Tag: rearfoot varus

Rearfoot to Hip Pathomechanical considerations.

In normal gait, the rearfoot strikes in slight inversion and then quickly moves through eversion in the frontal plane to help with the midfoot through forefoot pronation phases of gait. Some sources would refer this rearfoot eversion as the rearfoot pronatory phase, after all. pronation can occur at the rear, mid or forefoot. As with all pronation in all areas, when it occurs too fast, too soon or too much, it can be a problem and rearfoot eversion is no different.  If uncontrolled via muscles such as through tibialis posterior eccentric capabilities (Skill, endurance, strength) or from a structural presentation of Rearfoot Valgus pain can arise. 

From a scenario like in the video above, where a more rearfoot varus presentation is observed,  where the lateral to medial pronation progression is excessive and extreme in terms of speed, duration and magnitude this can also create too much lateral to medial foot, ankle and knee movement.  This will often accompany unchecked movements of internal spin through the hip. So one should see that these pronation and spin issues can occur and be controlled from the bottom or from the top, and hopefully adequately from both in a normal scenario.  It is when there is a biomechanical limitation or insufficiency somewhere in the chain that problems can arise. And remember, pain does not have to occur where the failure occurs, in fact it usually does not. So when you have knee pain from an apparent valgus posturing knee, make sure you look above and below that knee.  Also, keep in mind that as discussed last week in the blog post on ischiofemoral impingment syndrome (link), these spin scenarios can be quite frequently found with ipsilateral frontal plane lateral deviations (bumping of the hip-pelvis outside the vertical stacking of the foot-knee-hip stacking line). This stacking failure can also be the source of many of the issues discussed above, so be sure you are looking locally and globally. And remember, what you see is not the problem, it is their compensation around their deeper problem quite often.

If you have not read the blog post from last week on ischiofemoral impingement syndrome you might not know where the components of the cross over gait come in to play here nor how a rearfoot problem can present with a hip impingement scenario, so I can recommend that article one more time.

One last thing, just in case you think this stuff is easy to work through, remember that these rearfoot varus and valgus problems, and pronation rates. and limb spin rates are all highly variable when someone has varying degrees of femoral torsion, tibial torsion or talar torsion. Each case is different, and each will be unique in their presentation and in the uniqueness of the treatment recipe. I just thought I would throw that in to make your head spin a little in case it wasn’t already.

For example, a case where the rearfoot is a semi rigid varus, with tibial varum, and frontal plane lateral pelvic drift with components of cross over gait (ie. the video case above) will require a different treatment plan and strategy than the same rearfoot varus in a presentation of femoral torsion challenges and genu valgum. Same body parts, different orientations, different mechanics, different treatment recipe.  

So, you can fiddle with a dozen pair of shoes to find one that helps minimize your pains, you can go for massages and hope for the best, you can go and get activated over and over, you can try yet another new orthotic, you can go to a running clinic and try some form changes, throw in some yoga or pilates, compression wear, voodoo bands and gosh who knows what else. Sometimes they are the answer or stumble across it … or you can find someone who understands the pieces of the puzzle and how to piece a reasonable recipe together to bake the cake just right. We do not always get there, but we try.  

Want more ? Try our National Shoe Fit certification program for a starter or try our online teleseminars at www.onlinece.com (we did a one hour course on the RearFoot just the other night, and it was recorded over at onlineCE.com).

Dr. Shawn Allen,  of the gait guys

Reference:

Man Ther.  2014 Oct;19(5):379-85. doi: 10.1016/j.math.2013.10.003. Epub 2013 Oct 29.Clinical measures of hip and foot-ankle mechanics as predictors of rearfoot motion and posture.  Souza TR et al.

Health professionals are frequently interested in predicting rearfoot pronation during weight-bearing activities. Previous inconsistent results regarding the ability of clinical measures to predict rearfoot kinematics may have been influenced by the neglect of possible combined effects of alignment and mobility at the foot-ankle complex and by the disregard of possible influences of hip mobility on foot kinematics. The present study tested whether using a measure that combines frontal-plane bone alignment and mobility at the foot-ankle complex and a measure of hip internal rotation mobility predicts rearfoot kinematics, in walking and upright stance. Twenty-three healthy subjects underwent assessment of forefoot-shank angle (which combines varus bone alignments at the foot-ankle complex with inversion mobility at the midfoot joints), with a goniometer, and hip internal rotation mobility, with an inclinometer. Frontal-plane kinematics of the rearfoot was assessed with a three-dimensional system, during treadmill walking and upright stance. Multivariate linear regressions tested the predictive strength of these measures to inform about rearfoot kinematics. The measures significantly predicted (p ≤ 0.041) mean eversion-inversion position, during walking (r(2) = 0.40) and standing (r(2) = 0.31), and eversion peak in walking (r(2) = 0.27). Greater values of varus alignment at the foot-ankle complex combined with inversion mobility at the midfoot joints and greater hip internal rotation mobility are related to greater weight-bearing rearfoot eversion. Each measure (forefoot-shank angle and hip internal rotation mobility) alone and their combination partially predicted rearfoot kinematics. These measures may help detecting foot-ankle and hip mechanical variables possibly involved in an observed rearfoot motion or posture.

