A case sent to us all the way from Northern Ireland. This video looks at identification of static findings as they relate to findings and the case history. Part 2 looks at the dynamic findings and clinical correlations.
When the Short Toe Extensors Try to Rule the World !
A case of a runner with forefoot pain.
This is a runner of ours, one of the fastest young men in the state of illinois, top 10 in the country in mid-distance, top 20 in the USA in cross country.
He came in with left forefoot plantar pain. He explained (in a matter of words) that he was having pain at full forefoot loading at heel rise /push off.
We watched him walk, saw this visual problem present itself in dynamic motion (yup, no stop frame video on this one, not when you see it about 10 times a month !) and noted a subtle left lateral hip/pelvis shift past what would be considered normal for frontal plane mechanics.
On the table this is a photo of his feet. What do you see ?
We see a suspected (which you will try to confirm on examination) increase in short extensor (EDB, extensor digitorum brevis) muscle tone. Increased long extensor (EDL, extensor dig. longus muscle) tone would have represented itself with the distal toes also extended but here we see a relative dominance of the long flexors (FDL, Flexor dig. longus) with the heightened short flexor increase.
We also see more confirmation of heightened long flexor tone (FDL) by the degree of heavy callus formation on the very tip of the 2nd toe (it was on all 4 lateral toes but the photo is not clear enough to demonstrate). You can also see supporting evidence of heightened long flexor dominance by the subungual hematoma (bleeding under the 2nd toe nail). (How does this correlate ? Well, in most runners with excessive long flexor tone/use not only do they flex and claw so much in the shoes that the callus is on the tip of the toes but the nail also begins to lift as the nail is caught on the sock liner of the shoe as the toe flexes, slowly, mile by mile pulling the toe nail from the nail bed thus bleeding underneath it). Yes, it is NOT from the toes hitting the front end of the shoe !
Our examination confirmed weakness of all lumbrical muscles and of the flexor digitorum brevis and lateral quadratus plantae. The patient could feel the strength/engagement difference as compared to testing on the right foot of the same muscle groups (we always compare side to side, for us and for the patient’s awareness). The extensor digitorum brevis muscle mass on the lateral dorsum of the foot was tender as were the tendons along their course. There was also weakness higher up in the kinetic chain at the lower division of the transversus abdominus and internal abdominal oblique, and frontal plane hip stabilizers (gluteus medius; anterior-middle-and posterior divisions).The 2nd and 3rd metatarsal heads were remarkably tender to palpation and it was obvious that the metatarsal fat pads had migrated distally from the lumbrical muscle weakness.
Sometimes a grasp response by the long flexors can represent a propioceptive /balance deficit during single leg stance phase so be sure to test those centers as well (cerebellar, vision, joint position sense, inner ear-vestibular apparatus).
So, what is the take away for the non-medical person, the runner next door if you will ? Lets just say, symmetry wins and when asymmetry is apparent, bring it up to the people that do your body work. Hopefully, what you and they see will be assessed in a clinical light, and as a team you can get to the bottom of what is not working…….and in this case…..what was causing not only the plantar foot pain, but the left lateral hip sway outside the frontal plane.
———we are, The Gait Guys……Shawn and Ivo
The Quadratus plantae (Flexor accessorius) muscle. Do you have foot pain ?
(*There are two pictures here on the blog. Move your cursor over to the side of the photo and you will see that you can toggle between the photo and anatomy pic).
This is a great, but highly overlooked, muscle. The QP acts to assist in flexing the 2nd to 5th toes. Equally important is its effect of offsetting the oblique pull of the long toe flexor group (flexor digitorum longus). It has two heads, medial and lateral. The medial head is attached to the calcaneus, while the lateral head originates from the lateral border of the calcaneus, in front of the lateral process of the calcaneal tuberosity and the long plantar ligament.
The fact that we just love, and one that we believe is often overlooked is the acute angle at which the muscle heads attach into the tendons of the flexor digitorum longus (see picture) and has a rather dramatic alignment effect on the lateral 3 digits (since the line of pull on the long flexor tendons to these 3 digits is most dramatically changed by the purely posterior pull of the Quadratus Plantae. As you can see in this stripped down anatomy picture, without the QP pulling on the tendons of the FDL to these 3 lateral toes, those toes will have to curl medially and gently flex (*see the photo, a classic presentation!) By having a competent and active QP that oblique line of pull of the FDL /long flexors is rearranged to be more of a pure posterior pull and you will not see this classic lateral 3 digit curl and medial drift. This action is accentuated in a cavus foot type, where the pull of the FDL will be accentuated, due to the mechanical advantage afforded it and relative adduction of the forefoot with respect to the rear foot.
In the photo you can see a classic representation of a deficient Quadratus Plantae, in this case the patients lateral head was dramatically weaker than the medial, but both were weak. So, summary time….if you know your anatomy, know your biomechanics, and if you can test the muscle bundles specifically……..then you can see why form follows function (and in this case, why form has followed dysfunction). As we always say, “ya gotta know your stuff”, and you have to test what you suspect……there are other things that could also do this……so, let your eyes gain info, let your brain process and prove or disprove the information.
we are…….the gait guys !
Audio Podcast: The Gait Guys, Barefoot Concepts
This is a blast from the past from our parent company, The Homunuculus Group ! Our podcast from 2008 ! Still solid info several years later. Just trying to get you all up to speed before we start up the podcasts here in a month or so.
Here we talk about the foot, intrinsic foot musculature, Nike Free, Vibram 5Fingers and some of Dr. Ivo’s always brilliant neuromechanical discussions.
Enjoy !
Research to support that we are on target !
