Toes Spacers, anyone?

Less pain through better mechanics?

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We have been using toe separators for various foot problems like hallux valgus, hammer toes and flexor dominance/extensor weakness. Our reasoning is that through changing the angle of attachment of the muscle, you alter the mechanical advantage of that muscle and help it to work more efficiently. This seems implied in the literature with respect to foot orthoses (1-3) but we could not find any data regarding toe separators. Toe separators DO seem to reduce pain and increase function (4-6). Perhaps this is through better biomechanics, mechanical deformation, proprioceptive changes, or most likely a combination of all these factors and more.  We think clinical results speak volumes. It is nice to see more data coming out on these easy to implement clinical tools. 

What is you clinical reasoning or rationale for using these devices? We would love to hear and if you have an article for reference you could share, that would be great. 

 

1. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

2. Halstead J, Chapman GJ, Gray JC, Grainger AJ, Brown S, Wilkins RA, Roddy E, Helliwell PS, Keenan AM, Redmond ACFoot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016 Apr;35(4):987-96. doi: 10.1007/s10067-015-2946-6. Epub 2015 Apr 28.

3. Bishop C, Arnold JB, May T. Effects of Taping and Orthoses on Foot Biomechanics in Adults with Flat-Arched Feet. Med Sci Sports Exerc. 2016 Apr;48(4):689-96. doi: 10.1249/MSS.0000000000000807.

4. Chadchavalpanichaya N, Prakotmongkol V, Polhan N, Rayothee P, Seng-Iad S. Effectiveness of the custom-mold room temperature vulcanizing silicone toe separator on hallux valgus: A prospective, randomized single-blinded controlled trial. Prosthet Orthot Int. 2017 Mar 1:309364617698518. doi: 10.1177/0309364617698518. [Epub ahead of print]

5. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008 Mar;32(1):79-83. doi: 10.1080/03093640701669074.

6. Tang SF, Chen CP, Pan JL, Chen JL, Leong CP, Chu NK. The effects of a new foot-toe orthosis in treating painful hallux valgus. Arch Phys Med Rehabil. 2002 Dec;83(12):1792-5. 

 

 

Toe Break

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Here's on one of our favorite subjects: toe break:

No, this is not a post about fractures phalanges, but rather where your shoe bends, or should bend.

Toe break is where the shoe bends anteriorly. Ideally, we believe this to be at the 1st metatarsal phalangeal joint and metartarsal phalangeal articulations. This allows for the best “high gear” push off as described by Bojsen-Moller (1) High gear push off means that the pressure goes to the base of the great toe (1st MTP joint) for push off. (for an interesting post on this, see here .

If we think about rockers of the foot during the gait cycle (need a review? click here), it seems best that we accommodate each of them to the best of our abilities. Since most of us wear shoes, it would make sense that it flex in the right places. With regards to the forefoot, it should (theoretically) be under the 1st metatarsal phalangeal joint. This should provide both optimal biomechanical function (distribution of force to the 1st metatarsal phalangeal joint for push off/ terminal stance) and maximal perceived comfort (2).

If the shoe bends in the wrong place, or DOES NOT bend (ie, the last is too rigid, like a rockered hiking shoe, Dansko clog, etc), the mechanics change. This has biomechanical consequences and may result in discomfort or injury.

If the axis of motion for the 1st metatarsal phalangeal joint is moved posteriorly, to behind (rather than under) the joint, the plantar pressures increase at MTP’s 4-5 and decrease at the medial mid foot. If moved even further posteriorly, the plantar pressures, and contact time in the mid foot and hind foot (3). A rocker bottom shoe would also reduce the plantar pressures in the medial and central forefoot as well (4). It would stand to reason that this would alter gait mechanics, and decrease mechanical efficiency. That can be a good thing or a bad thing, depending on what you are trying to accomplish.

