Valgus Posts

A valgus post on an orthotic is a useful tool when you are trying to get weight off of the lateral and onto the medial column of the foot. It works best with people that have adequate range of motion in the first ray complex (they can get the head of the big toe to the ground) because if you don’t have adequate range of motion, you will only force the knee to the midline which sometimes can cause patellofemoral problems.

A valgus post as a post which begins wider laterally and narrows medially. It usually begins near the tubercle of the fifth metatarsal and can extend as far up as the end of the fifth toe. The idea is as you walk across the post, it forces the foot from lateral to medial helping to sink the first ray down to the ground. It functions similar to a first ray cut out (A notch cut out of the orthotic at the head of the first metatarsal) however is generally more gradual and sometimes better tolerated.

This type of posting is often used in people with internal tibial torsion who often having a difficult time getting weight onto the first right and keeping the knee in the sagittal plane.

In this video we briefly describe how the posting works. 

Increased unilateral foot pronation and its effects upward into the chain.

Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Nothing earth shaking here, we should all know this as fact. When a foot pronates more excessively, the arch can flatten more, and this can accentuate a leg length differential between the 2 legs. But it is important to note that when pronation is more excessive, it usually carries with it more splay of the medial tripod as the talus also excessively plantarflexes, adducts and medially rotates. This action carries with it a plantar-ward drive of the navicular, medial cuneiforms and medial metatarsals (translation, flattening of the longitudinal arch). These actions force the distal tibia to follow that medially spinning and adducting talus and thus forces the hip to accommodate to these movements. And, where the hip goes, the pelvis must follow . . . . and so much adaptive compensations.
So could a person say that sometimes a temporary therapeutic orthotic might only be warranted on just one foot ? Yes, of course, one could easily reason that out.
-Shawn Allen, one of The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #LLD, #leglength, #pronation, #archcollapse, #orthotics, #gaitcompensations, #hippain, #hipbiomechanics

Gait Posture. 2015 Feb;41(2):395-401. doi: 10.1016/j.gaitpost.2014.10.025. Epub 2014 Nov 3.
Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking.
Resende RA1, Deluzio KJ2, Kirkwood RN3, Hassan EA4, Fonseca ST5.

To Post (an orthotic) or not to post. That is the question

We have been tinkering with medial and lateral rearfoot and forefoot wedges for decades now collectively.
I would have to say that some of my greatest learning came from taking orthotics and foot beds and modifying them with various wedges (cork postings) and then asking the client how the changes impacted their gait and their pain somewhere in the kinetic chain. It was a huge learning curve, but without question, an invaluable one. I would do it all over again. It is also what allowed me to mostly get away from orthotic solutions for most clients. Because, armed with the knowledge at the foot-ground interface and then understanding how the muscles drive, slow, protect, co-contract etc I was able to melt the information into a package that much of the time, and hopefully, drives the client towards a solution, or at least more sound, stable and pain free function. If you are having someone make your orthotics and placing posts on them for you, there is a huge learning curve missing here for you. And, you are likely gonna get the prescription wrong, often. Trust me, often. We feel you should be playing these games yourself, one on one with the client, immediate feedback, immediate changes and teamwork. But, what do we know.

https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-017-0201-x

So you say your client needs more ankle rocker? Faking out ankle dorsiflexion and ankle rocker.

I was reminded again yesterday, after yet another foot pain client came in to see me, that many do not understand the absolute and deeper ramifications of putting an orthotic into a shoe (and onto a foot) and what effects of doing so can have on changing a necessary adaptation.

This client had medial heel pain, not plantar heel pain, not the posterior calcaneal area, the medial edge (see photo). The edge where the inside/medial edge of the calcaneus/heel meets the ground. This client could reproduce the pain on palpation and could reproduce it if they stood up, and everted the heel just a tiny bit.

This client had a healthy appearing foot and arch. But, as often is the case, appearances are deceiving. 

