The “Dodgy Foot”, a UK runner’s dilemma.

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We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK, often we cannot help, but when there is a story to tell that everyone can learn from, we offer what we can. This runner was frustrated, explaining a “dodgy foot”. We like the word.

dodg·y däjē/

-dishonest or unreliable; potentially dangerous; of low quality.

We can likely guarantee you that the solution here to this runner’s form issue is not wholly at the foot which appears “in toed” and slanted and appears ready to kick the back of the right heel, not to mention the knees that are about to brush together. Thus, merely working on their foot strike would be so remedial and corrupt that it would a crime.

Ivo and I do not take on cases via the internet because we cannot give all the information because we cannot examine the client, many do offer such services but people are not being given the whole story and we pledged long ago not to be part of the problem. Anyone who recommends exercises from things they see on a video gait analysis are basically doing the same disservice in our opinion. But sometimes, as in this case, their inquiry offers a opportunity for dialogue. This is one of those cases. I will not be presenting a solution, because I do not have the examination information I need, but I will propose a thought process that further investigation may afford progress towards some answers.

This appears like a non-pathologic cross over gait in my mind until proven otherwise, there may be other sources, causes and components, but when it quacks like a duck you’d be silly not to check for webbed feet. There are many component parts that leave someone with a cross over type gait (ie a narrow based gait, that if taken further, might as well result in running on a line). This runner even confirmed upon questioning that the left foot scuffs the inside of the right ankle/shin often, both sides scuff in fact but more left shoe on right shin. No Einsteinian epiphany there.

This means a narrow swing through (adducting) left limb.
This might mean stance and swing phase gluteus medius communication problems.
This might mean swing leg foot targeting problems.
This often suggests right, but sometimes both right and left, frontal plane pelvis sway problems which means pelvis control is challenged which means core lumbar stability control is challenged.
This means adaptive arm swing changes from the clean norm. Arm swing to a large degree is driven by the lower limb motor patterns, despite what some people will propose (dive into our archives to find some of those research articles).
This does NOT mean this runner has pain, or pain yet, or maybe never will have pain but there are many determinants of that which I will discuss below.

But, make no mistake, this is flawed gait mechanics, but that does not translate to injury, speed, outcome or pain. But when they come with those complaints attached, one would be foolish not to at least consider these biomechanics as a source.
The left swing leg is clearly targeting a more medial placement, meaning limb adduction (active or passive or both is to be determined) and this is a product of the cross over gait (unfamiliar with the cross over gait ? SEARCH our blog for the term, you will need a few hours of free time to get through it all). Some would call the cross over gait a lazy gait, but I would rather term it an efficient gait taken too far that it has now become a liability, a liability in which they can no longer stabilize frontal plane sway/drift. A wider gait on the other hand, as in most sprinters, is less efficient but may procure more power and the wider base is more stable affording less frontal plane drift. Just go walk around your home and move from a very narrow line walking gait to a wide gait and you will feel a more powerful engagement of the glutes. Mind you, this is not a fix for cross over gaits, gosh, if it was only that simple !

This runner might investigate whether there is right frontal plane drift, and if it is in fact occurring, find the source of the drift. It can come from many places on either limb. (This client says they are scuffing both inside ankles, which is not atypical and so we likely have drift on both right and left). We have discussed many of them here in various places on the blog over the years. Now as for “Why” the foot looks in toed, well that can also come from many places. Quite simply the adducted limb once it leaves toe off (a toe off that is most often a "low gear toe off", meaning not a medial/hallux toe off), can look like this. But, perhaps it is also a product of insufficient external rotation maintenance occurred during that left stance phase, affording more internal rotation which is being unchecked and observed here during early swing. Remember though, if this is in fact a cross over gait result, in this gait the limb approaches the ground unstacked (foot is too far inside a left hip joint plumb line) the foot will greet the ground at a far lateral strike and in supination. Pronation will thus be magnified and accelerated, if there is enough time before toe off. However, and you can try this on your own by walking around your home, put yourself in terminal stance at toe off. Make sure you have the foot inverted so you are toeing off the lateral toes (low gear toe off). Does this foot not look like the one in the photo ? Yes it does, now just lift the foot off the ground and you have reproduced this photo. And when combined with a right pelvis drift, the foot will sneak further medially appearing postured behind the right foot.

Keep this in mind as well, final pronation and efficient hallux (big toe) toe off does often not occur in someone who strikes the ground on a far lateral foot. I am sure this runner will now be aware of how poorly they toe off of the big toe, the hallux. They will tend to progress towards low gear toe off, off the lesser toes. This leaves the foot inverted and this is what you are seeing in her the photo above. That is a foot that is inverted and supinated and it carried through all the way through toe off and into early swing. It is a frequently component of the cross over gait, look for it, you will find it, often.

Final thoughts, certainly this can be an isolated left swing phase gluteus medius weakness enabling an adducted swing limb thus procuring a faulty medial foot placement, but it is still part of the cross over phenomenon. Most things when it comes to a linked human frame do not work in isolation. But i will leave you with a complicating factor and hopefully you will realize that gait analysis truly does require a physical exam, and without it you could be missing the big picture problem. What if she has a notable fixed anatomic internal tibia torsion on that left side. Yup, it could all be that simple, and that is not something you can fix, you learn to manage that one as a runner.

* Side bar rant: Look at any google search of runners photos and you will see this type of swing limb foot posturing often, far too often. That does not mean it is normal ! That means, that many people do this, but it cannot mean that it is optimal mechanics. And yes, you can take the stance that “I do it as well and i have no injuries or problems so what is the big deal?”. Our response is often “you do have an issue, it may be anatomic or functional, but you do have an asymmetrical gait and you think it is not a problem, YET”. And maybe you will run till you are 6 feet under and not have a problem because you have accommodated over many years and you are a great compensator, yes, some people get lucky. Some people also do not run enough miles that these issues express themselves clinically so lets be fair. But some of these people are reality deniers and spend their life buying the newest brace or gadget, trying a different shoe insert, orthotic or new shoe of the month and shop over and over again for another video gait analysis expert who can actually fix their pain or problem. And then there are those who have a 45 minute home exercise program that they need to do to keep their problems at bay, managing, not fixing anything. Or, they spend an hour a week on the web reading article after article on what are the top 4 exercises for iliotibial band syndrome for example. They shop for the newest Graston practitioner, the newest kinesio taping pattern, Voodoo bands, breathing patterns, compression socks etc. And sometimes they are the ones that say they still don't have a problem.You get the drift. Gosh darn it, find someone who knows what the hell they are doing and can help you fix the issues that are causing the problem. And yes, some of the above accoutrements may be assistive in that journey.

