Every foot has a story. 

 This is not your typical “in this person has internal tibial torsion, yada yada yada” post.  This post poses a question and the question is “Why does this gentleman have a forefoot adductus?”

The first two pictures show me fully internally rotating the patients left leg. You will note that he does not go past zero degrees and he has femoral retroversion. He also has bilateral internal tibial torsion, which is visible in most of the pictures. The next two pictures show me fully internally rotating his right leg, with limited motion, as well and internal tibial torsion, which is worse on this ® side

 The large middle picture shows him rest. Note the bilateral external rotation of the legs. This is most likely to create some internal rotation, because thatis a position of comfort for him (ie he is creating some “relief” and internal rotation, by externally rotating the lower extremity)

 The next three pictures show his anatomically short left leg. Yes there is a large tibial and small femoral component. 

 The final picture (from above) shows his forefoot adductus. Note that how, if you were to bisect the calcaneus and draw a line coming forward, the toes fall medial to a line that would normally be between the second and third metatarsal’s. This is more evident on the right side.  Note the separation of the big toe from the others, right side greater than left. 

Metatarsus adductus deformity is a forefoot which is adducted in the transverse plane with the apex of the deformity at LisFranc’s (tarso-metatarsal) joint. The fifth metatarsal base will be prominent and the lateral border of the foot convex in shape . The medial foot border is concave with a deep vertical skin crease located at the first metatarso cuneiform joint level. The hallux (great toe) may be widely separated from the second digit and the lesser digits will usually be adducted at their bases. ln some cases the abductor hallucis tendon may be palpably taut just proximal to its insertion into the inferomedial aspect of the proximal phalanx (1)

Gait abnormalities seen with this deformity include a decreased progression angle, in toed gait, excessive supination of the feet with low gear push off from the lesser metatarsals. 

 It is interesting to note that along with forefoot adductus, hip dysplasia and internal tibial torsion are common (2) and this patient has some degree of both. 

 His forefoot adductus is developmental and due to the lack of range of motion and lack of internal rotation of the lower extremities, due to the femoral retrotorsion and internal tibial torsion.  If he didn’t adduct the foot he would have to change weight-bearing over his stance phase extremity to propel himself forward. Try internally rotating your foot and standing on one leg and then externally rotating. See what I mean? With the internal rotation it moves your center of gravity over your hip without nearly as much lateral displacement as would be necessary as with external rotation. Try it again with external rotation of the foot; do you see how you are more likely displace the hip further to that side OR lean to that side rather than shift your hip? So, his adductus is out of necessity.

Interesting case! When you have a person with internal torsion and limited hip internal rotation, with an adducted foot, think of forefoot adductus!

1.  Bleck E: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatric Orthop 3:2-9,1983.

2. Jacobs J: Metatarsus varus and hip dysplasia. C/inO rth o p 16:203-212, 1960

The case of the dropped (plantarflexed) metatarsal head. Or, “How metatarsalgia can happen”.

This gentleman came in with fore foot pain (3rd metatarsal head specifically), worse in the AM upon awakening, with first weight bearing that would improve somewhat during the day, but would again get worse at the end of the day and with increased activity. The began insidiously a few months ago (like so many problems do) and is getting progressively worse.

Rest and ice offer mild respite, as does ibuprofen. You can see his foot above. please note the “dropped” 3rd metatarsal head (or as we prefer to more accurately say, “plantarflexed 3rd metatarsal head”) and puffiness and prominence in that area on the plantar surface of the foot. 

To fully appreciate what is going on, we need to look at the anatomy of the short flexors of the foot. 

