Clinical tidbit:

Heel pain in kids and adolescents? Have you considered Sever’s disease?

Apophysitis of the calcaneal apophysis is the most common cause of heel pain in adloscents and accounts for 8% of all pediatric overuse injuries! An apophysitis occurs (an injury involving a “pulling away” of bone from the tendons attachment site) because the strength of the tendon exceeds the strength of attachment of the tendon to the bone. It is most common in activites llike running, jumping and plantar flexion.

Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep 2010;9(5):265-268.

Wilson JC, Rodenburg RE. Apophysitis of the lower extremities. Contemp Pediatr 2011;28(6):38-46.

The partial truth about the Foot Tripod. The HEXApod.

The gait guys have talked about the foot tripod for a very long time. But the truth of the matter is that it is really a HEXApod. HEXA means 6. And when the foot is properly orientated and engaged on the ground, the 5 metatarsal heads and the heel should all be engaged with the ground, truly making it an asymmetrical hexapod. In an ideal scenario, the foot would be most stable if it looked like the strange symmetrical hexapod above with the contact points equally distributed around a center point. But that is not the human foot and this version of a hexapod is far simpler and likely inferior to the foot hexapod when human locomotion is to be attempted. The human foot is engineering marvel when it works properly.  

Perhaps the best example of what I mean by the foot being a HEXApod is in the pressure diagram above. In that first picture, on the right of that picture, we see multiple pressure points under the metatarsal heads of the right foot.  Minus the missing 1st metatarsal head pressure point (taken over by increased flexor hallucis longus activity represented by increased pressure at the big toe),  this pretty much confirms that the foot is not a tripod, rather a hexapod. The theory of the tripod, the 1st and 5th metatarsal heads and the heel, is only crudely accurate and honest. In this picture case, this person has increased lateral foot weight bearing (possibly why the 1st MET head pressure is absent) and possibly represented by pressure under the base of the 5 metatarsal. This is not normal for most people and if this person could get the 1st MET head down, they might even have a HEPTApod foot structure because of the 5th metatarsal base presentation (which sometimes represents peroneal muscle weakness). 

Where did we lead you astray after all these years of “tripod” talk ? We have always discussed the foot tripod. We have always discussed the imperative need to keep the limb’s plumb line forces within the area represented by the tripod.  If your forces fall more laterally within the tripod, as in this first discussed picture, one is at increased risk of inversion events and the myriad of compensations within the entire body that will occur to prevent that inversion. So again, why the tripod?  Well, it is easier to understand and it serves our clients well when it comes to finding active foot arch restoration as seen in this video of ours here.  But, the truth of the matter is that all of the metatarsal heads should be on the ground. The 2nd METatarsal is longer, the 3rd a little shorter, and the 4th and 5th even a little short than those. With the 1st MET shorter, these 5 form a kind of parabolic arc if you will. Each metatarsal head still should contact the ground and then each of those metatarsals should be further supported/anchored by their digits (toes) distally.  So the foot is actually more truly a HEXAPOD. Take the old TRIPOD theory we have always spoken about and extend a curved line beyond the forefoot bipod points (1st and 5th metatarsals) to incorporate contact points on the 2, 3 and 4th metatarsal heads. These metatarsals help to form the TRANSVERSE arch of the foot. It is this transverse arch that has given us the easily explainable foot TRIPOD because if a line is drawn between just the shorter 1st and 5th metatarsals, we do not see contact of the 2-4 metatarsal heads when we only look for pressure between these two bipod landmarks, but the obvious truth is that the 2-4 metatarsals are just longer and extend to the ground further out beyond this theoretical line drawn between the 1st and 5th MET heads.   

So, the foot is a HEXAPOD. Make no mistake about it. It is more stable than a tripod because there are more contact points inside the traditionally discussed foot tripod model. And frankly, the tripod theory is just a lie and just too fundamentally simple, unless you are an American 3 toed woodpecker.

Dr. Shawn Allen,     www.doctorallen.co

one of the gait guys

To met pad or not to met pad; that is the question. 

We use these in practice all the time. Think of it as a “helper” while you are training your patient or client to have better foot mechanics. 

“It’s all about the stress transfer, so what you’re trying to do is unload a certain spot on the foot—generally the met head with a met pad—and transfer it to a more proximal region,” 

Here is a nice evidence based review:

http://lermagazine.com/cover_story/evidence-based-use-of-metatarsal-pads

Social media reader comments and questions:
Reader: You demonstrated a peroneal exercise a few days back. In addition to the use of MT pads, is it effective in supporting transverse metatarsal arch?
  • The Gait Guys It can be. In our opinion, the exercises are key and the pad supports the exercises
  • The Gait Guys the goal is to restore foot function so that you do not need the pad. If your client is patient and willing to work on the exercises you likely won’t need a met pad, they may help speed things up, but remember, it is a crutch and crutches can be helpful but one can get lazy in using them and not do the supportive work. We only try to use them sparingly and only when necessary.

