Bunions

Dear Gait Guys:

if treated when still a child can you change a bunion without surgery? I have a young kid, 12, with a bilateral forefoot varus and bilateral bunions, he has started to compensate even through his hip and core already which I have been working on but wondered if, by retraining the foot, tripod exercises, lumbricals, interossei, can we actually change his foot? And do you have any other ways that I might be able to attack this foot in order to change it?

Thanks

J

Dear J

As we sure you are aware, bunions form from unopposed activity of the adductor hallicus. Normally, with an appropriate tripod, it serves to assist in forming the transverse and longitudinal arches of the foot during the stance phase of gait. When the 1st ray (in basic terms, the medial aspect of the foot) isn’t anchored, it acts unopposed and adducts the hallux instead, forming an abductovalgus deformity over time. This causes a medial shift of weight in the foot and the metatarsals to abduct to compensate for this. In other words, the big toe and medial tripod are supposed to be well anchored so that the lateral foot is pulled towards it. This forms the forefoot’s transverse arch. But when the medial tripod is not anchored, the lateral foot serves as the anchor and thus the big to is pulled towards that lateral anchor by the adductor hallucis muscle.

It is imperative that you restore function (and the ability) to fully descend the 1st ray (your child must relearn how to anchor that metatarsal head aspect of the tripod).  This is imperative for success.  We have a youtube video of a young child demonstrating how they learned this. You can often accomplish this with manual methods, mobilization, appropriate footwear and most importantly exercises to descend the 1st ray , particularly toe extensor exercises (both the EHB and the EHL which descend the head of the 1st). Sometimes, if the 1st ray is rigid and won’t descend, you will need to use an orthotic or a cork addition to their footbed with a Mortons toe extension to bring the ground up to the base of the 1st metatarsal.

It sounds like you are strengthening the core, which provides stability from above down. Pay close attention to the external rotators, as they will often be lengthened due to excessive internal rotation of the extremity.  But the key is restoring the skill, endurance and strength of those muscles that descend the head of the 1st metatarsal and that help reengage the medial tripod.

We hope this helps. PLease let us know

Ivo and Shawn

Think about what you are doing

“The bottom line is this. ….

For every impairment we detect, and for every altered movement pattern we see in our people (ie. more arm swing on one side, one shoulder dropped, one foot turned out etc…..) ……there is a good reason.

After 15 years of practice, here is what I have concluded.

There is a reason……and that reason must be one of avoidance of pain or threat (weakness, pending damage …..such as a subclinical developing tendonitis, cuff tear, tumor, infection etc) or, what you are seeing is the person’s strategy to compensate to avoid the above.  So, quite frequently, what you see is not the problem.  So, when you see your athlete/client doing something funky, or you lie them down and see an impaired ankle rocker or hip rotation, your VERY NEXT question should be “fact or fiction”….. Is this a true cause or is this a compensation ?  If what you do does not change it PERMANENTLY it was likely a secondary compensation, if you keep having to return to the same issue, you are not on the button so stop wasting your time.  That is not where the problem is most likely (unless some reasonable improvements in skill strength and endurance (SSE) make the change)……but……but…..BUT…..if you do work on the SSE and it improves the problem……the wise, savvy and awake coach, therapist etc must ask the hard question, “OK, so, did I really fix that or just lay enough SSE to mask the problem.  You can see that this can be a vicious cycle of self questioning.  So if any of you wonder why our hair has fallen out then you now know the true frustrations we go through every 45 minutes of very day with our clients.  “Did i fix it or mask it ?????”  Only time has the answer.

Here is a clue to help you……

If your client stops the homework and the improvements remain long term, without the development of NEW compensations and new injuries, then you got it.  But, if your client’s response was, “this tightened up today, and this was sore today, and this hurt during the first 10m…..etc” then you have to cast a jaundiced eye at what you did, and ask the hard questions.

For in reality if  you are doing the right things for  your client for the right reasons they should get healthier and less injury prone and have fewer complaints.  You should have a brethren of athletes that are all injury free, top shape, top of their game, and each workout should show improvements in skill strength and endurance in a balanced fashion…..”super athletes” if you will.  Some might argue that a hard workout can trigger any injury but I disagree.  A hard workout should trigger physiological advancements, not neurophysiological and neuromuscular setbacks.  The more appropriate muscle tone, range of motion in a joint and its accessory joints, the more competent the regional anchoring muscles are, and  when each component is doing its thing correctly, not borrowing things from others beside it, then this body should be humming like a new motor with freedom to tromp of the accelerator and push it to the floor without hesitation or risk.

But, if you keep cycling injuries, and new ones keep cropping up despite more exercise homework, more rehab, more stretching , more warm-up, etc then you are just MANAGING the issue and adding layers of compensation to your athlete/client.  You effectively raise the capacity of the compensated system but you do not narrow the gap between the asymmetries in the body that drove the compensation and the injury.

All we ask is for you all to think.  Think often, think deeply. Think about what you are doing.  And always ask, “Did I fix that or did I help them to add another layer of compensation ?”.  The body is pretty amazing and resilient, it will make fast immediate and profound changes if given the right recipe and it will complain if it does not like it.  Pain and altering its strategies (weakness, inhibition, loss of ROM etc) are its only ways to communicate with you and its owner.   If you are not listening to its silent dialogue, paying attention its detailed expressions (range of motion loss, tightness, soreness, weakness) then you are doomed to be just like all the others in your field…..and frankly mediocrity doesn’t get you or your client the gold medal !

The fact of the matter is this…..if it was easy to fix things on this human body (Hey, Mr. Jones….when you walk just keep thinking about turning in that right foot and swing that left arm a little more.”) I would like to think that guys like us would have figured it out by now and would have stopped making things more difficult. We would have written “the Bible” on this stuff and with its worldwide proceeds we would be sailing on a nice big yacht in the middle of the Caribbean drinking beer with Jimmy Buffet.  But since you have not seen that book yet and because Ivo and I are still pasty white with meager sized livers you can only assume that we are still on the journey just like you guys.  But, each day we hope to be one step closer.  Hang with us, we hope to get there before we are too old or before Jimmy is 6 feet under !

Cheers

Shawn and Ivo

It’s hard to follow Sandra Bullock in high heels. She wasn’t available for today’s Neuromechanics video, so we used someone cute instead. Today  Dr Ivo talks about 5 things to remember about proprioception when looking at gait.