Hallux rigidus (turf toe): A Case of Back Pain

Another case today. Right hallux limited dorsiflexion range. Causing early heel rise in late midstance phase of gait because the forefoot rocker was impaired. Thus, the client will see reduced hip extension and inhibit glureal function and either: 1- destabilize the Sacroiliac joint bc compression is lost across the joint And/or 2- force the patient to increase lumbar lordosis, or spin the torso/pelvis outward to equal the step length on the opposite side which occurred through proper hip extension. ( at the cost of tipping the right hemipelvis anterior thus affecting the lower right abdominals. ) Something has to give to make up for the loss at the big toe ! Certainly there are many other strategies to play out other than this one.

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.

Barefoot Winter Footwear: The mukluk.

In this, the latest of The Gait Guys videos, Dr. Shawn Allen talks about a neat product, the Steger Mukluk. It is about as close as you can get to a Minimalist Winter boot (in case you are chasing caribou in the north, or shoveling out from the Chicago Blizzard of 2011, or just working outside in the bitter cold). Some interesting principles of minimalist shoes apply here. Where do these guys come up with their ideas !

More garbage on the internet about running myths. We need a Gait Police. Wait ? Maybe that should be us ! This MSNBC article is exactly why we are trying to spread the word.  This article has so many half truths and misleadings that it isn’t even worth reading in our opinion. MAybe next time they will ask us for this kinda stuff. One of the first things you must know the next time you decide to watch your running in a mirror, or get a professional gait analysis done, is that what you see is not the problem…….so carry this main thought with you. * What you, or your gait analysis professional or your running partner behind you, see in that mirror or on that video is often not the problem.  How you are moving is your neuro-musculoskeletal system’s best interpretation to demonstrate a functional gait with the parts that ARE working correctly. In other words, what you are seeing is a best case scenario for the central nervous system to achieve stability most of the time. So, when your coach or therapist or gait “Specialist” tells you that you need to increase your arm swing on the right, or turn your left foot in……to make a correction towards what looks symmetrical to them and to you, please stop them and say “but that is not the problem, that is my strategy to run as best as i can. I am not doing those things because i have nothing better to do when i run!” And, even worse, tell them not to give you exercises to correct those visual flaws ! And educated person in the field of neuromusculoskeletal medicine has to make those recommendations based on the faulty sensory and motor patterns they assess, and the muscular weaknesses that are discovered.  Neuroadaptive changes are for a good reason, even though they may look bad. For example, a right foot might be turning out into the frontal plane for the good reason that your hip stability in the frontal plane is insufficient, and thus the best strategy determined by your central nervous system was to turn out the foot to better engage and protect that plane. It might not however, be logical to us to make the change so far away from the area of problem, but for those of us who do this daily over and over again, it makes pretty decent sense.  The patterns you display are neuromechanical strategies, strategies and compensations to best stabilize the body parts during the activity. It is obvious to the viewer that the pattern is wrong, but the brain has made these changes for a good reason. Don’t think you are smarter than your brain !  (how’s that for a final statement !) We are, The Gait Guys

5 crucial running mistakes ? Really ? Hogwash ! (click on title for the article link)

Asics Gel Speedstar 5

We were asked today to give our quick prelim opinion on this shoe. Aside from all the nice creature comforts of the new design it does not look too terribly different from previous models. I have the last model. I liked it. But, it was pretty curve lasted so, if this model is no different, and if you are a person with pronation control issues or if you still are not out of heel strike running you might not like this one. But it will allow you to mid-forefoot strike easier than the bulkier model trainers out there. It is light, sub 10oz. But our major concern is that it appears (we havent gotten a pair yet to cut them up, hopefully someone else will get to it and save us more work) that it still has a higher slope from a raised heel (>1:1) RF:FF (rear:forefoot ratio). From looking at my last pair and this one, i would be it still has about a 10mm heel rise over the forefoot height (maybe a few less if we are all lucky !, but we doubt it). Certainly better than more traditional trainers in this respect. This heel rise will inevitably still suggest or encourage heel strike. We have been pounding the floor for years to reduce this ratio…..we are so glad folks are finally listening. Maybe we can get fewer running injuries in our office and get a day on the beach with this new trend. Thanks to all the minimalist companies out there ! Just remember, walking is a different neuro-biomechanical task than running. Heel striking is not abnormal in walking because the heel rocker phase of gait is softer than in running. Also, remember, some foot types (forefoot varus, Rothbart, etc) are not likely to do well in these more minimalistic shoes ( a more curved lasted shoe could drive a foot more medially into it’s incompetent parts). Get evaluated by someone who knows what they are doing (in the doctors office and in the shoe store, that could be tough to find) so that your foot type, your running style and your shoes match up. Injuries are part of this recipe when the ingredients do not mix well !

