You need toe extension, more than you might think.

There is a major difference in these 2 photos.One foot is ready for foot loading, the other has one foot over the starting line, and is going to possibly have the risks related to inappropriate loading.

In clients with one of several possible issues related to poor control of the arch during weight bearing loading, it is not all too uncommon for us to bring to their attention that not only do they NOT utilize toe extension appropriately, and at the right time, they just simply have poor strength and endurance of the toe extensors (we will not be bringing up the complicated orchestration of the long and short toe extensors today, lets just keep it loosely as looking at them as a whole for today).

We know we say it an awful lot, that clients need more toe extension endurance and strength. But more often than not, they need more awareness of how little they are actually using their toe extensors during foot loading. This is why we despise flip flops and foot wear without a back strap on them, the flexors have to dominate to keep the footwear on the foot.  And, if you are into your toe flexors, you are definitely not into your toe extensors.

You can easily see in this photo that there is a major difference in the integrity and preparation of the foot arch prior to foot loading in these 2 sample photos. One the toes are up in extension, the other the toes are lazy and neutral.  The toe up photo demonstrates well that when the toes are extended, the Windlass mechanism draws the forefoot and rearfoot together and raises the arch. Go ahead, lift your toes, it will happen on you as well (unless your arch is so collapsed that the first metatarsal actually dorsiflexes during toe extension, in this case, you are a whole different management tier). From this arch raised position, the first metatarsal is adequately plantarflexed, this means the joint complexes proximal and distal to the metatarsals are all in the right position to load and cope with loads. In the toe neutral picture, these components are not prepared, the arch is already getting ready to weight bear load from a half-baked position. One cannot expect the foot complex to load well when it is starting from a position of "half way there". One should start the loading of the foot from the starting line, not 3 steps over the line and not 3 steps before the starting line.  There is no athletic or mechanical endeavor that does well when we start the challenge too soon or too late, timing is everything.

How you choose to prep your foot for contact loading, and yes, there is some conscious choice  here, one is lazy the other is optimal, can determine to a large degree if you or your client is about to fall into the long list of problems related to poorly controlled pronation (too much, too soon, too often, too fast). Any of those bracketed problems lead to improper loading and strains during time under tension.

We will almost always start our clients on our progressing protocol of arch awareness and we will loosely say arch restoration, and attempts at better optimizing the anatomy they have, with toe up awareness.  Many clients will have poor awareness of this component issue, on top of poor endurance and frank weakness. The arch is to a great degree build from a lifting mechanical windlass effect, from the extensors and foot dorslflexors, not from the foot flexors. This is one of our primary beefs with the short foot exercise of Janda, there needs to be a toe extensor component in that exercise (search our blog for why the short foot exercise is dead). The short foot exercise is not actually dead, all exercises have some value when placed and performed properly, but the short foot exercise is based off of the toes being down and utilizing the plantar intrinsics to push the arch up and shorten the foot, this is a retrograde motion and it is not how we load the foot, but, it does have value if you understand this and place it into your clients repertoire appropriately.  This is also why we have some conceptual problems in stuffing an orthotic under someones arch to "lift it up", ie. slow its fall/pronation.  There are times for this, but why not rebuild the proper pathways, patterns and mechanics ?

Teach your clients about toe extension awareness. TEach them that they need to relearn the skill that when the toes drop down to the ground that the arch does NOT have to follow them down, that the client can relearn, "toe up, arch up . . . . . then toes down, but keep the arch up".  IT is a mantra in our office, "don't let your arch play follow the leader".  Reteach the proper neurologic disassociation between the toes and arch.

Perhaps the first place you should be starting your clients with foot and ankle issues, is regaining awareness of proper toe extension from the moment of toe off, maintaining it through swing, and then keeping it until the forefoot has purchase on the ground again, and not any time sooner than that ! If their toes are coming down prior to foot contact, it is quite likely their arch is following the leader.

So, if your client comes in with any of the following, to name just a few:  tibialis posterior tendonitis, plantar fascitis, heel pain, forefoot pain, painful bunions, arch pain, hallux limitus, turf toe, . . . . and the list goes on. Perhaps this will help you get your client to the starting line.

Shawn & Ivo, thegaitguys.com

Abnormal Forefoot loading creates fatigue ?

