Forefoot valgus: A fixed structural defect in which the plantar aspect of the forefoot is everted on the frontal plane relative to the plantar aspect of the rearfoot; the calcaneum is vertical, the mid tarsal joints are locked and fully pronated

Want to know more? Join us Wednesday evening: 5 PST, 6 MST, 7 CST, 8 EST for Biomechanics 309: Focus on the forefoot on onlinece.com.

McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Forefoot Varus or Forefoot Supinatus?

Forefoot varus is a fixed, frontal plane deformity where the forefoot is inverted with respect to the rearfoot. Forefoot varus is normal in early childhood, but should not persist past 6 years of age (i.e. when developmental valgus rotation of forefoot on rearfoot is complete, and plantar aspects of fore- and rearfoot become parallel to, and on same plane as, one another (1)

Forefoot supinatus is the supination of the forefoot that develops with adult acquired flatfoot deformity. This is an acquired soft tissue adaptation in which the forefoot is inverted on the rearfoot. Forefoot supinatus is a reducible deformity. Forefoot supinatus can mimic, and often be mistaken for, a forefoot varus. (2)

A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous where a forefoot supinatus is acquired and develops because of subtalar joint pronation.

“Interestingly, only internal rotation of the hip was increased in subjects with FV – no differences were present in hip adduction and knee abduction between subjects with and without FV. The authors nevertheless conclude that FV causes significant changes in mechanics of proximal segments in the lower extremity and speculate that during high-speed weight-bearing tasks such as running, the effects of FV on proximal segments in the kinetic chain might be more pronounced.”

We wonder if the folks in this study had a true forefoot varus, or actually a forefoot supinatus (3).

The Gait Guys

1. Illustrated Dictionary of Podiatry and Foot Science by Jean Mooney © 2009 Elsevier Limited.

2. Evans EL1, Catanzariti AR2. Forefoot supinatus.
Clin Podiatr Med Surg. 2014 Jul;31(3):405-13. doi: 10.1016/j.cpm.2014.03.009.

3. Scattone Silva R1, Maciel CD2, Serrão FV3. The effects of forefoot varus on hip and knee kinematics during single-leg squat. Man Ther. 2015 Feb;20(1):79-83. doi: 10.1016/j.math.2014.07.001. Epub 2014 Jul 12.

Did you see this in our recent blog post here ? a reader made us look closer. Did you catch it ?
The clients right foot appears to have a dropped 1st met head. (we hate this term, because it is not accurate and is a sloppy clinical description). In this still photo it appears plantarflexed.  But in this video, consider the descended 1st met head as due to the disuse or weakness of the EHL muscle (extensor hallucis longus) of the 1st toe. Or, is this in fact a compensated forefoot varus ? Sure looks like it. But with all that anterior compartment weakness (as we discussed in the previous blog post link above) it could just be a mirage. In the photo above, in a normal foot the rearfoot plane (greenline) should parallel the forefoot line (orange line). In this case, in this actively postured foot (thus some inaccuracy here, we are merely making a teaching point from the photo) the upslope of the orange line suggests a forefoot varus. This would be true if the first Metatarsal head also was on this line, but you can see that it has its own idea. This represents, in theory (regarding this photo), a compensated forefoot varus. But remember, this client is  holding the foot actively in this posture. A true hands on assessment is needed to truly define a Forefoot varus, and whether it is anatomic, flexible, rigid or in many cases, just a learned functional posturing from weakness of the flexor/extensor pairing of the 1st metatarsal complex or from other weaknesses of the other forefoot evertors.  It gets complicated as you can see.

As always, knowledge of the anatomy and functional anatomy allows for observation, and observation leads to understanding, which leads to answers and then remedy implementation. Our thoughts, knowing the case, is that this is a functional appearance illusion of a compensated forefoot varus due to the EHL, EDL and tibialis anterior weakness (anterior compartment) and how they play together with the flexors. One must be sure to assess the EHL when examining the foot. Test all of the muscles one by one.  We have been talking about toe extensors for a long time, they can be a paramount steering wheel for the forefoot and arch posture. Podcast 71 talks about this Forefoot varus, and you should care.
In a 2009 study by Reynard et al they concluded: 

  • “The activity of extensor digitorum longus muscle during the swing phase of gait is important to balance the foot in the frontal plane. The activation of that muscle should be included in rehabilitation programs.” (1)

here is the video again.