I have dealt with this unique toe off issue very frequently. Once you see something enough times, you learn all of the variations and subtle nuances that a problem can take on. But, trying to fit everyone into a similar solution model is where the novice coach, trainer or clinician will get into trouble. Trust us, it all starts with an examination, a true clinical physical examination. If one leaves the investigatory process to a series of screens or functional movement patterns, “activation” attempts, digital gait analysis or strength tests one is juggling chainsaws and the outcome you want is often not likely to occur. There is nothing wrong with making these components part of the investigation process, but on their own, they are not enough to get the honest answer many times. Of course, Ivo and i were not able to jump the pond and examine this runner with our own eyes and hands so today’s dialogue was merely to offer this runner some food for thought to open their mind to our thought process, in the hopes that they can find someone to help them solve the underlying problem and not merely make the gait look cleaner. Making someone’s walking or running gait look cleaner is not hard, but making it subconsciously competent and clean (without thought or effort) requires a fix to the underlying problem. We can ALMOST guarantee you that the solution here to this runner’s form issue is not wholly at the foot that looks in toed and slanted. Merely working on their foot strike would be so remedial and corrupt that it would a crime.

Dr. Shawn Allen, one of the gait guys

#gait, #gaitproblems, #crossovergait, #gaitanalysis, #gluteweakness, #toeoff

Effects of high loading by eccentric triceps surae training on Achilles tendon properties in humans.

Maximum isometric force had increased by 49% and tendon CSA by 17% !
Tendons can change their cross sectional area, if you load them.

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Here I show lateral forefoot loading in a heel raise, and a medial forefoot loading in heel raise. This has to be part of the discovery process outlined below.

Isometrics are useful, they have their place. In a recent podcast to load up here in the future, we discuss the place and time to use isometrics, isotonics, eccentrics and concentrics.
One of the goals in a tendinopathy is to restore the tendon stiffness. Isometrics are a safe way to load the muscle tendon complex without engaging a movement that might have to go through a painful arc of movement. With isometrics here is neurologic over-spill into the painful arc without having to actually go there.
The key seems to be load. More load seems to get most people further along. Remember, the tendon is often problematic because it is inflamed and cannot provide a stiffness across its expanse. Heavy isometric loading seems to be a huge key for most cases. But, we have to say it here, not everyone fits this mold. Some tendons, in some people, will respond better to eccentrics, and strangely enough, some cases like stretching (perhaps because this is a subset of an eccentric it seems or because there is a range of motion issue in the joint that is a subset of the problem). Now the literature suggests that stretching is foolish, but each case is unique all in its own way, and finding what works for a client is their medicine, regardless of what the literature and research says.
Finding the right load for a given tendon and a right frequency of loading and duration of loading is also case by case specific. Part of finding the right loading position is a discovery process as well, as noted in the photos above. Finding the fascicles you want to load, and the ones you do not want to load (painful) can be a challenging discovery process for you and your client. Finding the right slice of the pie to load, and the ones not to load takes experimentation. When it is the achilles complex, finding the safe However, if one is looking for a rough template to build from, brief, often, heavy pain free loads is a good template recipe to start with.

Here, in this Geremia et al article, "ultrasound was used to determine Achilles tendon cross-sectional area (CSA), length and elongation as a function of plantar flexion torque during voluntary plantar flexion."
They discovered that, "At the end of the training program, maximum isometric force had increased by 49% and tendon CSA by 17%, but tendon length, maximal tendon elongation and maximal strain were unchanged. Hence, tendon stiffness had increased by 82%, and so had Young’s modulus, by 86%.

Effects of high loading by eccentric triceps surae training on Achilles tendon properties in humans. Jeam Marcel Geremia, Bruno Manfredini Baroni, Maarten Frank Bobbert, Rodrigo Rico Bini, Fabio Juner Lanferdini, Marco Aurélio Vaz
European Journal of Applied Physiology
August 2018, Volume 118, Issue 8, pp 1725–1736

Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles.

Attached is an older video from a few years back , it is very similar in execution to the heel-rise ball squeeze exercise which is the precursor to this more functional engagement as shown in this video today.

The important premise is that you have to have command of the entire posterior compartment if you are to get safe, effective, efficient and adequate ankle plantarflexion. As we have discussed many times, if you do not have the requisite skills as shown in this video you are in trouble and ankle sprains and other functional pathologies are not unlikely to visit you. Additionally, without requisite posterior compartment endurance and an ability to engage what I like to refer to as "top end" strength in the heel rise is an asymmetrial loading issue and can lead to compensatory adaptations up the kinetic chain. Make no mistake, the load will go somewhere, and thus the work will be done somewhere. In this video you should be able to clearly see and understand that one must be able to achieve top end posturing and have command of lateral and medial forefoot loading responses and challenges if clean forward function and power is to be achieved, and injuries from extremes of motion medially and laterally are to be avoided. Furthermore, as eluded to here and in several of our podcasts (and in the study included below), an inability to achieve top end posturing will lead to changes in forefoot loading, may spill over into endurance challenges prematurely in the posterior mechanism, and create changes in the timing of the gait cycle (things like premature or delayed heel rise, premature or delayed forefoot loading, recruitment of other components of the posterior chain just to name a few). This parsing and sharing of loads and responsibilities is laid out in the Kulmala study referenced today. The study could be extrapolated to say, I believe, that particularly in sprinting, a failure to achieve top end heel rise through effective posterior mechanism contraction, will change the load sharing between the posterior compartment and the quadriceps. After all, if the calf is weak, the ankle is not in as much plantarflexion, this could mean more knee flexion and thus raise demands on the quadriceps, logically changing knee mechanics. This is exactly why we spend so much time at every patient visit looking for full range of motion at the joints and then determine the skill, endurance and strength of the associated muscles in supporting that range. Then, of course, comparing this function to the opposite limb. Symmetry is not everything, but it is definitely a major factor in safe efficient and injury free locomotion.

* Please give great thought to the part in the video where I discuss the drop phase in jumping. All too often we at looking for the propulsive mechanics and forget that a failure there will also be represented during the adaptive phase. Ankle sprains rarely occur from propulsive pushing off, they occur from a failure to properly reacquaint the foot to the ground on the following step.
-Dr. Shawn Allen, one of the gait guys.

In this study the authors noted:
"During walking, the relative effort of the ankle extensors was almost two times greater compared with the knee extensors. Changing walking to running decreased the difference in the relative effort between the extensor muscle groups, but still, the ankle extensors operated at a 25% greater level than the knee extensors. At top speed sprinting, the ankle extensors reached their maximum operating level, whereas the knee extensors still worked well below their limits, showing a 25% lower relative effort compared with the ankle extensors."

And concluded that:
"Regardless of the mode of locomotion, humans operate at a much greater relative effort at the ankle than knee extensor muscles. As a consequence, the great demand on ankle extensors may be a key biomechanical factor limiting our locomotor ability and influencing the way we locomote and adapt to accommodate compromised neuromuscular system function."

Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189. Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles. Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.
https://www.ncbi.nlm.nih.gov/pubmed/27327033

https://youtu.be/8T9UzOaYxmo

the gait guys
#gait, #gaitproblems, #thegaitguys, #gaitanalysis, #heelrise, #calfstrength, #toeoff, #forefootloading, #metatarsalgia, #inversionsprain


Part 2: The amputated hallux & the complex biomechanical fall-out from it.

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Last week we promised Part 2 to this case, the amputated big toe.
Here is part 2. These are the complicated biomechanical fall-outs, so grab a big mug o' coffee and have at it !

In review, this person (all photos and case premissioned in swap for insight) had the distal hallux removed because of a progressive melanoma on the big toe. Can you believe that ! This is one more reminder that the sun and regular dermatologist screenings are wise.
This person had a complaint of progressing right gluteal and QL pain, spasm, tone and some persistent pain now in the 2nd metatarsal as well as some shoe challenges. We discuss this case briefly in and upcoming podcast, #139 or #140 we believe.

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Before we add our final thoughts to this case, lets cap our post from last week.

-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- More internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will likely be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree).
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities
- These factors are likely related to his complaints in the right gluteal and low back/QL area.

Now, onto our next thoughts.

- when the hallux is incompetent, in this case absent, there are few other choices to gain forefoot purchase on the ground other than more flexion gripping of the 2nd toe (then the 3rd, then 4th). This is a progressing "searching" phenomenon for forefoot stability and without the function of the big fella, the 2nd toe will begin a hammering phenomenon, often, but not always. We would not be surprised to see hammer toe development in this case, but this person is now very aware of it, and can at least now fight that battle with increased awareness. There is some mild evidence of this on the side lateral photo.

- We are happy to see that the proximal phalange was spared. The adductor hallucis is inserted medially there, and this will help to reduce bunion generation risk (medial metatarsal drift). Comparing the photo and the radiograph is a great example of how far back/proximal the 1st MTP joint is. One could easily assume that the entire hallux was resected from the photo, but the radiograph shows otherwise.

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- Toe off is obviously going to be compromised. The patient cannot adequately stabilize the 1st metatarsal (MET) and this will mean a compromised foot tripod, medial foot/tripod splay, arch pronation control challenges but toe off stabilization is going to have to be met by the 2nd and 3rd digits, as discussed above. They are not suited to be the major players here, they are synergistic to this end. Do not be surprised to see one of 2 strategies at toe off here:

1. heavy medial foot tripod toe off, dropping into the void and this maximize the internal spin challenges and minimizing the requisite foot supination stiffness generation phase that should be normal at toe off

2. avoidance of the above, with a forced conscious forefoot lateral toe off, a supinatory strategy, to avoid internal limb spin, more toe hammering, and the lurch heavily and abruptly off of the right foot and onto the left limb.

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3. taking #2 further, any time there is perceived challenges or deficits in strength, endurance, proprioception, balance, power and the like, the brain often will create a premature departure off of said limb, creating a requisite premature loading onto the opposite limb. This can cause a phenomenon well loosely refer to "catching" in the contralateral quadriceps mechanism. These clients, with their abrupt loading pattern onto the opposite limb will most often have troubles getting into initial gluteal hip stabilization strategies, and thus default into a quadriceps strategy, that in time can lead to quad shortness and increased tone, which can cause more compression across the patellofemoral joint and cause knee pain. This is more of a compression/loading response issue rather than tracking phenomenon, which we see at the typical diagnosis. We often look for causes in the opposite limb for contralateral knee pain. IT is quite often there if you are looking hard enough for it. Fix the problem, not the symptom.
There is a long host of other things than can arise from here, including heavy contralateral (in this case left sided) foot loading challenges, often more forefoot initial loading, and all of the problems than can arise when this pattern is cyclical, but that would take this post far too deep and long. So, . . . . another time.

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4. Shoe fit, we could make the case that a shoe that nicely hugs the forefoot, as opposed to a wide toe box'ed shoe, could help fight off the risk of 1st metatarsal abduction and thus bunion formation risk. However, one cannot dismiss the wider toe box giving the remaining toes a better environment to engage without hammering with over use of long flexors. We might suggest a trial of an elastic sleeve, one often used for plantar fascitis symptom management, placing a snug one around the forefoot when ambulating. This could help keep that metatarsal snug and stop the bunion-like drift we would be watching for.

have at it gang, cases like this are far and deep and require deep understanding of normal and abnormal biomechanics, and the rabbit hole deep myriad of compensations that can be engaged.

have a great weekend !

Shawn and Ivo

Hallux amputation: Part 1 . What is next for this person ?

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The stuff we get/see.
Hallux amputation.
What would you expect to present in this case ?
We will dive into this one next week, but here are some cursory things to consider:

It is the right foot.
-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- more internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree)
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities

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- there is so much more, we are just wetting your appetite here on this one.
see you next week on this one gang !

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Ivo and i are in the studio for another podcast this afternoon, hope you got to #137 this week ! lots more goodies to come !

cheers, shawn and ivo

Photo permission by patient

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

Plantar flexion matters, too. Don't get stuck only on ankle rocker/dorsiflexion.

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Plantarflexion matters, too.
"one must gain posterior length through anterior strength, lose the strength, lose the length."

We always seem to be harping on ankle rocker and ankle dorsiflexion. But, ankle plantarflexion matters just as much, but in different ways. This study went off of plantarflexion contracture, but we see shortness in the gastroc and soleus all the time, it seems in fact to go with loss of anterior compartment weakness, which is in essence, a functional (if not more truly restricted) loss of ankle rocker. Typically these 2 beasts are both in the same shopping bag. It is why we like to say, "one must gain posterior length through anterior strength, lose the strength, lose the length." This is not to say that shortness, tightness or contracture are the same thing, in fact they are on completely different spectrums. But, losing "posterior mechanism" length (short, tight or contracture), for whatever reason will do many potentially bad things to one's gait cycle and biomechanics. There are too many here of those to name, but, a functionally longer leg, tendency towards knee extension, knee flexion accomodation, early heel rise, abrupt departure from the limb and and abruptly onto the contralateral side, increased forefoot loading problems, toe clenching, loss of hip extension, impaired hip extension, increased quadriceps tone (and thus possible increased PF joint compression), changes in step and stride length and step width are just the start of some of the things your brain needs to start juggling.

The above are some of the thoughts immediately triggered by reading this abstract , , ,

Clinical Biomechanics. Volume 29, Issue 4, April 2014, Pages 423-428
The impact of simulated ankle plantarflexion contracture on the knee joint during stance phase of gait: A within-subject study
Joan Leung, Richard Smith, Lisa Anne Harvey. Anne M. Moseley, JosephChapparo

Helping the shoes bend where you do.

