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

The Great toe’s effect on external hip rotation.

We have a simple video for you today. 

When we assess our clients for gait and locomotion we do a quick screen of all the big player joints, from the toes at least up into the thoracic spine to start. Loss of mobility/range of motion means probable functional impairment. 

In this video we display the effects of the Windlass Mechanism of the great toe. A windlass mechanism according to Wikipedia is:

a type of winch used especially on ships to hoist anchors and haul on mooring lines and, especially formerly, to lower buckets into and hoist them up from wells.

In this case, dorsiflexing the big toe spools the plantarfascia and flexor hallucis longus and brevis around the metatarsophalangeal joint (1st. MTPJ), thus pulling the heel towards the forefoot thus raising the arch. When the arch raises, the talus moves cephalad (upwards) and because of the supinatory movement orientation, it spins the tibial externally which in turn spins the femur externally. This is what you see in this video, note the blue dots being carried laterally with the limb external rotation.

The point here today, if you have loss of external hip rotation, it could be crying for you to evaluate the range of motion of the 1st MTP joint , it could be crying for you to evaluate the skill of toe extension, strength or endurance or all of the above. Impairment of the 1st MTP has great inroads into ineffective locomotion. You must have decent range of motion to effectively supinate, to effectively toe off, to externally rotate the limb, to effectively acquire hip extension to maximize gluteal use.  Thus, one could easily say that impaired hallux/great toe extension (skill, ability, endurance, strength) can impair hip extension (and clean hip extension patterning) and result in possible terminal propulsive gait extension occurring through the lumbar spine instead of through the hip joint proper.

Think of the effects of two asymmetrical great toe extensions, comparing the great toe left to right. Asymmetry in the limbs, pelvis, hip extension and perhaps worse, the lumbar spine, is a virtual guarantee.  Compare hallux extension side to side, if you can achieve symmetry through skill, endurance and strength retraining, you must do it. If you have a hallux limitus, a bunion or anything that impairs the symmetry of great toe extension side to side, you have some interesting work to do. 

You have to know what you have in your client, and know what it means to their locomotion.  Seeing or recognizing what you have must translate into understanding and action. 

Play mental games with clinical entities.  In this case, if at terminal toe off you did not have full hallux extension like in this client, and thus you did not get that last little final external rotation spin in the limb at the hip … . . what could that do to your gait ? Go tape your toe and limit terminal extension (terminal dorsiflexion) and walk around, to feel it in yourself is to get first hand experience. 

Shawn Allen, one of the gait guys

“… knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position.” – The Gait Guys  

This video is just the kind of stuff that drives us nuts.  We do not have a personal problem with the good doctor, he may know (and most likely does know) far more than he is letting on here but is merely simplifying things for some reason. We merely have a problem with the information that is missing that could make this a valuable addition, or omission, to someone’s care. There are times to simplify things, but when we put out a video on the web where the world can see it, we try to be as thorough as possible even if this means that something will come across seemingly overcomplicated. The fact of the matter is that human biomechanics are in fact complicated and simplifying something, when it is just not possible to do so, really doesn’t help anyone. People, and maybe some medical professionals, who do not know better will see this and not see what is missing, importantly so, here.

In this video there is no regard to the pre-positioning of the metatarsal to that big toe. This is a very unique joint, it has an eccentric axis that changes with metatarsal plantarflexion and dorsiflexion. This eccentric axis is shifted by the shifting position of the relationship of the metatarsal head with the base of the hallux. Here, at this joint, we have a concave-convex joint interface which with all said joint types, has a roll-glide biomechanical rule.  This rule at this joint is unique in that the axis of roll-glide is eccentric meaning that the joint has a shifting axis during the motion of dorsi and plantarflexion.  This is dictated and dependent upon the posturing of the sesamoid bones properly beneath the metatarsal head.  You can hear more about this premise here, in a video we did a few years ago. It is long, but it is all encompassing.  What is important, that which is not noted here, is that with more metatarsal plantarflexion there is opportunistically more dorsiflexion at the joint.  (This is precisely the joint range loss that occurs in “turf toe”, hallux limitus.)  Thus, in the above video, to properly mobilize the big toe into dorsiflexion, the foot must be taken into full metatarsal plantarflexion (pointing the foot) where greater amounts of joint dorsiflexion will be found (because of the eccentric axis shift) and the joint should be also mobilized in full ankle and metatarsal dorsiflexion, but the therapy giver must know, and be expected to find, that less toe/joint dorsiflexion will ALWAYS be found in this position.  Knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position.   

* Here is a little experiment you can do to teach yourself this principle. It should also help you to realize the gait cycle.