Can you see the problem in this runner’s gait ?

You should be able see that they are heel impacting heavy on the outside of the rear foot, and that they are doing so far laterally, more than what is considered normal.  
This is a video of someone with a rear foot varus deformity.
These folks typically have a high arched foot, typically more rigid than flexible, and they are often paired with a forefoot valgus.  
Q: Do you think it might be important as a shoe fitter to know this foot type ?
A: Yes
Q.Should they be put in a shoe with a soft lateral crash zone at the heel ? 
A: No, absolutely not. Why would you want to keep this person deeper and more entrenched on the lateral heel/foot ?!
This foot type has a difficult time progressing off of the lateral foot. The lateral strike pattern and the tendency for the varus rear-foot (inverted)  keeps this person on the lateral aspect of the foot long into midstance.  This eats up time when they should be gradually progressing over to the medial forefoot so that they can get to an effective and efficient medial (big toe) toe off.  This gait type is typically apropulsive, they are not big speed demons and short bursts of acceleration are difficult for these folks much of the time. Combine this person with some torsional issues in  the tibia or femur and you have problems to deal with, including probably challenges for the glutes and patellar tracking dysfunction. What to see some hard, tight IT Bands ?These folks are often the poster child for it. Good luck foam rolling with these clients, they will hate you for recommending it !
They are typically poor pronators so they do not accommodate to uneven terrain well.  Because they are more on the outside of the foot, they may have a greater incidence or risk for inversion sprains. You may choose to add the exercise we presented on Monday (link  here) to help them as best as possible train some improved strength, awareness and motor patterns into their system. In some cases, but only when appropriate, a rear foot post can be used to help them progress more efficiently and safely. 
These foot types typically have dysfunction of the peronei (amongst other things). A weak peroneus longus can lead to a more dorsiflexed first metatarsal compromising the medial foot tripod stability and efficiency during propulsion while also risking compromise to the first metatarsaophalangeal (1st MTP) joint and thus hallux complications.  Additionally, a weak peroneus brevis can enable the rear foot to remain more varus. This muscle helps to invert the rearfoot and subtalar joints. This weakness can play out at terminal swing because the rear foot will not be brought into a more neutral posture prior to the moment of heel/foot strike (it will be left more varus) and then it can also impair mid-to-late midstance when it fires to help evert the lateral column of the foot helping to force the foot roll through to the big toe propulsive phase of terminal stance.  (* children who have these peroneal issues left unaddressed into skeletal maturity are more likely to have these rearfoot varus problems develop into anatomic fixed issues…… form follows function.)
You can see in the video the failed attempt to become propulsive. The client speeds over to the medial foot/big toe at the very last minute but it is largely too late. Sudden and all out pronation at the last minute is also fraught with biomechanical complications.
One must know their foot types. If you do not know what it is you are seeing, AND know how to confirm it on examination you will not get your client in the right shoe or give them the right homework.
* caveat: the mention of Monday’s exercise for this foot type for everyone with Rearfoot varus is not a treatment recommendation for everyone with the foot type. For some people this is the WRONG exercise or it might need modifications. Every case is different. The biomechanics all the way up need to be considered. Medicine is not a compartmentalized art or science. 
Shawn and Ivo, The Gait Guys

 

Can you see the problem in this runner’s gait ?

