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

– another blog article by Dr. Shawn Allen

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

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

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

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

the exercise has a retrograde approach and a prograde approach. 

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

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

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

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

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

Dr. Shawn Allen, one of the gait guys

Attempting to regain a level playing ground for your foot.

“Remember, we were born with both our rearfoot and forefoot designed to engage on the same plane (the flat ground). We were not born with the heel raised higher than the forefoot. And, the foot’s many anatomically congruent joint surfaces, their associated ligaments, the lines of tendon pull and all the large and small joint movements and orchestrations with each other are all predicated on this principle of a rearfoot and forefoot on the same plane. This is how our feet were designed from the start.  This is why I like shoes closer to zero drop, when possible, because I know that we are getting closer to enabling the anatomy as it was designed. This is not always possible, feasible, logical or reasonable depending on the problematic clinical presentation and there is plenty of research to challenge this thinking, yet plenty to support is as well. The question is, can you get back to this point after years of footwear compensating ? Or have your feet just changed too much, new acquired bony and joint changes that have too many miles on the new changes ? Perhaps you have spent your first 20-50 years in shoes with heeled shoes of varying heel-ball offset. Maybe you can get back to flat ground, maybe you cannot, but if you can, how long will it take? Months ? Years ?  It all makes sense to me, but does it make sense for your feet and your body biomechanics after all these years ? Time will tell.” -Dr. Allen

Fundamental foot skills everyone should have, subconsciously. This video shows a skill you must own for good foot mechanics. It needs to be present in standing, walking, squatting, jumping and the like. It is the normal baseline infrastructure that you must have every step, every moment of every day. 

Is your foot arch weak ? Still stuffing orthotics and stability shoes up under that falling infrastructure ? Try rebuilding a simple skill first, one that uses the intrinsic anatomy to  help pull the arch up.  If your foot is still flexible, you can likely re-earn much of the lost skills, such as this one. This is a fundamental first piece of our foot, lower limb and gait restoration program. We start here to be sure this skill is present, then add endurance work on it and then eventually strength and gait progressions. This is where it starts for us gang. 

Shawn and Ivo, the gait guys

The case of the missing toes.

OK, a bit dramatic but as you can see in the plantar view above, all you can see is the toe pads, the rest of the digit shafts are hidden.  

This is a classic example of a foot imbalance. We have talked about this many times before but the attached video link here  ( http://youtu.be/IIyg7ejYNOg ) shows it very well.  Read on.

There is shortness and increased resting tone in the short toe extensors (EDB, extensor digitorum brevis) and long toe flexors (FDL=flexor dig. longus) with insufficiency in the short flexors and long extensors. This pairing creates a hammer toe effect.  In the video, you can see that these toes are showing early hammering characteristics, but not yet rigid ones. The key word there is, “yet” so this is still a correctable phenomenon at this point.  You can also clearly see the distal migration of the metatarsal fat pad. The fat pad has migrated forward of the MET heads and is being pulled forward by the excess tension in the long toe flexors. As this imbalance in the toe flexors and extensors develops, the forefoot mechanics get impaired and the lumbricals (which anchor off off the FDL) become challenged. Their contributory biomechanics, amongst other things, help to keep the fat pad in place under the metatarsal heads. You can see in this video link above that by proximally migrating (towards the heel) just the fat pad back under the MET heads the resting mechanics of the toes changes, for the better.  

Remember the other functions of the lumbricals ?  their other major functions, namely: thinking from a distal to proximal orientation (a closed chain mode of thinking), they actually plantarflex the metatarsal on the fixed phalynx, assist in dorsiflexion of the ankle, and help to keep the toes from clawing from over recruitment of the flexor digitorum longus.

Here is another blog post we did on a similar presentation.http://thegaitguys.tumblr.com/post/14766494068/a-case-of-plantar-foot-pain-during-gait-this

Proper balance of the toe flexors and extensors, and their harmony with lumbricals and fat pad amongst other things will give healthy long flat toes that can help the proximal biomechanics of the foot.  If you have neuromas, metatarsalgia, hammer toes, claw toes, migrating toes, bunions or hallux valgus amongst many other things, this might be a good place to start.   

There are exercises that can help this presentation, but understanding “the why” is the first step.

Shawn and Ivo

The Gait Guys

The Power of Facilitation: How to supercharge your run.

While running intervals this crisp, cool 19 degree morning, something dawned on me. My left knee was hurting from some patellar tracking issues, but only on initial contact and toe off. I generally run with a midfoot strike. I began concentrating on my feet, lifted and spread my toes and voila! my knee pain instantly improved. Very cool, and that is why I am writing this today. 

Without getting bogged down in the mire of quad/hamstring facilitation patterns, lets look at what happened.

I contracted the long extensors of the toes: the extensor digitorum longus and the extensor hallicus longus; the short extensors of my toes: the extensor digitorum brevis, the extensor hallucis brevis: as well as the dorsal interossei.the peroneus longus, brevis and tertius were probably involved as well.