Here was the major problem:

- client had loss of terminal ankle dorsiflexion from prior fracture immobilization

- top end calf weakness * (see later)

- client had clear fatiguability of the anterior shin compartment muscles, and mild toe extensor weakness

- the client had high arched supportive orthotics

So, what is happening here, and often happens with the above limitations, the client does not have the muscular ability to maintain the arch sufficiently from the big players, as noted. In other words, the ankle has lost mobility and the foot has lost stability, a common pattern. To make up for a loss of ankle dorsiflexion we often collapse the arch a sufficient amount to pitch the talus medially and forward to help the tibia progress forward the requisite amount needed for forward locomotion across the foot-ankle complex. This is a normal compensation, and in time there may be a pathologic cost. This medial approach of the talus and arch collapse, requires calcaneal eversion. This eversion means more medial calcaneal loading into the shoe, orthotic or ground, including medial soft tissue (mostly fat pad) loading between the ground and the everting calcaneus.  

This is a normal compensatory strategy to move forward over a restricted ankle dorsiflexion range. However, the doctor this client saw previously (for plantar fascitis), felt that this motion was a problem they needed to block with an orthotic. One that resisted the heel eversion and more than normal arch collapse/pronation cycle. This remedy resolved the plantar fascial pain. But, the medial heel pain began shortly thereafter. 

So, here we have a client that is compensating, and finding a way (though there are biomechanical costs to this way), to get past a limitation, loss of ankle rocker in this case. But, the doctor put an orthotic in the shoe that stopped this "way".  Now the client has to evert the heel even harder, because of the presence of the orthotic preventing it) and it is causing a "bite" or friction plus compression of the medial soft tissues. 

So, this client now still cannot compensate well, in the manner they have attempted to do so, because of the orthotic. So, where are the loads going to go now ? Yes, some are being rammed into the medial aspect of the orthotic, but some are likely going to so elsewhere. Remember, the client is trying to progress their mass over and past the limited ankle rocker, and more pronation was their strategy. But, the orthotic is preventing that.  So, the loads are very likely going to move up the chain (because the orthotic is muting loads down into the foot). 

______

Me:     "Oh, wait, "Mr. Jones", didn't you say you were just recently beginning to have some posterior knee pain ?  Let me tell you why you are hyperextending your knee a little more than normal and taxing out your gastrocneumius.* One way you can progress forward, if you cannot do it through ankle rocker, is to extend your knee a little by contracting your quadriceps a small amount at midstance.  Lets discuss why the orthotic is not helping you, not solving your problem, and creating some new issues for you. Then lets get down to fixing the root problem."

Some things to think about.  Orthotics are not bad, but the user has to know when they are a device to help a client progress through a problem, and when they are inappropriate. Not all increased pronation is bad, particularly when it helps a client get through a problem. But, fix the root problem, and then help them regain proper amounts of pronation.

Oh, and one more thing, all you "drive more ankle rocker and dorsiflexion" people out there. Are you driving more ankle dorsiflexion, or are you merely pressing the talus into more medial posturing, plantarflexion and adduction? These are the talar motions in pronation. And when you pronate, you get more ankle rocker, faked out ankle rocker. So, are you truly helping your client get more ankle rocker and dorsiflexion ? Is this increased pronation what they are doing during their squats, to "apparently" get enough ankle rocker/dorsiflexion?  Be careful all those new found ankle rocker mobility drills are not just making your client pronate more than normal. We know it happens, we see all the time. Loss of ankle mobility and loss of foot stability are often a paired phenomenon, they are trying to talk to you and tell you to treat the root cause.

-Dr. Allen, one of the gait guys

So you prescribe and fit orthotics you say ?

"It all matters, and quite possibly, if you do not know it all, you cannot help your client."

How about this then, you have someone with a rearfoot valgus with internal tibial torsion.  How are they going to load now? What if you throw in a valgus knee and femoral torsion variant?  Are they going to pronate more or less ? What if that person had just internal tibial torsion on one leg and not the other, yet they had 2 rearfoot valgus feet presentations.  Now what?

Ouch, that is a strong statement. It likely needs softened, but, there is some truth within those words. 

