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

Do you have enough in the anterior tank ? Dr. Allen’s quiz question and lesson of the week.

One of my favorite sayings to my clients, “Do you have enough anterior strength to achieve and maintain posterior length?”  

Translation, do you have enough anterior lower leg compartment strength (tibialis anterior, long toe extensor muscle group, peroneus tertius) to achieve sufficient ankle dorsiflexion in order to achieve posterior compartment length (gastric, soleus, tibialis posterior, long toe flexor muscle) ?  You see, you can either regularly stretch the calf-achilles complex or you can achieve great anterior compartment strength, to drive sufficient ankle dorsiflexion, in effect EARNING the posterior compartment length. This is a grounded principle in our offices. It is the premise of the Shuffle Walk exercise (link) and many others we implement in restoring someones biomechanics.

Now on to today’s quiz question.

In this photo, both people are just mere moments before heel strike. 

1. Who is gonna need to have more eccentric strength in the anterior compartment ? And what if they don’t have it ? Repercussions ?  

2. Who is toeing off the lateral forefoot ? 

3. Who is crossing over more and thus could have more gluteus medius weakness ?

A picture is worth a thousand words. Answers and dialogue below.

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1. The lady in the high heeled shoes. If she heel strikes first, the larger longer heel on her shoe will mean she will need more of a prolonged eccentric loading of the anterior compartment to lower the forefoot to the ground. I hope she shortens her strike so she can get close to mid foot strike, it will negate most of this issue.  Repercussions? Forefoot pain, clenching/hammering of her toes from use of the long flexors to dampen loading of the metatarsal heads, and even possibly anterior shin splint like pain.

2. The lady is clearly in more lateral toe off, this is from the intoe’ing we see. This is low gear toe off. She may have limb torsion, internal tibial torsion to be specific, or insufficent external hip rotation control as a possibility. There are several possibilities here.

3. Hard to say, but the man seems to be crossing over more.

There is also no arm swing, hands are in the pockets, this is a big hit to gait economy. We have discussed these numbers in previous blog posts, the numbers are significant and real.  Step width is also a real factor, reduced step width leads to joint stacking challenges and is found with weaker hip abductors and changes in the iliotibial band length.

A picture can be worth a thousand words. I am a few short of the mark today, but I wanted to keep it short.

Dr. Shawn Allen, one of the gait guys

The Pitfalls of Motion Control Features.

Welcome to Monday, folks. Today Dr Ivo discusses why not all shoes are created equal and why you need to understand and educate your peeps about shoes!

Internal tibial torsion is when the foot is rotated internally with respect to the tibia. When the foot is straight (like when you are walking, because the brain will not let you walk too internally rotated because you will trip and fall), the knee will rotated OUTSIDE the saggital plane (knee points out). Putting a medially posted shoe on that foot rotates the foot EVEN FURTHER laterally. Since the knee is a hinge joint, this can spell disaster for the meniscus.

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Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg
In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).

a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°). more cool stuff on torsions here

Wow, cool stuff, eh?

Got Motion Control? Sometimes too much of a good thing is a bad thing!

Welcome to Monday and News You can Use, Folks.

Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.

You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.

Now THERE”S some internal tibial torsion!

So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)

 We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)

What would you do? Here’s what we did:

  • acupuncture to reduce swelling
  • took him out of his motion control shoes (which pitch him further outside the saggital plane)
  • gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
  • potty squats in a pain free range
  • ice prn
  • asked him to avoid full flexion

Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!

The “Dodgy Foot”, a UK runner’s dilemma.

We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK,  The runner was frustrated, explaining a “dodgy foot”.  We like the word. 

dodg·y    däjē/

-dishonest or unreliable; potentially dangerous; of low quality.

We can guarantee you that the solution here to this runner’s form issue is not wholly at the foot which appears “in toed” and slanted and appears ready to kick the back of the right heel, not to mention the knees that are about to brush together.  Thus, merely working on their foot strike would be so remedial and corrupt that it would a crime. 

Ivo and I do not take on cases via the internet because we cannot give all the information because we cannot examine the client, many do offer such services but people are not being given the whole story and we pledged long ago not to be part of the problem.  Anyone who recommends exercises from things they see on a video gait analysis are basically doing the same disservice in our opinion. But sometimes, as in this case, their inquiry is simple, there is a photo or video and it allows us to highlight an important component of an individuals gait which can lead them on a road to appropriate discovery. This is one of those cases.  I will not be presenting a solution, because I do not have the examination information I need, but I will propose a solid thought process that further investigation may afford progress towards resolution.

This is a non-pathologic cross over gait in my mind until proven otherwise, there may be other sources, causes and components, but when it quacks like a duck you’d be silly not to check for webbed feet. This runner even confirmed upon questioning that the left foot scuffs the inside of the right ankle/shin often, both sides scuff in fact but more left shoe on right shin. No Einsteinian epiphany there. 

  • This means a narrow swing through  (adducting) left limb. 
  • This means stance and swing phase gluteus medius communication problems. 
  • This means swing leg foot targeting problems. 
  • This often suggests right, but sometimes both right and left, frontal plane pelvis sway problems which means pelvis control is challenged which means core lumbar stability control is challenged. 
  • This means adaptive arm swing changes from the clean norm.  
  • This does NOT mean this runner has pain, or pain yet, or maybe never will have pain but there are many determinants of that which I will discuss below. 