How is your medial-lateral foot and ankle stability ? In many injured folks it is an issue and needs to be investigated. Remember, skill, endurance, strength IN THAT ORDER ! Today, Fatigue is the topic du jour !
If you are in a heeled shoe of any degree (greater heels suggests greater risk) , and this likely pertains to increased heel dropped running shoes we would propose, fatigue of the frontal plane is risky business. 
“EMG measurements from habitual high-heeled shoe wearers demonstrated an imbalance of gastrocnemius lateralis versus gastrocnemius medialis activity in fatigue conditions, which correlated with abnormal lateral shifts in the foot-ground or shoe-ground COP of these women.”
Some of this is from the natural foot architecture, a blog post on this very topic is in order we think !
“The results demonstrated accelerated fatigue of the peroneus longus muscle in marching conditions … . EMG analysis further revealed substantial fatigue of the pre-tibial and triceps surae muscles during intensive marching”
Don’t forget to assess fatigue gait brethren ! Motor patterns, skill, strength are all great, but what about fatigue ?! Test for it and you will find it ! 
And, think about this if you are a forefoot strike runner, for obvious reasons, the heels is similarly in a raised posture.

Dr. Shawn Allen

Gait Posture. 2002 Feb;15(1):56-63.
Analysis of muscular fatigue and foot stability during high-heeled gait.
Gefen A

Med Biol Eng Comput. 2002 May;40(3):302-10.
Biomechanical analysis of fatigue-related foot injury mechanisms in athletes and recruits during intensive marching.
Gefen A1.

Steppage gait ? Or just a runway model ?  Take the thinking farther.

Today we have a short blog post for you. You may take the topic simply on the surface or cogitate over it and find some deeper epiphanies from the well of knowledge we have tried to present here on our blog for the past 4+ years.  

It is clear that in this video that the model has a consciously driven steppage gait. Meaning, she is lifting her limb/foot via exaggerated hip flexion and knee flexion to clear the foot.  This is often seen unilaterally in a foot drop case where the client has a neurologic lesion that for one reason or another has impaired the client’s ability to extend the toes or dorsiflex the ankle sufficiently to clear the foot (so they do not drag toes and trip/fall).  

But, why is she doing this steppage gait ? It is highly unlikely that she has bilateral lesions.  Sure, she was asked to walk this way by her mentor but again, take it further.  Is there a factor making this gait necessary regardless of the coaching ? 

Obviously the answer is yes or we wouldn’t be doing a blog post on this topic.  She is wearing ridiculously high heels. This is forcing her into an extreme plantarflexed foot and ankle posture. IF she were to swing her leg normally during the swing phase she would drive the foot and ankle into dorsiflexion (a normal gait event) and the long pointed heel would be made more prominent as it was driven forward and downward. This would surely catch on the ground, immediately driving the foot into sudden violent forefoot loading and pitch her into a forward fall.  Yes, you have seen this on the run way videos on youtube, and yes we know you laughed too ! You see, when wearing heels this high, one must deploy a certain degree of steppage gait to clear the heel because ankle plantarflexion is fraught with the risk we just discussed above, the heel is too prominent and will catch. How much steppage (knee flexion and hip flexion to clear the foot) is necessary ? Well, to a large degree it depends on how much of a heel is present.  If you are wearing a small heeled shoe, lets say 1 inch, then a small steppage is necessary.

None the less, there is a bigger problem lurking and brewing underneath when heels are a regular occurrence. Slowly and gradually the disuse of the anterior compartment muscles (Extensor dig., Ext. hallucis, peroneus tertius, tibialis anterior) will weaken and the posterior compartment will shorten respectively. IF left too long, it will result in tightness (yes, there is a difference between tightness and shortness, one is a neurlogical protective mechanism, the other is a more permanent change.) We have said this many times here and in our videos, much of posterior compartment problems (ie achilles tendonitis, Sever’s, Hagglunds etc) are related to a degree of anterior compartment weakness, skill deficits or endurance challenges.  Wearing high heels often will often, but not always, increase this risk. 

If you are an athlete, but someone who wears high heels often, you may have to do extra work to keep your anterior compartment competent on several levels.  Eccentric strength is just as important as concentric in this region. Remember, many gait problems come on slowly, a slow simmering smoldering fire. And remember this last point about heeled shoes, your forefoot is always being loaded initially in ankle plantarflexion, this is not normal and in time this will have a cost in many people.  