Take home messages:

    Where a shoe flexes will, in part, determine plantar pressures
    Changes in shoe flex points can alter gait mechanics
    More efficient “toe off” will come from a shoe flexing at the 1st metatarsal phalangeal joint and across the lesser metatarsal phalangeal joints
    examine the “toe break” in your clients shoes, especially of they have a foot problem

1. F Bojsen-Møller Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979 Aug; 129(Pt 1): 165–176.

2. Jordan C1, Payton C, Bartlett R Perceived comfort and pressure distribution in casual footwear. Clin Biomech (Bristol, Avon). 1997 Apr;12(3):S5.

3. van der Zwaard BC1, Vanwanseele B, Holtkamp F, van der Horst HE, Elders PJ, Menz HB Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait. J Foot Ankle Res. 2014 Mar 19;7(1):20.

4. Schaff P, Cavanagh P Shoes for the Insensitive Foot: The Effect of a “Rocker Bottom” Shoe Modification on Plantar Pressure Distribution Foot & Ankle International December 1990 vol. 11 no. 3 129-140

plantar pressure image above from : Dawber D., Bristow I. and Mooney J. (1996) “The foot: problems in podiatry and dermatology”, London Martin Dunitz Medical Pocket Books.

 

About Toe Walkers...

Photo courtesy of Surestep

Photo courtesy of Surestep

Idiopathic Toe Walking in kids..Is it flexor dominance?

You see this at times in the office. Kiddos (or adults) who walk on their toes for no apparent reason. many have shortened heel cords with limited ankle dorsiflexion (1,2). Some studies report an incidence of 7-24% in pediatric populations (3) with an average of about 5% in children that are 5.5 years old (4). It seems to occur in about 2% of normally developing kids aged 5.5 years and 40% of those that have some sort of neuropsychiatric diagnosis or missed a developmental window (5-7), with an increased incidence familialy (8). The question here is why, not what.

We have discussed our opinions of flexor dominance here many times and suffice it to say that increased corticospinal activity seems to have the double whammy effect of increased firing of the distal flexors due to a lack of input to the axial extensors in the rostral and caudal reticular formations respectively(possibly from decreased spindle and /or GTO input and/or mechanoreceptor dysafferentation?) and lack of reciprocal inhibition of the extensors from the increased firing of the flexors segmentally. Is it the cortical abnormailities and missed developmental windows seen in so many of these folks that drives this? These are the sorts of things that keep us up at night....

Physical treatment modalities (2) seem to help, we think most likely to plastic changes in the connective tissue. Orthotics may prove useful due to similar mechanisms, especially if there is an equinus deformity or forefoot to rearfoot abnormaility (9). More agressive (and invasive) measures like Botox, seem to not. An interesting study using whole body vibration (10) produced some immediate but short lived positive results. This really gets you thinking about joint and muscle mechanoreceptors and the cerebellum, and makes us think that perhaps we also should be looking (and treating) north of the foot. We could not find any studies looking at the effects of proprioceptive or vestibular exercises effects on this, but think it could be promising area of therapy and we will continue to employ them until our clinical results tell us otherwise. 

 

1. Barrow WJ, Jaworski M, Accardo PJ. Persistent toe walking in autism. J Child Neurol 2011;26(5):619-621

2. Harris NM. Multidisciplinary approach led to positive results for pediatric patient with idiopathic toe walking. Presented at the Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting, Broomfield, CO, April 15, 2016.

3. Engelbert R, Gorter JW, Uiterwaal C, et al. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? BMC Musculoskelet Disord. 2011;12:61.

4. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics 2012;130(2):279-284.

5. https://tmblr.co/ZrRYjx1VV59rl

6. Williams, C. , Curtin, Wakefield and Nielsen Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71

7. https://tmblr.co/ZrRYjx1WTNcdK

3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen

8. Pomarino D, Ramirez Llamas J, Pomarino A. Idiopathic toe walking: tests and family predisposition. Foot Ankle Spec 2016;9(4):301-306

9. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: a randomized controlled trial. Prosthet Orthot Int 2016;40(2):262-269.

10. Williams CM, Michalitsis J, Murphy AT, et al. Whole-body vibration results in short-term improvement in the gait of children with idiopathic toe walking. J Child Neurol 2016;31(9):1143-1149.