You should be able see that they are heel impacting heavy on the outside of the rear foot, and that they are doing so far laterally, more than what is considered normal.  
This is a video of someone with a rear foot varus deformity.
These folks typically have a high arched foot, typically more rigid than flexible, and they are often paired with a forefoot valgus.  
Q: Do you think it might be important as a shoe fitter to know this foot type ?
A: Yes
Q.Should they be put in a shoe with a soft lateral crash zone at the heel ? 
A: No, absolutely not. Why would you want to keep this person deeper and more entrenched on the lateral heel/foot ?!
This foot type has a difficult time progressing off of the lateral foot. The lateral strike pattern and the tendency for the varus rear-foot (inverted)  keeps this person on the lateral aspect of the foot long into midstance.  This eats up time when they should be gradually progressing over to the medial forefoot so that they can get to an effective and efficient medial (big toe) toe off.  This gait type is typically apropulsive, they are not big speed demons and short bursts of acceleration are difficult for these folks much of the time. Combine this person with some torsional issues in  the tibia or femur and you have problems to deal with, including probably challenges for the glutes and patellar tracking dysfunction. What to see some hard, tight IT Bands ?These folks are often the poster child for it. Good luck foam rolling with these clients, they will hate you for recommending it !
They are typically poor pronators so they do not accommodate to uneven terrain well.  Because they are more on the outside of the foot, they may have a greater incidence or risk for inversion sprains. You may choose to add the exercise we presented on Monday (link  here) to help them as best as possible train some improved strength, awareness and motor patterns into their system. In some cases, but only when appropriate, a rear foot post can be used to help them progress more efficiently and safely. 
These foot types typically have dysfunction of the peronei (amongst other things). A weak peroneus longus can lead to a more dorsiflexed first metatarsal compromising the medial foot tripod stability and efficiency during propulsion while also risking compromise to the first metatarsaophalangeal (1st MTP) joint and thus hallux complications.  Additionally, a weak peroneus brevis can enable the rear foot to remain more varus. This muscle helps to invert the rearfoot and subtalar joints. This weakness can play out at terminal swing because the rear foot will not be brought into a more neutral posture prior to the moment of heel/foot strike (it will be left more varus) and then it can also impair mid-to-late midstance when it fires to help evert the lateral column of the foot helping to force the foot roll through to the big toe propulsive phase of terminal stance.  (* children who have these peroneal issues left unaddressed into skeletal maturity are more likely to have these rearfoot varus problems develop into anatomic fixed issues…… form follows function.)
You can see in the video the failed attempt to become propulsive. The client speeds over to the medial foot/big toe at the very last minute but it is largely too late. Sudden and all out pronation at the last minute is also fraught with biomechanical complications.
One must know their foot types. If you do not know what it is you are seeing, AND know how to confirm it on examination you will not get your client in the right shoe or give them the right homework.
* caveat: the mention of Monday’s exercise for this foot type for everyone with Rearfoot varus is not a treatment recommendation for everyone with the foot type. For some people this is the WRONG exercise or it might need modifications. Every case is different. The biomechanics all the way up need to be considered. Medicine is not a compartmentalized art or science. 
Shawn and Ivo, The Gait Guys

 

Do you think I need to replace my shoes?

These shoes appear to be well past their prime, to say the very least ! These poor dogs have the rear and forefoot varus “worn” right into them. You can see this represented particularly easily from the front, look at the lateral sloping of the shoe. It almost appears as if his foot could slide off the outside edge of the shoe. One can easily postulate that an inversion ankle sprain is just one unfortunate step away.

It looks like this medially posted shoe is not working for this fellow (you can see the medial post on the inner edge of the EVA midsole if you look carefully)  If you have questions on the “flare”?/post click here) . The client told us that they are “only a few years old” and planned on running one more 1/2 marathon in them this spring! Of course we mentioned they should put a office visit on the books the day after that race, because their ankles and knees were likely going to need it !

One can only imagine the lateral (genu varum) forces being placed on the knees, and who knows what kinds of increased shear forces are imparted into the menisci.  The lateral (inversion / varus) forces are going to impart a tendency of external rotation into the hips, and if one is busy externally rotating they are not going to internally rotate the hips when it is necessary to as the pelvis passes over the foot in midstance.  Additionally, an inverted /varus postured foot is more rigid because it is supinated which makes for a poor pronation/shock absorbing foot during the accomodative phase of the stance phase.

There are many more issues we could discuss here. But this was never meant to turn into a diatribe on specific biomechanical flaws, not this time at least.  Just remember this, whatever biomechanical flaws your feet have (and most of us have them) will eventually be pressed into the EVA foam of your shoes. Meaning, in time your shoes will reflect your aberrant flaws biomechanically.  And these newly built-into-the-shoe problems will now magnify the foot’s challenges and can accelerate pathology locally and globally.  Change your shoes often and as we have suggested in older blog posts, please consider having 2 shoes in your regular rotation.  One shoe being older and one being newer. We suggest starting an new shoe into the rotation once the old shoe has 200-250 miles and then alternating shoes every other day.  This way the foot is never seeing an older more deformed shoe for more than a day before getting some correction.  The point here, don’t let a shoe get 400-500 miles on it, in all its deformed glory, and then suddenly force the foot into a sudden biomechanical correction with a brand new shoe.  Abrupt changes lead to abrupt biomechanical demands on the system, so limit them and limit your risk for injury.

