“I’ll plead the 1st … .”   More foot geek stuff from The Gait Guys.

The 1st Ray that is!

The “1st ray” consists of the 1st metatarsal and the medial cunieform, essentially the long bones associated with the big toe. It is a functional unit we often refer to when discussing foot biomechanics.

You have heard us speak of the 1st ray needing to descend to form the medial tripod of the foot (tripod review: head of 1st metatarsal, head of 5th metetarsal, center of calcaneus). This action depends to some degree on the competency of the peroneus longus, which attaches from the upper lateral fibula and the associates interosseous membrane; curves around the lateral malleolus, crosses under the foot and attaches to the base of the 1st metatarsal and medial cunieform. The tibialis posterior is supportive to this action. This action is opposed (or modulated, for every Yin there is a Yang; it’s all about balance) is the tibialis anterior, which attaches to the top of the base of the 1st metatarsal and 1st cunieform.

As a result, 1st rays can be elevated or depressed. (here is a latin term to impress your friends with: Metatarsus Primus Elevatus, or elevation/dorsiflexion of the 1st ray/metatarsal). Clinically, we see more that are elevated, resulting in a faulty (collapsing) medial tripod of the foot. The important thing is isn’t necessarily its position, but rather its flexibility. The inflexible ones (isn’t it always?) are the problem children, because they result in altered (notice I didn’t say bad) biomechanics. The further we move from ideal, the closer we seem to move to some compensation pattern. The flexible ones are still a problem but we can control and dampen their rate of flexible collapse.

Generally speaking, a plantar flexed 1st ray that is rigid, has a tendency to throw your center of gravity (an often your knee) to the outside of the foot tripod (think of a rigid cavus foot) and a dorsiflexed to the inside of the foot tripod. Sure, there are LOTS of other factors, but we are talking in generalities here.

Look carefully at the images above and note the position of the 1st metatarsal heads. In the top set, the 1st is depressed (or plantarflexed). In the bottom set they are elevated (or dorsiflexed). Cool, eh? 

NOTE: please refrain from using the term “dropped metatarsal”. Nothing gets dropped, it is correctly stated as plantarflexed (rigid or flexible).

Be on the look out for these on your clinical exam.

Ivo and Shawn. Bringing you one step closer to foot geekdom each day!

copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will be plagued with the curse of Toelio…..

Podcast #16: Monkeys, Newton Shoes & Gait Vision

Gait, running, Newton Shoes, Forefoot Strike, Gait Software, limb torsion problems, foot tripod and lots more !

LINK: http://thegaitguys.libsyn.com/podcast-16-monkeys-newtons-gait-vision

Join us today for the following topic list and show note links:

Links to DVD’s & e-downloads: http://store.payloadz.com/results/results.asp?m=80204

1- scars of evolution:

Bigfoot blog post:    http://thegaitguys.tumblr.com/day/2011/11/05

Why gait must be taught slowly. Even running gait must be taught slowly.

2- email from a reader

wondering if you had any internal femoral torsion videos? I have been looking online and noticed most of the articles were on children with IFT. I have internal femoral rotation, a “winking patella” and I believe an externally rotated tibia? I am a runner and I am trying to find some more info on my awesome gait:) As you can imagine, I have had my fair share of injuries from running (hip, knee, and foot) and I have tried foam rolling but I am hoping you have some other recommendations

3- The Almighty Foot Tripod exercise – good for pronation of the foot

4- DISCLAIMER: We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors

5- Blog post we liked recently:  Perception/vision and Gait analysis software.

http://thegaitguys.tumblr.com/search/vision

2 blog posts here…….review them before the pod

The Observation Effect:   http://www.sciencedaily.com/releases/1998/02/980227055013.htm

6- SHOE TALK:   Skora Shoes
7- Our dvd’s and efile downloads
Are all on payloadz. Link is in the show notes.
Link: http://store.payloadz.com/results/results.asp?m=80204

The Foot Tripod; Part 2

Here we go. More stuff you can use today. Pay attention to the subtleties of this simple, yet effective exercise we use on a daily basis.

