Extensor Hallucis Brevis Case Treatment

EHB CASE treatment: For this particular case we used simple stuff. In more complex cases we will add Western Acupuncture methods as well. But in this case we used the simplest of methods ……. a blend of MAT, AMIT, followed by graded iso’s every 15degrees over and over again in multiple vectors integrating larger and further reaching muscle groups. For example, first simple hallux extension at the interphalangeal joint, then combine that with foot dorsiflexion, then combine those 2 with ankle inversion (so all 3 now), then added hip abduction and then lateral trunk flexion (abs, paraspinals, QL etc) to those. This took care of ramping up the local motor pattern and the longer more complex chain motor patterns that were primary in that particular injury (ie. almost pure frontal plane failure in this case, from what showed up weak on the neuromuscular assessment). Just reteaching the brain how to reintegrate that EHB back onto the field with the rest of the team. It came back fast and complete. No need to use a jackhammer when a simple mallet was sufficient this time around. hope that helps.

It is Fun Friday Follies time. Enjoy a great actor moving with finesse and style. Great footwork too. Walken initially trained as a dancer in music theatre at the Washington Dance Studio before moving on to dramatic roles in theatre and then film.

This was a classic on MTV at one time.

Gait / Running Injury: Misdiagnosed Big Toe Extensor Hallucis Brevis tear in a distance runner from a simple ankle sprain.

* Sorry for the less than perfect video. Need some editing time.  Watch from 0:32 onwards for the topic at hand.

This young man, State caliber cross country runner, came in to see us after some unsuccessful treatment for an inversion ankle sprain several weeks prior. Although his swelling and range of motion had improved he was still having pain despite treatment.

On examination it was revealed that there was no loss of integrity of the lateral ligamentous restraints, no joint gapping was noted and the ligaments were non-tender. There was no swelling. Balance was clean. Even the immediate local lateral ankle muscular restraints, largely peronei, were competent with skill, endurance and strength assessment.

After further pointed discussion, after the ankle was cleared as a causative /symptomatic generator, we insisted the patient be more specific with his pain region. After requesting he palpate around to focalize the area of complaint this time he pointed not to his lateral ankle but rather pointed to the lateral dorsum of the foot over the fleshy mass of the short extensor muscle group just distal and anterior to the lateral malleolus. Inversion of the ankle was pain free but inversion of the forefoot on the rearfoot reproduced his pain pin point to the EHB (extensor hallucis origin area).

Upon reassessing his gait it was now obvious that he was unable to engage the left hallux (big toe) extensors. You can clearly see his lack of toe extension (lift) on the video at 0:32 seconds. When consciously requested to do so it immediately reproduced his pain ! If you look very carefully, that the hallux was not extending during swing phase through midstance contact phases of gait.

After specific muscle testing found only the EHB (extensor hallucis brevis) weak and not the EDB at all (extensor digitorum brevis) we began a few minutes of manual therapy to the EHB. Within ~5 -10 minutes the EHB was painfree and he could engage the muscle again actively. The muscle was clearly healed from it low grade strain, he was just unable to reactivate it during the gait cycle. Post treatment, he was able to walk immediately with much less pain and with ability to use the EHB in gait.

We followed up a second visit with him but he was pain free and was discharged from care. There were no gait compensations and screens for functional sensory motor compensations were unremarkable. Case closed.

Good results come from a precision diagnosis which can only come from a sound base of knowledge of anatomy, physiology and biomechanics …. when it comes to this kinda stuff.  Would you have picked this up on someone’s gait ? We didn’t at first.  Use your clinical examination to drive your suspicions in your gait analysis. What you see is not always what you get during gait analysis, this easily could have been a similar presentation of a hallux limitus.

Details, details, details. The devil is in the details, The proof is in the pudding……. etc.

Shawn & Ivo

Of gait, running and waffles: No we are not talking about carb loading today.

define: Waffling (verb):  waf-fle .   To speak or write, esp. at great length, without saying anything important or useful.

Far too often we read articles and blog posts on what could be great topics but all to often they are just another spin on the latest craze or never really amount to anything useful. Our time is valuable, and so is yours. I mean, really, enough barefoot articles already ! If you are going to write something about barefoot running or minimalism it has come time to put a new spin on it. Find something with vitality to add to it. Find the next dimension for God’s sake.  Stop waffling around !

One of our favorite things early every morning before the rest of the world opens their eyes, is to read Seth Godin’s blog. He is short, sweet and to the point. They are skull crushers sometimes, they are reality checks. We got the waffle idea from his blog yesterday. And today, found at the bottom, we paraphrased his mountain discussion.  

