Yay for the lift, spread and reach exercise!

Toe spreads and squeezes are aimed at strengthening specific intrinsic foot muscles—the dorsal and plantar interrosei, according to Irene S. Davis, PhD, PT, director of the Spaulding National Running Center and a professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School in Boston. Doming or foot shortening exercises contract most of the muscles on the plantar side of the foot, and help to strengthen the abductor hallucis muscle

see our post here: https://tmblr.co/ZrRYjx1iuSYMM

Goo YM, Heo HJ, An DH. EMG activity of the abductor hallucis muscle during foot arch exercises using different weight bearing postures. J Phys Ther Sci 2014;26(10):1635-1636.

 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

One way to correct an dysfunctional Extensor Hallucis Brevis

The Extensor Hallicus Brevis, or EHB  (beautifully pictured above causing the  extension (dorsiflexion) of the proximal big to is an important muscle for descending the distal aspect of the 1st ray complex (1st metatarsal and medial cunieform) as well as extending the 1st metatarsophalangeal joint.

Since this muscle is frequently dysfunctional, and is one of THE muscles than can lower the head of the 1st metatarsal, along with the peroneus longus and most likely the tibialis posterior (through its attachment to the 1st or medial cunieform), needling can often assist in normalizing function and works especially well, when coupled with an appropriate rehab program. Here is one way to needle it effectively. 

Congenital clubfoot anyone?

This gentleman, a longtime patient came in for new orthotics, as his old ones were 10 years old. From the pedographs above, you can see it is his LEFT foot. 

Note the following:

  • shortened apparent foot length left compared to right (the foot is merely deformed and plantarflexed)
  • The increased plantar pressures laterally, from the foot being supinated 
  • increased arch height L > R
  • clawing of digits 2-4 to provide stability

This case made me think about some common issues that you may be wondering about if you see these folks. 

There are several things you should think about:

  • People with clubfoot generally have a high arched, rigid, cavus foot. 
  • These folks generally are fixed in some degree of plantar flexion.
  • Because of the plantar flexed posture of their foot, they generally have a loss of a ankle rocker
  • If you utilize an orthotic with these patients, you need to make sure that there is significant ramp delta (heel higher than the 1st metatarsal)
  • Clubfoot can often be unilateral.
  • Clubfoot is usually not congenital
  • Gait training and balance (proprioceptive) work can be especially helpful in these cases. 

and what have we been saying for the last several years?

“The development of bone marrow edema after transitioning from traditional running shoes to minimalist footwear is associated with small intrinsic foot muscle size, according to research from Brigham Young University in Provo, UT.

The findings, epublished in late October by the International Journal of Sports Medicine, suggest that runners with small intrinsic foot muscles may benefit from strengthening exercises prior to attempting the transition to minimalist running.

Investigators randomized 37 habitually shod runners to 10 weeks of running in minimalist footwear or their own shoes, and performed magnetic resonance imaging at baseline and after the intervention to detect bone marrow edema and assess intrinsic foot muscle size.

Eight of the runners in the minimalist group had developed bone marrow edema at 10 weeks, as well as one in the control group. Those who developed bone marrow edema had significantly smaller intrinsic foot muscles than those who did not.

In addition, running in minimalist footwear was associated with a 10.6% increase in abductor hallucis cross-sectional area, a statistically significant change”.

Source:

Johnson AW, Myrer JW, Mitchell UH, et al. The effects of a transition to minimalist shoe running on intrinsic foot muscle size. Int J Sports Med 2015 Oct 28. [Epub ahead of print]

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.

This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not.  A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.

Hmmm..

We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?

Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB.  Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.