Sometimes, when someone has a foot that is a half or whole size smaller and the shoe doesn't bend where their 1st MTP joint bends, you have to perform shoe surgery. Rather than throwing a pair of shoes away because its causing pain at the joint (and you have ruled out all other causes and this is the only pair of shoes that bothers them), sacrifice a few hundred miles on the newer shoes and make it bend where your client bends.

ADDENDUM to video:
Sometimes, when someone has a foot that is a half or whole size smaller and the shoe doesn't bend where their 1st MTP joint bends, you have to perform shoe surgery. Rather than throwing a pair of shoes away because its causing pain at the joint (and you have ruled out all other causes and this is the only pair of shoes that bothers them), sacrifice a few hundred miles on the newer shoes and make it bend where your client bends.

ADDENDUM: we recieved a good question about this, as to "Where and how deep etc" to make the cut.

the shoe bends momentarily before the toe bends, so i like to create the cut (start little, just enough for the client to feel the shoe now bends easier and is creating less pressure into the joint) , i like to create the cut about 2mm to where the metatarsalphalangeal joint bends, proximal on the sole of the shoe...... since the shoe will begin to flex at heel lifting before much toe dorsiflexion occurs. But, as ivo said, they are not bending at the regular build in toe break of the shoe (where it naturally breaks/bends) so you will typically be proximal to that toe break interval. And yes, start small, because the cut will grow larger, and often fast........so the shoe will trash out sooner. I encourage folks to return the shoe if it is new, it was a bad shoe fit......but if they have 50 miles or more on it and the shoe is not working, rather than trash them........play surgeon and learn ! The client will most likely say "that was it, the shoe bends easily now, i can toe off comfortably".......... until the cut extends and ruins the shoe. In my experience that is about at another 150 miles

 

Your big toe is impairing your limb rotation.

Hallux limitus and impaired limb rotation.
No rocket science here, but always good to remember the mechanical principles.
If you cannot get over the medial foot tripod cleanly, for whatever reason, be it loss of 1st MPJ ROM (hallux limitus) or because of pain or forefoot typing issues, or you will be impairing normal rotation of the entire limb. In the above cases, remaining perhaps in more relative external limb rotation, impacting gluteal function. But, going too fast and too far over the medial foot tripod without controlled loading through that region can be just as detrimental, too much internal spin. Stuff we pound sand on all the time.
 

J Am Podiatr Med Assoc. 2011 Nov-Dec;101(6):467-74.

Hallux limitus and its relationship with the internal rotational pattern of the lower limb.

Lafuente G1, Munuera PV, Dominguez G, Reina M, Lafuente B.

Calf strength, the medial foot tripod, and pain in the great toe

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It has become evident that this component, the proper function of the 1st ray complex, is overlooked in some of the clinical world. Hallux joint pain is a difficult one to diagnose and treat at times. The source of pain and dysfunction can seemingly come from anywhere, but the more one understands the complex mechanics of this joint and regionally associate joints, the better clinical results one will achieve.  

One thing that has become recurrently obvious upon the many outside professional referrals that come though my office is the imbalance and/or weakness or endurance impairments in the posterior mechanism in relation to a painful 1st metatarsophalangeal joint (MTP). When I say posterior mechanism I am referring to the gastrocnemius, soleus, peronei, long flexors, and tibialis posterior namely. 

And, let me be clear, putting a theraband under the 1st metatarsal, encouraging your client to drive greater downward purchase of the head of the 1st MET during simulated foot tripod loading, does not necessarily help your client if their 1st MET is slightly more dorsiflexed. Do not be fooled by the flashy rehab guru tricks out there, proper clean function is achieved, not forced. If you have not earned it, you do not own it. 

It is quite simple really. If one does not have balanced function, including skill (motor pattern), endurance or strength of plantarflexion of the ankle, one cannot properly posture the first metatarsal (1st MET) in plantarflexion to sufficiently alter the sesamoid posturing underneath the metatarsal head, to sufficiently engage the unique eccentric axis (and it's necessary shift) of the 1st MTP to enable ample clean hallux dorsiflexion. Furthermore, without all this,  one will not be able to anchor the medial foot tripod properly.  This can lead to pain, functional hallux limitus, hallux rigidus to name a few. And, let me be clear, putting a theraband under the 1st metatarsal, encouraging your client to drive greater purchase of the head of the 1st MET during foot loading, does not necessarily help your client if their 1st MET is slightly more dorsiflexed. Do not be fooled by the flashy rehab guru tricks out there gang, proper clean function is achieved, not forced. 

A simple example might be a runner who fatigues the posterior mechanism in a long run. As the calf fatigues, they lose ample heel rise, thus ample plantarflexion of the 1st MET, thus proper posturing and translation of the sesamoids, thus successful eccentric axis shift, and thus clean dorsiflexion of the 1st MTP joint.  A player in a jumping sport who has less than ample strength of the posterior mechanism can have much the same issue at the resultant toe.  These are just garden variety examples.  But, should be clear that ample skill, endurance and strength (S.E.S.), our favorite mnemonic, of the posterior mechanism is necessary for pain free, functional toe off in the gait cycle or in jumping mechanics. 

If you are not systematically testing for these S.E.S. issues in the posterior mechanism, you are likely missing a major component in the proper posturing of the ankle and foot and thus proper functioning of the first ray complex and thus enabling clean function at the 1st MTP joint.  

(Sidebar rant: My past personal problems at this great toe joint started when a fellow chiropractor pulled on my toe many moons ago, for some random reason. It was the proverbial,  axial distraction "adjustment". The cavitation was heard around the world (the saliva inducing "pop" that fools many into blissful success), and my problems began.  I had painful dysfunction for many years after that for some strange reason, something was damaged but I was too stubborn and stupid to fix my own foot. I eventually remedied the problem through diving deeper into the complex mechanics of this joint and regionally associated areas. For this very intimate reason, it is why I am not one to perform this maneuver or recommend it. If we can be smarter in our understanding, we can be wiser in our interventions. Besides, axial distraction of this joint is not normal function of this joint. If I had a soap box to stand on for this topic, I would tell people to stop doing HVLA manipulations to this joint, mobilizations are more than ample to elicit a joint range response or a neurologic mechanoreceptor response. The more you understand this profoundly complicated and interesting joint, the 1st MTP joint, the more you will understand how to help your client. But, what do I know, I am just a dumb chiropractor, right Joe Rogan :) 

- Shawn Allen, 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

The Great toe’s effect on external hip rotation.

We have a simple video for you today. 

When we assess our clients for gait and locomotion we do a quick screen of all the big player joints, from the toes at least up into the thoracic spine to start. Loss of mobility/range of motion means probable functional impairment. 

