Can you guess why this person has left-sided plantar fasciitis?

This question probably seem somewhat rhetorical. Take a good look at these pedographs which provide us some excellent clues.

First of all,  note how much pressure there is over the metatarsal heads. This is usually a clue that people are lacking ankle rocker and pressuring these heads as the leg cantilevers forward.  This person definitely have a difficult time getting the first metatarsal head down to the ground.

Notice the overall size of the left foot compared to the right (right one is splayed or longer). This is due to keeping the foot and somewhat of a supinated posture to prevent excessive tension on the plantar fascia.

The increase splay of the right foot indicates more mid foot pronation and if you look carefully there is slightly more printing at the medial longitudinal arch. This is contributing to the clawing of the second third and fourth toes on the right. Stand up, overpronate your right foot and notice how your center of gravity (and me) move medially.The toes will often clench in an attempt to create stability.

The patient’s pain is mostly at the medial and lateral calcaneal facets, and within the substance of the quadratus plantae with weakness of that muscle and the extensor digitorum longus. She has 5° ankle dorsiflexion left and 10 degrees on the right and hip extension which is similar.

The lack of ankle rocker and hip extension or causing her to pronate through her midfoot, Tensioning are plantar fascia at the insertion. The problem is worse on the left and therefore that is where the symptoms are.

Pedographs can be useful tool in the diagnostic process and provide clues as to biomechanical faults in the gait cycle.

The Mighty Interossei

By request of one of our readers (Thank you Richard S), we were asked to “dig up” some information about the interossei. After scouring the literature, we turned up an interesting paper, talking about their anatomy. 

Of interesting note, the paper found extensive connections of the musculature with the surrounding fascia (talk about myofascial meridians!) as well as a fairly consistent slip of the peroneus longus which contributes to the 1st dorsal interossei. This is important considering the peroneus fires from midstance on, as do the interossei (and other foot intrinsics). Perhaps (since as the fore foot is extending in late midstance and pre swing) it assists in descending the head of the 1st metatarsal and resisting extension (contracting eccentrically) of the metatarsal phalangeal joints, helping to maintain stability of the fore foot for push off. 

“The extensive connections among the interossei indicate that they could be
important stabilisers of the foot during those times when rigidity is required. The
pull of the interossei is transformed across the tarsometatarsal joints by means of
their attachment to the ligamentous meshwork. Thus they will act upon the tarsometatarsal
joints. Crossing those joints on their plantar aspect, the interossei are well
placed to assist in resisting extension. Even though their close attachment proximal
to the joints creates a short lever arm and therefore relative inefficiency as flexors
when weight is borne on the ball of the foot (MacConaill, 1949), the large mass of the
combined interossei probably indicates that they do have a significant role in resisting
extension at these joints. Also, the shapes of the tarsometatarsal joint surfaces
restrict angular motion.”

Definitely a good read and available FREE full text online here

PAUL J. KALINt AND BRUCE ELLIOT HIRSCH: The origins and function of the interosseous
muscles of the foot  J. Anat. (1987), 152, pp. 83-91 

Sometimes it is easy and straight forward.

HISTORY: A 56 YO 200 # male construction worker presents with pain at the bottom of his right foot, worse in the am, getting better as the day goes on till midday, then getting worse again. Better with rest and ice. More supportive shoes and a heel gel pad offer him some relief. Past history of plantar fascitis. 

OBJECTIVE:           Tenderness at medial calcaneal facet right side;  tenderness also in the arch and over the flexor hallucis longus tendon and short flexors of the toes. Ankle dorsiflexion is less than 5 degrees on the right, and 15 on the left.  Hip extension was less than 10 degrees bilaterally. He has mild bi-lat. external tibial torsion.

Gait evaluation reveled an increased progression angle right greater than left.  Very limited ankle dorsiflexion noted bi-lat (decreased ankle rocker). 

There is weakness of the short flexors (FDB) and long extensors (EDL) of the toes on the right. Poor endurance of the intrinsic musculature of the arch as well as interossei musculature during standing arch test.

PEDOGRAPH FINDINGS: 

ASSESSMENT:       From history and exam, plantar fascitis.

PLAN:           He was given the following exercises:  lift/spread/reach, the one leg balancing, shuffle walks and toes up walking. These were filmed via ipad and sent to him.  We are going to build him a medium heel cup, full length orthotic made out of acrylic.  We will see him again later this week.  We will do some symptomatic treatment utilizing manual stimulation techniques, pulsed ultrasound and additional exercises aimed at improving dorsiflexion as well as hip extension. 

 

Achilles tendonitis: Lift the heel, right? It does not appear so.

There was a recent article in one of our favorite journals, Lower Extremity Review which reviewed and expanded on another study from Medicine and Science in Sports and Exercise we spoke about several PODcasts ago titled “Running shoes increase achilles tendon load in walking: an acoustic propagation study.”

 

The article discusses a new technique (1,2) for looking at tensile loads in the achilles and looks at 12 symptom free individuals on a treadmill barefoot and in a shoe with a 10 mm drop and found:

“Footwear resulted in a significant increase in step length, stance duration, and peak vertical ground reaction force compared with barefoot walking. Peak acoustic velocity in the Achilles tendon (P1, P2) was significantly higher with running shoes.”(1)

 

According to LER: “The researchers also found changes in basic gait parameters associated with walking in running shoes versus barefoot, which Wearing said may help explain the increased tendon load with shoes. Shoes increased mean ankle plantar flexion by 4° during quiet stance as measured by electrogoniometry. When walking with shoes, participants adopted a lower step frequency but greater step length, period of double support, peak vertical ground reaction force, and loading rate than when walking barefoot. The researchers also noted that participants’ stance phase was relatively longer (4%) during shod walking than during barefoot walking.” (3)

 

Of course, our big question is why?

