.

.

.

.

.


Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

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Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

- another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. 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

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

How relaxed, or shall we say “sloppy” is your gait ?  Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion.   Now, visualize a line up from that right foot through the spine. You will see that it is clearly under the center/middle of the pelvis. But of course, it is easier to stand on one leg (as gait is merely transferring from one single leg stance to the other repeatedly) when your body mass is directly over the foot.  To do this the pelvis has to drift laterally over the stance leg side.  Sadly though, you should be able to have enough gluteal and abdominal cylinder strength to stack the foot and knee over the hip. This would mean that the pelvis plumb line should always fall between the feet, which is clearly not the case here.  This is sloppy weak lazy gait. It is likely an engrained habit in most people, but that does not make it right. It is pathology, in time something will likely have to give.   This is the cross over gait we have beaten to a pulp here at The Gait Guys over and over … . . and over.   This gait this gait, this single photo, means this client is engaging movement into the frontal plane too much, they have drifted to the right. We call it frontal plane drift. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain, this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, a compensation in arms swing or thoracic spine rotation or head tilt  … … something has to give, something has to compensate.   So, how sloppy is your gait ?   Do you kick or scuff the inside of your opposite shoe ? Can you hear your pants rub together ? Just clues. You must test the patterns, make no assumptions, please.  Shawn Allen, one of the gait guys

How relaxed, or shall we say “sloppy” is your gait ?

Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion. 

Now, visualize a line up from that right foot through the spine. You will see that it is clearly under the center/middle of the pelvis. But of course, it is easier to stand on one leg (as gait is merely transferring from one single leg stance to the other repeatedly) when your body mass is directly over the foot.  To do this the pelvis has to drift laterally over the stance leg side.  Sadly though, you should be able to have enough gluteal and abdominal cylinder strength to stack the foot and knee over the hip. This would mean that the pelvis plumb line should always fall between the feet, which is clearly not the case here.  This is sloppy weak lazy gait. It is likely an engrained habit in most people, but that does not make it right. It is pathology, in time something will likely have to give. 

This is the cross over gait we have beaten to a pulp here at The Gait Guys over and over … . . and over.   This gait this gait, this single photo, means this client is engaging movement into the frontal plane too much, they have drifted to the right. We call it frontal plane drift. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain, this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, a compensation in arms swing or thoracic spine rotation or head tilt  … … something has to give, something has to compensate. 

So, how sloppy is your gait ? 

Do you kick or scuff the inside of your opposite shoe ? Can you hear your pants rub together ? Just clues. You must test the patterns, make no assumptions, please.

Shawn Allen, one of the gait guys

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.

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Look at your patients and clients shoes!

Can you see the varus cant to the heel counter of these shoes? This is an Asics  Gel  Kayano; a shoe we seem to see manufacturers defects in frequently. This could be a good thing for an overpronator, but could be a bad thing for a supinator. With a drop ( ramp delta) of 13 mm, and a narrow toe box, we are not huge fans…