Rothbart’s Foot Type: A Case discussion

We received a case question from a field doctor today.

Q: I have a pt. that demonstrates pretty classic Rothbart foot  with forefoot compensated varus – sesamoid pain of digit 1. She is a dancer as well which obviously complicates things. Would you generally post under the first MT and try to bring her more medial on her foot with a lateral heel post or just post the first MT in her day shoes?

* The Gait Guys response:

Rothbart’s foot is a difficult foot type. We would consider it an underdevelopment issue. The first metatarsal is typically short, elevated (referred to as metatarsus primus elevatus) and supinated (if you are looking down at your own right foot, it is spun clockwise).  This, as you can see all 3 components in the picture, leaves a very incompentent first toe.  Many times, if the ankle and subtalar joints are in neutral positioning the first metatarsal (MET) head doesn’t even touch the ground. The problem is that the foot does not work well that way !  So, the owner will typically spin the foot  outward into external rotation ( we will show this in a video we will attach later tonight that will help the understanding of this issue, it is important) in order to shift the tripod to help find grounding of the first MET onto the ground. The problem is that in this foot type, the grounding is not entirely complete. 

Thus, what Rothbart did, wisely, was devise a Rothbart wedge. This wedge slid in from the medial side and basically brought the ground up to the elevated and spun metatarsal. 

Background info: Under the 1st MET are 2 sesamoids, like tiny patellae, that improve mechancial advantage to the first metatarsophalangeal joint (MTPJ). The short flexor to the big toe , the flexor hallucis brevis (FHB) has these 2 sesamoids embedded within its tendon, and when paired with a well orchestrated movement pattern between the long big toe flexor (FHL) and FBH as well as the long and short extensors (extensor hallucis longus and brevis, EHL, EHB) and some assistive means from the abductor and adductor hallucis muscles the 1st MTPJ joint can adequately dorsiflex (extend) the big toe to its necessary range of 40+ degrees so we can toe off properly from this medial aspect of the toe. 

In a Rothbart foot type scenario, this neuromechanical phenomenon is impaired, because the medial aspect of the foot and big toe are not grounded.  The wedge, when slipped underneath the 1st MET, improves this dramatically.  It brings the sloped edge of the wedge up to the elevated and spun toe and attempts to restore equal weight bearing on both sesamoids. It likely also reduces the postural slump phenomenon (often referred to as bio implosion) that we will not discuss here at this time (the postural collapse comes from first a collapse of the medial foot, then genu valgum, then hip internal spin, pelvic unlevelling and then increases in lumbar lordosis, thoracic kyphois and cervical lordosis. Orthotic companies base much of their purpose on this principle, and it does have some merrits, but the question remains…….must we support the deformity forever, or can something functionally be done to improve it.)

In  your case Doc (assuming this is yet another foot from the Joffrey Ballet Dance company that we worked for) placing a wedge under the first MET is not possible in dance slippers.  IT will help him/her in their daily shoes but as you know we are merely supporting the deformity.  What we would suggest is making every attempt, in addition to the supportive help at this time, to improve their ability to plantarflex the first metatarsal.

How do you do this ?  This works well on Forefoot varus feet that are flexible and have some skills left in their playbook.  Increasing the  skill, endurance and strength (our 3 tenants, S.E.S.) of the extensors (both short and long, EHL & EHB) will help to drop the first metatarsal into plantarflexion.  So will improving the pull up on the other end of the metatarsal base, ie. tibialis anterior, posterior etc. Many insufficient feet do not have adequate extensor strength to the toes. This creates many anterior compartment syndromes (shin splints etc).