Have a great Friday

Ivo and Shawn

The Almighty Foot Tripod

You have heard us talk time and time again about the importance of the foot tripod. To review, it consists of the center of the calcaneus, the base of the 1st metatarsal and the base of the 5th metatarsal.  To see some of our other posts on the foot tripod, including other exercises, click here

Join Dr Ivo in this brief and informative video demonstrating an exercise that most people with an inadequate foot tripod will benefit from.

Remember Skill, Endurance and Strength. There are many nuances to this simple exercise, don’t take it lightly!

The Gait Guys: Hammering it out, daily, to give you the goods!

Is Your Foot Tripod Stable Enough to Walk or Run without Injury or Problem ?

The all to common case of the Wobbling Tripod.

Note the music we have chosen today. We tried to match the rate of the dancing tibialis anterior tendon to the tempo of the song, just for fun of course. Well, actually, for neurological reasons as well, as with a steady tempo or beat, your nervous system can learn better. Why do you think we teach kids songs to learn (or you can’t get the theme from the “Jetsons” out of your head).

This is a great video. This client has an obvious problem stabilizing the foot tripod during single leg stance as seen here.  There is also evidence of long term tripod problems by the degree of redness and size (although difficult to see on this plane of view) of the medial metatarsophalangeal (MTP) joint (the MPJ or big knuckle joint) just proximal to the big toe.  This is the area of the METatarsal head, the medial aspect of the foot tripod.

As this client moves slowly from stance into a mild single leg squat knee bend the challenges to the foot’s stability, the tripod, become obvious.  Stability is under duress. There is much frontal plane “Checking” or shifting and the tibial and body mass is rocking back and forth on a microscopic level as evidenced by the dancing tibialis tendon at the ankle level.  The medial foot tripod is loading and unloading multiple times a second. 

Is it any shock to you that this person has chronic foot problems which are exacerbated by running ?  Every time this foot hits the ground the foot is trying to find stability. The medial tripod fails and the big knuckle joint (the 1st MPJ or big toe joint) is enlarging from inflammation and early cartilage wear and decay, not to mention the knee falling medially as well!  Hallux limitus (turf toe) is subclinical at this time, but it is on the menu for a later date. A dorsal crown of osteophytes (the turf toe ridge on the top of the foot) is developing steadily, soon to block out the range necessary for adequate toe off in this client.  And that means a limitation in  hip extension sometime down the road (and premature heel rise……. did you read Wednesday’s blog post on that topic ?).

*addendum:

Take the time to develop the skill. We ask our clients to work on standing with the toes up to find a clean tripod and do some shallow squats working on holding the tripod quietly. Be sure your glutes are in charge. Then, again using the toes pressed flat but be sure the tripod is still valid, esp the medial tripod. No toe curling/hammering. Keep that glute on. Move the swing leg forward during a squat, and then behind you during a squat (mimicing early and late midstance phases of gait/running). This will help your brain realize when it needs this stability and it will also act to press you off balance and will make the foot check and challenge. Do this until you feel the foot fatigue on the bottom. Then Stop. Repeat later. If the medial tripod collapses, the knee will drop inwards and excess pronation is inevitable. We modified this with our prescription of the “100 ups”…..combine the two !

Shawn and Ivo … .  comfortably numb.

Once you have been to the Dark Side of the Moon  (and hopefully you didn’t have any Brain Damage) you will know it well and know what to expect when you return again.  Meaning, when you have seen these issues over and over again, hopefully in your daily work if not regularly here at The Gait Guys, you will quickly know what things to assess and look for in your athletes.  And you might just turn into a Pink Floyd fan at the same time, or at least crave some Figgy Pudding (but you have to eat yer’ meat! How can you have any pudding if you don’t eat  yer’ meat?).

The Toe Waving Exercise, Part 2

In part one of this series, we talked about the importance of the short flexors of the toes (FDB or flexor digitorum brevis) in forming and maintaining the foot tripod. In this installment, we discuss another important muscle used in this exercise,  the extensor digitorum longus (EDL).

We have shown you time and time again, dominance of the long flexors in gait, which cause biomechanical imbalances. We remember that through reciprocal inhibition, the log flexors will reciprocally inhibit the long extensors, so increased activity in the former, means decreased activity and activation in the latter.