 

 

What is the deal with "toe separators"?

Less pain through better mechanics?

We have been using toe separators for various foot problems like hallux valgus, hammer toes and flexor dominance/extensor weakness. Our reasoning is that through changing the angle of attachment of the muscle, you alter the mechanical advantage of that muscle and help it to work more efficiently. This seems implied in the literature with respect to foot orthoses (1-3) but we could not find any data regarding toe separators. Toe separators DO seem to reduce pain and increase function (4-6). Perhaps this is through better biomechanics, mechanical deformation, proprioceptive changes, or most likely a combination of all these factors and more.  We think clinical results speak volumes. It is nice to see more data coming out on these easy to implement clinical tools.

What is you clinical reasoning or rationale for using these devices? We would love to hear and if you have an article for reference you could share, that would be great.

TGG

1. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

2. Halstead J, Chapman GJ, Gray JC, Grainger AJ, Brown S, Wilkins RA, Roddy E, Helliwell PS, Keenan AM, Redmond ACFoot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016 Apr;35(4):987-96. doi: 10.1007/s10067-015-2946-6. Epub 2015 Apr 28.

3. Bishop C, Arnold JB, May T. Effects of Taping and Orthoses on Foot Biomechanics in Adults with Flat-Arched Feet. Med Sci Sports Exerc. 2016 Apr;48(4):689-96. doi: 10.1249/MSS.0000000000000807.

4. Chadchavalpanichaya N, Prakotmongkol V, Polhan N, Rayothee P, Seng-Iad S. Effectiveness of the custom-mold room temperature vulcanizing silicone toe separator on hallux valgus: A prospective, randomized single-blinded controlled trial. Prosthet Orthot Int. 2017 Mar 1:309364617698518. doi: 10.1177/0309364617698518. [Epub ahead of print]

5. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008 Mar;32(1):79-83. doi: 10.1080/03093640701669074.

6. Tang SF, Chen CP, Pan JL, Chen JL, Leong CP, Chu NK. The effects of a new foot-toe orthosis in treating painful hallux valgus. Arch Phys Med Rehabil. 2002 Dec;83(12):1792-5.

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Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

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All about Toe Break.

No, this is not a post about fractures phalanges, but rather where your shoe bends, or should bend.

Toe break is where the shoe bends anteriorly. Ideally, we believe this to be at the 1st metatarsal phalangeal joint and metartarsal phalangeal articulations. This allows for the best “high gear” push off as described by Bojsen-Moller (1) High gear push off means that the pressure goes to the base of the great toe (1st MTP joint) for push off. (for an interesting post on this, see here 

If we think about rockers of the foot during the gait cycle (need a review? click here), it seems best that we accommodate each of them to the best of our abilities. Since most of us wear shoes, it would make sense that it flex in the right places. With regards to the forefoot, it should (theoretically) be under the 1st metatarsal phalangeal joint. This should provide both optimal biomechanical function (distribution of force to the 1st metatarsal phalangeal joint for push off/ terminal stance) and maximal perceived comfort (2).

If the shoe bends in the wrong place, or DOES NOT bend (ie, the last is too rigid, like a rockered hiking shoe, Dansko clog, etc), the mechanics change. This has biomechanical consequences and may result in discomfort or injury.

If the axis of motion for the 1st metatarsal phalangeal joint is moved posteriorly, to behind (rather than under) the joint, the plantar pressures increase at MTP’s 4-5 and decrease at the medial mid foot. If moved even further posteriorly, the plantar pressures, and contact time in the mid foot and hind foot (3). A rocker bottom shoe would also reduce the plantar pressures in the medial and central forefoot as well (4). It would stand to reason that this would alter gait mechanics, and decrease mechanical efficiency. That can be a good thing or a bad thing, depending on what you are trying to accomplish.