We pride ourselves here at The Gait Guys to try and push the limits every day. The two of us, learn from each other with every phone call and every blog post. It is common dialogue to say, “Dude, I learned alot from your blog post today, thanks man !” Sadly it is often followed up with, “Are we the only ones that get excited about this stuff ?”.  Some days we just get frustrated. Clinically, we see stuff missed every day by other therapists, doctors, trainers etc.  And that is ok, we miss stuff too. We are students as well. We try to honor our limits.  The most honest and respectful thing you can do for your patient, your client, or the guy coming in for a new pair of shoes, is to say “Wow, I really do not feel comfortable assisting you. This is a little beyond my expertise level. I am going to refer you to a colleague who will know just what to do with this to help you out.”  A referral to the next level is always a relationship builder. it builds trust with your client and with your level-up referral.  It is the right thing to do. It is easy to try to fit every case and client that comes into your store, clinic or gym into the common mold. Into the same things you do day in and day out.  But that is not being honest with yourself or your client and their needs; Seth Godin said it perfectly in his post today, we will get to that in a moment.

Everyone (ok, almost everyone) walks on two feet in this world. They walk into your establishment.  Did you see it ? Did you see how they moved when they were causal and did not think you were looking.  That is the time to grab their gait pattern and imprint it into your head.  That is the time they are showing their best compensation for their problems. That is the time they either have on, or do not have on, their glasses.  How do they carry their purse, their briefcase ? They are in their most natural form.  They are not putting on a show and trying to give you their best interpretation of a good gait.  They are not on a treadmill with a camera on them. In our office we almost always stand at the front desk and turn to watch them saunter down the hall into a treatment room.  They are in their “day shoes” that could be too old, they are not in their new fresh workout shoes. (See the video above of a good friend, physician and just a great guy. He has a rare form of muscular dystrophy. He is an awesome smart doctor but even he was unaware of what his “day shoes” were truly doing to his gait. So we slapped him around a little, lovingly of course, and sent him off for new shoes.) When folks walk into your establishment it is when we  have them at their most natural, most vulnerable.  It is why we both love shopping malls and airports.  The most honest gait comes rising to the top.

Few walk well, many walk poorly. When the first thing that hits the ground does so improperly or does so in the wrong shoe for their foot type or anatomy the rest of the motor pattern is a compensation. Just because they have a flat foot does not mean that foot is weak and incompetent and needs an orthotic or stability shoe.  It just ain’t that simple, trust us.  Watch your people walk. It is the most fundamental movement pattern of all. Forget assessing their shoulder movement pattern looking for the golden key to their problem if their arm swing in gait is altered. Gait is the most repetitive and subconscious motor pattern we do all day long besides breathing (and even that one is done poorly by many folks). It is the one that is done for 4000-8000+ times a day. And if you are doing it wrong, in the wrong shoes, with the wrong skill set then it is part of the fundamental problem. We care that a client might have an impaired upper limb driver problem in a log-roll type motor pattern on your floor……but we often care more if they are not walking like an Egyptian (sorry, couldn’t resist) we mean walking with clean fundamental motor patterns.  Sure, the impaired body rolling could be the driver of the impaired gait, don’t try to catch us on that one.  If it is, then it could be part of the solution. We are just trying to drive home a point here. Thousands of bad steps is a mountain to climb to offset with some home exercises unrelated to the gait issue.  Why not get deeper into their gait, bring their awareness to a higher level, give them hourly corrective queue’s and see their problems unravel ? If the “log rolling” is in fact part of the solution then the gait should begin to clear up, if not, head back to the drawing board. Being good at gait issues is what we do. It is not hard, it just asks something more of you and it takes time. Analogy…  it asks so much more from us to undertake that long difficult arduous painful task of climbing up to the peak of that mountain when it would be so much more fun to turn around half way up and enjoy the effortless ride down on our backsides. Becoming good at gait analysis is first a painful task of 1000’s of hours of time studying anatomy, biomechanics and video footage. You are not offering gait analysis if you just buy a treadmill and a video camera. But after a few years, like anything else worth mastering (thank you Malcolm Gladwell), it becomes an almost effortless art form.

So, enough pseudo-waffling.  See how easy it is ! Sad isn’t it ?  Now spend the rest of the day with honest intent at truly looking at your client’s gait. And if you are a blogger or writer, step up and give us all something new and fresh. If you are trying to get the attention of all of us in the Gait Brethren here at The Gait Guys, with your next barefoot article, you had better start it with “This ain’t just another barefoot article….”. Stop waffling !  Go climb a fresh mountain for God’s sake, that one has been trampled to death !

Seth Godin (paraphrased from his blog today)…

“Repeating easy tasks again and again gets you not very far. Attacking only steep cliffs where no progress is made isn’t particularly effective either. No, the best path is an endless series of difficult (but achievable) hills. The craft of your career comes in picking the right hills. Hills just challenging enough that you can barely make it over. A series of hills becomes a mountain, and a series of mountains is a career.”

We are The Gait Guys…….and after yesterday’s blog post (if you read it) we are SEEING “all things gait” a little clearer.  Are you ? If you read our blog post (1/31/2012) you will know what we mean.  And if not, we have an old mountain out back for you to climb.

Shawn and Ivo ……… waffling and climbing……. at the same time.