Sit in a chair, cross one ankle over the opposite knee and see what happens to the joint ranges as you proceed.  

  • dorsiflex the ankle and big toe. With your muscles only, not your hands, actively pull back the ankle and toe striving to get the most amount possible of dorsiflexion at both joints.  You should see that there is some toe dorsiflexion of the big toe.  
  • now keeping that big toe dorsiflexed as strongly as possible, begin to plantarflex the foot, thus moving the 1st metatarsal into plantarflexion as well. You should note that the relative amount of toe-metatarsal dorsiflexion DRAMATICALLY increases !
  • you can also do this passively. This time start at full foot plantarflexion (foot pointed) and passively pull that big toe back into dorsiflexion.  A huge range is likely to be found if you have a cleanly functioning foot.  Now, try to hold that significant range while you push the ankle into dorsifleixon.  At the end of the metatarsal and ankle dorsiflexion range you should feel the big toe start to resist this range you are trying to maintain, the big toe will forcibly start to  unwind the dorsiflexion. This is because of the eccentric shift of the joint and tension building in the passive tissues in the bottom of the foot. 
  • You want, and need, these relationships to occur properly and timely in the gait cycle and there are milliseconds to get it right and that means the entire kinetic chain must be clean of flaws, otherwise compensation will occur. (Note: Blocking or trying to control these issues with a foot bed, shoe type or orthotic can either be helpful therapeutically, or harmful to the chain.)

This is precisely what happens in the gait cycle. During swing phase the foot/ankle is in dorsiflexion to create foot clearance and to prepare the foot tripod for the contact phase with the ground.  There is some big toe (hallux) dorsiflexion represented in this swing phase, but it is not a significant amount you likely learned from your own self-demo above, mainly because it is not possible, nor warranted.  But, once the foot is on the ground and moving through the late stance phase of gait into heel rise, the ankle is plantarflexing. Thus, the metatarsals are plantarflexing, and this is causing the slide and climb of the metatarsal head up onto the sesamoids.  This causes the requisite shift of the axis of the 1st MTP joint (metatarsophalangeal) and affording the greater degree of toe dorsiflexion to occur to allow full foot supination, foot rigidity to sustain propulsive loading and also, never to forget, sufficient hip extension for gluteal propulsion. At this point, the range of the big toe in dorsiflexion is far greater than the dorsiflexion of the joint at ankle dorsiflexion. Impairment of this series of events is what leads to turf toe, hallux limitus as it is called. And when that becomes more permanent, even mobilizing the joint, as seen in the video above or otherwise, is not likely to get you or your client very far in terms of normal gait restoration.  And forcing it, won’t made it so either.

Remember this, the kinetic chain exists and functions in both directions. If you are starting with a hip problem that limits hip extension, and thus full range toe off during gait, in time you will lose the end range of the toe-off dorsiflexion range. And any attempts to try and regain it at the foot will fail long term if you do not remedy the hip.  ”If you don’t use it, you will lose it”. So to gain it back actively, sometimes you have to restore all of the functional losses of the entire kinetic chain to get what you are hoping for.  And for all you people doing “activation” to the glutes on your athletes, finding you are having to do it over and over and over again…….day after day after day, well … . . we hope you take this blog article to heart and put this thought process into action.

Remember, if you do not have the requisite strength, skill and endurance of the 2 toe extensors and 2 toe flexors as well as sufficient strength of the tibialis anterior (as well as many other components) you are likely to see impairment of this joint.  In this environment, do not expect joint mobilizations to offer you anything functionally lasting.  

We are not saying that joint mobilizations are useless and unnecessary, not by any means.  We are saying that you have to know what you are doing when you do them, so you can get the results you desire or, to realize why you are not getting the results you desire.  

Treat your clients with clear biomechanical knowledge and you will get the results you desire. If you go in with limited knowledge, results may speak for themselves. 

Gait analysis and understanding movement of the human body is a difficult task. It takes many years to learn the fundamental parameters and then many decades to implement the understanding wisely and with effectiveness.  Here at the gait guys, we hope to someday get to this point. We too, are students of gait and gait pathology. It is a journey.

“Once you understand the way broadly, you can see it in all things.”  -Miyamoto Musashi

 

Shawn and Ivo, The Gait Guys

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.

What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
– a rigid high arched cavus foot
– perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
– a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
– weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
– contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
– presence of a rigid forefoot valgus
– avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop

Jon “Bones” Jones great toe dislocation.

For you UFC fans out there (and for you gait fans) who saw this injury at UFC 159 here was some update video on his toe shortly after the injury. Here is the picture (graphic).