Last night we did our monthly lecture on www.onlineCE.com.  We had a packed room, biggest audience to date.  It is likely because people are realizing that the small stuff matters.  We talked for an hour on foot types and  how they present, how they potentially load, and how other mechanical issues above can impact how a foot type loads. 

We have all seen the pedographs like in the photo. The unwise depend on a static pedograph mapping for diagnostic help and God forbid that is all you use for making orthotics (that may only help if your client is  a professional stander), the more wise use the dynamic pedograph mapping to see how their client moves across the ground, and the wise use it as a mere piece of the data, combine it with a clinical exam, look far up into the biomechanical chain for other locomotive challenges that could change the dynamic loading pattern across the foot and ground.  What do we mean exactly ?  Well, a client with a rearfoot valgus foot type will load the heel and rest of the foot one way if they are doing a good job stacking the hip over the knee, and knee over the foot. But, if they have weakness in the hip affording a frontal plane drift of the pelvis over the foot, that is going to magnify the rearfoot valgus loading pattern (addendum: they could also tip into rearfoot varus posturing as well). That is just one example, of many.  In otherwords, it is the same foot type, but both of these are going to show a dynamic change in the loading pattern response. So, said another way, you cannot diagnose a foot type by the pedograph mapping. Nor should one make an orthotic for someone based off of a pedograph mapping, nor without an examination of the entire kinetic change.  What is your client able, and unable, to do? That is a big question, and when you start by asking those 2 questions, you get closer to the prize.  The pedograph only shows the static or dynamic pressures from the superincumbent load, it does not tell you if it is good or bad, and it does not tell you what they are doing, or why they are loading that way. It only shows the loading. Your job is to find out why they are loading that way, and then determine if that is part of their problem they have sought you out for.

So, does  your head spin now ? Does this suddenly make you sweat ? Do you realize you are missing pieces of the pie in helping your client?  Not yet maybe ?  How about this then, you have someone with a rearfoot valgus with internal tibial torsion. How are they going to load now? What if you throw in a valgus knee and femoral torsion variant? Are they going to pronate more or less ? What if that person had just internal tibial torsion on one leg and not the other, yet they had two rearfoot valgus feet presentations. Now what? Suddenly the loading is different in both feet and up the chains. There is likely going to be different challenges to limb spin control from side to side. This aberrant and asymmetrical loading is going to come up to a pelvis, upon which a single spinal column is trying to find a sound base of support and mobility to work and transfer loads from. 

And, what if this client also has some tibial varum on that same side ? What if they had external tibial torsion or some femoral torsional presentation on one side ?  You can see now how complicated this gets. And that is just on the structural components. What about the dynamic components ?  We here at The Gait Guys feel that this is all critical stuff to take into consideration and it is sometimes the stuff that is the tipping point between a successful management of a clients complaints, and unsuccessful.  

In closing, think about this. If you are sending out your orthotics for fabrication, have you conveyed this all to your fabricator ?  All they know is what a pedograph might show, and what the foot mold looks like. You have to provide them with all this other information, because essentially they are blind (this of course assumes your fabricator can mind juggle all the torsions, valgus/varus, pelvis drift loads etc,  oy vey ! That is hard to do !) This is why we do all of our modifications in office, in the rare case we need a temporary orthotic modification. But, we will aim to just correct what mechanics are aberrant and avoid the whole orthotic crutch when we are able. But lets face it, sometimes, for a period of time, we all need a crutch to get through a problem, to find better mechanics where we can strengthen from or gain protecting from temporarily.  That is what splints do, taping, crutches, braces, one might even argue what corrective exercises do. It is a path on the journey for your client, and sometimes they need help through the muddy parts.

And, don't be "that guy" that says orthotics are useless. They are a crutch , a tool. A small tool, one might argue that it should only be pulled out when the other tools are not working to get the job done.  Do not make them your first line of defense, except when that is called for.  After all, not all people were blessed with sufficient anatomical  and mechanical parts to avoid needing a crutch, so don't be "that guy" that preaches from that extreme, because it is not honest. Or, maybe, you just do not see the biomechanical messes we see in our clinics, that is quite the realistic possibility. 