CONCLUSIONS AND CLINICAL RELEVANCE:
The abductor hallucis muscle acts as a dynamic elevator of the arch. Understanding this mechanism may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and Charcot neuroarthropathy. (see our video attached, it is much of what we talked about in this video just a few months ago).
*From the article: “Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait.
RESULTS:
All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted ‘V’ shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch.
http://www.ncbi.nlm.nih.gov/pubmed/17559771
Foot Ankle Int. 2007 May;28(5):617-20.
Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study.
Wong YS. Island Sports Medicine & Surgery, Island Orthopaedic Group, #02-16 Gleneagles Medical Centre, 6 Napier Road, Singapore, 258499, Singapore. yueshuen@yahoo.com
A question from a doctor on the topic of limb alignment development.
/The following question was forwarded to us from an internist on the USA east coast.
Question:
“I have a large number of female patients, many of them elderly. I have noted that women in our society tend to progress to valgus knee deformity with age, and that TKR (total knee replacement) doesn’t seem to correct that deformity. Men tend more to the varus in our society. I had formerly chalked that up to inherit gender difference.
3 or 4 years ago, I had occasion to spend a lot of time waiting outside the main Tokyo train station and observed a large number of people coming and going. I observed the following:
1. Young women had legs that were either straight or varus.
2. Young women tended toward toeing in.
3. They did all this in ridiculous high heels.
After some thought, I tend to attribute it to prolonged sitting in sesa (knees folded under), though being barefoot or in slippers while inside may also contribute. Women in our society sit with their legs crossed. Additionally, extensive shoe wearing leads to foot pronation.
So, could you direct me to someone who might have an interest in this observation and can refer me to any research that might have been done in this area? I’ve had the dickens of a time trying to find anything on it, or even a specialized area of study that cares about such things.”
The GAIT GUYS RESPONSE:
Thanks for your confidence in us. Here are some thoughts:
Frontal plane deformities (or development) is twofold: genetic (and X linked) and developmental. Children usually go through a varus to straight to valgus to straight development (Ron Valmassey talks about this in his text Clinical Biomechanics of the Lower Extremities). Women generally have larger Q angles (from birth) and this angulation often causes assymetrical epiphyseal development (increased pressure on the lateral malleolus/tibial plateau stunts growth) with overgrowth of the medial femoral condyle. Developmental changes are secondary to weight (obesity causes increase in valgus angle) and posture/muscular devlopment. The increased genu valgus places weight medial to the midline (2nd met) of the foot and the foot accomodates by pronating (often excessively, as noted by both of you). This causes medial rotation of the lower leg and thigh, resulting in lengthening of the glutes (esp G max) resulting in stretch weakness and subsequent over reliance on the gastroc/soleus group for propulsion (remember this group tries to invert the heel in an attempt to cause supination once you go past midstance. Weak intrinsics (as pointed out by Dr Mark) further fuels this cycle. “W” sitting (sometimes a cultural development, as pointed out by Dr Birgit) plays in as well.
As for “toeing in”; may women have the combination of genu valgus with internal tibial torsion (often with femoral retroversion) which makes the condition difficult to treat (the rearfoot needs to be supported, but the forefoot needs to be valgus posted) otherwise the knee is placed outside the saggital plane and the meniscus becomes macerated due to conflicting biomechanics at the knee (Thus the short term fix with orthotics with a return of the pain later).
Yes, high heels and open back shoes are evil as are open backed shoes (we spoke at a convention in Chicago a few years back on this, before some of the research was out).
Thanks for allowing us to participate. below are some references for you.
-The GAIT GUYS…….Ivo and Shawn
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J Orthop Sports Phys Ther. 2008 Mar;38(3):137-49.
Differences in lower extremity anatomical and postural characteristics in males and females between maturation groups.
Shultz SJ, Nguyen AD, Schmitz RJ.Source
Applied Neuromechanics Research Laboratory, Department of Exercise and Sport Science, University of North Carolina at Greensboro, 1408 Walker Ave., Greensboro, NC 27402, USA. sjshultz@uncg.edu
RESULTS:
When comparing maturation groups, limb length, pelvic angle, and tibial torsion increased with maturation, and anterior knee laxity, genu recurvatum, tibiofemoral angle, and foot pronation decreased with maturation. Females had greater general joint laxity, hip anteversion, and tibiofemoral angles, and shorter femur and tibial lengths than males, regardless of maturation group. Maturational changes in knee laxity and quadriceps angles were sex dependent.
CONCLUSIONS:
We observed a general change of posture with maturation that began with greater knee valgus, knee recurvatum, and foot pronation in MatGrp1, then moved toward a relative straightening and external rotation of the knee, and supination of the foot in later maturation groups. While the majority of the measures changed similarly in males and females across maturation groups, decreases in quadriceps angles and anterior knee laxity were greater in males compared to females, and females were observed to have a more inwardly rotated hip and valgus knee posture, compared to males, particularly in later maturation groups.
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J Bone Joint Surg Br. 1995 Sep;77(5):729-32.
Development of the clinical tibiofemoral angle in normal adolescents. A study of 427 normal subjects from 10 to 16 years of age.
Cahuzac JP, Vardon D, Sales de Gauzy J.
Source
Centre Hospitalier Universitaire de Toulouse-Purpan, France.
Abstract
We measured the clinical tibiofemoral (TF) angle and the intercondylar (IC) or intermalleolar (IM) distance in 427 normal European children (212 male and 215 female) aged from 10 to 16 years. In our study, girls had a constant valgus (5.5 degrees) and displayed an IM distance of < 8 cm or an IC distance of < 4 cm. By contrast, boys had a varus evolution (4.4 degrees) during the last two years of growth and displayed an IM distance of < 4 cm or an IC distance of < 5 cm. Values above these for genu varum or genu valgum may require careful follow-up and evaluation.