But, make no mistake, this is flawed gait mechanics. The left swing leg is clearly targeting a more medial placement, meaning limb adduction (active or passive or both is to be determined) and this is a product of the cross over gait (unfamiliar with the cross over gait ? SEARCH our blog for the term, you will need a few hours of free time to get through it all).  Some would call the cross over gait a lazy gait, but I would rather term it an efficient gait taken too far that it has now become a liability, a liability in which they can no longer stabilize frontal plane sway/drift. A wider gait on the other hand, as in most sprinters, is less efficient but may procure more power and the wider base is more stable affording less frontal plane drift. Just go walk around your home and move from a very narrow line walking gait to a wide gait and you will feel a more powerful engagement of the glutes. Mind you, this is not a fix for cross over gaits, gosh, if it was only that simple !

This runner must investigate whether there is right frontal plane drift, and if it is in fact occurring, find the source of the drift.  It can come from many places on either limb. (This client says they are scuffing both inside ankles, which is not atypical and so we likely have drift on both right and left). We have discussed many of them here in various places on the blog over the years. Now as for “Why” the foot looks in toed, well that can also come from many places. Quite simply the adducted limb once it leaves toe off can look like this. But, perhaps it is also a product of insufficient external rotation maintenance occurred during that left stance phase, affording more internal rotation which is being unchecked and observed here during early swing.  Remember though, if this is in fact a cross over gait result, in this gait the limb approaches the ground unstacked (foot is too far inside a left hip joint plumb line) the foot will greet the ground at a far lateral strike and in supination.  Pronation will thus be magnified and accelerated, if there is enough time before toe off. However, and you can try this on your own by walking around your home, put yourself in terminal stance at toe off. Make sure you have the foot inverted so you are toeing off the lateral toes (low gear toe off). Does this foot not look like the one in the photo ? Yes it does, now just lift the foot off the ground and you have reproduced this photo. And when combined with a right pelvis drift, the foot will sneak further medially appearing postured behind the right foot. 

Keep this in mind as well, final pronation and efficient hallux (big toe) toe off does often not occur in someone who strikes the ground on a far lateral foot. I am sure this runner will now be aware of how poorly they toe off of the big toe, the hallux.  They will tend to progress towards low gear toe off, off the lesser toes. This leaves the foot inverted and this is what you are seeing in her the photo above. That is a foot that is inverted and supinated and it carried through all the way through toe off and into early swing. It is a frequently component of the cross over gait, look for it, you will find it, often. 

Final thoughts, certainly this can be an isolated left swing phase gluteus medius weakness enabling an adducted swing limb thus procuring a faulty medial foot placement, but it is still part of the cross over phenomenon.  Most things when it comes to a linked human frame do not work in isolation.  But i will leave you with a complicating factor and hopefully you will realize that gait analysis truly does require a physical exam, and without it you could be missing the big picture problem.  What if she has a notable fixed anatomic internal tibia torsion on that left side. Yup, it could all be that simple, and that is not something you can fix, you learn to manage that one as a runner.  

* Side bar rant: Look at any google search of runners photos and you will see this type of swing limb foot posturing often, far too often.  And yes, you can take the stance that “I do it as well and i have no injuries or problems so what is the big deal?”.  Our response is often “you do have an issue, it may be anatomic or functional, but you do have an asymmetrical gait and you think it is not a problem, YET”. And maybe you will run till you are 6 feet under and not have a problem because you have accomodated over many years and you are a great compensator, yes, some people get lucky. Some people also do not run enough miles that these issues express themselves clinically so lets be fair. But some of these people are reality deniers and spend their life buying the newest brace or gadget, trying a different shoe insert, orthotic or new shoe of the month and shop over and over again for another video gait analysis expert who can actually fix their pain or problem. And then there are those who have a 45 minute home exercise program that they need to do to keep their problems at bay, managing, not fixing anything.  Or, they spend an hour a week on the web reading article after article on what are the top 4 exercises for iliotibial band syndrome for example. They shop for the newest Graston practitioner, the newest kinesio taping pattern, Voodoo bands, breathing patterns, compression socks etc.  And sometimes they are the ones that say they still dont have a problem.You get the drift.  Gosh darn it, find someone who knows what the hell they are doing and can help you fix the issues that are causing the problem.  And yes, some of the above accoutrements may be assistive in that journey. 

I have dealt with this unique toe off issue way too many times not to roll my eyes at it any longer. It is to the point that it is an automated evaluation and solution program that begins to run in my head. Once you see something enough times, you learn all of the variations and subtle nuiances that a problem can take on. But, trying to fit everyone into a similar solution model is where the novice coach, trainer or clinician will get into trouble. Trust us, it all starts with an examination, a true clinical physical examination.  If one leaves the investigatory process to a series of screens or functional movement patterns, “activation” attempts, digital gait analysis or strength tests one is juggling chainsaws and the outcome you want is often not likely to occur. There is nothing wrong with making these components part of the investigation process, but on their own, they are not enough to get the honest answer many times.  Of course, Ivo and i were not able to jump the pond and examine this runner with our own eyes and hands so today’s dialogue was merely to offer this runner some food for thought to open their mind to our thought process, in the hopes that they can find someone to help them solve the underlying problem and not merely make the gait look cleaner. Making someone’s walking or running gait look cleaner is not hard, but making it subconsciously competent and clean (without thought or effort) requires a fix to the underlying problem. We can ALMOST guarantee you that the solution here to this runner’s form issue is not wholly at the foot that looks in toed and slanted. Merely working on their foot strike would be so remedial and corrupt that it would a crime.

Dr. Shawn Allen, one of the gait guys