The balanced activity of the long flexors and long extensors helps to create harmony during gait. Working the long extensors with this exercise (along with others, like tripod standing, toes up walking and the shuffle gait exercises) helps one to achieve this balance.

The Gait Guys; promoting foot and gait competency every day here, on Youtube, Facebook, Twitter, and in our offices and yours.

all material copyright 2012 The Homunculus Group/The Gait Guys. All rights reserved. If you rip off our stuff, you will never have an adequate foot tripod and will have gait problems for the remainder of your days.

The Toe Waving Exercise: Part 1

Welcome to Friday, Folks. A little exercise here for you today that we use all the time.

There are at least 3 muscles important in forming and maintaining the foot tripod. The short flexors of the lesser digits (Flexor Digitorum Brevis or FDB) are one of the important component sfor creating and maintaining the foot tripod (the tripod between the head of the 1st metatarsal, head of 5th metatarsal and center of calcaneus).

It arises by a narrow tendon from the medial process of the calcaneal tuberosity the plantar aponeurosis, and from the connective tissue between it and the adjacent muscles. As it passes forward, and divides into four tendons, one for each of the four lesser toes which divide into 2 slips ( to allow the long flexor tendons to pass through), unite and divides a second time, inserting into the sides of the second phalanx.

Because the axes of the tendons passe anterior to the metatarsal phaalngeal joint (MTP), they also provide an upward (or dorsal) movement of the MTP joint complex, moving it posterior (or dorsal) with respect to the 1st metatarsal heal (thus functionally moving the 1st met head “down”). This is a boon for people with a forefoot varus, as it can help create more mobility of the 1st ray, as well as help descend the head of 1st ray to form the medial tripod (and assist the peroneus longus in anchoring the base of the big toe). It also helps the lumbricals to promote flexion of the toes at the MTP, rather than the distal interphalangeal joint.

In this brief video, Dr Ivo explains the exercise to a patient (Thank you N, for allowing us to use this footage).

The Toe Wave: try it. Use it with your patients. Spread the tripod. We know you want to….

Ivo and Shawn


all material copyright 2012: The Homunculus Group/The Gait Guys

Part 2 of the EHB: Bringing the Extensor Hallucis Brevis of the Foot Back to Life.

Today we show you a proprietary exercise we developed here at The Gait Guys. It was developed out of necessity for those clients who are too EHL dominant (long big toe extensor muscle) and big toe short flexor dominant (FHB). These two muscles are what we call a foot functional pair.  Big toes like these will be dysfunctional and will not be able to gain sufficient purchase on the ground to produce stability and power without impacting the joint (1st metatarsophalangeal joint).  Imbalances like these lead to altered joint loading responses and can be a possible predictor for premature damage to the joint over time. These imbalances are also what lead to injuries to the big toe, the arch and other areas of the foot. After all, when the big is weak or dysfunctional gait will be compensated.  When imbalance at this joint occurs because of EHB weakness the medial tripod anchor (the head of the 1st metatarsal) is compromised possibly transmitting stress into the foot, arch and medial stabilizers such as the tibialis posterior for example.

This exercise is to be weaned back to less and less yellow band resistance until the EHB can be engaged on its own. Then the gait retraining must begin. Simply reactivating and strengthening the skill and muscle is not enough. The pattern must be then taken to the floor and learned how to be used in the gait cycle.

Do we need to mention the critical function this muscle plays in extension of the 1st MPJ, of its importance in hallux rigidus/limitus, in bunions, hallux valgus, toe off function, arch height and function ? We hope not.

It is a process restoring gait. All too often the “Devil is in the Details”.
If you liked this video, visit our daily blog: www.thegaitguys.tumblr.com
or our website: www.thegaitguys.com
See our other free videos here on youtube on our “The Gait Guys Channel”.
Or our other videos here: http://store.payloadz.com/results/results.asp?m=80204

Shawn and Ivo
The Gait Guys

all material copyright 2012 The Gait Guys/ The Homunculus Group: all rights reserved.

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Stage 1 of Correcting a flat foot, video demonstration.

Here is a case of a young man that was brought into us by his parents. Their concern was that their son was displaying what they thought was foot weakness. 