“Dr. Robert Klapper, an Orthopedic Surgeon at Cedars-Sinai Medical Group, was a guest on Tuesday night’s edition of UFC Tonight to discuss the injury and the recovery process in detail.” He does a pretty good job in highlighting the injury. He went over the FHB (flexor hallucis brevis) injury and the sesamoid concern which impressed us that he was fairly knowledgeable in the critical function of this toe and joint.  We still remain very concerned about the amount of dorsiflexion he is able to regain at that joint.  These kinds of injuries can lead to hallux rigidus and some premature degenerative changes in the toe cartilage which can impair heel rise through toe off in gait. (it also might affect his sprawl (see below for definition) for all you MMA junkies!). Although first metatarsophalangeal instability (big toe joint) is an uncommon condition it can result from disruption of the capsular-ligamentous complex which is most certainly the result of Jon Jones injury. Patients can experience pain with push-off and hallux rigidus type of symptoms including loss of end range of the joint which is critical for gait.  Quite often the joint needs restabilization which can be done through many surgical methods including anchoring the plantar plate to the extensor hallucis longus tendon. When this toe is not sufficiently stabilized the anchoring of the head of the medial tripod of the foot (the 1st metatarsal head) often becomes unstable. And when it becomes unstable more foot pronation can occur and bunion formation and hallux drift can occur, amongst many other things such as chronic sesamoiditis and functional imbalance (and thus power) across the joint. These things can all affect speed, agility, balance, power and the like. 

Lets hope that Jones’ toe restilizes on its own. We won’t know for several more weeks however.  One thing is for sure, with our 45 years experience, no  matter what the media spins right now, he is not out of the woods yet. Seriously.  It will be interesting to see if there is evidence of favoring of the joint in his next fight, whenever that is.

oh, and here was our Tweet to Bones Jones after the fight. Never heard from him……. tisk tisk tisk.    #regret (we hope not !)

27 Apr

good win. You are gonna need to restore function for that toe once it heals. Ouch ! Nasty ! champ !

define: Sprawl (wikipedia)

A sprawl is a martial arts and wrestling term for a defensive technique that is done in response to certain takedown attempts, typically double or single leg takedown attempts. The sprawl is performed by scooting the legs backwards, so as to land on the upper back of the opponent attempting the takedown. The resultant position is also known as a sprawl or sprawling position.

Ideally, the sprawling athlete should arch his back as much as possible and keep his knees off the mat. His options here including attempting to gain leverage on the lower back by hooking underneath the elbows; throwing in a headlock; and grabbing his opponent’s ankles and trying to get behind his opponent.

Shawn and Ivo, The Gait Guys……. hoping Jonny Bones reaches out to  us if things don’t come out so well !

About 8 years ago (?) I was in my Muscle Activation Class (MAT) here in Chicago and somewhere during the course of the class the topic came up about problems with the big toe. This really nice fella spoke up about a major injury to his thumb (the photo is not of him but here is a link to this fella’s story) and how doctors then proceeded to amputate his big toe to replace the thumb.

Gosh, with my brain knowing all that it does about gait as well as hand function, thoughts began to swim in every direction. What would I do if I were presented with the same scenario?  Without my thumb my work as a manual medicine physician would definitely be changed. But, heck, my gait would forever be changed too! I would be sentenced to a life of never ending gait compensations that could never be treated. My mind swirled around impaired hip extension and gluteal dysfunction, not to mention:

  • foot tripod incompetence
  • pronation and supination dysfunction guaranteed
  • virtually guaranteed hammer toe formation
  • metatarsal stress impacts
  • inappropriate loads on the medial column stabilizers such as the tibialis posterior now that the medial foot tripod was impaired let along the new absence of the long and short toe flexors that often provide compensatory activity to help an insufficient medial tripod.
  • impaired ipsilateral and contralateral arm swing
  • impaired shoulder function
  • core and hip impairments and asymmetry
  • the list goes on and on……. perhaps for hours !  We could do a whole 1-2 hour lecture just on the gait compensations and the subsequent motor impairment patterns that would ensue.

Seeing this photo and reading this fella’s story brought my mind back to the swirling thoughts I had while sitting in that lecture hall that day. And now some 8+ years later i am still brought to the same uncertain conclusion.  Would I go for the switcheroo ?   The transplant isn’t guaranteed successful, if it was that might sway things a little. But the gait impairments are guaranteed. 

What would  you do ? 

We hope you ( and us here at The Gait Guys) never are confronted with this most difficult presentation.  However, in just a few years, with the advent of 3D printers the anxiety of this issue is likely going to become a non-issue.

Just some food for thought today.  Or maybe we should have said “Foot for thought.”

Shawn and Ivo