Dragging your tongue ? When the tongue of your shoe keeps getting pulled to the side. Do you know what it means ? It means plenty, if you are sharp.

By: Dr. Shawn Allen

This one pisses off most people it happens to. Why does it typically happen only on one side, on one shoe ? Look at the photo case above. Look closely to the left foot, the tongue of the shoe is pulled laterally compared to the right, or shall I say, dragged.

This is a fairly common phenomenon, and there is a reason for it, several actually. So, no, you do not need to staple the tongue to the shoe upper, or tighten your shoe laces, or stitch the tongue to the medial shoe upper. You need to stop externally spinning your foot in your darn shoe.  What ?!

Yes, you very well may be avoiding normal internal rotation progression of the pelvis over the fixated limb. Loss of internal hip rotation is often a common finding clinically. As one passes the swing leg forward, the forward progressing pelvis eventually meets this loss of internal rotation over the fixated leg and femoral head. The swing leg none the less progresses further forward to get to its’ heel strike and the stance phase leg has to externally spin over the ground (I like to give the analogy of putting out a cigarette butt on the ground or squishing a bug (PETA don’t come after me)). This is called an Abductory or Adductory twist (good video demo here) depending on whether your reference point is the forefoot or rear foot. Regardless, the heel is spinning inward, the forefoot is relatively spinning outward. This spin of the foot inside the shoe (this happens minutely just before the shoe spins on the ground) and pulls the tongue laterally with it.  

This problem can also come from, and often does, a premature heel rise from things like a:

•  loss of ankle rocker
• short calf
• lack of hip extension
  
• hallux rigidus / limitus or even a painful big toe
• etc

There are even several other causes I will not list here today, I could have you waste your whole day on the list and the mental gymnastics of things to consider. Basically, anything that impairs the stance phase mechanics creating a premature heel rise or failure of completing internal hip rotation can cause an Abd/Adductor twist of the foot/heel and drag the tongue laterally. Sure, there are others, but the purpose of my blog post here today was to explain a neat little biomechanical phenomenon that  has huge clinical insight if you know what it means.  You cannot fix this problem if you do not do a physical exam, understand clean and faulty gait biomechanics, and maybe can even find small objects in a dark room.  What I mean is it takes some educated exploration and a curiosity to want to fix things.  

There are clues often right in front of you, all you have to do is pay attention and sometimes ask a simple question. 

“Mr. Jones, when you stick out your tongue, does it drag laterally ?”  

Ok, maybe not that exact question. But, when I see a loss of internal rotation or terminal hip extension in a runner, and when I have time to explain things deeply with a openly receiving client, I might start the conversation with that fun question and then explain what I really meant was the tongue of the shoe on that affected side. 

You can’t swallow bandaids to fix things, as much as you wish it was that easy. Sure, you can avoid all of this fun by buying a shoe that has the tongue of the shoe sewn to the medial upper of the shoe, but then you wouldn’t have to fix anything.  Where would you “get your fun on” then ?  Be brave, go all in, fix the problem dammit.  

These are the things that keep me up at night. Welcome to my nightmares.

Dr. Shawn Allen, one of the gait guys

Photo courtesy of this weartested.org link: http://weartested.org/wp-content/uploads/2015/03/altra-superior-2-top-socks.jpg

Gait Problem: The solitary externally rotated foot, or “why is my one foot turned out ?”

In a previous post (and on the Cross Over video and hip biomechanics video) we talked about the externally rotated limb/foot as a compensation for a same sided weak gluteus medius.  You should recall that in the scenario of a weak gluteus medius, a wonderful frontal plane stabilizer, the foot can turn out to help better engage and protect that frontal plane cheat or compensation by drawing the quadriceps availability into play in that frontal plane. By turning out the foot the knee hinge range goes with the foot and so the quadriceps can now actually help to engage and protect motion into this frontal plane. We call the foot turn out in this scenario, “the kickstand effect”, like a kickstand on your bike, it flips out to add stability in another plane. This is a nice compensation, one seen often, but it has its own set of sequelae such as patellar tracking syndrome, IT band syndrome, trochanteric bursitis and foot pronation challenges to name just a few.

However, there are other reasons for the externally rotated solitary foot. Lets look at another cause.
* Limited internal hip rotation range will be the topic today.

In order to pass through the midstance phase of gait, in walking or running, the hip must internally rotate at least 4-6 degrees. Actually, to be perfectly accurate, since the hip is the fixed part (foot is fixed on the ground) the acetabulum socket of the pelvis which sits upon the hip’s femoral head, must be able to externally rotate those 4-6 degrees on the femoral head in order to get the subsequent full, timely and optimal hip extension and gluteus maximus contraction.  So, what we are saying is that the pelvis which is sitting upon the hip’s femoral head must be able to oscillate to accommodate the swing phase of the opposite leg. For example, if the right foot is on the ground the pelvis is going to rotate clockwise upon that right femoral head which has been brought on by the left leg forward swing phase of gait.