In this case, you could try to improve extensor strength but you will have to make sure  they can get adequate function of the short hallux flexor (FHB) to help anchor the sesamoids if they can get them more purchase on the ground.  We would use our therapy approach. Treat the wedge as an orthotic (for the big toe!).  Place the wedge sufficient in size to reduce their medial foot collapse.  Initiate the protocol above, and as improvements are noted in S.E.S. then begin to reduce the degree and amount of the wedge correction.  We use a grinder in our offices, but sandpaper or a nail file will do the job, it is why we use a cork-type product.

Supporting this foot type with a high arch bearing device will artificially help reduce the bio-implosion issue to the body posture, but those supportive structures would do well with improved S.E.S. as well.  The problem with a high orthotic is that it will  maintain the metatarsus primus elevatus issue (raise 1st MET) and they will have to pronate even harder through the forefoot. This will not be good.  In some cases we will implement a custom rearfoot varus wedge ground in our office to be precise, to help reduce the rearfoot pronation that may be employed by the client to help the medial foot on the ground. But, from what we are imagining here in our heads, we think the forefoot implementation and homework is the first way to go.  Placing a thin sheet of EVA foam under the MET head might also soften the blow on that inflammed sesamoid in the mean time.  

The Gait Guys hope this helps a bit, perhaps opening some other thoughts for treatment on your end or more pointed future questions on this case.  Tune in again in case we hear back.

We will see if we can put a little video together that will support this dialogue, it makes it so much easier to digest. 

More Gait Guy Gait Gaffs: What it would look like if “The Flash”, ran with heel strike ? click here. Note the excellent anterior compartment use (nice ankle dorsiflexion and toe extension at terminal swing/ pre-impact) but heavy, nasty, heel strike. What is interesting here is that he has adopted a nice forward lean (ala. natural or chi running style) but when combining this with a heel strike gait you end up with an anterior pelvic tilt (which begins inhibition of the lower abdominals) and you then have to begin the power through phase in early-mid stance phase with the hamstrings. You need tremendous lower abdominal strength, and hamstring length and strength to run this way (go ahead, get up and try it running through your office ! let out a great “Yaulp” from the ensuing hamstring pull (ala Robin Willliams in Dead Poets Society) when you find out your abdominals are not strong enough to lean that far forward and still heel strike, without enough hamstring length (on second thought, just trust  us……although i know now we have challenged some of you). This is a medical disclaimer, dont do it !

Excerpts from Dan Empfield’s “Shoe Height and Ramp Angle”

http://www.slowtwitch.com

http://www.slowtwitch.com/Products/Running_Footwear_by_type/Shoe_Height_and_Ramp_Angle_1948.html

Written by: Dan Empfield
Date: Tue Mar 15 2011

The following are exact quotes taken from Dan’s article on the slowtwitch.com website.  This is a very good article. Please read his entire article in the posted link above, so that we do not take something away from the hard work and writing of Dan.  We take zero credit for this work, it is all Dan’ Empfield’s. Thanks for the great work Dan and www.slowtwitch.com  Visit them both !

“Ramp Angles
What we’re talking about here is the distance your heel sits off the ground versus your forefoot, when you’re standing in the shoe. In order to calculate an angle, you’ve got to solve a right triangle equation, specifically, in a size-9 shoe, the distance from the heel to the forefoot is a right triangle’s long arm, the delta between heel and forefoot height is the short arm, connect these two arms via the hypotenuse, the slope of the hypotenuse is the ramp angle (or, just look at the image furthest above).
Who wants to calculate that? Not me.

So, let’s just talk about heel height, forefoot height, and the delta between them. Typical of today’s conventional running shoes is a 24mm heel and a 12mm forefoot. The delta between them is 12mm. This number is much easier to get one’s arms around, so, from here on in I’m going to talk about Ramp Delta (a metric of my own invention—if you’ve got a better term, lay it on me, maybe I’ll abandon mine and adopt yours). The complaint with a large ramp delta is this: If I’m a midfoot striker, can I midfoot strike without that propped-up heel getting in the way? Probably so if we’re talking 10mm, maybe 12mm, but 15mm? (Which is not by any means unheard of.) That’s questionable.

