The foot tripod: the importance of the toe extensors in raising the arch.

* this is a two part series……. we have a great follow up video tomorrow that requires this video and blog post first.  So, wrap your head around these simple principles today and then we will apply them to a great runner and their video, tomorrow.

Stand up. Both feet on the floor. Close your eyes and raise your toes up off the floor, just the toes, and then let them fall. Pay great attention to what happens to your arch height as you raise and lower the toes. Yes, do this now. Then come sit down again and watch this video and read some more . Go !

What you should have noted, unless your foot is so flat and weak is that when you raise your toes off the floor (when standing or non-weight bearing actually) is that your arch should raise up. This lifting of the arch will improve your foot tripod ability (anchoring of the heads of the 1st and 5th metatarsal heads, with the heel at the 3rd point of the tripod) and it will shorten the longitudinal arch length. So, do you think that toe extension ability (range, skill, endurance AND STRENGTH) will play a significant part in treating plantar foot pain syndromes (plantar fascitis to name the most obvious and simple nemesis)? You better believe it ! Go ahead, prove us wrong.

In this video the young fella starts out with flat pes planus feet, increased foot progression angles (30 degree splay outwards) and excessive internal limb spin which is helping to drive the flat feet. 

For you clinical nerds, yes he could have external tibial torsion however, what you cannot see is that when we bring his feet back to neutral forward posturing and correct his arches his patella aligned forward and a squat test showed a pristine forward sagittal tracking.  Had it been a case of external tibial torsion, the knees would have been angled inwards and tracked medially, eventually knocking together. Again, this was not the case.

This was just a young boy with feet that had never learned the S.E.S (Skill, Endurance, Strength) of normal foot posture and intrinsic and extrinsic foot neuromuscular use.  Yes, we are once again harping on S.E.S.  It is critical that you get that SES concept down, in prior posts we have discussed the neurological logic to this progression via looking at nerve diameter/conductance. It is factual, not something we made up.

It took all of 1 week for this young man to gain this quick skill correction. On the  first visit we spent 20 minutes teaching him awareness of arch changes with toe extension use (the Windlass mechanism is engaged with Toe Extension) and awareness of the forefoot bipod contact points. We then followed that up with foot progression improvements to get his feel aligned better.  Soften the knee hyperextension that is frequent with pes planus and we were off to the races. Stage two for “Shuffle walks” was set, all he needed was this initial skill set, and you can see that in one week he had it nailed down to under a 1 second !!!!  Rock Star !!!  

He was now at our office to get the homework for the Endurance and Strength components. In this case, an orthotic had been attempted previously by other doctors but he still was not getting the skill set to find the corrected foot posturing on his own. Orthotics pre-position and offer a platform of correction to work off of, but you still have to earn the skill (unless you want to depend on orthotics for your whole life !).

We like the term Orthotic Therapy, meaning (when appropriate) use the device to help the process along when the client cannot find the pattern sufficiently.  It is clear in this case, this boy does not need the orthotic help he just needs the endurance and strength now that we have taught him the skill.  Sure, in basketball camp when he is focused on the ball the feet could use the help of an orthotic, but with the goal to earn his way from them in time. Some people with severe prontation control issues will always need the help. But our goal is to lessen the need and perhaps relegate the need to sports only. On the other hand, some people have such mild over-pronation issues, that this homework is sufficient to allow the orthotics to be tossed in the garbage.  Each case is different.

What is amusing is that in one week this boy practiced so hard and so much (as you can see) that he made me laugh at the end because it was clear he was already laying down the new skill pattern subconsicously, as noted by the fact that he was having troubles collapsing in the new tripod-neutral position.

Fixing flat feet. It is possible, not always , but often. You just have to know what your client has and what to do with it. Anyone can prescribe orthotics, be different, go the extra mile for your athletes and clients.

Start with working toe extensors and increase their awareness of what  happens with the arch when the toes go up and down. Teach them the tripod and then to integrate the two.  People will travel far and wide to find you if you master this stuff. We are honored that people fly in to see us from around the country. And when they see how simple a logical process can be, they wonder why they had to. But they are still happy they did.

Shawn and Ivo……. sometimes described as the fruit out on the far far branches (yes, maybe the ugly gnarly fruit) but we are still hanging tight to the branch none the less.   

Athlete with Plantar Fascitis

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

It has been a year, but this video is still as important as it ever was. Now that we have many of new viewers, perhaps they missed this one. It is always good to review. Enjoy !

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