Take home messages:

  • Where a shoe flexes will, in part, determine plantar pressures
  • Changes in shoe flex points can alter gait mechanics
  • More efficient “toe off” will come from a shoe flexing at the 1st metatarsal phalangeal joint and across the lesser metatarsal phalangeal joints
  • examine the “toe break” in your clients shoes, especially of they have a foot problem

1. F Bojsen-Møller Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979 Aug; 129(Pt 1): 165–176.

2. Jordan C1, Payton C, Bartlett R Perceived comfort and pressure distribution in casual footwear. Clin Biomech (Bristol, Avon). 1997 Apr;12(3):S5.

3. van der Zwaard BC1, Vanwanseele B, Holtkamp F, van der Horst HE, Elders PJ, Menz HB Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait. J Foot Ankle Res. 2014 Mar 19;7(1):20.

4. Schaff P, Cavanagh P Shoes for the Insensitive Foot: The Effect of a “Rocker Bottom” Shoe Modification on Plantar Pressure Distribution Foot & Ankle International December 1990 vol. 11 no. 3 129-140

plantar pressure image above from : Dawber D., Bristow I. and Mooney J. (1996) “The foot: problems in podiatry and dermatology”, London Martin Dunitz Medical Pocket Books.

Zero Drop? Think before you drop. More to think about before you make the jump (or run, or walk or stand…)

Ramp Delta. Drop. Heel to toe differential. Stack height differential. You have likely heard all the words before. We are talking about the difference in height between the center of the heel and ball of the big toe on the foot. It is literally “how much heel” the shoe has. Some have upwards of 20mm, some none at all (zero drop). The average seems to be 10-15 mm for many shoes, but that tradition is evolving to less and less (Brooks for example now has the “Pure” Series with a 4 mm average and one shoe that can be either 4 or zero (The Drift)). New Balance has their miniumus, Altra has their army of shoes, Saucony has a variable selection. Everyone is on target with their collection of minimalist or minimalist-trending (or as we like to call them, “gateway”) shoes.

Since we are born “sans” shoes, zero seems “natural” or maybe the best, right? Maybe, maybe not. A lot depends on you and your anatomy however logic dictates that we were born with the rear and forefoot on the same plane so there has to be a natural logic to the zero drop trend. The problem remains, how long have you been forcing this non-natural state and how long (if at all) will you be able to return to the “less is more” trend?

If you have been in shoes with more drop your whole life, your musculoskeletal system and neurology has adapted to that. If we take away our favorite chair, pair of shoes, golf club or whatever, you may have something to say about it. Same for your feet. If you drop/lower your heel, there are biomechanical changes and possible consequences.

You may have read this weeks post, talking about having enough ankle range of motion available. Dropping the heel requires more dorsiflexion (or extension) of the ankle. If that range of motion is not available, then the motion needs to occur somewhere else.

So, where elsewhere in the body is the motion going to occur ? Dropping the ankle requires more knee extension. Do you have that range of motion available? Are your knees painful when you wear a zero drop shoe?

How about your hips? Dropping the heel requires more hip extension as well. This extension is often accompanied by internal rotation of the hip (ankle dorsiflexion, along with foot abduction and forefoot eversion are all components of pronation, which will cause medial rotation of the hip. Do you have this range of motion available, or do you have femoral retro torsion, and a zero drop shoe makes that worse?

What about the effect on the low back? Dropping the heel decreases the lumbar lordosis (the natural curve forward). Don’t believe us ? Just look at any woman in a 3 inch pump and you will see some lovely curves. This places additional stress on the posterior ligaments and joint capsules and compression and shear on the discs. Some spines won’t tolerate this, just like some won’t tolerate heels, which increases the lumbar lordosis and places more stress on the posterior joints.

What about the mid back? Dropping the heel decreases the thoracic curve. How much extension (backward movement) do you have in your mid back?

The same with the neck…and the list goes on….

As you can see, it is much more complex than just changing to a shoe with less drop. Because of the biomechanical changes and demands, it will probably cost you something, be it range of motion, comfort, function. We are not saying it isn’t worth it, or that you shouldn’t do it; we are saying go slow and listen to your body. What may be right for someone else may not be right for you … . either in the short or long term.

Earn your way. Don’t throw caution to the wind. We see people everyday that have suffered the above consequences due to listening to the wonderful marketing of the minimalist trend and from embracing some of the nonsense on the web.  We call these people, “patients”.  Don’t make yourself a patient, use your head when it comes to your feet.