The flexor digitorum brevis (FDB) is innervated by the medial plantar nerve and arises from the medial aspect of the calcaneal tuberosity, the plantar aponeurosis (ie: plantar fascia) and the areas bewteen the plantar muscles. It travels distally, splitting at the metatarsal phalangeal articulation (this allows the long flexors to travel forward and insert on the distal phalanges); the ends come together to divide yet another time (see detail in picture above, yes, we are aware it is the hand, but the tendon structure in the foot is remarkably similar)) and each of the 2 portions of that tendon insert onto the middle of the middle phalanyx (1) 

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsal phalangeal joint, and proximal interphalangeal joint (although this second action is difficult to isolate. try it and you will see what we mean). In addition, it moves the axis of rotation of the metatasal phalangeal joint dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly (much like the function of the extensor hallucis brevis above in the drawing from Dr Michauds book, yes, we are aware this is a picture of the 1st MTP).

Can you see the subtle extension of the metatarsal phalangeal joint and flexion of the proximal interphalangeal joint in the picture?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a tole in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, especially if there is a concomitant loss of ankle rocker, the metatarsal heads are driven into the ground (plantarflexion), causing irritation and pain. Metatarsalgia is born….

So what is the fix? Getting the FDB back on line for one. 

  • How about the toe waving exercise? 
  • How about the lift spread reach exercise? 
  • How about retraining ankle rocker and improving hip extension?
  • How about an orthotic with a metatarsal pad in the short term? 
  • How about some inflammation reducing modalities, like ice and pulsed ultrasound. Maybe some herbal or enzymatic anti inflammatories?

The Gait Guys. Increasing your gait and foot literacy with each and every post. 

1. http://en.wikipedia.org/wiki/Flexor_digitorum_brevis_muscle

2. Tosovic D1, Ghebremedhin E, Glen C, Gorelick M, Mark Brown J.The architecture and contraction time of intrinsic foot muscles.J Electromyogr Kinesiol. 2012 Dec;22(6):930-8. doi: 10.1016/j.jelekin.2012.05.002. Epub 2012 Jun 27.

3.Okai LA1, Kohn AF. Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.Motor Control. 2014 Jul 15. [Epub ahead of print]

4. Zelik KE1, La Scaleia V, Ivanenko YP, Lacquaniti F.Coordination of intrinsic and extrinsic foot muscles during walking.Eur J Appl Physiol. 2014 Nov 25. [Epub ahead of print]

Flat Dogs

Take a look at these pedographs. Wow!

  • No rear foot heel teardrop.
  • No midfoot arch on left foot and minimal on right.
  • An elongated 2nd metatarsal bilaterally and forces NOT getting to the base of the 1st metatarsal and stalling on the 2nd: classic sign of an uncompensated forefoot varus.
  • increased printing of the lateral foot on the right

Knowing what you know about pronation (need a review? click here) Do you think this foot is a good lever? Do you think they will be able to push off well?

What can we do?

  • foot exercises to build the intrinsic and extrinsic muscles of the foot (click here, here, here, and here for a few to get you started)
  • perhaps an orthotic to assist in decreasing the pronation while they are strengthening their foot
  • motion control shoe? Especially in the beginning as they are strengthening their feet and they fatigue rather easily

The prints do not lie. They tell the true story of how the forces are being transmitted through the foot. For more pedograph cases, click here.

The Gait Guys. Teaching you more about the feet and gait. Spreading gait literacy throughout the net! Do your part by forwarding this post to someone who needs to read it.

Some times there is not an easy answer.

A patient came in with intermittent pain in his feet, bilateral and symmetrical of approximately 1 months duration.  It is bothering him in the arches and the ends of the toes. He can akin it to no singular precipitaIng event. The discomfort is sharp at times, and he can sometimes get cramping. He has been taking good care of his feet, washing his feet as of late. There are no alleviating factors; lots of activity can sometimes cause more pain but not consistently.  It seems to happen in all different types of shoes, so shod or unshod makes no difference. He is unable to reproduce the pain or discomfort.