Want to learn more about this kind of stuff? Keep up with our blog here. OR take some of our lecture recorded classes on www.onlineCE.com . We have a library of classes there for you to take anytime. And meet us once a month over there, every 3rd Wednesday. And, stay tuned for some new teaching gigs we have coming your way.

-Shawn and Ivo,  the gait guys

Leg length discrepancies and total joint replacments.

5mm cut off ?  MaybeYou are likely to come across hip and knee arthroplasty clients (total joint replacements). When they take a joint out and replace it with a new one, it can be a true challenge to restore leg lengths to equality side to side. Problems often arise down the road once gait is resumed and rehabilitation is completed. It can take time for the leg length discrepancy (LLD) to begin to create compensatory problems. This article seems to suggest that 5mm is the tipping point where gait changes becoming a problem are founded. Other sources will render different numbers, this article found 5mm. The authors found that both over- and underrestoration of leg length/offset showed similar effects on gait and that Gait analysis was able to assess restoration of biomechanics after hip replacement.  I would chose to use the word “change” over restore, since the gait analysis is merely showing the deployed strategies and compensations, never the problem.  But it is a tool, and gait analysis can be a decent tool to show “change”.*Remember, it is not always a product of true length, it can come from the pelvis posturing and/or from the acetabular orrientation, which can be a postoperative sequella. One cannot over look  acetabular inclination, anteversion and femoral component anteversion/retroversion issues.Just remember, before you start making LLD changes with inserts, cork, orthotics etc be sure that you have restored as best as possible, pelvis-hip-spine mechanics because changes here can reflect as a mere leg length discrepancy. And it goes the other way as well, a LLD can cause those changes above.

* Just use your brain and don’t just lift the heel, give them a full sole lift. Heel lifts for this problem are newbie mistakes. Don’t be a newbie.

- Dr. Shawn Allen

Leg length and offset differences above 5 mm after total hip arthroplasty are associated with altered gait kinematicsTobias Renkawitz, Tim Weber, Silvia Dullien, Michael Woerner, Sebastian Dendorfer, Joachim Grifka,Markus Weber
http://www.gaitposture.com/article/S0966-6362(16)30148-5/abstract?platform=hootsuite

Podcast 107: Unilateral Training: Warping the Nervous System

Plus: Changing an existing orthotic to make it work, Meniscal tear truths, Shoe Insole truths, Plantar Pressures

Show Sponsors:

softscience.com
Altrarunning.com

Other Gait Guys stuff

A. Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_107f.mp3

http://thegaitguys.libsyn.com/episode-107-0

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

________________________

Show Notes:

Running helps mice slow cancer growth
https://www.sciencedaily.com/releases/2016/02/160216142825.htm

The future of Wearables
http://readwrite.com/2016/02/19/future-of-wearables

mensicus surgery is dead ?
http://www.regenexx.com/should-i-have-meniscus-surgery/#

Why you should be training your CNS
http://www.outsideonline.com/2055066/cross-educate-your-body#article-2055066

The business of insoles
http://www.outsideonline.com/2057156/business-insoles-support-system-or-super-rip

Altered plantar pressures
http://link.springer.com/article/10.1007%2Fs00167-016-4015-3

1st met pain in an orthotic?

This patient came in with pain at the base of the first metatarsal that she believed was related to her orthotic. The first picture shows the foots relationship to the orthotic. Notice how the sesamoid bones and distal aspect of the first metatarsal under lap the orthotic shell. In other words, the shell is longer than her foot. When she dorsiflexes her big toe, she’s hitting the distal of the orthotic.

The next view shows the orthotic with a typical first ray cutout. Notice how far forward the shell of the orthotic goes (next picture). I have placed a pen pointing to the area where the orthotic shell is too long.

In addition to reviewing her first ray descending exercises, a simple fix was to grind back the orthotic shell and be careful to bevel the edge so that it was not hitting the sesamoids and it did not impinge upon the descending first ray. I have placed a pen where the cut out now is (pre and post gluing in the pictures). The cork underlying the base of the first ray was also ground away (last picture)

A simple fix for a common problem. Make sure that your orthotic shell lengths fall just short of the 1st ray and not impinge on the sesamoids!