The Gait Guys

Ivo and Shawn

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our material.

So what can you tell us about this foot?    Hmmm. Pedograph again….You guys must think this is important, eh? You bet!  The best $150 dollars you will spend and one of the best education (and sales) tool you can buy.   So, back to the foot. Lets divide it into 3 sections; the rearfoot, the midfoot and the forefoot.   What do we see in the rearfoot? plenty of pronation, that’s for sure. How do you know? Look at the width of the print and the elongation of the heel print medially; ideally it is shaped like a teardrop. You would expect to see the calcaneus tipped into valgus (eversion) wile standing. What else? A heavy heel strike; look at all that ink!  Next, the midfoot; Lots of printing here = lots of midfoot pronation. Look at how the 2nd and 3rd cunieforms and cuboid print. This much ink under the cuboid means that the peroneus is having a hard time everting and assisting in supination  of the foot.   The forefoot? We see ink under met heads 2, 3 and 5, but not under 1.Looks like they can’t get the head of the 1st metatarsal down. This would lead us to believe they have an uncompensated forefoot varus (forefoot inverted with respect to the rearfoot). What about the toes? looks like overactivity of the long flexors to us, including the flexor hallucis longus (the brevis would only print more proximally; see our post here). This activity is probably to try desperately to stabilize the obviously unstable foot.  Where do you begin? Lots of diligent work on the clients behalf, maybe consider an orthotic that you can slowly pull the correction out of as they improve, to give them mechanics they don’t have. How about the tripod? Increase mobility of that 1st ray and get the 1st met head down and help to keep it there. Mobilization/manipulation, toe waving, tripod standing are a good start. Next tone down some of that long flexor tone. How about some more tripod standing, toes up walking and some shuffle walks. The intrinsics are next, and so on.   Yes, you should own a pedograph.  Need one? One of our friends (Another Shawn) can get you one. contact him at:  303 567 2271   You be able to interpret a pedograph. It provides a window to the gait cycle unlike any you have seen. Need help? Search our blog here with hundreds of examples, go to our Youtube channel and watch some of our great, free videos.   Thirsty for more? We have THE ONLY book published (as far as we know) on them exclusively and you can get it by  clicking here . We are told by our publisher that it is being converted to e-book format, but have not been given a conversion date.     Ivo and Shawn. Articulate. In your face. Pushing your limits daily. Changing the way the world looks at the feet and gait.    
  all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you use our stuff without asking us, we WILL find you and and send Toelio to deal with you.

So what can you tell us about this foot?

Hmmm. Pedograph again….You guys must think this is important, eh? You bet!  The best $150 dollars you will spend and one of the best education (and sales) tool you can buy.

So, back to the foot. Lets divide it into 3 sections; the rearfoot, the midfoot and the forefoot.

What do we see in the rearfoot? plenty of pronation, that’s for sure. How do you know? Look at the width of the print and the elongation of the heel print medially; ideally it is shaped like a teardrop. You would expect to see the calcaneus tipped into valgus (eversion) wile standing. What else? A heavy heel strike; look at all that ink!

Next, the midfoot; Lots of printing here = lots of midfoot pronation. Look at how the 2nd and 3rd cunieforms and cuboid print. This much ink under the cuboid means that the peroneus is having a hard time everting and assisting in supination  of the foot.

The forefoot? We see ink under met heads 2, 3 and 5, but not under 1.Looks like they can’t get the head of the 1st metatarsal down. This would lead us to believe they have an uncompensated forefoot varus (forefoot inverted with respect to the rearfoot). What about the toes? looks like overactivity of the long flexors to us, including the flexor hallucis longus (the brevis would only print more proximally; see our post here). This activity is probably to try desperately to stabilize the obviously unstable foot.

