Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe. 

What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head. 

This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.

So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:

  • impaired toe off
  • premature heel rise
  • watchful eye on achilles issues
  • impaired hip extension and gluteal function
  • impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)
  • impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)
  • lateral toe off which will promote ankle and foot inversion, which will challenge the peronei
  • frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function
  • possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)
  • possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading
  • impaired arm swing, more notable contralaterally

There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.

* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).

If you know the complicated things, then the simple things become … … . . simple.

Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left. 

… .  sorry for the rant, too much coffee this morning, obviously.

Shawn Allen, one of the gait guys

Podcast 95: Head tilt while squatting or running.

We have a strong show for you today. Ankle instability from a neurologic perspective, shoe wear, head tilt and the neurologic and functional complications… we also talk about Efferent Copy and motor learning.

A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_95final.mp3

Direct Download:  http://thegaitguys.libsyn.com/pod-95

-Other Gait Guys stuff
B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

Human exoskeletons: The Ekso
http://www.thedailybeast.com/articles/2015/08/03/the-mechanical-exoskeleton-shaping-the-future-of-health-care.html

Ankle muscle strength influence on muscle activation during dynamic and static ankle training modalities
http://www.tandfonline.com/doi/abs/10.1080/02640414.2015.1072640?rfr_id=ori%3Arid%3Acrossref.org&url_ver=Z39.88-2003&rfr_dat=cr_pub%3Dpubmed&#.VcYWR-1VhBc

Chronic ankle instability:

http://tmblr.co/ZrRYjx1akudcm

http://tmblr.co/ZrRYjx1ah6ThV

http://thegaitguys.tumblr.com/post/68785250796/just-because-a-muscle-tests-weak-doesnt-mean-it
http://thegaitguys.tumblr.com/post/117109093439/last-week-we-ran-an-archived-piece-named-just

the future of footwear and orthotics ?
http://lermagazine.com/special-section/conference-coverage/the-future-of-footwear-and-orthoses-is-here-now-what

squats- head posture-gait vision-gravity
http://thegaitguys.tumblr.com/search/vision

Music: brain rhythm
http://www.kurzweilai.net/the-brains-got-rhythm

Podcast 94: The Shoe & Motor Control Podcast

Shoes, Minimalism, Maximalism, Motor fatigue, Brain stuff and more !

A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_94final.mp3

Direct Download:  http://thegaitguys.libsyn.com/podcast-94

-Other Gait Guys stuff
B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

movement and brain function; based on your piece: http://www.vancouversun.com/touch/story.html?id=11237102

shoe fit:
http://running.competitor.com/2015/07/shoes-and-gear/sole-man-the-pros-and-cons-of-buying-cheap-running-shoes_129297

http://www.runresearchjunkie.com/relevant-gems-from-the-2015-footwear-biomechanics-symposium/

Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1090-7. Epub 2006 Sep 1.

The effect of lower extremity fatigue on shock attenuation during single-leg landing.

Coventry E1, O’Connor KM, Hart BA, Earl JE, Ebersole KT.

Dr. Ted Carrick podcast

http://thewellnesscouch.com/bc/bc-07-professor-frederick-ted-carrick-on-the-past-of-functional-neurology

https://itunes.apple.com/au/podcast/backchat/id972497993?mt=2

movement patterns talk: http://www.anatomy-physiotherapy.com/28-systems/musculoskeletal/lower-extremity/knee/1191-altered-movement-patterns-in-individuals-with-acl-rupture

http://lermagazine.com/issues/june/balance-data-suggest-somatosensory-benefit-of-minimalist-footwear-design
Wilson SJ, Chander H, Morris CE, et al. Alternative footwear’s influence on static balance following a one-mile walk. Med Sci Sports Exerc 2015;46(5 Suppl);S562.

http://lermagazine.com/issues/june/running-shoe-reveal-study-links-max-cushioning-higher-load

movement patterns talk: http://www.anatomy-physiotherapy.com/28-systems/musculoskeletal/lower-extremity/knee/1191-altered-movement-patterns-in-individuals-with-acl-rupture

If you plan to live that long, you better start thinking about preservation:
http://www.cnbc.com/id/102730128  

Music piece/ Bass players:
http://mentalfloss.com/article/64955/science-proves-supreme-power-bassists

All about Toe Break.

No, this is not a post about fractures phalanges, but rather where your shoe bends, or should bend.

Toe break is where the shoe bends anteriorly. Ideally, we believe this to be at the 1st metatarsal phalangeal joint and metartarsal phalangeal articulations. This allows for the best “high gear” push off as described by Bojsen-Moller (1) High gear push off means that the pressure goes to the base of the great toe (1st MTP joint) for push off. (for an interesting post on this, see here 

If we think about rockers of the foot during the gait cycle (need a review? click here), it seems best that we accommodate each of them to the best of our abilities. Since most of us wear shoes, it would make sense that it flex in the right places. With regards to the forefoot, it should (theoretically) be under the 1st metatarsal phalangeal joint. This should provide both optimal biomechanical function (distribution of force to the 1st metatarsal phalangeal joint for push off/ terminal stance) and maximal perceived comfort (2).