Have a burning desire to learn more about forefoot varus, here are 25 blog post links from our last few years. And/or you can take our National Shoe Fit program (downloadable links below).

Knowing what you are seeing during your exam and gait analysis can only truly come from coupling your observations with a clinical exam.  Anything less is speculation and guess work.  It is gambling, and this is not Vegas baby, this is someone’s health.

Shawn and Ivo, The Gait Guys

________________

National Shoe Fit Certification Program:

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

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1. Foot (Edinb). 2009 Jun;19(2):69-74. Epub 2008 Dec 31. Foot varus in stroke patients: muscular activity of extensor digitorum longus during the swing phase of gait.  Reynard F, Dériaz O, Bergeau J.

Other web based Gait Guys lectures:

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

Podcast 71: Forefoot Varus, Big Toe Problems & Charlie Horses”

*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: 

Direct Download: 

http://traffic.libsyn.com/thegaitguys/pod_72final.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-71

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. American College of Cardiology. Running out your healthy heart. How much exercise is too much ?

Running for 7 minutes a day cuts risk of death by 30%, study says
http://wgntv.com/2014/07/29/running-for-7-minutes-a-day-cuts-risk-of-death-by-30-study-says/
 
2. The history of “Charlie Horses”
 
3. A runner with strange shin bruises.  
from : Joy 

Hi, I’m a great follower of your blog – fascinating stuff! I was wondering if I could ask you a quick question as nobody I’ve spoken to has been able to help:

I’ve been getting bruises that appear on my shin during running. They don’t hurt, I’m just wary of ignoring what could be a warning sign. Have you ever come across this before? (It’s mainly the spot where I had a tibial stress fracture last year, but I also get a few other apparently spontaneous bruises on my lower legs.)

4. Is that a forefoot varus or are you just happy to see me ?
Functional vs Anatomic vs. Compensated forefoot varus foot postures. A loose discussion.
5. A reader’s pet peeve about shoe store “gait analysis”.
6. Thoughts on pronation and the like.
7. Case study:  First toe fusion and implications long and short term.
“I had a patient today with an MTP fusion of his great toe after adverse complications from a bunionectomy.  Do you have any recommendations for gait training when great toe dorsiflexion is no longer an option?  He is currently compensating by externally rotating his foot and overpronating.  I’m thinking through it and  I know he has to gain the motion elsewhere to help normalize his gait as much as possible, so possibly gaining ankle dorsiflexion and hip extension.  Just wondering if you have any tips to share or articles to point me to for further ideas.  Continuing my research now.  I’m a relatively new grad and this is my first patient I’m seeing with this fusion. Many thanks

Podcast 71: Forefoot Varus, Big Toe Problems & Charlie Horses”

*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: 

Direct Download: 

http://traffic.libsyn.com/thegaitguys/pod_72final.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-71

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. American College of Cardiology. Running out your healthy heart. How much exercise is too much ?

Running for 7 minutes a day cuts risk of death by 30%, study says
http://wgntv.com/2014/07/29/running-for-7-minutes-a-day-cuts-risk-of-death-by-30-study-says/
 
2. The history of “Charlie Horses”
 
3. A runner with strange shin bruises.  
from : Joy 

Hi, I’m a great follower of your blog – fascinating stuff! I was wondering if I could ask you a quick question as nobody I’ve spoken to has been able to help:

I’ve been getting bruises that appear on my shin during running. They don’t hurt, I’m just wary of ignoring what could be a warning sign. Have you ever come across this before? (It’s mainly the spot where I had a tibial stress fracture last year, but I also get a few other apparently spontaneous bruises on my lower legs.)

4. Is that a forefoot varus or are you just happy to see me ?
Functional vs Anatomic vs. Compensated forefoot varus foot postures. A loose discussion.
5. A reader’s pet peeve about shoe store “gait analysis”.
6. Thoughts on pronation and the like.
7. Case study:  First toe fusion and implications long and short term.
“I had a patient today with an MTP fusion of his great toe after adverse complications from a bunionectomy.  Do you have any recommendations for gait training when great toe dorsiflexion is no longer an option?  He is currently compensating by externally rotating his foot and overpronating.  I’m thinking through it and  I know he has to gain the motion elsewhere to help normalize his gait as much as possible, so possibly gaining ankle dorsiflexion and hip extension.  Just wondering if you have any tips to share or articles to point me to for further ideas.  Continuing my research now.  I’m a relatively new grad and this is my first patient I’m seeing with this fusion. Many thanks

Forefoot Valgus or Plantarflexed 1st ray?