In this video we display the effects of the Windlass Mechanism of the great toe. A windlass mechanism according to Wikipedia is:

a type of winch used especially on ships to hoist anchors and haul on mooring lines and, especially formerly, to lower buckets into and hoist them up from wells.

In this case, dorsiflexing the big toe spools the plantarfascia and flexor hallucis longus and brevis around the metatarsophalangeal joint (1st. MTPJ), thus pulling the heel towards the forefoot thus raising the arch. When the arch raises, the talus moves cephalad (upwards) and because of the supinatory movement orientation, it spins the tibial externally which in turn spins the femur externally. This is what you see in this video, note the blue dots being carried laterally with the limb external rotation.

The point here today, if you have loss of external hip rotation, it could be crying for you to evaluate the range of motion of the 1st MTP joint , it could be crying for you to evaluate the skill of toe extension, strength or endurance or all of the above. Impairment of the 1st MTP has great inroads into ineffective locomotion. You must have decent range of motion to effectively supinate, to effectively toe off, to externally rotate the limb, to effectively acquire hip extension to maximize gluteal use.  Thus, one could easily say that impaired hallux/great toe extension (skill, ability, endurance, strength) can impair hip extension (and clean hip extension patterning) and result in possible terminal propulsive gait extension occurring through the lumbar spine instead of through the hip joint proper.

Think of the effects of two asymmetrical great toe extensions, comparing the great toe left to right. Asymmetry in the limbs, pelvis, hip extension and perhaps worse, the lumbar spine, is a virtual guarantee.  Compare hallux extension side to side, if you can achieve symmetry through skill, endurance and strength retraining, you must do it. If you have a hallux limitus, a bunion or anything that impairs the symmetry of great toe extension side to side, you have some interesting work to do. 

You have to know what you have in your client, and know what it means to their locomotion.  Seeing or recognizing what you have must translate into understanding and action. 

Play mental games with clinical entities.  In this case, if at terminal toe off you did not have full hallux extension like in this client, and thus you did not get that last little final external rotation spin in the limb at the hip … . . what could that do to your gait ? Go tape your toe and limit terminal extension (terminal dorsiflexion) and walk around, to feel it in yourself is to get first hand experience. 

Shawn Allen, one of the gait guys

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Shawn and Ivo, The Gait Guys

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

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


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

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

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

Dr. Shawn Allen & Dr. Ivo Waerlop

Jon “Bones” Jones great toe dislocation.

For you UFC fans out there (and for you gait fans) who saw this injury at UFC 159 here was some update video on his toe shortly after the injury. Here is the picture (graphic).

“Dr. Robert Klapper, an Orthopedic Surgeon at Cedars-Sinai Medical Group, was a guest on Tuesday night’s edition of UFC Tonight to discuss the injury and the recovery process in detail.” He does a pretty good job in highlighting the injury. He went over the FHB (flexor hallucis brevis) injury and the sesamoid concern which impressed us that he was fairly knowledgeable in the critical function of this toe and joint.  We still remain very concerned about the amount of dorsiflexion he is able to regain at that joint.  These kinds of injuries can lead to hallux rigidus and some premature degenerative changes in the toe cartilage which can impair heel rise through toe off in gait. (it also might affect his sprawl (see below for definition) for all you MMA junkies!). Although first metatarsophalangeal instability (big toe joint) is an uncommon condition it can result from disruption of the capsular-ligamentous complex which is most certainly the result of Jon Jones injury. Patients can experience pain with push-off and hallux rigidus type of symptoms including loss of end range of the joint which is critical for gait.  Quite often the joint needs restabilization which can be done through many surgical methods including anchoring the plantar plate to the extensor hallucis longus tendon. When this toe is not sufficiently stabilized the anchoring of the head of the medial tripod of the foot (the 1st metatarsal head) often becomes unstable. And when it becomes unstable more foot pronation can occur and bunion formation and hallux drift can occur, amongst many other things such as chronic sesamoiditis and functional imbalance (and thus power) across the joint. These things can all affect speed, agility, balance, power and the like. 

Lets hope that Jones’ toe restilizes on its own. We won’t know for several more weeks however.  One thing is for sure, with our 45 years experience, no  matter what the media spins right now, he is not out of the woods yet. Seriously.  It will be interesting to see if there is evidence of favoring of the joint in his next fight, whenever that is.

oh, and here was our Tweet to Bones Jones after the fight. Never heard from him……. tisk tisk tisk.    #regret (we hope not !)

27 Apr

good win. You are gonna need to restore function for that toe once it heals. Ouch ! Nasty ! champ !

define: Sprawl (wikipedia)

A sprawl is a martial arts and wrestling term for a defensive technique that is done in response to certain takedown attempts, typically double or single leg takedown attempts. The sprawl is performed by scooting the legs backwards, so as to land on the upper back of the opponent attempting the takedown. The resultant position is also known as a sprawl or sprawling position.

Ideally, the sprawling athlete should arch his back as much as possible and keep his knees off the mat. His options here including attempting to gain leverage on the lower back by hooking underneath the elbows; throwing in a headlock; and grabbing his opponent’s ankles and trying to get behind his opponent.

Shawn and Ivo, The Gait Guys……. hoping Jonny Bones reaches out to  us if things don’t come out so well !

About 8 years ago (?) I was in my Muscle Activation Class (MAT) here in Chicago and somewhere during the course of the class the topic came up about problems with the big toe. This really nice fella spoke up about a major injury to his thumb (the photo is not of him but  here is a link to this fella’s story ) and how doctors then proceeded to amputate his big toe to replace the thumb. 
 Gosh, with my brain knowing all that it does about gait as well as hand function, thoughts began to swim in every direction. What would I do if I were presented with the same scenario?  Without my thumb my work as a manual medicine physician would definitely be changed. But, heck, my gait would forever be changed too! I would be sentenced to a life of never ending gait compensations that could never be treated. My mind swirled around impaired hip extension and gluteal dysfunction, not to mention: 
  foot tripod incompetence 
 pronation and supination dysfunction guaranteed 
 virtually guaranteed hammer toe formation 
 metatarsal stress impacts 
 inappropriate loads on the medial column stabilizers such as the tibialis posterior now that the medial foot tripod was impaired let along the new absence of the long and short toe flexors that often provide compensatory activity to help an insufficient medial tripod. 
 impaired ipsilateral and contralateral arm swing 
 impaired shoulder function 
 core and hip impairments and asymmetry 
 the list goes on and on……. perhaps for hours !  We could do a whole 1-2 hour lecture just on the gait compensations and the subsequent motor impairment patterns that would ensue. 
  Seeing this photo and reading this fella’s story brought my mind back to the swirling thoughts I had while sitting in that lecture hall that day. And now some 8+ years later i am still brought to the same uncertain conclusion.  Would I go for the switcheroo ?   The transplant isn’t guaranteed successful, if it was that might sway things a little. But the gait impairments are guaranteed.  
 What would  you do ?  
 We hope you ( and us here at The Gait Guys) never are confronted with this most difficult presentation.  However, in just a few years, with the advent of 3D printers the anxiety of this issue is likely going to become a non-issue. 
 Just some food for thought today.  Or maybe we should have said “Foot for thought.” 
 Shawn and Ivo

About 8 years ago (?) I was in my Muscle Activation Class (MAT) here in Chicago and somewhere during the course of the class the topic came up about problems with the big toe. This really nice fella spoke up about a major injury to his thumb (the photo is not of him but here is a link to this fella’s story) and how doctors then proceeded to amputate his big toe to replace the thumb.