If the shoe bends in the wrong place, or DOES NOT bend (ie, the last is too rigid, like a rockered hiking shoe, Dansko clog, etc), the mechanics change. This has biomechanical consequences and may result in discomfort or injury.

If the axis of motion for the 1st metatarsal phalangeal joint is moved posteriorly, to behind (rather than under) the joint, the plantar pressures increase at MTP’s 4-5 and decrease at the medial mid foot. If moved even further posteriorly, the plantar pressures, and contact time in the mid foot and hind foot (3). A rocker bottom shoe would also reduce the plantar pressures in the medial and central forefoot as well (4). It would stand to reason that this would alter gait mechanics, and decrease mechanical efficiency. That can be a good thing or a bad thing, depending on what you are trying to accomplish.

Take home messages:

  • Where a shoe flexes will, in part, determine plantar pressures
  • Changes in shoe flex points can alter gait mechanics
  • More efficient “toe off” will come from a shoe flexing at the 1st metatarsal phalangeal joint and across the lesser metatarsal phalangeal joints
  • examine the “toe break” in your clients shoes, especially of they have a foot problem

1. F Bojsen-Møller Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979 Aug; 129(Pt 1): 165–176.

2. Jordan C1, Payton C, Bartlett R Perceived comfort and pressure distribution in casual footwear. Clin Biomech (Bristol, Avon). 1997 Apr;12(3):S5.

3. van der Zwaard BC1, Vanwanseele B, Holtkamp F, van der Horst HE, Elders PJ, Menz HB Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait. J Foot Ankle Res. 2014 Mar 19;7(1):20.

4. Schaff P, Cavanagh P Shoes for the Insensitive Foot: The Effect of a “Rocker Bottom” Shoe Modification on Plantar Pressure Distribution Foot & Ankle International December 1990 vol. 11 no. 3 129-140

plantar pressure image above from : Dawber D., Bristow I. and Mooney J. (1996) “The foot: problems in podiatry and dermatology”, London Martin Dunitz Medical Pocket Books.

The Gait Guys: The National Shoe Fit Certification program.

Do not take our word for it … . see what these experts in their fields think about our online certification course.

http://twinbridgesphysiotherapy.com/course-reviews/the-national-shoe-fit-certification-the-gait-guys/

Can there be a higher recommendation for our National Shoe Fit certification program ? Thank you Dr. Religioso ! We are grateful for your amazing work on your end ! 
http://www.themanualtherapist.com/2014/08/review-shoe-fit-course-via-gait-guys.html

Podcast 84: Toe Walkers, Hip Impingment & Olympic Lifting Shoes

Plus: pulmonary edema syndrome in Triathlete swimmers, truths about olympic lifting shoes and more !

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_84f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-84

Other Gait Guys stuff

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

Are Triathletes Really Dying of Heart Attacks?

 
We had some stuff on FB last week about head positioning during running.  Alot of people tried to simplify it.  There is more to it. Here is another perspective.
 
Toe Walking children
 
Olympic lifting shoes ? or Converse Chuck Tailors ?
 
Journal of Foot and Ankle Research | Abstract | The associations of leg lean mass with foot pain, posture and function in the Framingham foot study
http://www.jfootankleres.com/content/7/1/46/abstract
 
Hip Impingements
 
Achilles oddity: Heeled shoes may boost load during gait | Lower Extremity Review Magazine
http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait
 

pronation

Here is an abstract you should look at.
Br J Sports Med. 2014 Mar;48(6):440-7. doi: 10.1136/bjsports-2013-092202. Epub 2013 Jun 13.

Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study.

http://www.ncbi.nlm.nih.gov/pubmed/23766439

And then there is this article we came cross at Runner’s World online. Here is the article “Five things i learned about buying running shoes”.
In all fairness we do not think the article was meant to teach or say much, but we do feel like it robbed 2 minutes of our productive life, at least it was entertaining.
So it is our turn now, let us serve you some real meat.  Here are some loose thoughts on why shoe fit and research has limitations in our opinion, mostly commentary on the first article and why you need to takes its commentary with a grain of salt.
The problem lies in the knowledge base. Most researchers just do not seem to know enough about the foot types , osseous torsions, the kinetic chain, and the like, to do an ALL ENCOMPASSING study. Plus, such a study would be an infinite nightmare. This is where a clinician is needed, to draw upon all of the issues at hand, not just some of the issues.  
For example, in this study, they just looked at arch heights and their determination as to whether the foot was pronating to a degree  (foot-posture index and categorized into highly supinated (n=53), supinated (n=369), neutral (n=1292), pronated (n=122) or highly pronated (n=18).)
No where did they talk about foot types such as the very common forefoot variants of varus and valgus let along their compensated and uncompensated forms. No where were there discussions of tibial or femoral torsion or the possibly necessary foot pronation needs to bring the knee joint back to the sagittal plane. Plus, just because a foot is flat, doesn’t truly mean it is over pronated. It may be flat because of genetics, we have talked about genetic trends here in previous blog posts.  We see plenty of flat competent feet in our clinics. The may appear flat or over pronated , but that is not the case for many people. The FUNCTION must be examined, and this does not come from visual inspection or from gait analysis video. We always say “what you see in someones gait or foot function is often their compensation around other issues, it is not their problem”.
Shawn and Ivo, the gait guys