Month: March 2012

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.

(Source: http://www.youtube.com/)

Tibialis posterior

A question from one of our readers:

Hi guys,

What are your favourite tib post strengthening exercises or do you usually stay with the anterior strength work?

Thanks

D

Our Response:

Hi,
Thanks for your question. As you know the tibialis posterior muscle from the interosseous membrane, lateral part of the posterior surface of the tibia, and superior two-thirds of the medial surface of the fibula. It travels between the flexor digitorum longus and flexor hallucis longus to insert into the tuberosity of the navicular, cuneiforms, cuboid, and the bases of the 2-4th metatarsals.

The function of the tibialis posterior is one of ankle plantar flexion, calcaneal inversion and plantar flexion as well as stabilization (through compression) of the first ray complex (talus, medial cuneiform, navicular and base of the first metatarsal). It acts additionally to help decelerate subtalar pronation. Further stabilization of the midfoot comes from smaller tendon slips inserting onto the other cuneiforms, metatarsals, the cuboid and the peroneus longus tendon.

The more common problems that can occur with the tibialis posterior complex are those of muscular strain, tendonitis, tendon insufficiency (stretch) and partial or complete tears. Excessive or prolonged pronation causes excessive dorsiflexion of the distal first ray complex, increased pronatory effects, and as discussed above, dysfunction of the 1st MPJ joint. The dorsiflexed 1st toe will compromised the efficiency of the windlass mechanism which “winds up” the plantar fascia, properly positions the paired sesamoids, and thus limit effective dorsiflexion of the 1st MPJ. This dorsiflexion of the first ray requires the tibialis posterior to undergo excessive eccentric load for a longer period of time, thus placing more stress on the tendon and muscle belly.

Clinically we find that more people are flexor driven. Therefore we work quite a bit with increasing extensor function, thus a lot of our rehab protocals involve strengthing Anterior Tib as opposed to Posterior Tib. To this one must ask what is your criterior for strengthening the posterior tib, if over pronation or navicular drop has led you to this conclusion then you may want to reexamine the clinical findings for what muscles may actually be involved.

That being said, there times when it is clinically necessary to strengthen the Posterior Tibialis muscle and we like the following exercises

1. Single Leg Balance with Arch Supports:
Begin standing on one foot. Attempt to raise the medial longitudinal arch and hold in tact while maintaining the body stable over the foot.
2. Single Leg Balance with Arm Swings
Perform the exercise above and add to it multi planar arm swings while maintaining medial arch integrity and balance. Cross body arm swings that generate torso rotation, and simulated axe and pitching motion with each arm are effective motions to use.
3. Seated Forefoot Adduction and Inversion
This exercises utilizes some sort of resistive device such as a theraband that will wrap around the forefoot to attach somewhere lateral to the body creating lateral resistance. while stabilizing the ipsilateral knee with the contralateral hand the exercise is performed by adducting the forefoot against resistance towards the midline.
4. Inverted Calf raises
This exercise is performed standing. it should be started as a double support exercise and can be transitioned into a single support for added challenge. the exercise is performed by performing a standard calf raise with or with out Y-axis resistance and adding an inverted moment at the apex of the raise and then lowering back down.
5. Closed Chain Unilateral Supination
Standing on one leg on a step with the knee slightly flexed and the medial border of the foot over the edge of the step. Exercise is performed by lowering and lifting the arch from pronation to supination.

6. Now perform the sequence with appropriate arch intergrity WITHOUT the arch supports

These exercises should get you started. Good luck and let us know if you have any other questions.

The Gait Guys

In this great little slow mo video we see some things. Do you ? … The Perfect Runner.

1. First clips….. awesome toe extension through the entire swing phase all the way into early contact phase.  You have read here before on our blog entries how critical toe extension is for stable and optimal arch contruction prior to foot loading. Suboptimal arch height can mean that pronation loading occurs in a suboptimal foot tripod posturing and can mean difficulties controlling the normal end point where pronation should stop and convert back into supination to ensure rigid toe off.  (It is kind of like two runners in a 100m sprint. One starts at the line off the blocks and the other gets to start 1 second earlier 10 meters back from the line and gain speed towards the line before the gun goes off.  This is what it is like to start pronation prematurely, or with a suboptimal arch, the starting line where things are fair to all parts has been moved. The foot (the other guy in the race) doesnt have a chance.  Maybe a bad example but you catch the drift we’re surfin’ here.)  Back to our point, Niobe has great running form and great technicals.  Great midfoot strike, yes a little forefoot here but that is what happens when you are barefoot naked on hard surfaces. You have to get good form before you can clean up the technicals.  We spend alot of time on the technicals of running once form is clean. It is what makes the difference between 2nd place and a winner. And it is these little things that mushroom into nagging injuries over time.  We cannot express enough how important toe extension range and strength is for proper foot function and a strong neutral foot tripod.  We rarely have to address long toe flexor strength, short flexor strength yes, but not long.  Toe curls, towel scrunches, picking up stuff is not on our list of homework.

2. Second clip. He is skirting the issue of cross over without going too far. He could do a bit better but all in all pretty decent.

3. Emmanual Pairs, big dude ! No cross over. Awesome form.

4. Krysha Bailey. Long jumper. As with all sprinters, no cross over, beautiful form.

Just some easy topics and viewing for a Saturday blog post.

Have a good day brethren !

Shawn and Ivo

(Source: http://player.vimeo.com/)