Gosh, with my brain knowing all that it does about gait as well as hand function, thoughts began to swim in every direction. What would I do if I were presented with the same scenario?  Without my thumb my work as a manual medicine physician would definitely be changed. But, heck, my gait would forever be changed too! I would be sentenced to a life of never ending gait compensations that could never be treated. My mind swirled around impaired hip extension and gluteal dysfunction, not to mention:

  • foot tripod incompetence
  • pronation and supination dysfunction guaranteed
  • virtually guaranteed hammer toe formation
  • metatarsal stress impacts
  • inappropriate loads on the medial column stabilizers such as the tibialis posterior now that the medial foot tripod was impaired let along the new absence of the long and short toe flexors that often provide compensatory activity to help an insufficient medial tripod.
  • impaired ipsilateral and contralateral arm swing
  • impaired shoulder function
  • core and hip impairments and asymmetry
  • the list goes on and on……. perhaps for hours !  We could do a whole 1-2 hour lecture just on the gait compensations and the subsequent motor impairment patterns that would ensue.

Seeing this photo and reading this fella’s story brought my mind back to the swirling thoughts I had while sitting in that lecture hall that day. And now some 8+ years later i am still brought to the same uncertain conclusion.  Would I go for the switcheroo ?   The transplant isn’t guaranteed successful, if it was that might sway things a little. But the gait impairments are guaranteed. 

What would  you do ? 

We hope you ( and us here at The Gait Guys) never are confronted with this most difficult presentation.  However, in just a few years, with the advent of 3D printers the anxiety of this issue is likely going to become a non-issue.

Just some food for thought today.  Or maybe we should have said “Foot for thought.”

Shawn and Ivo

Hip Biomechanics: Part 5 of 6 
 Sagittal Plane Functional Biomechanics  Thus far we have discussed the hip biomechanics mostly in the frontal plane.  The sagittal plane mechanics are much less complex since the axis of movement is in the frontal plane (the axis is directed horizontally through the femoral heads and pelvis) and the body weight for the most part rests on this same plane (unlike the frontal plane mechanics where the body weight is a moment arm away from the center of the hip rotation).  One of the main reasons the mechanics are a little less complicated for the most part is due to the fact that even with the pelvic obliquity that occurs during gait cycles of swing and stance, the body weight still remains largely over this trans-femoral head axis.    In the sagittal plane the prime movers are the abdominas and gluteals (flexion and extension of the hip respectively) with some help from the ilopsoas for hip flexion perpetuation. The calf compartment is also  helpful as is arm swing.  The hip flexor synergistic muscles are the quadriceps and abdominals while the hip extensor synergist is mainly the hamstring group.  This is certainly simplified since transaxial rotation through a vertical oriented axis does occur as a coupled motion and thus we cannot talk about sagittal plane movements, or even frontal plane movements for that matter, without at least considering the effects of movement generation or stabilization by the hip intrinsics (gemelli, oburators, quadratus femoris, piriformis).    The greatest body function in the sagittal plane is gait and many of the body’s compensations and conditions stem from alterations in hip joint function through this movement negotiation through the sagittal space.  For the therapist, clinician or trainer the greatest problem can be the body’s numerous back-up systems which compensate and share normal or abnormal loading.  The basis of gait evaluation needs to be based from a holistic perspective.  Gait cannot be evaluated without consideration of the entire organism. A minor functional limitation in the first metatarsophalangeal (MTP) joint can significantly impact hip, pelvic and spinal biomechanics.  The best and simplest example of this is the clinical scenario of hallux limitus.  We will entertain the equally devastating functional hallux limitus later on in the chapter but the point to note here is that a minor loss of the last few degrees of the normal MTP joint dorsiflexion (45-60 degrees is necessary, patient specific) can be devastating to sagittal plane motion of the body.  Even a loss of the last 5 degrees of this normal range, although appearing relatively normal on an examination and possibly without symptoms (ie. early stages of progression into a more noticable hallux limitus), can impact normal and efficient toe off.  If toe off is early, even to a small degree, then the stance phase will be abbreviated via early heel rise.  If heel rise is early this creates a functional change in the kinetic chain, both open chain and closed chain.  There are many closed chain changes that will occur. One such change might be toe off propulsion forces being imparted through a more flexed tibiofemoral joint (knee) which will impart both translatory shear forces in the sagittal plane and torsional forces through the joint, both causing potential maceration effects on the menisci.  However, perhaps the easiest functional changes to understand are the changes at the hip.  It is well known on EMG studies that hip flexion is both an active and passive motion during gait.  The active flexion of the hip is generated largely by iliopsoas concentric contraction.  However, this is not the first mechanism to generate hip flexion.  In fact, hip flexion is first generated passively through engagement of the kinetic chain.  The first movement of the swing phase is rotational or torsional activation of the oblique pelvis through core activiation of the abdominal muscle group.  Through activation of the internal and external abdominal obliques and transversus abdominus, in addition to activation of their synergists and cocontration of their antagonistic stabilizers, the obliqued pelvis is rotated.  Better said, the trailing leg’s lagging pelvis is moved forward by contract of the synergistic oblique activation.  This forward movement generates a sagittal momentum and movement of the toe off leg.  Once movement is generated then the iliopsoas activates concentrically to perpetuate hip flexion.  In other words, the ilopsoas is not an initiator of hip flexion, rather, a perpetuator.  When hallux limitus limits the stride length via early generation of heel rise the pelvic obliquity is limited.  As a result, the degree of initial swing phase leg movement is less from the generation of pelvis de-rotation via abdominal activation and more through ill-directed iliopsoas hip flexion.  Thus, as hip flexion still needs to occur, the iliopsoas is called upon to compensate; it now becomes a hip flexion initiator as well as its previous function of hip flexion perpetuator.  This demand is minimal but with repetitive demand thousands of steps per day, the iliopsoas eventually looses its ability to continue these compensations, as does its now over burdened synergists.  The result is either hypertrophy, inhibition, hypertonicity, spasm, shortening, insertional tendonitis, origin tendonitis or a combination thereof but make no mistake, such burden will eventually cause dysfunction within the muscle itself or within its synergists or antagonistic pair.  The scenario may result in either joint dysfunction at the lumbar spine near the muscle’s origin, at the sacroiliac joint over which it crosses, or at the hip joint proper.  The ensuing joint derangement or dysfunction is complex and creates numerous compensation patterns locally and globally since the main function of the muscle is to create hip flexion, external rotation, and abduction in the open kinetic chain and trunk flexion and trunk internal rotation in the closed kinetic chain. In a nutshell, the loss of dorsiflexion of the hallux, even to a minor degree, must be made up somewhere in the sagittal plane.  If it is not immediately made up for at the more proximal joints (1st metatarsal-midfoot joint, talo-navicular, ankle mortise-tibiotalar, or knee) the hip will undoubtedly change its function as described above to compensate, it is well suited to do so.  Keep in mind that such compensations may be better suited at the ankle, knee or hip depending on the degree of hip ante/retrotorsion or tibial internal/external torsion if present but none the less these compensations have consequences to changes in function of muscles either eccentrically, isometrically or concentrically or by recruiting assistance from synergists or antagonistic groups.  Additionally, a person with a very flexible midtarsal joint may stop the more proximal compensations via restoration of the necessary first ray (first toe) complex dorsiflexion at that more immediately proximal joint complex.  
 Shawn and Ivo (yup, that is Dr. Allen thinking he is a bad ass in the picture above, clay pigeon shooting and a cubano……. thinks he is Clint Eastwood or something. Regardless, don’t mess with The Gait Guys !).

