Do you really understand what it takes to control the 1st Metatarsal during loading ?

Do you have dorsal (top) foot pain, at the peak of the arch? Think you are tying your shoes too tightly and that is the cause? Do you have pain over the dorsal or plantar mid foot on heel rise or jumping/landing or going up stairs ?

Just because you raise your heel and load the ball of the foot does not necessarily mean you have adequately plantarflexed the 1st metatarsal and loaded it soundly/stable with the medial tarsal bone. Heel rise, and thus loading onto the medial foot tripod, must be met with ample, stable, durable, 1st metatarsal plantarflexion and the associated medial tarsal bones. Also, without this, loading of the sesamoids properly cannot occur, and pain may ensue.

The first ray complex can be delicate in people who are symptomatic. In some people who do not have a good tibialis posterior-peroneus sling mechanism working harmoniously, in conjunction with a competent arch tripod complex to achieve a compentent arch complex (ie, EDL, EHL, tib anterior and some of the other foot intrinsics) this tarsometatarsal interval can become painful and instead of the 1st ray complex being stable and plantarflexing as the heel departs and the 1st ray begins taking load, it may not do so in a stable plantarflexed posturing. In some people it can momentarily dorsiflex as the arch subtly collapses (when it should be stable and supinated in heel rise).

"Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle."-Duallert et al

Soon, I hope to show you a video of how to watch for this problem, how to train it properly, how we do it in my office.
Dr. Allen

Reference:

Clin Biomech (Bristol, Avon). 2016 May;34:7-11. doi: 10.1016/j.clinbiomech.2016.03.001. Epub 2016 Mar 10.  The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Dullaert K1, Hagen J2, Klos K3, Gueorguiev B4, Lenz M5, Richards RG6, Simons P7.

https://www.ncbi.nlm.nih.gov/pubmed/27015031

Too much extensor tone: The banana toe.

Too much extensor tone.
We are often talking about the subtle balanced relationship of the long and short toe flexors and extensors. We often discuss that hammer toes are too much long flexor and short extensor tone (with too little in the short flexor and long extensor).
Here we see the opposite. We see too much long extensor tone (note the upward banana-shaped orientation of the big toe). When this foot is on the ground, the pad and distal 1/2 of the big toe does not even touch the ground, standing or in gait. IF you look closely at the blown up pic, you can sort of see (sorry, should have taken more pics) the increased callus development in the contact area of the short flexor attachment (FHB, flexor hallucis brevis).

This relationship is the opposite of the above with hammer toes. Too much long extensor, too much short flexor, and not enough long flexor and short extensor. These clients need more homework for long flexor and short extensor. This is one of the reasons why we developed the exercise below in the youtube link.

Calf strength, the medial foot tripod, and pain in the great toe

It has become evident that this component, the proper function of the 1st ray complex, is overlooked in some of the clinical world. Hallux joint pain is a difficult one to diagnose and treat at times. The source of pain and dysfunction can seemingly come from anywhere, but the more one understands the complex mechanics of this joint and regionally associate joints, the better clinical results one will achieve.  

One thing that has become recurrently obvious upon the many outside professional referrals that come though my office is the imbalance and/or weakness or endurance impairments in the posterior mechanism in relation to a painful 1st metatarsophalangeal joint (MTP). When I say posterior mechanism I am referring to the gastrocnemius, soleus, peronei, long flexors, and tibialis posterior namely. 

And, let me be clear, putting a theraband under the 1st metatarsal, encouraging your client to drive greater downward purchase of the head of the 1st MET during simulated foot tripod loading, does not necessarily help your client if their 1st MET is slightly more dorsiflexed. Do not be fooled by the flashy rehab guru tricks out there, proper clean function is achieved, not forced. If you have not earned it, you do not own it. 

It is quite simple really. If one does not have balanced function, including skill (motor pattern), endurance or strength of plantarflexion of the ankle, one cannot properly posture the first metatarsal (1st MET) in plantarflexion to sufficiently alter the sesamoid posturing underneath the metatarsal head, to sufficiently engage the unique eccentric axis (and it's necessary shift) of the 1st MTP to enable ample clean hallux dorsiflexion. Furthermore, without all this,  one will not be able to anchor the medial foot tripod properly.  This can lead to pain, functional hallux limitus, hallux rigidus to name a few. And, let me be clear, putting a theraband under the 1st metatarsal, encouraging your client to drive greater purchase of the head of the 1st MET during foot loading, does not necessarily help your client if their 1st MET is slightly more dorsiflexed. Do not be fooled by the flashy rehab guru tricks out there gang, proper clean function is achieved, not forced. 