Hmmm. That IS the question, isn’t it?

We remember that Forefoot valgus is a condition where the forefoot is everted with respect to the rearfoot.

With a plantar flexed 1st ray, the forefoot is actually in varus (ie inverted) and the the 1st ray is dropped (thus, plantar flexed).

If you look at the picture, you will see the entire forefoot is everted, thus we are  looking at a true forefoot valgus. The question here, is “does the 1st ray move into dorsiflexion”? This would be the difference between a flexible (plastic or rigid deformity and is a function of the rigidity of the subtalar and midtarsal joints as well as the flexibility of the 1st ray.

The literature states that forefoot valgus is the most commonly seen frontal plane deformity of the foot (McPoil 1988, Burns, 1977). We have not found this in clinical practice, but rather forefoot varus. This may be due to most folks seeing us have an issue, and more issues seem to be caused by rigid varus deformities, since they cause the knee to collapse inward.

It’s origin can be multifactorial, ranging from a congenital malformation of the calcaneocuboid joint (more on that joint here) with the absence of a calcanean process, which allows a greater degree of eversion (Bojsen-Moller 1979); over rotation of the talar neck (Sglaraato 1971), or association with a pes cavus foot in compensation to an inverted rearfoot and inflexibilty of the subtalar joint (Lutter 1981). Neuromuscular diseases are believed to cause as many as 95% of these deformities (Dwyer 1975).

The question is, what do we do with it?

  • we insure that the foots mechanics are the best they can be through manipulation and mobilization
  • make sure the joints proximal and distal to the foot are functioning properly
  • muscle test and strengthen weak muscles (think about the poor peroneals in these folks!)
  • make sure they are NOT in a motion control shoe; more flexible is better
  • Make sure their shoe has adequate room in the toe box
  • sometimes, we post the insole of the shoe (or orthotic) in valgus, especially with rigid deformities

A little lost? Take our National Shoe Fit Program, available for instant download 24/7/365 by clicking here.

The Gait Guys. Often a valgus slant on a varus reality. Still bald. Still good looking. Improving your gait competency with each post.

Sometimes, you just need to add a little pressure….

Cyclists are no different than runners; often when the effort is increased (or the conditions reproduced), the compensation (or problem) comes out.

Take a good look at this video of a cyclist that presented with right sided knee pain (patello femoral) that begins at about mile 20, especially after a strong climb (approx 1000 feet of vertical over 6 miles through winding terrain).

The first 7 seconds of him are in the middle chain ring, basically “spinning” ; the last portion of the video are of him in a smaller (harder) gear with much greater effort.

Keep in mind, he has a bilateral forefoot varus, internal tibial torsion, L > R and a right anatomically short leg of approximately 5mm. His left cycling insole is posted with a 3mm forefoot valgus post and he has a 3mm sole lift in the right shoe.

Can you see as his effort is increased how he leans to the right at the top of his pedal stroke of the right foot and his right knee moves toward the center bar more on the downstroke? Go ahead, stop it a few time and step through it frame by frame.  The left knee moves inward toward the center bar during the power stroke from the forefoot valgus post.

So what did we do?

·      Worked on pedal stroke. We gave him drills for gluteal (max and medius) engagement on the down stroke (12 o’clock to 6 o’clock) to assist in controlling the excessive internal spin of the right leg. Simple palpation of the muscle that is supposed to be acting is a great start.

·      Did manual facilitation of the glutes and showed him how to do the same

·      Worked on abdominal engagement during the upstroke (the abs should initiate the movement from 6 o’clock to 12 o’clock)

·      Manually stimulated the external oblique’s

·      Placed a (temporary, hopefully) 5mm varus wedge in his right shoe to slow the internal spin of the right lower extremity

·      Taught him about the foot tripod and appropriate engagement of the long extensors; gave him the standing tripod and lift/spread/reach exercise (again to tame internal spin and maintain arch integrity)

Much of what you have been learning (for as long as you have been following us) can be applied not only to gait, but to whenever the foot contacts anything else.

The Gait Guys. Experts in human movement analysis and providing insight into biomechanical faults and their remediation.

All material copyright 2013 The Gait Guys/The Homunculus Group. Please use your integrity filter and ask before using our stuff.