PS: Note the nice after-market “venting feature” in the right shoe near the little toe.

What some folks will try to do to save a few bucks…

Ivo and Shawn, The Gait Guys

The Great Myth of Rotating your Shoes : Here are the Actual Facts as we see them.

Everyone has heard the rules, rotate into new shoes about every 400-500 miles.  We disagree, kind of, and we have talked about it on previous blog posts in the past and on our podcasts.  Many shoe reps have agreed with the methods we employ for our runners.

The EVA foam often used in shoe manufacturing has a lifespan, or better put, a given number of compression and shear cycles. It can go through a rather fixed number of compression cycles before it loses its original structural properties, the older the foam gets the faster the degradation process and the more risks it poses for runners.  It is known that EVA foam compressed into a focal vector or area over and over again becomes softer and more giving into that vector/area over time.  Hence, if you have a compensation pattern or a known foot type (forefoot varus, forefoot valgus, rearfoot varus, rearfoot valgus or a combination of these 4) you will break down a certain region or zone of the shoe’s EVA foam. For example a forefoot varus foot type will often drive some heavy focal compression into the foam under the first metatarsal. However, if you combine it with a rear foot valgus it will drive shear forces and compression into the  EVA foam along the entire medial aspect of the shoe (see the 2 pictures attached, you can see the evidence of excessive medial compression and medial shear in a foot that has severe rearfoot valgus and forefoot varus. This is a very poor shoe prescription for the foot type involved).

Here is what you need to do / know:

1- Know your athletes foot type so you can make more informed decisions.

2- Know the type of foam of the shoes you are recommending (ie. Altra uses A-Bound foam instead of EVA just as an example. A-Bound is an environmentally friendly energy-return compound is made of recycled materials. It reduces the impact of hard surfaces while still maintaining ground feedback. Traditional running shoe foam compresses 70-90% while A-Bound™ compresses 2-3x less so it won’t deform over time.).  Cheap shoes use cheap materials.  Altra goes the extra mile for foam quality and many others are beginning to follow suit. If you think you are getting a deal on shoes, know what “the deal” is, it just may be cheaper materials.

3-  500 miles is not the rule for everyone and every shoe.  If you have a relatively neutral forefoot and you are a forefoot or midfoot strike runner you will get far more miles out of a shoe.  If you depend on a stability shoe with dual densities of foam to slow your pronation and control your medial foot because of a rearfoot valgus and/or forefoot varus know that the shoe’s foam will break down less uniformly because of foam interface junctions and whatnot.  This is a science. Engineers call it “the mechanics of material deformation”.  We wonder how many mechanical engineers shoe companies have on board in their R&D divisions ?  We know for a fact that a few do not. There was a reason we snuck quietly into the mechanical engineering departments of our Alma Mater and sat quietly in the “Materials” classes. At the time our roommates just told us it was  cool class, little did we know why it was so interesting to us, until now.

4- Here is what we recommend. Fit the foot type to the right shoe selection. If you are weak in this territory consider taking our intense “National Shoe Fit” program. Fit is everything. Make the wrong choice for your client and the shoes will break down quicker and into poor and risky patterns. Make the right choice and be their hero. If you are looking for a way to improve clientele happiness and store loyalty our Shoe Fit Program is the way. Just read the testimonials here on our blog. Some of the top stores in the Nation have quietly taken the National Shoe Fit Program from us, they have good reason to. They also have good reason to keep it quiet, to get the edge on the competition.

You can email us to get this information and the e-file program download. Why not certify your entire store staff ?

Email us at   thegaitguys@gmail.com.  This program will teach you foot anatomy, functional anatomy, shoe anatomy, foot types and matching foot type to shoe type as well as many other aspects of gait and lower limb biomechanics.

* 5- Try this recommendation.  At 250 miles buy a new shoe to accompany your shoe that already has 250 miles. Now you are rotating 2 shoes. From this 250 mile point moving forward, alternate the newer show with the older shoe. This way you are never in a shoe that is notably more deformed in a specific area of the EVA foam because of your compensations, limitations or foot type. Essentially you are always just a day away from a newer shoe that has less driving force into abnormally compressed EVA foam.  The older the shoe gets the more it accelerates your foot and body into that deformation and hence why many injuries occur as their shoes get older. Continue to alternate shoes on every other run (new, old, new, old).  Once you hit 400-500 miles on the old shoes, ditch them and get a new pair again to restore the cycle once again.  In fact, to be specific here is what we recommend. Monday, old shoe. Tuesday, new shoe. Wednesday do not run, rather, rest or cross train. Thursday go back to the older shoe. Friday new shoe and repeat. This way you are 4 days between runs in the older more deformed shoe. The one day off running in mid week gives tissues that were challenged by the “old shoe run” a bit more time to repair.

