There are few places we will accept a cross over gait as safe and normal, this is one of them.

Anyone want to place a bet this person does not have a rigid pes planus ? We are happy to take your money if you bet against this one. (hint: a rigid pes planus, is RIGID, it will not form an arch like this, even from upward pressure, in most people who have it).
A rigid pes planus can result from a long standing (years) insufficient tibialis posterior or complete tear of one (again, moon’s ago) resulting in an inability to invert the heel and raise the arch. We saw one this week.

Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

– another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. Shawn Allen, one of the gait guys

Some Fat on Flat Feet

Normal feet:

  • more hindfoot dorsiflexion (read ankle rocker)
  • hindfoot more flexible
  • no or different compensation, if any


Symptomatic Flat feet:

  • less hindfoot dorsiflexion (read, reduced ankle rocker)
  • hindfoot was more everted, but less flexible.
  • forefoot compensates for reduced motion in rearfoot by increasing motion 
  • hallux hypermobility
  • symptomatic flat feet lacked positive joint energy for propulsion 


Asymptomatic flat feet:

  • less hindfoot dorsiflexion (read, reduced ankle rocker)
  • hindfoot was more everted, but less flexible.
  • forefoot compensates for reduced motion in rearfoot by increasing motion 
  • hallux hypermobility
  • asymptomatic flat feet needed to absorb more negative ankle joint energy during loading response. This may risk fatigue and overuse syndrome of anterior shank muscles


“Hence, despite a lack of symptoms flatfoot deformity in asymptomatic flat feet affected function. Yet, contrary to what was expected, symptomatic flat feet did not show greater deviations in 3D foot kinematics than asymptomatic. Symptoms may rather depend on tissue wear and subjective pain thresholds.”

http://www.ncbi.nlm.nih.gov/pubmed/23796513

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.

The Rigid Flat Foot: Do you know what you are actually dealing with ?

In these 5 photos of a client with a flat arch we see some great opportunity to discuss some of the clinical issues and clinical thinking that needs to occur.  As usual we write our blog posts on the fly with a principle at hand that we want to drive home, or in this case “into the ground”.  There are many more clinical issues with this type of foot and its problems, so today’s list and dialogue is not meant to be exhaustive.  But, if you take one thing away from this case, it should be that not all flat feet can take a stability shoe or an orthotic. So, if you are in the mind set that “when it is flat, jack it up (the arch)” and “when it is high (the arch), cushion it” hopefully you will open your eyes a bit to the reality that it just is not that simple.  IF you want to learn more about these issues we have purposefully put together the National Shoe Fit program for stores and doctors/therapists so they can learn more about the anatomy of the feet and shoes and how to pair them up to create the best recipe for a person.  

Now, onto this case.

In this case you should notice a few things. 

1- the rigidity of the flat foot as portrayed in the photo where we are pushing up with our thumb on what once was the peak of the arch (yes, there are 5 photos in this case, click on one to enlarge or scroll) . We are attempting to push up, but the midfoot is completely rigid. This is a classic Rigid Flat Foot Deformity, A Rigid Pes Planus if you will. 

2- There is a prominence at the navicular bone, both top (dorsal) and bottom (plantar) aspects of the foot (see photo of my hand with finger and thumb indicating these areas). The plantar prominence is the actual naviular bone (mostly) that has become weight bearing (termed “weight bearing  navicular” and crudely by some as a dropped navicular, a term we dislike). And the dorsal prominence is a dorsal crown of osteophytes. This means a dorsal ridge of bone has formed at the navicular-1st cuneiform bone/joint interval because of the constant and repetitive compression of the two against each other dorsally as midfoot arch collapse occurred repeatedly and then became a fixed permanent entity.

3- The hyper dorsiflexion range at the 1st MTP joint (the big toe). This range is excessive at actually was able to exceed 90 degrees (see photo) !  Even at rest the hallux (big toe) is extended suggesting the volume of dorsiflexion it gets all the time.  By the way, there was little to no hallux 1st MPJ joint plantarflexion (downward bend), not in a foot this flat. In fact most of that is from the contracture of the short extensors of the toes as noted by the photo showing the hammer toe formation (hammer toe = contractured short extensor myotendon, and to the long flexors as well). Hammer toes are almost always seen in a flat foot presentation, to a degree.

Now, lets put some things together (but a reminder, this is a single principle today, there are many more issues here).

Today’s Principle: Passing the Buck

Normally we need to have just slightly greater than 90 degrees of ankle mortise dorsiflexion to progress the body over the ankle.  Put in other words, we need to be able to get the tibia slightly past vertical (perpendicular to the ground, hence 90+ degrees). Depending on the reference, anywhere from 15-25 degrees past that 90 degree vertical, thus 105 to 120 degrees) is the goal.

If an ankle cannot get that range, the range must be achieved either proximal or distal to that joint, ie. Passing the Buck beyond the ankle mortise joint.  Proximally, one can hyperextend the knee to enable the body mass to pass sagittally over the ankle but a better strategy (arguably) is to compensate distally via collapsing the arch and pronate more than normally through the midfoot putting undue stress and strain into the plantar fascia and over time eventually collapsing the arch and creating the dorsal and plantar bony prominences we mentioned in #2. By dropping the arch, the subtalar joint exceeds its ranges and the talus and navicular collapse medially and plantarwards. 
When the arch drops to the planus stage the tibia is passively thrust forward achieving the necessary forward tibial progression to get body over and past the ankle to enable forward progression. 
Remember, this pes planus will dorsiflex the long metatarsal bone (meaning make it parallel to the ground). This will screw up the 1st Metatarsal-phalangeal joint function and  impair the Windlass Mechanism of Hicks at the big toe (translation, it will impair the sesamoids, possibly leading to sesamoiditis, and change the normal toe function and its tendons.  This is seen both in the pes planus foot and in hallux rigidus turf toe presentations where the big toe loses its  normal ranges as compared to this case here).

So, the normal range can as for the buck to be passed proximally into the kinetic chain or distally. Which one would you want, if you had to chose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !
Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns. 
Here is a tougher question for you. Would you want this phenomenon on one side and be uniliaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*So, a flat RIGID foot.  If you jam an agressive orthotic (or possibly even a motion control shoe) under this foot it could very likely be painful to those rigid bony prominences and it will remove the client’s “passing the buck” compensation. Now the forces may have to revert to the proximal strategy at the knee.  So, when do YOU go with the orthotic or motion control shoe ? When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe

As promised. We fixed the volume.  Less hiss next time. Enjoy

Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch. Muscle specifically discussed are a team: FHB (flexor hallucis brevis), AbDuctor hallucis, and tibialis posterior. He discusses the functional anatomy, normal and pathologic movement patterns of the arch and first ray complex and big toe (hallux). His foot’s ability to show the optimal patterns for the arch and hallux are excellent examples. Follow up videos and DVDs will show more details you need to know, and some of the exercises he and Dr. Ivo Waerlop use to restore a foot that has lost these abilities. The DVDs are in the works. Take their lectures and CME on www.onlineCE.com. Visit them at www.thegaitguys.com and on their facebook PAGE & Twitter of the same name for daily feeds of unique things.