The feet were normal in appearance. Arches were normal to slightly cavus. He had a mild, uncompensated forefoot varus. No global redness. Mild redness noted at medial and lateral nail beds of the great toe. He had a loss of long axis extension of the metatarsophalangeal arIculaIons and talonavicular arIculaIons bi-­‐lat. No tenderness to palpation of the dorsal or plantar surfaces of the feet are noted. No difference in neurological integrity with respect to sensaIon, motor strength or deep tendon reflex on either side. Nail bed filling was normal. Feet were cool
and moist to touch.  He did have weakness of the short extensors of the great toes, somewhat of the long extensors of the remainder of the digits. Ankle dorsiflexion is 10 degrees on each side.

Gait was tandem with a slight crossover. 

Hmm. Pretty boring, eh?

This is what we thought the differential should include:

1.   Early Gouty arthropathy.  This would be rare in a bilateral situation but possible.
2.   Athlete’s foot. This usually presents with more redness or this could be a variant.
3.   Lack of arch support during the day and his feet are fatiguing.
4.   Lumbar spinal canal stenosis; note that he has no change with squatting or sitting, so this is unlikely.

This is what we recommended:

 He is going to try either TinacIn or Lotrimin on his feet for 2 weeks, twice per day applicaIons, changing his socks between, making his feet wet and moist before application. Will switch to a boot that breathes batter and is more supporIve for work (he is a mason), to see if this works well. Foot strengthening exercises for the muscular deficiencies were prescribed. If this does not alleviate the discomfort, we will consider running labs and imaging looking at the possibility of gouty arthropathy and/or stenosis.

The Gait Guys. Showing that we don’t always have all the answers, but have a pretty good idea of how to get them.

Welcome to rewind Friday Folks.

Think about all those folks in the Northeast who have been shoveling (OK, the folks in Colorado as well) and their feet being rubber boots!

Here’s an oldie, but a goodie.

Here’s one paper we though had merit (sure, go to Pub Med and search foot odor. There were 119 entries). We think we may try this in the office…

The Gait Guys: Yes, smelly feet are something we have to deal with at the office on a daily basis. One of the pitfalls of being a Foot Geek : )
Make sure to check back later for more on malodorous extremities…                        
 
J Int Soc Sports Nutr. 2007 Jul 13;4:3.

A novel aromatic oil compound inhibits microbial overgrowth on feet: a case study.

Source

West 1140 Glass Avenue Spokane, Washington, 99205, USA. drbill@omnicast.net.

Abstract

ABSTRACT:

BACKGROUND:

Athlete’s Foot (Tinea pedis) is a form of ringworm associated with highly contagious yeast-fungi colonies, although they look like bacteria. Foot bacteria overgrowth produces a harmless pungent odor, however, uncontrolled proliferation of yeast-fungi produces small vesicles, fissures, scaling, and maceration with eroded areas between the toes and the plantar surface of the foot, resulting in intense itching, blisters, and cracking. Painful microbial foot infection may prevent athletic participation. Keeping the feet clean and dry with the toenails trimmed reduces the incidence of skin disease of the feet. Wearing sandals in locker and shower rooms prevents intimate contact with the infecting organisms and alleviates most foot-sensitive infections. Enclosing feet in socks and shoes generates a moisture-rich environment that stimulates overgrowth of pungent both aerobic bacteria and infectious yeast-fungi. Suppression of microbial growth may be accomplished by exposing the feet to air to enhance evaporation to reduce moistures’ growth-stimulating effect and is often neglected. There is an association between yeast-fungi overgrowths and disabling foot infections. Potent agents virtually exterminate some microbial growth, but the inevitable presence of infection under the nails predicts future infection. Topical antibiotics present a potent approach with the ideal agent being one that removes moisture producing antibacterial-antifungal activity. Severe infection may require costly prescription drugs, salves, and repeated treatment.