A simple example might be a runner who fatigues the posterior mechanism in a long run. As the calf fatigues, they lose ample heel rise, thus ample plantarflexion of the 1st MET, thus proper posturing and translation of the sesamoids, thus successful eccentric axis shift, and thus clean dorsiflexion of the 1st MTP joint.  A player in a jumping sport who has less than ample strength of the posterior mechanism can have much the same issue at the resultant toe.  These are just garden variety examples.  But, should be clear that ample skill, endurance and strength (S.E.S.), our favorite mnemonic, of the posterior mechanism is necessary for pain free, functional toe off in the gait cycle or in jumping mechanics. 

If you are not systematically testing for these S.E.S. issues in the posterior mechanism, you are likely missing a major component in the proper posturing of the ankle and foot and thus proper functioning of the first ray complex and thus enabling clean function at the 1st MTP joint.  

(Sidebar rant: My past personal problems at this great toe joint started when a fellow chiropractor pulled on my toe many moons ago, for some random reason. It was the proverbial,  axial distraction "adjustment". The cavitation was heard around the world (the saliva inducing "pop" that fools many into blissful success), and my problems began.  I had painful dysfunction for many years after that for some strange reason, something was damaged but I was too stubborn and stupid to fix my own foot. I eventually remedied the problem through diving deeper into the complex mechanics of this joint and regionally associated areas. For this very intimate reason, it is why I am not one to perform this maneuver or recommend it. If we can be smarter in our understanding, we can be wiser in our interventions. Besides, axial distraction of this joint is not normal function of this joint. If I had a soap box to stand on for this topic, I would tell people to stop doing HVLA manipulations to this joint, mobilizations are more than ample to elicit a joint range response or a neurologic mechanoreceptor response. The more you understand this profoundly complicated and interesting joint, the 1st MTP joint, the more you will understand how to help your client. But, what do I know, I am just a dumb chiropractor, right Joe Rogan :) 

- Shawn Allen, the gait guys

Looking for the subtle clues will help you. You should have hypotheses and work to prove or disprove them. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

We used to call this a “windswept” presentation. It is not that it is incorrect, but it is so vague.  

Look at these fippy floppers. Look closely at the dark areas, where foot oils and whatnot have played their changes in the leather upper of the flops. The right f.flop displays more lateral heel loading, rear foot inversion if you will. You can even see that there is less big toe pressure on this right side and even some increased lateral forefoot loading. This client appears to be more supinated clearly. You can even see there is more lightness to the arch leather on the right, again, more supination is suggested.

The left f.flop suggests the opposite. More medial heel pressures and more over the medial forefoot and arch. 

Now this clients f.flops tell a story.  So, this client is being windswept to the right we used to say, appearing to pronate more on the left and supinating more on the right.  Why are they doing this? Is the left leg functionally longer and by pronating they reduce the functional length of the leg (yet, increase internal spin of the limb and the host of naughty things that come with that). Is the right leg shorter, and by supinating they are raising the ankle mortise and arch which helps reduce the length differential ?  MAybe a bit of both, finding common ground for a more symmetrical pelvis ?  Who knows. This is where you need your physical exam, but, now you have some hypotheses to prove or disprove. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

Is there some right hip pain from the right frontal pelvis drift creating some aberrant loading on the greater trochanter from ITB tension ? Perhaps a painful right hallux big toe, and they are unloading it to avoid pain? Maybe some knee pain or low back pain ? Who knows? Take your history and start putting the pieces together, it is your job. Just don’t screen them and throw corrective exercises at them, you owe it to them to examine them, take their history, watch them walk, teach them about what you see, and then sit down, spread the puzzle pieces out, look for the straight edges and corner pieces, and begin to build their puzzle. 

Clues, they are everywhere, if you look for them.

Dr. Shawn Allen, one of the gait guys

It has been a year, but this video is still as important as it ever was. Now that we have many of new viewers, perhaps they missed this one. It is always good to review. Enjoy !