Do you note a central theme here? They are all extensors. So what, you say. Hmmm… 

Lets think about this from a neurological perspective:

In the nervous system, we have 2 principles called convergence and divergence. Convergence is when many neurons synapse on one (or a group of fewer) neuron(s). It takes information and “simplifies” it, making information processing easier or more streamlined. Divergence is the opposite, where one(or a few) neurons synapse on a larger group. It takes information and makes it more complicated, or offers it more options.

In the spinal cord, motor neurons are arranged in sections or “pools” as we like to call them in the gray matter of the cord. These pools receive afferent information  and perform segmental processing (all the info coming in at that spinal cord segment) before the information travels up to higher centers (like the cerebellum and cortex). One of these pools fires the extensor muscles and another fires the flexor muscles.. 

If someone in the movie theater keeps kicking the back of our seat, after a while, you will say (or do) something to try and get them to stop. You have reached the threshold of your patience. Neurons also have a threshold for firing.  If they don’t reach threshold, they don’t fire; to them it is black and white. Stimuli applied to the neuron either takes them closer to or farther from threshold.  When a stimulus takes them closer to firing, we say they are “facilitating” the neuron. If it affects a “pool” of neurons, then that neuronal pool is facilitated. If that pool of neurons happens to fire extensor muscles, then that “extensor pool” is facilitated.

When I consciously fired my extensor muscles, two things happened: 1. Through divergence, I sent information from my brain (fewer neurons in the cortico spinal pathway) to the motor neuron pools of my extensor muscles (larger groups of motor neurons) facilitating them and bringing them closer to threshold for firing and 2. When my extensor muscles fired, they sent that information (via muscle spindles, golgi tendon organs, joint mechnoreceptors, etc) back to my cerebellum, brain stem and cortex (convergence) to monitor and modulate the response.

When I fired my extensor muscles, I facilitated ALL the neuronal pools of ALL the extensors of the foot and lower kinetic chain. This was enough to create balance between my flexors and extensors and normalize my knee mechanics.

If you have followed us for any amount of time, you know that it is often “all about the extensors” and this post exemplifies that fact.

 Next time you are running, have a consciousness of your extensors. Think about lifting and spreading our toes, or consciously not clenching them. Attempt to dorsiflex your ankles and engage your glutes. It just may make your knees feel better!

The Gait Guys. Facilitating your neuronal pools with each and every post.

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. If you rip off our stuff, we will send Lee after you!

Lebron James and his funky toes. We have the scoop as to what is going on.

http://bleacherreport.com/articles/1757693-everybody-look-at-lebron-james-toesimage

This is what happens when you get too much short extensor tone and/or strength in the digits of the foot.  Now this is his trailing foot and he has moved into toe off so he should be activating his toe extensors and the tibialis anterior (ie. the anterior compartment) to create clearance for that foot so that he doesn’t catch the toes on the swing through phase of gait.  In this case we do not see alot of ankle dorsiflexion (which we should see at this point) so we are  seeing a compensation of perhaps increased short extensor (of the toes) activity.  

We also see what appears to be a drifting of the big toe (the hallux) underneath the 2nd toe. This often happens when a bunion or hallux valgus is present.  Now we do not see a bunion present here but the viewing angle is not optimal however it does appear that there is a slight drift of the hallux big toe towards the lesser toes . We are not sure if we would qualify this as hallux valgus, and if so it is mild, but none the less we see a slight lateral drift. What is interesting is that despite the obvious activity of the lesser toes short extensor muscle (EDB) we do not see a simultaneous activity of the short extensor of the hallux (EHB, extensor hallucis brevis). Does he need to do our exercise ? See video link here ! 

And so, when the lesser toes are in extension as we see here and the big toe is not moving into extension, and when that is simultaneously combined with even a little hallux valgus tendency, the big toe will drift underneath the lesser toes as we see here, even appearing to push the 2nd toe further into extension.  

As for his little toe, well, Dr. Allen  has one just like it so perhaps he missed his calling in the NBA. Some folks just do not have as plantarward orientation of the 5th toe and so it migrates upward (dorsally) a little. This can be from birth but it can also come from trauma. But in time because the toe is not more plantar oriented, the dorsal muscles (the extensors) become more dominant and the toe just starts to take on this kind of appearance and orientation. It will reduce significantly when the foot is on the ground and the extensors are turned off, but it looks more shocking during the swing phase because of the extensor dominance in that phase.

This kind of presentation if left unchecked can lead to hammer toes, plantar fat pad migration distally exposing the metatarsal heads to more plantar forces without protection and a host of other problems.  Lebron needs to do our Shuffle Walk Exercise to get more ankle rocker (dorsiflexion) and also work to increase his long toe extensors (EDL) and lumbricals.  This will flatten his toes and improve mechanical leverage.  Remember, if you gait better foot function with increased ankle dorsiflexion you will get more hip extension and more glute function.  But does the big fella really need to jump any higher? We are sure he would accept being faster though … .  who wouldn’t ?