6- Dedicate your shoes to running only. Running gait is not the same as walking gait. Why would you want to break down the EVA foam at the rear foot during walking (because heel strike is normal in walking) when in running you are a mid-forefoot striker ?  Keep walking shoes for walking, running shoes for running. Otherwise you are just asking for trouble.

Check out our National Shoe Fit program and certification process here as well as links to our other teaching DVD’s & e-downloads:
 http://store.payloadz.com/results/results.asp?m=80204

Shawn and Ivo. Helping you use your head (and shoe knowledge) better everyday.
The Gait Guys  (have you checked out our RebelMouse page ? https://www.rebelmouse.com/TheGaitGuys/

Keeping up with our awesome informative podcasts ? It is all free stuff ! https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

How about our youtube channel ? http://www.youtube.com/user/thegaitguys

How about our Facebook PAGE ?  https://www.facebook.com/pages/The-Gait-Guys/169366033103080

The Dual Density Foam Running Shoe.

This goes along nicely with yesterdays post. Note the photo attached. This is a great example of something we all see everyday. A laterally tipped foot in a stability shoe.  Clearly a shoe that has been mis-prescribed for the wrong reason. Or has it ?

This client is clearly tipped laterally in the shoe, forcing supination.  Did this client self fit the shoe themselves in a discount store ? Were they fitted in a retail running store ? Where did things go wrong ? Or did they ?  The initial knee jerk reaction is to say this is the wrong shoe for this client.  Lets go a little deeper and ask some harder questions and see if you are considering some alternatives.

The assumption is frequently one of, “you are a hyperpronator so you need a stability shoe”. In this case is this person a hyperpronator ?  There is no way to know, not in the shoe.  On initial knee jerk observation this looks like a supinator in a stability shoe, a poor match.  But read on …

1. What if this person has significant flat feet, pes planus with severe pronation problems, but they find the stability they need by standing on the outer edge of the foot in the mechanically locked out position (supination).  Perhaps this is a less fatiguing posture, perhaps a less painful posture. This is often a comfort thing for hyperpronators to display.  What you see is not always what you get because there are two types of feet, those that drop or collapse into the weakness and those that fight the collapse and weakness the whole way via an alternative compensation.  You cannot tell by looking, certainly not from this picture of someone in a shoe. There must be a functional assessment and some gait evaluation. 

2. There exists the high arched flexible foot that pronates excessively, quickly and for a long time (this is the flexible cavus foot) and then there is the high arched rigid foot (the equinovarus foot).  The first described foot may need support from a stability shoe even though they have a high arch on presentation/examination and the later described foot can often go right into a neutral non-supportive shoe.  Can you tell either of these from this picture ? No you cannot.

3. Maybe the person in the photo has tibial varum (bowed lower leg) combined with a rearfoot varus and forefoot varus. This could mean they pronate heavily through the midfoot-forefoot and less so through the rearfoot-midfoot. In this case they are still a heavy pronator but not through what is typically noted or detected by significant medial arch collapse.  In this case the dual density shoe is not going to help all that much because the pronation is occurring mostly after the bulk of the shoe’s dual density stability foam has been passed through by the foot. Can this be detected by this photo ? Again the answer is no. The shoe fitter needs to be clinically aware that this type of client needs a forefoot varus posted shoe to help post up that medial tripod (1st metatarsal head).

4. Maybe, just maybe this is a typical rearfoot-midfoot pronating client, excessive mind you, and all they need is some foot and gait retraining to break their old compensation pattern of lateral weight bearing (standing or walking) and with this correct shoe they can then engage a healthier motor pattern. 

Which is it ?

Do you know how to navigate your way through these issues to make the right decision ?  There is no way to know here without seeing the foot naked and moving across the floor, and with a clinical examination to boot.

You can get all these things through our National Shoe Fit Certification program found here.

LINK:  http://store.payloadz.com/results/results.aspx?advsearch=1&m=80204

Email us and we will share the necessary info to get you started.  thegaitguys@gmail.com

Shawn and Ivo, The Gait Guys

A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools 3/4 foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.
Jim

______________________

Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo

_______________________

Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.
Jim

_________________________________

You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo

A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools 3/4 foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.
Jim

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Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo

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Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.
Jim

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You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo

Here is some classic Shawn and Ivo, talking about rearfoot varus in one of our older “Manual Medicine Advisor” Podcasts. Sit back and enjoy!