Now, if that right hip joint does not have adequate internal rotation, the clockwise spin of the pelvis on the femur head will hit an early limitation end range. We will talk about the consequences in a moment but first we need to remind you of things we have talked about in previous blog posts:  when we limit internal hip rotation the degree of hip extension will also be limited.  You need sufficient internal rotation at the hip to get the subsequent hip extension and resultant gluteus maximus optimization. 

Now, back to the possibilities when the pelvis cannot rotate clockwise enough on the right femoral head (ie. internal hip rotation). A few things can happen as the limitation is reached:

1. the left foot (swing limb) can drop to the ground prematurely rendering a short step length
2. the pelvis rotation on the hip will hit capsular close packing and compression and come to a halt but the forward momentum of the body-pelvis swing will cause an external rotation pivot of the foot and this extra spin from the foot will achieve the last needed pelvic motion (we call this “cigarette foot”, like putting out a cigarette under the ball of your shoe). Interesting note for those of you who run on crushed gravel or other forgiving surfaces, pay attention to this subtle spin on these surfaces, this could be the spin that you feel at toe off. This is sort of like the Abductory twist of the foot phenomenon, however that is a typically reserved term more for an excessively pronated foot.
3. the individual will simply limit their stride length to avoid the above problem range however they will also be limiting hip extension, weakening the gluteus maximus.  Premature heel rise will go with this issue (seen beautifully in this video above).
4. Since internal rotation is a precursory range before hip extension, if you limit internal rotation you will limit hip extension. When hip extension is limited quite often you will ask for more saggital extension from the joint complex above or below the hip, so looking above the hip we can see increased lumbar extension or below we can see knee hyperextension, both compensation can make up for the loss of hip extension.
5. As the internal limitation is met, pelvic obliquity can be adopted to normalize linear saggital gait progression. Eventually the core will become asymmetrical and create a pelvic obliquity distortion pattern which can be seen on static standing, typically a clockwise pattern (if we are talking about the right hip limitation) to enable more of the internal rotation at the hip (re-read #1 to understand this).
6. And finally, the easiest of the patterns,  the brain sometimes will sense this aberrant pattern and simply turn the right leg-foot outwards into external rotation.  Why ? Because, when you move through midstance and hit the internal hip rotation limitation a compensation must be met as described above. If from the start of the gait cycle you merely set the foot progression angle into external rotation (as in the video above), the pattern (albeit dysfunctional) gets to groove the aberrant pattern more smoothly.  At the severe cost of weakening the internal limb rotator muscles and gluteus maximus (sacral and coccygeal divisions to be specific) and perhaps even more detrimental losing the advantages of proper toe off of a rigid foot (again, look at the arch collapse, toe hammering and premature heel rise in the video above, there is a price to pay for compensating). In this scenario, you are literally creating the hip range of motion (by externally rotating the limb) that you didn’t have.

Of course the best solution is just to figure out why the internal hip rotation is limited (address both tightness in soft tissues and the weaknesses that drove that protective tightness, yes stretching rarely solves the world’s problems).  Then regain symmetry, and the optimal and efficient motor patterns.

And of course, there are neurological sequelae occur as a result of this strategy, but that is the subject of another post on another day.

The externally rotated foot is an adaptive strategy. It is biomechanically brilliant, but fraught with compensations and prostitution of far reaching motor patterns (yes, this pattern will often effect normal arm swing in the contralateral limb, see our arm swing blog posts from last week).  Simply telling someone to turn the foot back to forward facing neutral (5-15degrees progression angle) is not the solution.  Gosh, if it was that easy doctors like us would also have long tails and be seen swinging from trees eating bananas. 

The externally rotated foot. There is more to it than meets the eye. Dig deeper and you will find the answer, if you do not mind some heavy thinking.

Shawn & Ivo, The Gait Guys ……. Rubix’s cube kind of guys.

Hip internal rotation

Q: why do The Gait Guys test for internal hip rotation loss with the client supine and leg straight ?

A: because this is as close as you can get to representing midstance phase of gait where they are converting from external rotation at rearfoot strike to moving through the pronatory phase where internal limb rotation is paramount. A loss on the table is a key exam finding ! it must be listened to.

* key……the leg is straight at zero degress of leg raise……ie. the leg is flush on the table. if you lift the leg…..you have effectively put them more in early midstance…..ideally you would love to drop them a bit further into hip extension to see if you can get the internal rotation with hip extension which would represent the approach to toe off.

Q: so what are the internal hip rotators you would check functionally then to find out who is inhibited (& could be related to loss of the range ?)

A: lower TVA, anterior G. Med, TFL, v. lateralis, rectus femoris, lateral hamstrings, coccygeal g. maximus, iliocostalis T/L paraspinals…….to start with. Find me one that is weak and i will show you one that might get them more internal hip rotation.