Email from a reader: Chronic IT Band and Plantar Fasciitis

I have been reviewing your Youtube videos and blog posts over the last few weeks, I am a triathlete suffering from plantar fasciitis and ITB issues, and I’m not really close to a major center where I can get treatment so I’m self educating. I’m very interested in the videos you have about function of the foot, and how the toes relate to the arch, fascinating! You mention exercises for the feet, to help the muscles function and learn to work separately. I was wondering if you have any of these exercises posted online, I am not able to hold the arch position or use my toes separately, I think these movements would go a long way to helping me figure why I’m having issues with the PF. Great job on all the info, I love being able to access info like you guys have online, makes me want to learn more… thanks!!
 
 
Becky H
AB, Canada
_______________________
Dear Becky:
Sorry to hear about your chronic issues.  Make sure you evaluate your glutes. The pelvis must remain relatively quiet and not tip forward or backward (anterior or posterior tilt) during all forms of ambulation. When it tips more forward the glutes become challenged and can become inhibited. When inhibited internal rotation of the hip minimizes or is lost and the ITBand tightens to attempt to drive that internal rotation. It is a good internal rotator as is the anterior g. medius and coccygeal division of the glute maximus (hence the glute connection).  This will put stain on the patellofemoral joint and may cause tracking issues or lateral knee regional pain (or ELPS….. excessive lateral patellar pressure syndrome).  Additionally, when the foot tries to pronate more to drive more internal limb rotation (because it is obviously not happening at the hip in this scenario) the plantar fascia can become strained because of the pronation lengthening of the longitudinal arch of the foot.
Regarding the foot exercises……. they are coming….. we just need time. We would pay for more time, but we cannot seem to find it on amazon or ebay.  If anyone is selling, we will line up to buy !
thanks for your email question.
Keep the emails coming. Those of you who have emailed us recently or in the past, we  have received them and they are being answered in length in the podcasts we are about to launch. They are coming, you will love them.  It just comes down to editing time.  There is that “time” word again !

A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools 3/4 foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.
Jim

______________________

Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo

_______________________

Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.
Jim

_________________________________

You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo

A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools 3/4 foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.
Jim

______________________

Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo

_______________________

Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.
Jim

_________________________________

You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo

The Chef: Another abnormal gait pattern in celebrity chef and The Travel Channel’s Anthony Bourdain.

It was just a few nights ago after a 13  hour day with patients that I got home and climbed into bed, looking forward to flipping through channels to find something to alter my brainwave state. I needed to find something that would allow me to dial down into a slumber.  Much to my happiness I found one of my favorite shows, “No Reservations” with my favorite chef.  I get a real kick out of Tony. This is one smart dude. He is pretty slick with the english language.  Did you ever get to read his New
York Times best seller “Kitchen Confidential”?  What a killer book. We recommend the audio book read by the author himself.  It turned the restaurant scene upside down.  Has anyone ever told you not to order fish Monday through Thursday ? It is all in the book.  Why else do I love Bourdain?  His command of the english language is exceptional, and creative.  For example, he once said, “what would it be like to be a meat-filled Pinata at a Pit Bull convention?”.  Things like that stick with you.

Anyhow, so there I am lying in bed dozing off, listening to Bourdain talk about Mozambique and there he is in all his slender glory walking down the street with his sidekick Samir.  “Red Alert, Red Alert ! “  The clinical brain snaps back on.  Dammit !  Knowing very well I had to rewind the cable box to see it again, but knowing I was slowly descending into deeper brainwaves, I quickly rewind and grab my iphone to record the gait you see above.  You see, when you are a gait nerd like us, nothing escapes you when it is this obviously wrong. It is a disease; trust us.  We cannot go anywhere anymore without noticing pathologic gait.  It appears we cannot even watch a cooking show. And since we live on a planet where everyone walks, it must be a penance for something we must have done in another life.

Onto Bourdain’s gait. 

Look at Tony’s circumducting feet compared to Samirs (on the right).  Samir clearly engages pelvis lift on the swing leg side which is typically brought on by engagement of the hip abductors (g. medius) on the stance leg side. This lift on the swing side allows the swing leg to have ample room to pendulum through without having to prostitute the knee or foot posturing.  The knee and foot simply sagittally hinge through, this is economical gait.

Bourdain on the other hand shows little if any swing side pelvis lift driven by stance leg hip gluteus medius engagement.  This creates a clearance problem for the pendulum swing leg.  So now the problem becomes how to get the leg to swing through without catching the toes and foot. You must create clearance. Clearance can be obtained by:

  1. generating opposite  hip abduction forcing the swing leg hemi-pelvis to lift
  2. increasing hip flexion which will initiate a steppage gait. This will be combined with increased knee flexion. This is productive and necessary if you are climbing stairs or trying to unload a painful turf toe near the end of stance phase push off.  When seen in normal walking gait it may represent neurologic pathology.  But folks with hip problems or weakness will use it to get around to avoid tripping.
  3. circumduct the swing leg hip. The act of swinging the leg outward and around will eat up the leg length.
  4. circumduct the foot.

Bourdain is doing #4. It is a pretty lazy gait strategy, you can see it is lazy. It probably requires very little energy to flip the foot outside the normal ankle dorsiflexion foot swing progression.  What must be the cost to activating the peronei and the lateral toe extensors to flip that foot around like that ? Sure you can see that the knees are for a moment carried outside the sagittal plane but who cares, right ? 

There are a couple of concerns. One is that failure on a single step to generate sufficient foot/ankle circumduction will result in a foot catch and a fall.  Another is the trouble in always getting that circumducting foot to land precisely in the near sagittal plane. When you move the foot on an arc you really only have a narrow target to land the foot within the 5-15degree landing zone. Circumduct too far and the foot is in-toed and more rigid due to it being supinated during midstance, circumduct too little and the foot is more out-toed and increased pronation risk increases.  This goes for running as well.

Go back and watch Samir’s walk. Clean and done right, the swing leg is a passive pendulum. Tony’s is obviously different. Who knows, maybe he has bad hips ? Maybe it was always a struggle to walk normally. He is 6’4” so we cannot blame it on excessive height unless he lives in a house that has 6 foot ceilings, because then his strategy would be our gait of choice. It would be the only one that would effectively work !  Maybe that is it. Maybe he lives in Smallville ?

We don’t think so.  The only for sure way to know would be to get him on our exam table and see what parts he is not using. We would put big money on weak gluteus medius, bilaterally.  It is the one we see most often in this abnormal gait pattern.

Shawn and Ivo, tortured gait observers in a world of ambulatory pathology.

Welcome to our hell.