EHB: Extensor Hallucis Brevis

Did you know that the EHB (extensor hallucis brevis) the topic of today’s video tutorial, originates off of the forepart of the medial aspect of calcaneus & lateral talocalcaneal ligament. It is just above the bulk origin of the EDB (extensor digitorum brevis). It is frequently torn/strained in ankle inversion sprains and frequently goes undiagnosed. It can be torn/avulsed from the bone if the inversion sprain is focused below the lateral ankle joint. This occurs mostly when the foot is more plantarflexed before the inversion event. A foot cannot afford to have an impaired big toe ! Don’t miss this one !

Today, something a little different.  I worked for the world famous Joffrey Ballet Dance company on an off for a few years treating the dancers before shows and productions.  These folks always had the most amazing strength (try this one ! bet you cannot do it……in fact, don’t try it…..you will probably dislocate your MTP (metatarsophalangeal joint; the big knuckle joint) of the big toe.)

These folks also had many problems with their hips, knees and spine mechanics from the demands of turn out, jumping, overuse and the demands of things like en pointe.  This is an example of what is referred to as “en pointe” which means “on the tip”.  There is “demi pointe” which means on the ball of the foot which is much safer and we will do another video on that another time to explain some critical components to it right, there is more to it than just getting up on the ball of your foot.

En Pointe is a  terrible challenge in our opinion. So if you are thinking of putting your darling children in ballet…… just beware of the facts and do some logical thinking on your own.

En pointe or classical point ballet it typically done in point shoes or slippers which have a reinforced toe box that allows a more squared off stable surface to stand in pointe position.  It does not however allow a reduction in the axial loading that you see in this video and it certainly does not help with proper angulation of the big toe, if anything the slipper will gently corral the toes together rendering abductor hallucis muscle function nearly obsolete.   The box will also not stop the valgus loading that typically occurs at the joint as you see occurring here in her right foot if your joint line has a more aggressive angulation (genetics).  You can already see the deforming force that is creating a valgus toe position here. Despite what the studies say, this is one we would watch carefully.  Now, there are studies out there that do not support hallux valgus and bunion formation in dancers (see ** at end of this post).  However, we are just asking you to use common sense.  If you see a bunion forming, if the toe is getting chronically swollen, if the toe is drifting off line then one must use common sense and assume that the load is exceeding joint integrity.  Prolonged and excessive loading of any joint cartilage is likely to create a risky environment to crack, fissure, wear down or damage the cartilage or the bony surface underneath (subchondral bone).  So, if you think that loading your entire body mass axially on the small joint surface of the big toe is a great idea, that is fine, just do not bring your kids to our office and expect to get a happy face sticker at the check out counter.  We are going to read you the risks that are born from logical thinking.  This is not meant in any way to take away from the amazing feat that this is for dancers, but it just is not a smart thing to do if you want a healthy first joint (MPJ – metatarsophalangeal joint) and foot for that matter. After all, if you screw up this joint, toe off will be impaired and thus the windlass effect at the joint will be impaired thus leading to a multitude of other dysfunctional foot issues.

Now, back to the “en pointe” position.  Did you try it yet ? Heed our warning ! Just trust us, this is bloody hard.  Since serious foot deformities can result from starting pointe too early, pre-professional students do not usually begin dancing en pointe until after the age of 10 or so , remember, the adolescent foot has not completed its bone ossification and the bone growth plates have not closed.  Thus, damage and deformity are to be expected if done at too young an age.  If you asked our opinion on this, we would say to wait until at least the mid-teenage years……. but by that point in the dance world a prodigy would miss her or his opportunity.  Thus, we see the problems from going “en pointe” too early in many. In the dance world, there are other qualifications for dancers before En Pointe is begun, things like holding turnout, combining center combinations, secure and stable releve etc. 

 

Achieving en pointe is a process.  There is a progression to get to it.  Every teacher has their own methods but it is not a “just get up on your toes” kind of thing. 

Shawn & Ivo……. Dreaming of Sugar Plum fairies…….. (ok, maybe not)  but knowing your biomechanics of the foot and gait are an integral part of dance as well.

* and after watching this video, if your next thought was……” I wonder what the incidence of posterior ankle impingement injures occur in dancers” or if you said under your breath……. “hey, extreme plantarflexion at the ankle loads the Lisfranc joint pathomechanically ….. I wonder if that joint is ever an issue in dancers……. ?”   then you will clearly be on the route to becoming one of……… The Gait Guys

____________________________________________________________

** Hallux Valgus in Dancers. A Myth ? 

Abstract: Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.

[Sequential lateral soft-tissue release of the big toe: an anatomic trial]. Z Orthop Unfall. 2007 May-Jun;145(3):322-6. Roth KE, Waldecker U, Meurer A.Source: Abteilung für Orthopädie, Universitätsklinik Mainz. roth@orthopaedie.klinik.uni-mainz.de ___________ Summary:  Dr. Ivo in his brief video today discussed the altering of the origin/insertion effects on the adductor hallucis and the big toe.  When the first metatarsal is not anchored on the ground the lateral toes cannot be pulled towards the medial foot, instead the lateral foot acts as the anchor and the big toe/hallux is pulled laterally towards the anchor rendering the all famous bunion/hallux valgus. This surgical study pretty much proves this principle. This study showed that when the soft tissues (capsule, tendon and ligament) are surgically released, the contractile affects on the joint angle of the bunion/hallux valgus are released and the hallux valgus angle was predominantly and significantly improved.  A significant correction of the intermetatarsal angle did not take place however. Kind of a radical procedure ultimately destabilizing the joint and medial foot structure…….but hey……whatever floats your surgical boat.  To each his own.  We suppose that on a case by case basis all options need to be considered. ……we’re still the gait guys…….. with no scalpels, but with big oars

More on Bunions: proof we know what we are talking about

Although the study did not analyze the association between shoe fit and hallux valgus angle, it did find that 79.7% of 153 children had hallux valgus angles of 5º or more. An angle of more than 15º is typically considered clinically abnormal.

The right fit matters, shoe studies suggest

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe

As promised. We fixed the volume.  Less hiss next time. Enjoy

Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch. Muscle specifically discussed are a team: FHB (flexor hallucis brevis), AbDuctor hallucis, and tibialis posterior. He discusses the functional anatomy, normal and pathologic movement patterns of the arch and first ray complex and big toe (hallux). His foot’s ability to show the optimal patterns for the arch and hallux are excellent examples. Follow up videos and DVDs will show more details you need to know, and some of the exercises he and Dr. Ivo Waerlop use to restore a foot that has lost these abilities. The DVDs are in the works. Take their lectures and CME on www.onlineCE.com. Visit them at www.thegaitguys.com and on their facebook PAGE & Twitter of the same name for daily feeds of unique things.