METHODS:

A 63-y female volunteered to enclose feet in shoes and socks for 48 hours. Aerobic bacteria and yeast-fungi counts were determined by swab sample incubation technique (1) after 48-hours feet enclosure, (2) after washing feet, and (3) after 8-hours socks-shoes exposure to an aromatic oil powder-compound consisting of arrowroot, baking soda, basil oil, tea tree oil, sage oil, and clove oil.

CONCLUSION:

Application of this novel compound to the external surfaces of feet completely inhibited both aerobic bacteria and yeast-fungi-mold proliferation for 8-hours in spite of being in an enclosed environment compatible to microbial proliferation. Whether topical application of this compound prevents microbial infections in larger populations is not known. This calls for more research collected from subjects exposed to elements that may increase the risk of microbial-induced foot diseases.

The Gait Guys. Bringing you the good, the bad and the smelly….

What do you do with these Dogs?

Take a good look at these feet. Hard to not cringe, we know. In this photo, the gentleman’s feet are relaxed! Imagine what it they will look like with some additional long flexor tone!

So, keeping in mind his tibial varum (bend in the tibia) and uncompensated forefoot varus (inability to get the head of his 1st ray down to the ground), what can we do?

  • how about we increase extensor strength? He could do the lift, spread, reach exercise while tripod standing. He could do the toe waving exercise.   He could do shuffle walks.
  • teach him to stretch his long toe flexors. Frequently. 20-30 mins minimum; daily
  • you could manipulate his feet to ensure better biomechnics
  • you could massage his feet to improve mobility and circulation
  • you could facilitate his long toe extensor muscles
  • you could inhibit his long toe flexor muscles
  • you could improve ankle dorsiflexion by showing him how to stretch the calves, 20-30 mins daily
  • you could improve ankle dorsiflexion by making sure he has adequate hip extension
  • he could wear correct toes, to improve the biomechanical advantage of the long toe extensors
  • he could wear shoes with a wider toe box
  • he could wear shoes with less ramp delta (or drop)
  • he could wear shoes with less torsional rigidity

and the list goes on. There are many simple things you teach a person with feet like this. many of them we have introduced you to here on the blog. Spend some time. Learn some cool stuff. Read the blog. Follow us on Facebook. Attend a Biomechanics class we teach the 3rd Wednesday of each month on onlinece.com . Check out our Youtube Channel. Consider furthering your education and taking the National Shoe Fit Program.

The resources are there. All you need to do is dig a little deeper.

We are The Gait Guys and we are all things gait.

Holy Twisted Femurs, Batman. What is going on here?

So, this is what femoral antetorsion looks like!

Remember that ante torsion occurs during development and is when the neck of the femur makes greater than a 12 degree angle with the shaft. We did a great post on this a while ago, click here to read it.

If you remember that the femur heads point anteriorly in a standing position, this would accentuate that, so they stand with an increased progression angle (ie feet toed out; see 1st picture).

With the increased femoral neck angle, these folks have a greater range of internal rotation of the femur, and decreased external rotation. Can you see this in the pictures above? We have rotated her legs fully internally and externally.

A few questions for you:

if you look carefully at the 1st picture, you will note she has external tibial torsion. Why?

  • this condition can develop in utero, but more commonly occurs postnatally with”W” sitting (sitting with knees together and legs abducted, with buttocks between the legs or feet. Think about that constant internal force on the femurs and external rotatory force on the lower tibia! Have your kids sit differently!

What type of shoe should this person be in?

  • The condition itself does not dictate the type of shoe thay should be in. This individual has a rigid, cavus foot BUT has an uncompensated forefoot varus with a great deal of forefoot pronation. In addition to exercises to strengthen the external rotators of the thigh, and inverters of the foot, a shoe with some motion control features is indicated in this instance

The Gait Guys…..Twisted? Yes! And still bald, middle aged and geeky as well.

A bit confused? Dig into our blog more, or watch our youtube channel. Maybe it’s time to push your knowledge base to the next level and take the National Shoe Fit Program. email us at thegaitguys@gmail.com