A bigger problem yet: Once I midfoot strike, the heel will touch down almost immediately—how much will the rear of the shoe compress? If it doesn’t sufficiently compress, am I plantar flexing (pushing off) with an achilles tendon not sufficiently elongated?
Part of this depends on how firm the shoe is in the heel. If the midsole is less dense, the shoe may compress to a point where the shoe functions as if it had a smaller ramp delta.

Are traditional shoes made for heel strikers?
This is a contention I hear over and over again, with greater regularity. The running boom has spawned a lot of runners who didn’t get the proper running technique memo (the narrative goes) and companies like Asics and Brooks have accommodated their overstriding, heel-striking, overpronating technique with shoes perfectly made for this inefficient method of running.
I buy this line of reasoning up to a point. I have some problems with this line of thinking and we’ll get to these, but, here’s an experience related to me by a shoe designer, Dave Jewell of Zoot, from a bit earlier in his career:

“We cut all the competition up with a band saw. We wanted to see what the midsole heights were. What we found was rather astounding. Yes their stated midsole heights were fairly correct but their overall height was rather outrageous. We found shoes that were stated as 25mm heel and 13mm forefoot. The total height was 34mm heel and 22mm forefoot. People were still buying them but it seemed to us like they were too tall.”  Dave does not rail against companies that make shoes with a taller heel, or a larger ramp delta. Rather, he offers this observation from the latest Hawaiian Ironman:

“The race up front is won by folks who can run in anything but choose the shoes with the smaller delta—say, 10mm or less. But those finishing the race from 3 hours behind to 10 hours behind tended to run in a shoe that has a 12mm delta. Are all of these people running in the wrong shoe? Clearly they are running in what’s most appropriate to their running style. Running shoe companies for years have offered different shoes with different deltas. In the past the shoes with the low delta were racing flats.”

Does a low ramp delta require a low overall shoe height?
Some believe ardently that a firm connection between the foot and the ground is a must. Danny Abshire (founder and owner of Newton Shoes) believes this and offers the following rationale: There are thousands of nerve endings in the foot responsible for proprioception, and a loss of communication between the ground and these nerve endings interrupts the proper interaction between nerves and muscles. Adding distance between the foot and the ground interrupts this communication.
Newton’s shoes are known for an exceptionally low ramp delta as well as generally low shoe heights. Still, Dave Jewell notes that, “Now there are shoes with a low delta and thicker overall midsoles that are getting some traction.”

Does a low ramp delta necessarily mean a neutral shoe?
This is where the natural/barefoot/minimalist guys lose me. Yes, no doubt you’ll overpronate less if you don’t overstride. But in my experience, it’s dangerous fiction to flatly state that an overpronator can, and should endeavor to, “teach” himself to run in a neutral shoe through engaging in exercises to strengthen his feet.”

Part 2: Progressing out of orthotics.

another Facebook Q. Is there a point during, or post treatment when the foot intrinsics perform and maintain their function without the exercises? Is it shuffle gait and moonwalk for life? and…. Are there any foot conditions that require ‘orthotic therapy’ to be maintained long term?

The Gait Guys answer:

Over time (about 3-6 mos avg, sometimes longer in our experience) the neural pattern becomes ingrained through neural adaptation and collateralization. As long as the exercises become a habit and ingrained into the motor pattern, then it is automatic; but think about how many layers of compensation are present and how long the problem took to occur. It takes time to restructure the nervous system and those pathways. The key here is adaptation of a new motor pattern; then life becomes rehab. There are many other exercises as well; keep an eye out for our new site launch and watch for some of them there. We have a DVD on the works as well.

When a person is UNABLE to function normally (ie they lack the ROM, muscle capacity, anatomy, neural drive IOW an anatomical problem) they MAY require an orthotic to make up for those ROM’s or mechanics they lack. An example may be an uncompensated FF varus where they lack the ROM in the 1st ray, or the individual with a loss of ankle rocker due to trauma, an arthrodesis, or some other anomaly.

The key is, if you are doing your job, their prescription should change and become less and less. This is one reason we sometimes use orthotics constructed of EVA, because they are easier to modify.

Believe it or not (LOL), some people won’t do the exercises you prescribe or aren’t willing to make the changes to be independent of them; these individuals will often need to wear them indefinitely.