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]

Podcast 77: Gait analysis, Forefoot Running & more.

Plus, the 5 neurologic gait compensation expressions.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-77

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Google X acquires ‘tremor-canceling spoon’ startup
http://venturebeat.com/2014/09/10/google-x-acquires-tremor-canceling-spoon-startup/

The 5 expressions of neurologic gait decomposition,
Last week we did an online teleseminar … . .
An acoustic startle alters knee joint stiffness and neuromuscular control
http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract
Effectiveness of Off-the-Shelf, Extra-Depth Footwear in Reducing Foot Pain in Older People: A Randomized Controlled Trial
http://biomedgerontology.oxfordjournals.org/content/early/2014/09/08/gerona.glu169.abstract
reader:
I really appreciate learning from you!! I have a bit of a loaded question that I will try to explain clearly to the best of my ability. About 2 years ago, I broke my left shin (hairline-fibula) in a MMA fight. After it healed, a few things have been happening that I assume are connected but can’t quite put my finger on. My ankle mobility on my left ankle is worse than my left. I seem to have permanent turf toe as well. My right glute, ham, and erector are hyperactive.
Additionally, many times when sprinting, pushing a sled, etc, my right quad will become fatigued much more than my left. I believe it’s because I’m not fully extending my left ankle, and relying on my right leg more. Whenever I squat or deadlift, I feel similar too. The right glute and erectors get much more of a “pump” than my left. With all of this, is there anything you would recommend? I truly appreciate it!! It is very frustrating. Thank you again!

Podcast 77: Gait analysis, Forefoot Running & more.

Plus, the 5 neurologic gait compensation expressions.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-77

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Google X acquires ‘tremor-canceling spoon’ startup
http://venturebeat.com/2014/09/10/google-x-acquires-tremor-canceling-spoon-startup/

The 5 expressions of neurologic gait decomposition,
Last week we did an online teleseminar … . .
An acoustic startle alters knee joint stiffness and neuromuscular control
http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract
Effectiveness of Off-the-Shelf, Extra-Depth Footwear in Reducing Foot Pain in Older People: A Randomized Controlled Trial
http://biomedgerontology.oxfordjournals.org/content/early/2014/09/08/gerona.glu169.abstract
reader:
I really appreciate learning from you!! I have a bit of a loaded question that I will try to explain clearly to the best of my ability. About 2 years ago, I broke my left shin (hairline-fibula) in a MMA fight. After it healed, a few things have been happening that I assume are connected but can’t quite put my finger on. My ankle mobility on my left ankle is worse than my left. I seem to have permanent turf toe as well. My right glute, ham, and erector are hyperactive.
Additionally, many times when sprinting, pushing a sled, etc, my right quad will become fatigued much more than my left. I believe it’s because I’m not fully extending my left ankle, and relying on my right leg more. Whenever I squat or deadlift, I feel similar too. The right glute and erectors get much more of a “pump” than my left. With all of this, is there anything you would recommend? I truly appreciate it!! It is very frustrating. Thank you again!

Podcast 72: Neuroplasticity, EVA Shoe Foam, and Shoe Trends

Maximalist shoes and the death of Minimalism ? Could this be true ?

*Show sponsor: www.newbalancechicago.com

Lems Shoes.  www.lemsshoes.comMention GAIT15 at check out for a 15% discount through August 31st, 2014.

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_73f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-72

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1. Neuroplasticity: Your Brain’s Amazing Ability to Form New Habits
new link (does not have the old photo ivo mentioned that he loved)
 
2. Last week we pounded the sand on EVA foam and maximalist shoes. There was alot of attention, emails and good social media discussion on the topic.  
LETS REVIEW IT
file:///Users/admin/Downloads/p142_Heel_shoe_interactions_and_EVA_foam_f_web_150dpi.pdf
 
3. Then there just last week there was an article in LER on “the death of minimalist shoes” ? 
READ THIS: 
The rise and fall of minimalist footwear | Lower Extremity Review Magazine
http://lermagazine.com/cover_story/the-rise-and-fall-of-minimalist-footwear
 

4.  Physical Therapy as Effective as Surgery for Meniscal Tear

Kathleen Louden

March 20, 2013
Torn Meniscus? Thinking about surgery? Think again…


5. Cast study: the broken foot tripod