Toes Spacers, anyone?

Less pain through better mechanics?

We have been using toe separators for various foot problems like hallux valgus, hammer toes and flexor dominance/extensor weakness. Our reasoning is that through changing the angle of attachment of the muscle, you alter the mechanical advantage of that muscle and help it to work more efficiently. This seems implied in the literature with respect to foot orthoses (1-3) but we could not find any data regarding toe separators. Toe separators DO seem to reduce pain and increase function (4-6). Perhaps this is through better biomechanics, mechanical deformation, proprioceptive changes, or most likely a combination of all these factors and more.  We think clinical results speak volumes. It is nice to see more data coming out on these easy to implement clinical tools. 

What is you clinical reasoning or rationale for using these devices? We would love to hear and if you have an article for reference you could share, that would be great. 

1. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

2. Halstead J, Chapman GJ, Gray JC, Grainger AJ, Brown S, Wilkins RA, Roddy E, Helliwell PS, Keenan AM, Redmond ACFoot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016 Apr;35(4):987-96. doi: 10.1007/s10067-015-2946-6. Epub 2015 Apr 28.

3. Bishop C, Arnold JB, May T. Effects of Taping and Orthoses on Foot Biomechanics in Adults with Flat-Arched Feet. Med Sci Sports Exerc. 2016 Apr;48(4):689-96. doi: 10.1249/MSS.0000000000000807.

4. Chadchavalpanichaya N, Prakotmongkol V, Polhan N, Rayothee P, Seng-Iad S. Effectiveness of the custom-mold room temperature vulcanizing silicone toe separator on hallux valgus: A prospective, randomized single-blinded controlled trial. Prosthet Orthot Int. 2017 Mar 1:309364617698518. doi: 10.1177/0309364617698518. [Epub ahead of print]

5. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008 Mar;32(1):79-83. doi: 10.1080/03093640701669074.

6. Tang SF, Chen CP, Pan JL, Chen JL, Leong CP, Chu NK. The effects of a new foot-toe orthosis in treating painful hallux valgus. Arch Phys Med Rehabil. 2002 Dec;83(12):1792-5. 

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-toes

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.

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