Hip Biomechanics: Part 5 of 6

Sagittal Plane Functional Biomechanics

Thus far we have discussed the hip biomechanics mostly in the frontal plane.  The sagittal plane mechanics are much less complex since the axis of movement is in the frontal plane (the axis is directed horizontally through the femoral heads and pelvis) and the body weight for the most part rests on this same plane (unlike the frontal plane mechanics where the body weight is a moment arm away from the center of the hip rotation).  One of the main reasons the mechanics are a little less complicated for the most part is due to the fact that even with the pelvic obliquity that occurs during gait cycles of swing and stance, the body weight still remains largely over this trans-femoral head axis. 

In the sagittal plane the prime movers are the abdominas and gluteals (flexion and extension of the hip respectively) with some help from the ilopsoas for hip flexion perpetuation. The calf compartment is also  helpful as is arm swing.  The hip flexor synergistic muscles are the quadriceps and abdominals while the hip extensor synergist is mainly the hamstring group.  This is certainly simplified since transaxial rotation through a vertical oriented axis does occur as a coupled motion and thus we cannot talk about sagittal plane movements, or even frontal plane movements for that matter, without at least considering the effects of movement generation or stabilization by the hip intrinsics (gemelli, oburators, quadratus femoris, piriformis). 

The greatest body function in the sagittal plane is gait and many of the body’s compensations and conditions stem from alterations in hip joint function through this movement negotiation through the sagittal space.  For the therapist, clinician or trainer the greatest problem can be the body’s numerous back-up systems which compensate and share normal or abnormal loading.

The basis of gait evaluation needs to be based from a holistic perspective.  Gait cannot be evaluated without consideration of the entire organism. A minor functional limitation in the first metatarsophalangeal (MTP) joint can significantly impact hip, pelvic and spinal biomechanics.  The best and simplest example of this is the clinical scenario of hallux limitus.  We will entertain the equally devastating functional hallux limitus later on in the chapter but the point to note here is that a minor loss of the last few degrees of the normal MTP joint dorsiflexion (45-60 degrees is necessary, patient specific) can be devastating to sagittal plane motion of the body.  Even a loss of the last 5 degrees of this normal range, although appearing relatively normal on an examination and possibly without symptoms (ie. early stages of progression into a more noticable hallux limitus), can impact normal and efficient toe off.  If toe off is early, even to a small degree, then the stance phase will be abbreviated via early heel rise.  If heel rise is early this creates a functional change in the kinetic chain, both open chain and closed chain.  There are many closed chain changes that will occur. One such change might be toe off propulsion forces being imparted through a more flexed tibiofemoral joint (knee) which will impart both translatory shear forces in the sagittal plane and torsional forces through the joint, both causing potential maceration effects on the menisci.  However, perhaps the easiest functional changes to understand are the changes at the hip.  It is well known on EMG studies that hip flexion is both an active and passive motion during gait.  The active flexion of the hip is generated largely by iliopsoas concentric contraction.  However, this is not the first mechanism to generate hip flexion.  In fact, hip flexion is first generated passively through engagement of the kinetic chain.  The first movement of the swing phase is rotational or torsional activation of the oblique pelvis through core activiation of the abdominal muscle group.  Through activation of the internal and external abdominal obliques and transversus abdominus, in addition to activation of their synergists and cocontration of their antagonistic stabilizers, the obliqued pelvis is rotated.  Better said, the trailing leg’s lagging pelvis is moved forward by contract of the synergistic oblique activation.  This forward movement generates a sagittal momentum and movement of the toe off leg.  Once movement is generated then the iliopsoas activates concentrically to perpetuate hip flexion.  In other words, the ilopsoas is not an initiator of hip flexion, rather, a perpetuator.  When hallux limitus limits the stride length via early generation of heel rise the pelvic obliquity is limited.  As a result, the degree of initial swing phase leg movement is less from the generation of pelvis de-rotation via abdominal activation and more through ill-directed iliopsoas hip flexion.  Thus, as hip flexion still needs to occur, the iliopsoas is called upon to compensate; it now becomes a hip flexion initiator as well as its previous function of hip flexion perpetuator.  This demand is minimal but with repetitive demand thousands of steps per day, the iliopsoas eventually looses its ability to continue these compensations, as does its now over burdened synergists.  The result is either hypertrophy, inhibition, hypertonicity, spasm, shortening, insertional tendonitis, origin tendonitis or a combination thereof but make no mistake, such burden will eventually cause dysfunction within the muscle itself or within its synergists or antagonistic pair.  The scenario may result in either joint dysfunction at the lumbar spine near the muscle’s origin, at the sacroiliac joint over which it crosses, or at the hip joint proper.  The ensuing joint derangement or dysfunction is complex and creates numerous compensation patterns locally and globally since the main function of the muscle is to create hip flexion, external rotation, and abduction in the open kinetic chain and trunk flexion and trunk internal rotation in the closed kinetic chain. In a nutshell, the loss of dorsiflexion of the hallux, even to a minor degree, must be made up somewhere in the sagittal plane.  If it is not immediately made up for at the more proximal joints (1st metatarsal-midfoot joint, talo-navicular, ankle mortise-tibiotalar, or knee) the hip will undoubtedly change its function as described above to compensate, it is well suited to do so.  Keep in mind that such compensations may be better suited at the ankle, knee or hip depending on the degree of hip ante/retrotorsion or tibial internal/external torsion if present but none the less these compensations have consequences to changes in function of muscles either eccentrically, isometrically or concentrically or by recruiting assistance from synergists or antagonistic groups.  Additionally, a person with a very flexible midtarsal joint may stop the more proximal compensations via restoration of the necessary first ray (first toe) complex dorsiflexion at that more immediately proximal joint complex. 

