Curly toes?

-We have all seen them. We like them, we hate them, we despise them, we scratch our heads.

-The question becomes why?

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-it’s pretty obvious from the picture that there is dominance of the flexor muscles and not enough intrinsic strength in the extensor muscles. Look at the prominence of the extensor tendon‘s and posturing of the toes.

– Flexor dominance occurs essentially because of too much activity in the central nervous system, particularly the lower brainstem, over activating the flexors and shutting down (reciprocally inhibiting) the extensors.

-This doesn’t necessarily mean that it is a neurological problem however the nervous system is what’s driving the bus here. Extensor tone is largely regulated by the cerebellum and vestibular system with the flexor tone being regulated by the cortex as well as lower, sub cortical systems.

– The cerebellum and vestibular system get the majority of their input from joint and muscle And joint mechanoreceptors as well as the vestibular apparatus. Their output is predominantly to axial extensor muscles as well as muscles which would be directly affected, from a gravitational standpoint, from those systems as well.

– When we don’t have enough afferent information traveling in from these systems, the flexor systems have a tendency to predominate. Think about protective posture’s and DNS work.

Driving the extensors and working on posture/balance/coordination and perhaps long, sustained stretching of the flexor musculature can help to end the bane of curly toes. 

–so let’s go ahead and make those feet, lower extremity, lower kinetic chain muscles and joints and core more competent and help these folks out.

#curlytoes #flexordominance #toeproblem #toeproblems #footproblem #footproblems 

Can you say Forefoot Adductus?

-Take a look at these tootsies. Draw an imaginary lines for the center of the hill: this should normally pass up through the foot either through the second metatarsal or between the second and third. Can you see how the foot is somewhat banana shaped?

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– This is also called metatarsus adductus. The deformity is at the apex of the tarsal/metatarsal joint, also known as Lisfranc joint. The fifth metatarsal base is often prominent in the foot is convex in shape with a higher arch.

-This is usually caused by intrauterine positioning and if caught early will usually spontaneously resolve. Since this gal is over 34, that’s probably not her reality. It is interesting to note that along with this congenital deformity, hip dysplasia and internal tibial torsion (which she has) are extremely common.

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– Gait abnormalities seen with this include a decreased progression angle, and a propulsive gait often secondary to poor intrinsic function of the foot musculature

#forefoot #forefootadductus #adductus #foot #footproblem #gait #clinicalexam #thegaitguys 

What happens when a ganglionectomy goes south

What happens when a ganglionectomy goes south?

- This patient had a ganglionectomy. Unfortunately, they tagged the joint capsule of the first MTP. By affecting the integrity of the capsule, as well as the surrounding musculature, she’s developed the beginnings of a hallux valgus (bunion) as well as hallux limitus (limited dorsiflexion of the first metatarsalphalangeal articulation). 

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- she has degeneration of the first MTP as well as an osteophytic  crown at the distal aspect of the first metatarsal and tenderness over the capsule as well as the extensor hallucis tendon and proximal phalanx. 

-dorsiflexion is 30° on this side, 50 on the opposite side. We need about 50° to have adequate for foot rocker

– she also has moderate external tibial torsion, right greater than left and a left anatomically short leg secondary to a femur fracture.

– Since the mobility of the first ray was limited, we worked on first Ray mobility as well as exercises to descend the 1st ray, with acupuncture for pain control. 

-we are considering an orthotic to assist in raising the base and dropping the head of the first metatarsal to create more hallux dorsiflexion. When performed manually, she had a few extra degrees we would like to take advantage of. 

-We will keep you posted :-)

#ganglionectomy #footproblem #footproblems #halluxlimitus #bigtoewoes #bunion #bunions #bunionsurgery 

6th Toe Disease

It’s probably fair to say that a good number of us see people with “sixth toe” problems or a Taylor’s bunion more often than not. This problem is often accompanied by internal tibial torsion and sometimes femoral retro torsion. This video reviews a case that came in yesterday.

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#6thtoe #6thtoedisease #tailorsbunion #lateralfootpain #footpain #footproblem #gait

One cause of hammertoes

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One cause of hammertoes

Take a look at this gals left foot. Notice the high, cavus arch as well as increased tone in the long flexors of the toes. Is it any wonder she has weakness of the long extensors on that side?

Look at the other picture and note that she has a shorter leg on the left. Yes, it is anatomical and tibial on clinical exam. She also has limited ankle dorsiflexion and hip extension bilaterally, left greater than right.

When the foot is cavus it puts an increased stretch on the long flexor muscles of the foot because the metatarsalphalangeal joint is in relative extension. More than likely this will activate the Ia afferents from the muscle spindles causing more tone in the flexors. Yes, that will decrease over time but you will also increase the relative length of the long flexor tendons and decrease the length of the long and short extensor tendons.

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 More tone in the flexors equals less tone in the extensors. Combine this with a lack of ankle dorsiflexion and hip extension and it’s prescription for more hammertoes. In addition, she has an anatomical short leg on the left putting that foot in relative supination with respect to the right. She will need to claw her toes in an attempt to create stability on that side.

The fix will be getting better control and strength in the long extensors and improving ankle dorsiflexion and hip extension.

What's wrong with the big toe on the right?

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So this is what happens when you don’t wear the right shoes as a kid…

This woman came into the office with lower back pain. Do you notice anything peculiar about her feet?

She said that when she was young she was told by the doctor she was “dink toed” and given special shoes (on a sidenote, she has bilateral external tibial torsion and no evidence of forefoot adductus) . The shoes evidently (according to the doctor) were too tight and caused the deformity that you see here. She stated that the shoes were extremely painful while wearing them and then for quite a while when she stopped. This is always been her “problem foot“ with limited toe dorsiflexion and ankle dorsiflexion on that side.

Notice how the distal phalanx of the Halex is stunted and it’s with is increased. Dorsiflexion at the MTP is limited with respect to the other side and dorsiflexion flexion at the IP is limited as well. It appears that the growth plate was damaged resulting in a hypo plastic digit which, due to insufficient length, transfers a lot of weight during terminal stance and preceding ( at the end of her gait cycle, preparing for propulsion) to the second metatarsal head where she gets moderate discomfort.

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We can increase the motion of the first ray with mobilization and exercise but unfortunately we are not able to lengthen her digit.

Growth plates are fragile things and what we do to children early on can have a profound impact upon their adult life.
footproblem #toeproblem #hallux #halluxdeformity #bigtoe #gait #gaitanalysis #footexam