Fee for today’s long distance consult: …  Lebron, lets say 10,000$ and we will call it even.  Sound good ?  But a lifetime of prettier, stronger and more functional toes……priceless. Have  your people contact our people.  (Ok, we don’t have people, but we do have an email address here on our blog !).

Shawn and Ivo, The Gait Guys.  Even helping the elite, little by little.

Lebron James and his funky toes. We have the scoop as to what is going on.

http://bleacherreport.com/articles/1757693-everybody-look-at-lebron-james-toesimage

This is what happens when you get too much short extensor tone and/or strength in the digits of the foot.  Now this is his trailing foot and he has moved into toe off so he should be activating his toe extensors and the tibialis anterior (ie. the anterior compartment) to create clearance for that foot so that he doesn’t catch the toes on the swing through phase of gait.  In this case we do not see alot of ankle dorsiflexion (which we should see at this point) so we are  seeing a compensation of perhaps increased short extensor (of the toes) activity.  

We also see what appears to be a drifting of the big toe (the hallux) underneath the 2nd toe. This often happens when a bunion or hallux valgus is present.  Now we do not see a bunion present here but the viewing angle is not optimal however it does appear that there is a slight drift of the hallux big toe towards the lesser toes . We are not sure if we would qualify this as hallux valgus, and if so it is mild, but none the less we see a slight lateral drift. What is interesting is that despite the obvious activity of the lesser toes short extensor muscle (EDB) we do not see a simultaneous activity of the short extensor of the hallux (EHB, extensor hallucis brevis). Does he need to do our exercise ? See video link here ! 

And so, when the lesser toes are in extension as we see here and the big toe is not moving into extension, and when that is simultaneously combined with even a little hallux valgus tendency, the big toe will drift underneath the lesser toes as we see here, even appearing to push the 2nd toe further into extension.  

As for his little toe, well, Dr. Allen  has one just like it so perhaps he missed his calling in the NBA. Some folks just do not have as plantarward orientation of the 5th toe and so it migrates upward (dorsally) a little. This can be from birth but it can also come from trauma. But in time because the toe is not more plantar oriented, the dorsal muscles (the extensors) become more dominant and the toe just starts to take on this kind of appearance and orientation. It will reduce significantly when the foot is on the ground and the extensors are turned off, but it looks more shocking during the swing phase because of the extensor dominance in that phase.

This kind of presentation if left unchecked can lead to hammer toes, plantar fat pad migration distally exposing the metatarsal heads to more plantar forces without protection and a host of other problems.  Lebron needs to do our Shuffle Walk Exercise to get more ankle rocker (dorsiflexion) and also work to increase his long toe extensors (EDL) and lumbricals.  This will flatten his toes and improve mechanical leverage.  Remember, if you gait better foot function with increased ankle dorsiflexion you will get more hip extension and more glute function.  But does the big fella really need to jump any higher? We are sure he would accept being faster though … .  who wouldn’t ?

Fee for today’s long distance consult: …  Lebron, lets say 10,000$ and we will call it even.  Sound good ?  But a lifetime of prettier, stronger and more functional toes……priceless. Have  your people contact our people.  (Ok, we don’t have people, but we do have an email address here on our blog !).

Shawn and Ivo, The Gait Guys.  Even helping the elite, little by little.

How to properly regain ankle rocker: A Prince of an Exercise

If you have been with us here at The Gait Guys you will know by now that we like to take Fridays and make them a blog post recycle.  This week we have a beauty and it parlays beautifully into our blog posts from the last 2 days on ankle rocker. We did this video about 3 years ago. We can tell because Dr. Allen hasn’t yet shaved his dome and he looks much younger.  Plus he stopped wearing sweater vests !  Ouch !

Today we show a staple in our in-office and home exercise programs. The Shuffle Walk and the Moon Walk.  We have altered these exercises in the last year or so, thus we really need to get that Foot Exercise DVD done that we have been promising for 2 years+.  

Anyhow, STOP passively stretching your calf muscles !!!!!!

Do the Shuffle walk instead.  We have a rule in our offices. If you are going to participate in a running sport, you must do 2 minutes of Shuffle Walks EVERY SINGLE DAY.  

The size of the anterior compartment muscles is much smaller than the bulbous large posterior compartment so the tug of war is always in the favor of the calf to become too dominant.  Drive some SES (Skill, Endurance and Strength) into the anterior compartment and you will see a stronger arch, control pronation better and very likely see shin splints disappear once and for all. 

Watch the video today and learn why some of our teams can be seen Shuffling around the outdoor track. It is pretty amazing to drive by a school and see an entire team shuffling and know that they are doing it because of The Gait Guys. It is comforting that we do not have to see many shin splint cases in our offices anymore because the teams are being proactive. Shin splints are SOOOOO boring and easy to fix.  

Enjoy gang, From the archives……..

Shawn and Ivo