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

.

.

.

don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

.

.

.

.

.

.

Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

Eliminating the fake out of ample ankle rocker through foot pronation in the squat and similar movements:  How low can you go ? 

This is a simple video with a simple concept. 

* Caveat: To avoid rants and concept trolling, am blurring lines and concepts here today, to convey a principle. Do not get to tied up in specifics, it is the principle I want to attempt to drive home.  What you see in this video is clearly more lunge/knee forward flexion rather than hip hinge movement. However, keep in mind, that this motion does occur at the bottom of many movements, including the squat. 

You can achieve or borrow what “appears” to be more ankle dorsiflexion, a term we also loosely refer to as ankle rocker, through the foot, foot pronation to be precise. Do not mistaken this extra forward tibial progression range as ankle rocker mobility however. When you need that extra few degrees of ankle dorsiflexion deep in your squat, or similar activities, you can get it through your foot. Often the problem is that you do not think that is where it is coming from, you might just think you have great ankle mobility.  Many deep squatters are borrowing those last few degrees of the depth of the squat from the foot. This is not a problem, until it is a problem.  Watch the video above.  Why ? Because when the foot pronates and begins to collapse (hopefully a controlled collapse/pronation) the knee follows. Forcing the knees outward in a squat like some suggest is a bandaid, but I assure you, the problem is still sitting on the table. 

Go do a body weight squat with the toes up like in this video. Toes up raises the arch from wind up of the windlass and increased activity of the toe extensors and some assistance from the tibialis anterior and some other associated “helper” muscles.  When the arch is going up, it cannot go down. So, you raise your toes and do your squat. This will give you a better, cleaner representation of how much mobility in your squat/lunge/etc is from ankle dorsiflexion, knee flexion and  hip flexion. You can cheat and get some from the foot. The foot can be prostituted to magnify the global range, and like I said, this is not a problem until it IS a problem.   We know that uncontrolled and unprotected increases in foot pronation can cause a plethora of problems like plantar tissue strain, tibialis posterior insufficiency and tendonopathies, achilles issues, compression at the dorsum of the cuneiform bones (dorsal foot pain) to name a few. This dialogue however is not the purpose of this blog post today. You can read more about these clinical entities, proper foot tripod skills and windlass mechanics on other blog posts on this site. 

Today, we just wanted to bring this little “honesty” check to your awareness. Has been a staple in my clinic for over a decade, to help me see where limitations are and to show folks how they can cheat so much through the foot. Go ahead, try it yourself, see how much you use your foot to squat further if you have end range mobility issues in the hips, knees or ankles.  The foot is happy to give up the goat, it just doesn’t know the repercussions until they show up. 

So, lift your toes, do a full squat. Go as low as you can with good form with the toes up.  Then, at the bottom of the squat or the bottom of  your clean mobility, suddenly drop your toes and let the arch follow if it must. Here is the moment of truth, at that moment the toes go down, feel what happens to the foot, ankle, tibial spin, knee positioning, pelvis posture changes. Careful, these are subtle. You may find you are using foot pronation more that you should, more than is safe.  Now try this, bottom out your cleanest squat as you regularly would, and at the bottom, raise your toes and try to reposition the foot arch and talus height. In other words, reposture your foot tripod, see how difficult this is if you can do it at all. Perhaps you will find your toe extensors are too weak to even get there.  This is how we cheat and borrow. We should not make it a habit, it should be used when we need it, but it should not be a staple of your squatting diet, it should not be a regular event where you prostitute sound biomechanics.  Unless you wish to pay for it in some way.  What should happen is that you should be able to bring your toes down and not let the arch follow, but that is a skill most have not developed. It is a staple move in your clients’ movement diets.

Does all this mean you should squat with your toes up ? No, but it may serve you well in awareness, evaluation, and looking for potholes and power leaks. At the very least, give it some thought and consideration. You may see some smiles and have some lightbulb moments between you and your athletes and clients. 