Where do you begin? Lots of diligent work on the clients behalf, maybe consider an orthotic that you can slowly pull the correction out of as they improve, to give them mechanics they don’t have. How about the tripod? Increase mobility of that 1st ray and get the 1st met head down and help to keep it there. Mobilization/manipulation, toe waving, tripod standing are a good start. Next tone down some of that long flexor tone. How about some more tripod standing, toes up walking and some shuffle walks. The intrinsics are next, and so on.

Yes, you should own a pedograph.  Need one? One of our friends (Another Shawn) can get you one. contact him at: 303 567 2271

You be able to interpret a pedograph. It provides a window to the gait cycle unlike any you have seen. Need help? Search our blog here with hundreds of examples, go to our Youtube channel and watch some of our great, free videos.

Thirsty for more? We have THE ONLY book published (as far as we know) on them exclusively and you can get it by clicking here. We are told by our publisher that it is being converted to e-book format, but have not been given a conversion date.

Ivo and Shawn. Articulate. In your face. Pushing your limits daily. Changing the way the world looks at the feet and gait.

all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you use our stuff without asking us, we WILL find you and and send Toelio to deal with you.

The Toe Waving Exercise, Part 2

In part one of this series, we talked about the importance of the short flexors of the toes (FDB or flexor digitorum brevis) in forming and maintaining the foot tripod. In this installment, we discuss another important muscle used in this exercise,  the extensor digitorum longus (EDL).

We have shown you time and time again, dominance of the long flexors in gait, which cause biomechanical imbalances. We remember that through reciprocal inhibition, the log flexors will reciprocally inhibit the long extensors, so increased activity in the former, means decreased activity and activation in the latter.

The balanced activity of the long flexors and long extensors helps to create harmony during gait. Working the long extensors with this exercise (along with others, like tripod standing, toes up walking and the shuffle gait exercises) helps one to achieve this balance.

The Gait Guys; promoting foot and gait competency every day here, on Youtube, Facebook, Twitter, and in our offices and yours.


all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will never have an adequate foot tripod and will have gait problems for the remainder of your days.

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The Mighty Extensor Digitorum Longus  (EDL): a pedograph case.

We have long been promoting appropriate function of the long extensors of the toes (predominantly the EDL, but also the Extensor hallucis longus) here, in our practices, our lectures, on Youtube, in our book……You get the idea. Lets tale a closer look at this muscle (picture left above)

The EDL has a proximal attachment in the lower leg up at the condyle of the tibia, proximal fibula, the interosseus membrane, and the connective tissues between the muscles. It travels down the leg, under the extensor retinaculum and attach to the base of the distal phalanges of toes 2-4. These muscles act from initial contact (to help eccentrically lower the foot to the ground), loading response (to continue to lower the foot slow or attenuate pronation), midstance and terminal stance (to provide compression of the metatarsal phalangeal and interphalangeal joints, and to offset the long flexors (which are often overactive, due to flexor dominance)).

What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right. what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has an uncompensated forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the forfoot varus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises. Make sure the articulations are mobile with joint mobilization, manipulation and massage. Make sure the knee and hip are functioning appropriately. Give the client lots of homework and put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe). As a last resort, if they cannot make an adequate tripod (because of lack of motivation or anatomical constraints), use a foot leveling orthotic.

Ivo and Shawn. Two guys, making a difference, every day.


all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will be plagued with foot fungus and bunions for all your days.

The Toe Waving Exercise: Part 1

Welcome to Friday, Folks. A little exercise here for you today that we use all the time.

There are at least 3 muscles important in forming and maintaining the foot tripod. The short flexors of the lesser digits (Flexor Digitorum Brevis or FDB) are one of the important component sfor creating and maintaining the foot tripod (the tripod between the head of the 1st metatarsal, head of 5th metatarsal and center of calcaneus).

It arises by a narrow tendon from the medial process of the calcaneal tuberosity the plantar aponeurosis, and from the connective tissue between it and the adjacent muscles. As it passes forward, and divides into four tendons, one for each of the four lesser toes which divide into 2 slips ( to allow the long flexor tendons to pass through), unite and divides a second time, inserting into the sides of the second phalanx.

