A clear cut case of Form follows Function.  Leave a deforming force long enough and the body will accommodate. 

When the lateral quadratus plantae (QP) is weak and the flexor digitorum longus pulls unopposed (relying on the QP to properly orient the long flexor pull) for too long the 4th and 5th toes and drift medially and spin inwards toward the midline of the foot (as seen in the photo). Then, as the 4th toe presses down on the fleshy pad of the 5th toe, over time the fleshy pad is pancaked and triangulated. Then, with repeated pressure a corn like hardness becomes of the tip of that triangluted tissue, it resembles a hard callus. A corn is a coalescing of the skin cells into a tighter formation, a reaction to fend off repeated pressure and friction.  Form follows prolonged function.  Shave these things down and they will come back, unless you get to the root source of the problem, which could be all the way up the chain. 

-Dr. Allen

Toe sardines. What have we done to our feet ?

Note that form follows function. If you are observant, you will see the deformation of the 5 digit, just like in this case as the quadratus weakens and the long flexors dominate. The toe begins to spin laterally, and thus the plantar toe pad begins to deform medially, look closely, you can see that here in the video.

Does this look like your foot ? There are a few subtle issues here. 

In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit, the one you use during road rage, is the reference digit. Next time you are questioned, tell them you threw them your reference finger, not “the bird”, it is a more accurate descriptor.

In this foot, note how neatly and tightly packed the cute little toes are, all snuggled up to their brothers and sisters. Remember, form follows function. Obviously function has been low on these fellas, at least in abduction.  This often comes from snug toe box footwear and lack of abduction (toe spread) use.  But make no mistake, this is a weak foot.

Today we wish to really focus your attention to an old topic, just a revisit. We can see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL). See this post here for an explanation of this phenomenon.  There is also obvious imbalance between the long and short flexors and extensors in these toes, the long flexors are expressing more tone, and that means the long extensors are deprived. 

Note that form follows function. If you are observant, you will see the deformation of the 5 digit, just like in this case as the quadratus weakens and the long flexors dominate. The toe begins to spin laterally, and thus the plantar toe pad begins to deform medially, look closely, you can see that here in the video. This spin can carry the toe nail so far laterally sometimes that the nail can begin to touch the ground during gait and cause painful nail lifting with even some losing the nail. 

There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box.  The client needs to be retaught how to access the toe extensors and abductors. Lumbrical retraining, which is a recurrent topic here on our blog, should also be instituted. 

Shawn Allen, one of the gait guys

The mighty Quadratus Plantae! Here is a video short on this awesomely important muscles function, testing and exercise. Enjoy!

The deeper your knowledge and experiences, the more things you will see. As in life, the more experiences you have the wiser you become and the clearer the bigger picture becomes. All these things enrich the experience or observation. These experiences take simple black and white and render an infinite palate of grey tones. 

To the untrained observer, these are just two feet. With a little more experience these are two feet of different length. Deeper further, these are two different sized feet with different plantar pressure responses (helped here by increasing the greyscale contrast). Deeper yet, this represents a left foot (viewers right) that has a dysfunctional flexor digitorum longus (FDL) and lateral quadratus plantae muscle. All of these observations allow the skilled and knowledgeable viewer to extrapolate and theorize, with clear thought processes, which leg could be shorter/longer, how the pelvis might be distortioned, step length and stride length variability, foot stability and so much more.

The life long student does not need the contrast enhanced picture on the right to heighten the visibility of the plantar pressures, but it helps.  This is what wisdom and experience do, they enable you to look deeper into something and to see it for what it truly is, not what it appears to be.

Come listen to our teleseminar tonight (Wednesday March 18th, 2015) on www.onlinece.com at 7pm central. Log in early to get set up. Come listen in while we delve into one of the bigger questions, if the left foot (viewers right) is longer it has likely pronated more over a longer period of time stretching out plantar soft tissues and corrupting joint function in multiple areas. But if this is the case, why then are they presenting with plantar pressures that are more representative of supination standards ?  

This is mental gymnastics. It is good stuff to do regularly, even though this is a static presentation, many good theories and thoughts can be brought forth. Getting the answer is not the goal, getting the thought process down is.

The more you know, the more truth you will see.

See you tonight, we will break this down into a microscopic level that will challenge you all.

Shawn and Ivo, the gait guys

Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there. 

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left.  The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function  (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot  or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ?  Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. 

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow.  We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation.  See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?

Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there. 

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left.  The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function  (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot  or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ?  Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. 

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow.  We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation.  See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot.  Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level.  If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg.  In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg.  Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ?  Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation.  Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ?  What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption.  See you tomorrow friends !

Shawn and ivo, the gait guys