Shawn and Ivo (yup, that is Dr. Allen thinking he is a bad ass in the picture above, clay pigeon shooting and a cubano……. thinks he is Clint Eastwood or something. Regardless, don’t mess with The Gait Guys !).

Abnormal wear pattern on a Newton Shoe  
  Understanding what went wrong in this runner to cause unilateral Right shoe “toe off” wear pattern is important.  It happens alot.  Many times it doesn’t get this far but there is evidence on a shoe, more on one side, none the less.  It is quite often “What is wrong with the part/person that goes into a shoe”, than “the shoe itself”. It wasn’t the Newton Shoe in this case (it is almost never a shoe material issue), it was the limb attached to it. The shoes are the window to the gait cycle!   
  This is one of our running clients.  They presented with some right hamstring soreness and pain after longer runs.  There were no foot complaints, the shoe wear pattern was just something that we felt was interesting to share as it made sense with their clinical presentation.    
  Client clinically demonstrated:  
     inhibited right glute max  
  tight right quadriceps  
  weak right lower abdominals  
   Summary:   
  Subsequent to #1-3 above there was a loss of right hip extension, thus shortened right stride. When hip extension is limited the heel rise is premature and the calf engagement can be premature. When premature the calf is asked to lift the person during midstance instead of forward propulsion and its other activities during late midstance.   
  Premature heel rise, premature calf muscle engagement, premature foot plantarflexion all lead to greater pressure at the forefoot and thus through toe off……plus some hamstrings complaining as well !  
   Knowing your gait cycles, knowing which muscles should fire at a given time in the gait cycle, and knowing why they fire and what joints they stabilize is a valuable tool in diagnosis of a runners issues.  Of course, it would be very simple to say “hey, you are toeing off real hard on that right side”.  “BRILLIANT SHERLOCK ! ” would be our first response, there is nothing like stating the obvious.  But the how and why is where the brain actually needs to be engaged, and when it is, things can get very interesting and fun in figuring out what is going on in athletes and patients. Knowing how and why things happen allows you to fix the problem.  And in this case if you are attempting to fix this person at the level of the foot you are missing the true problem originating at the hip.  And when you know the origin of the problem in this case, you also get a new shoe wear pattern for the next shoes and best of all, you conquer a chronic  hamstring problem as well.   
   Shawn and Ivo………. Pipe smoking English sleuths…….. (OK, we are good at the board game CLUE and nothing more, who are we kidding !)

Abnormal wear pattern on a Newton Shoe

Understanding what went wrong in this runner to cause unilateral Right shoe “toe off” wear pattern is important.  It happens alot.  Many times it doesn’t get this far but there is evidence on a shoe, more on one side, none the less.  It is quite often “What is wrong with the part/person that goes into a shoe”, than “the shoe itself”. It wasn’t the Newton Shoe in this case (it is almost never a shoe material issue), it was the limb attached to it. The shoes are the window to the gait cycle!

This is one of our running clients.  They presented with some right hamstring soreness and pain after longer runs.  There were no foot complaints, the shoe wear pattern was just something that we felt was interesting to share as it made sense with their clinical presentation. 

Client clinically demonstrated:

  1. inhibited right glute max
  2. tight right quadriceps
  3. weak right lower abdominals

Summary:

Subsequent to #1-3 above there was a loss of right hip extension, thus shortened right stride. When hip extension is limited the heel rise is premature and the calf engagement can be premature. When premature the calf is asked to lift the person during midstance instead of forward propulsion and its other activities during late midstance.

Premature heel rise, premature calf muscle engagement, premature foot plantarflexion all lead to greater pressure at the forefoot and thus through toe off……plus some hamstrings complaining as well !


Knowing your gait cycles, knowing which muscles should fire at a given time in the gait cycle, and knowing why they fire and what joints they stabilize is a valuable tool in diagnosis of a runners issues.  Of course, it would be very simple to say “hey, you are toeing off real hard on that right side”.  “BRILLIANT SHERLOCK ! ” would be our first response, there is nothing like stating the obvious.  But the how and why is where the brain actually needs to be engaged, and when it is, things can get very interesting and fun in figuring out what is going on in athletes and patients. Knowing how and why things happen allows you to fix the problem.  And in this case if you are attempting to fix this person at the level of the foot you are missing the true problem originating at the hip.  And when you know the origin of the problem in this case, you also get a new shoe wear pattern for the next shoes and best of all, you conquer a chronic  hamstring problem as well.


Shawn and Ivo………. Pipe smoking English sleuths…….. (OK, we are good at the board game CLUE and nothing more, who are we kidding !)


Part 2 of the EHB: Bringing the Extensor Hallucis Brevis of the Foot Back to Life.

Today we show you a proprietary exercise we developed here at The Gait Guys. It was developed out of necessity for those clients who are too EHL dominant (long big toe extensor muscle) and big toe short flexor dominant (FHB). These two muscles are what we call a foot functional pair.  Big toes like these will be dysfunctional and will not be able to gain sufficient purchase on the ground to produce stability and power without impacting the joint (1st metatarsophalangeal joint).  Imbalances like these lead to altered joint loading responses and can be a possible predictor for premature damage to the joint over time. These imbalances are also what lead to injuries to the big toe, the arch and other areas of the foot. After all, when the big is weak or dysfunctional gait will be compensated.  When imbalance at this joint occurs because of EHB weakness the medial tripod anchor (the head of the 1st metatarsal) is compromised possibly transmitting stress into the foot, arch and medial stabilizers such as the tibialis posterior for example.

This exercise is to be weaned back to less and less yellow band resistance until the EHB can be engaged on its own. Then the gait retraining must begin. Simply reactivating and strengthening the skill and muscle is not enough. The pattern must be then taken to the floor and learned how to be used in the gait cycle.

Do we need to mention the critical function this muscle plays in extension of the 1st MPJ, of its importance in hallux rigidus/limitus, in bunions, hallux valgus, toe off function, arch height and function ? We hope not.

It is a process restoring gait. All too often the “Devil is in the Details”.
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Shawn and Ivo
The Gait Guys

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