Because the axes of the tendons passe anterior to the metatarsal phaalngeal joint (MTP), they also provide an upward (or dorsal) movement of the MTP joint complex, moving it posterior (or dorsal) with respect to the 1st metatarsal heal (thus functionally moving the 1st met head “down”). This is a boon for people with a forefoot varus, as it can help create more mobility of the 1st ray, as well as help descend the head of 1st ray to form the medial tripod (and assist the peroneus longus in anchoring the base of the big toe). It also helps the lumbricals to promote flexion of the toes at the MTP, rather than the distal interphalangeal joint.

In this brief video, Dr Ivo explains the exercise to a patient (Thank you N, for allowing us to use this footage).

The Toe Wave: try it. Use it with your patients. Spread the tripod. We know you want to….

Ivo and Shawn


all material copyright 2012: The Homunculus Group/The Gait Guys

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The extensor hallucis brevis revisited…or……axes of rotation

In a previous post, we described the attachments and importance of this little, but important muscle. Today we will explore that further.(4 images above, toggle through them)

We recall that the EHB is not only a dorsiflexor of the proximal hallux, but also a descender of the head of the 1st metatarsal . Why is this so important?

The central axis of a joint (sometimes called the instantaneous axis of motion) is the center of movement of that articulation. It is the location where the motion will occur around, much like the center of a wheel, where the axle attaches. In an articulation, it usually involves one bone moving around another. Lets look at an example with a door hinge.

A hinge is similar to a joint, in that it has parts with is joining together (the door and the jamb), with a “joint” in between, The axis of rotation of the hinge is at the pivot rod. When the door, hinge and jamb are all aligned, it functions smoothly. Now imagine that the hinge was attached to the jamb 1/4” off center. What would happen? The hinge would bind and the door would not operate smoothly.

Now let’s think about the 1st metatarsal phalangeal joint. It exists between the head of the 1st metatarsal and the proximal part of the proximal part of the proximal phalanyx. Normally, because the head of the 1st metatarsal is larger than the heads of the lesser ones, the center of the joint is higher (actually,almost 2X as high; 8mm as opposed to 15mm). We also remember that the 1st metatarsal is usually shorter then the 2nd, meaning during a gait cycle, it bears the brunt of the weight and hits the ground earlier than the head of the 2nd.

The head of the 1st metatarsal should slide (or should we say glide?) posteriorly on the sesamoids during dorsiflexion of the hallux at pre swing (toe off). It is able to do this because of the descent of the head of the 1st metatarsal, which causes a dorsal posterior shift of the axis of rotation of the joint. We remember that the head of the 1st descends through the conjoined efforts of supination and the coordinated efforts of the peroneus longus, extensor hallucis brevis, extensor hallucis longus, dorsal and plantar interossei and flexor hallucis brevis (which nicely moves the sesamoids and keeps the process gong smoothly).

Suffice it to say, if things go awry, the axis does not shift, the sesamoids do not move, and the phalanyx crashes into the 1st metatarsal, causing pain and if it continues, a nice spur you can write home about.

Ivo and Shawn….Still Bald…Still good looking…still promoting foot literacy everywhere

In this F-Scan film we see increased pressure on the lateral column of the foot with forces traveling to the 2nd metatarsal as they come across the foot. This is most likely due to an uncompensated forefoot varus. Note the hot spots at the 2nd and 5th met heads. This patient also has a Morton’s toe which is a longer digit.

Rule #1…..never assume. Examine your clients even after F-Scans, pedographs, stop frame digital movie etc. What you see is often not the problem, rather their adaptive compensation around the parts that are working and those that are not. The problem can be local, where it appears the deficit is, or it can be elsewhere. Let the clinical examination draw the correct conclusions. For example, in this case, we could have metatarsus primus elevatus or a Rothbart Foot variant or a combination of all of the above with the FF varus.
There is nice engagement of the hallux flexors but when you see this in combination with a preceding insufficient 1st metatarsal grounding (as evidenced here of lack of “heat” under the 1st Metatarsal) a late supination attempt may be suspected to reduce a late midstance pronation vector. Again, let your clinical examination draw the correct conclusions.