One last thing. We are not necessarily talking about dress shoes, although they are a greater culprit.  Many running shoes still have accentuated rear foot stack heights where the heel will be many millimeters above the plane of the forefoot.  Do not discount these shoes as a possible contributor of your problem, remember, physiological adaptation takes time to express into a biomechanical symptom creating problem, and it may take quite some time to resolve your compensations and adaptations.

PS: drive that “cross over gait” lady.  Fools.

Shawn and Ivo

the gait guys

More research on Forefoot Running: Forefoot Varus and the toe extensor muscles.

Lately we have all seen much in the news about the forefoot strike loading in runners and many of the proposals and rebuttals regarding injury rates.  Our dialogue less than 2 weeks ago on some of Lieberman’s recent comments (our blog article “Dear Dr. Lieberman”, click here) seem to be ringing true again. Here are just two more insightful and important studies when it comes to looking at some of the proposed ideas and causes of forefoot varus. Naturally, a thinking mind would wonder if some of these weaknesses in anterior and posterior tibialis muscles as well as extensor toe musculature, as proposed in just these 2 articles, are causal to the forefoot injuries that seem inevitable as Lieberman seems to suggest (again, see our blog post). Naturally, weaknesses and poor motor patterns of some or all of these muscles is going to create and insufficient and possibly inefficient and pathologic forefoot loads because of the forefoot varus foot type these muscular imbalances can functionally produce.  We have been pounding sand on this issue for years but still no one listens.  The medial research, as evidenced here is supportive of our theories and everyday clinical findings.

To summarize, ONCE AGAIN, not everyone is suited or possibly ready for forefoot load/contact/strike running.  And if you have injury or problems in doing so, don’t blame your minimalist shoe……. it is either a foot type that needs functional repair or a foot type that is fixed an must opt for midfoot strike.

There is SO MUCH MORE to this game than just strap on some minimalist shoes and start forefoot loading your way on your next run.  Buyer beware !

Shawn and Ivo…….. the gait guys……..two guys who are “Gandhi’d” regularly. 

“First they ignore you, then they laugh at you, then they fight you, then you win.”

- Mahatma Gandhi

______________________________________________

http://www.ncbi.nlm.nih.gov/pubmed/20307453

Foot (Edinb). 2009 Jun;19(2):69-74. Epub 2008 Dec 31.

Foot varus in stroke patients: muscular activity of extensor digitorum longus during the swing phase of gait.

Reynard F, Dériaz O, Bergeau J.

Clinique romande de réadaptation, SUVA Care, Av. Gd-Champsec 90, Sion, Switzerland. fabienne.reynard@crr-suva.ch

Abstract

CONCLUSIONS: The activity of extensor digitorum longus muscle during the swing phase of gait is important to balance the foot in the frontal plane. The activation of that muscle should be included in rehabilitation programs.

_______________

http://www.ncbi.nlm.nih.gov/pubmed/16882899

J Bone Joint Surg Am. 2006 Aug;88(8):1764-8.

The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy.

Michlitsch MG, Rethlefsen SA, Kay RM.

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.

Abstract

RESULTS: The muscular contributor to varus deformity was the anterior tibialis in thirty feet, the posterior tibialis in twenty-nine feet, both the anterior tibialis and the posterior tibialis in twenty-seven feet, and another contributor in two feet. Seventy feet had varus deformity during both stance phase and swing phase. Of these seventy feet, twenty-five exhibited dysfunction of the anterior tibialis, twenty exhibited dysfunction of the posterior tibialis, and twenty-three exhibited dysfunction of both muscles. Therefore, the timing of varus was not predictive of the contributing muscle or muscles.

CONCLUSIONS: The current study demonstrated a higher prevalence of anterior tibialis dysfunction, both alone and in combination with posterior tibialis dysfunction, as a contributor to pes varus in patients with pes varus and cerebral palsy than had been reported previously. Dynamic electromyography provides clinically useful information for the assessment of such patients.

Good Form video from Newton→

Great little video from Danny at Newton…….it doesnt matter what shoe you have if your technique is crummy. Here he demonstrates very well what good contact form is……..we like to say…..“land so subtle on the forefoot that it is a hair distance to kiss your heel to the ground before you push off…..if you remain high on your forefoot at contact you lose your shock absorption because the foot mechanics are more close to supination.”