At the beginning of the video you can see that his foot progression angle is significant.  Certainly greater than the 10-15 degree “so called” normal range.  His arches are also somewhat collapsed. His knees were also displaying some hyperextension which is quite common with flat foot posturing.

This was his third visit into our office. He was given the corrective neuromuscular strategy that you see here and some specific exercises to help him get to this stage of correction.  The first stage of any correction is developing the awareness of what you are doing wrong (ie. become consciously aware of your incompetence). That was session one.  Session two focused on developing this corrective pattern, helping him find the skills to develop some conscious competence with a more normal foot stability skill pattern (endurance and strength still need to be added). 

Here you will see that, when queued, he immediately moves into a narrower base of stance (this will always happen when they can form a competent foot tripod, as you can see here).  In other words, the worse the foot collapse, the wider the feet will be positioned.  In his case, he now positions his feet under his hips and knees. 

You will also see the early success (after just 2 visits !) of a critical neuromuscular pattern.  He is showing some competence in holding the arch up and letting the toes move into flexion onto the ground.  Most flat footed children cannot separate “maintaining arch up, and moving into toes down”, rather they are into the pattern of “when the toes drop to the floor, the arch drops as well”.  This is a critical pattern (ability to hold arch up) to recognize and develop.  The child must develop the ability to independently flex and extend the toes on a static arch, while holding tripod,  before gait retraining can ensue.  This is mainly because the speed of gait and difficulty of single leg stance while displaying the correct pattern is just too much of a skill mastery issue. Often these pupils do not have enough hip frontal plane stability nor pelvic stability as well.

Also, note that he uses the skill of toe extension to help with arch height determination.  This goes right back to our blog posts last week on the Windlass Mechanism.  He is using the power of the windlass effect (toe extension) to take up the slack in the plantar fascial around the great toe metatarsal joint and thus pull the rear foot towards the forefoot (ie. raising the arch via this mechanism ! ).  Without a competent windlass a competent arch cannot be obtained (thus the ridiculousness of plantar fascial release surgery !).  Additionally, understanding the windlass and the effects of this simple video should give you insight into our success in quickly treating plantar fascitis. 

(addendum: also note at the end of the video that i ask him to collapse into his old pattern, this was after 30 minutes of corrective motor pattern exercises.  I laugh because in a solid posture that he shows at the end of the video, plus 30 minutes of new patterning, he found it difficult to find his old collapsed pattern.  This is a frequent occurance ! It gives you and the patient confidence that headway is being made.)

You must develop isometric, eccentric and concentric strength of the plantar intrinsic muscles that stabilize, raise, and control the lowering of the arch (as well as the arch controlling extrinsic muscles such as tibialis anterior and posterior among others) if you are going to make a difference in someones foot mechanics.  Just putting someone into a pair of ANY minimalist shoe (let alone barefoot) doesn’t guarantee strengthening of the foot or a remedy for a pair of feet like in this video. The process is a little more complicated than slipping on a pair of low ramp angle “shoes” and wearing them all day long…….in these types of cases all it does is raise their risk of injury or further foot incompetence down the road. 

For our fellow clinicians out there who are following us and trying to learn more about this kind of stuff……. wouldn’t your clinical world be nice if just prescribing a minimalist shoe would strengthen the foot in the correct pattern !?  We argue that, as in this kids foot, they would strengthen his foot in his poor postured patterns. So, we guess these companies are not lying when they say their shoes “strengthen” your feet, they just leave out the word “correctly”.

So, we do not argue with the point that going minimalist will strengthen your foot…… the question is “do you want to strengthen the correct pattern or a compensated one?”. 

here at The Gait Guys…….we know which pattern we want to strengthen.

We remain strong advocates that not all feet belong in minimalist shoes…… at least not initially, and some, never.  It would be nice if just slipping on a shoe could fix all of your foot problems, but it just isn’t that easy.  This is the topic no one is talking about, except The Gait Guys ……… because it doesn’t sell shoes.

There is much more to it than this video shows……. but we have to start somewhere.  Educating you with the issues we feel passionate about is the first step sometimes.

We remain…….obviously passionate………..

Shawn and Ivo….. The Gait Guys