 

Would an increase in step length result in increased tension? Perhaps, as the force that the heel would hit the ground would be increased because of a longer acceleration time (F=ma) and that is also what they found. The friction of the heel striking the ground would accelerate anterior translation of the talus, which plantar flexes, everts and abducts, accelerating pronation. The medial gastroc would be called into play to slow calcaneal eversion and this would indeed increase achilles tension.

 

Or perhaps it’s the fact that the foot will strike in slight greater plantarflexion (at least 4 degrees according to the study) and this results in an immediate greater load to the Achilles tendon.  Go ahead and try this while walking even if you’re barefoot. Walk across the floor and strike more on your forefoot. You will notice that you have an increased load in the tricep surae group.

 

Does this slight plantarflexion of the ankle contribute to greater eccentric load during stance phase?  This would certainly activate Ia afferent muscle spindles which would increase tensile stresses in the Achilles tendon.

 

This seems to fly directly in the face of the findings of Sinclair (4) who investigated knee and ankle loading in barefoot and barefoot inspired footwear and found increased Achilles loading in both compared to “conventional shoes”.

 

Of course this also begs the question of  what type of shoes were they in? High top shoes or low top shoes and were the shoes tied or not? High top shoes seem to reduce Achilles tension more so than low top shoes, especially if they are tied (5).

 

 Whatever the reason, this questions the use of putting a lift or a higher heel shoe underneath the foot of people that have Achilles tendinitis.  Once again what seemed to make biomechanical sense is trumped by science.

 

 We think training people to have greater amounts of hip extension as well as ankle dorsiflexion,  as well as appropriate foot and lower extremity biomechanics with the requisite  skill, endurance and strength is a much better way to treat Achilles tendonitis regardless of whether they’re wearing footwear or not.

 

The Gait Guys

 

References:

1. Wearing SC, Reed LF, Hooper SL, et al. Running shoes increase Achilles tendon load in walking: An acoustic propagation study. Med Sci Sports Exerc 2014;46(8):1604-1609.  http://www.ncbi.nlm.nih.gov/pubmed/24500535

2. Reed LF, Urry SR, Wearing SC. Reliability of spatiotemporal and kinetic gait parameters determined by a new instrumented treadmill system. BMC Musculoskelet Disord 2013;14:249.

3. Black, Hank. Achilles oddity: Heeled shoes may boost load during gait. In the Moment:Rehabilitation   LER Sept 2014  http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait

4. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech (Bristol, Avon). 2014 Apr;29(4):395-9. doi: 10.1016/j.clinbiomech.2014.02.004. Epub 2014 Feb 23.

5. Rowson S1, McNally C, Duma SM. Can footwear affect achilles tendon loading? Clin J Sport Med. 2010 Sep;20(5):344-9. doi: 10.1097/JSM.0b013e3181ed7e50.

Too much pressure for the holidays? Take a look at that midsole of yours…

In the vein of last weeks post on plantar pressures, we find that midsoles DO DECREASE plantar pressures, especially across the midfoot (30% less pressure in this study), again dependent on foot type (In this study, low vs high arched individuals). They also INCREASE plantar contact area. Contact area can be useful for helping to influence biomechanics of different foot types (often more contact area = more force attenuation)

We also saw that they increase pressures LATERALLY (see our post here).

Bottom line? You need to look at foot type and remember that “shoes are medicine”. Watch what you are prescribing and think about what you are trying to accomplish. There is no substitute for good biomechanics.

We are The Gait Guys. Bringing you the best of gait, each week.

Shoe Types and plantar pressures

J Am Podiatr Med Assoc. 2009 Jul-Aug;99(4):330-8. Effect of running shoe type on the distribution and magnitude of plantar pressures in individuals with low- or high-arched feet. Molloy JM, Christie DS, Teyhen DS, Yeykal NS, Tragord BS, Neal MS, Nelson ES, McPoil T. Source US Army-Baylor University Doctoral Program in Physical Therapy, Ft Sam Houston, TX 78234-6138, USA. Joseph.Molloy@amedd.army.mil

Abstract BACKGROUND:

Research addressing the effect of running shoe type on the low- or high-arched foot during gait is limited. We sought 1) to analyze mean plantar pressure and mean contact area differences between low- and high-arched feet across three test conditions, 2) to determine which regions of the foot (rearfoot, midfoot, and forefoot) contributed to potential differences in mean plantar pressure and mean contact area, and 3) to determine the association between the static arch height index and the dynamic modified arch index.

METHODS:

Plantar pressure distributions for 75 participants (40 low arched and 35 high arched) were analyzed across three conditions (nonshod, motion control running shoes, and cushioning running shoes) during treadmill walking.

RESULTS:

In the motion control and cushioning shoe conditions, mean plantar contact area increased in the midfoot (28% for low arched and 68% for high arched), whereas mean plantar pressure decreased by approximately 30% relative to the nonshod condition. There was moderate to good negative correlation between the arch height index and the modified arch index.

CONCLUSIONS:

Cushioning and motion control running shoes tend to increase midfoot mean plantar contact area while decreasing mean plantar pressure across the low- or high-arched foot.

all material copyright 2012  The Gait Guys/ The Homunculus Group. Please ask before using our stuff or Santa will bring you athletes foot this holiday season.