Plan on blocking this foot pronation range with an orthotic ? How dare you ! At least try to do it through reteaching this and the tripod skill first. Give your a client a chance to improve rather than a bandaid to cope. 

Dr. Shawn Allen, one of the gait guys

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.

This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not.  A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.

Hmmm..

We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?

Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB.  Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.

Podcast 95: Head tilt while squatting or running.

We have a strong show for you today. Ankle instability from a neurologic perspective, shoe wear, head tilt and the neurologic and functional complications… we also talk about Efferent Copy and motor learning.

A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_95final.mp3

Direct Download:  http://thegaitguys.libsyn.com/pod-95

-Other Gait Guys stuff
B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

Human exoskeletons: The Ekso
http://www.thedailybeast.com/articles/2015/08/03/the-mechanical-exoskeleton-shaping-the-future-of-health-care.html

Ankle muscle strength influence on muscle activation during dynamic and static ankle training modalities
http://www.tandfonline.com/doi/abs/10.1080/02640414.2015.1072640?rfr_id=ori%3Arid%3Acrossref.org&url_ver=Z39.88-2003&rfr_dat=cr_pub%3Dpubmed&#.VcYWR-1VhBc

Chronic ankle instability:

http://tmblr.co/ZrRYjx1akudcm

http://tmblr.co/ZrRYjx1ah6ThV

http://thegaitguys.tumblr.com/post/68785250796/just-because-a-muscle-tests-weak-doesnt-mean-it
http://thegaitguys.tumblr.com/post/117109093439/last-week-we-ran-an-archived-piece-named-just

the future of footwear and orthotics ?
http://lermagazine.com/special-section/conference-coverage/the-future-of-footwear-and-orthoses-is-here-now-what

squats- head posture-gait vision-gravity
http://thegaitguys.tumblr.com/search/vision

Music: brain rhythm
http://www.kurzweilai.net/the-brains-got-rhythm

Podcast 89: 2015 Shoe Talk, Foot Beds, and shoe stuff you need to know.

A. server links

http://traffic.libsyn.com/thegaitguys/pod_89f.mp3

http://thegaitguys.libsyn.com/89

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

E. Our Book: Pedographs and Gait Analysis and Clinical Case Studies

electronic copies available here:

Amazon/Kindle: 

http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

Barnes and Noble / Nook /iTunes Readers:

http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

 Hardcopy available from our publisher:

http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

 

Running Shoes : Alex and Blaise ?

http://www.theglobeandmail.com/life/health-and-fitness/fitness/which-running-shoe-is-right-for-you/article22276071/

 

And on that same topic, Foot beds, sock liners and orthotics:

 

super feet

what you put in your shoe can change the way the shoe was designed to work……careful what you put in the shoe 

 

‘Rocker’ Shoes Could Help Facilitate Post-Marathon Recovery
http://www.runnersworld.com/running-shoes/rocker-shoes-could-help-facilitate-post-marathon-recovery

 

and … 

Effect of rocker shoes on plantar pressure pattern in healthy femal… - PubMed
http://www.ncbi.nlm.nih.gov/pubmed/24370440

 

Why Running Shoes do not work:

http://www.scienceofrunning.com/2010/01/why-running-shoes-do-not-work-looking.html

Podcast 77: Gait analysis, Forefoot Running & more.

Plus, the 5 neurologic gait compensation expressions.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-77

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Google X acquires ‘tremor-canceling spoon’ startup
http://venturebeat.com/2014/09/10/google-x-acquires-tremor-canceling-spoon-startup/

Injecting New Data Into Our Brain Is Possible
http://realitysandwich.com/222887/injecting-new-data-into-our-brain-is-possible/

The 5 expressions of neurologic gait decomposition,

Last week we did an online teleseminar … . .

An acoustic startle alters knee joint stiffness and neuromuscular control
http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract

http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract

Effectiveness of Off-the-Shelf, Extra-Depth Footwear in Reducing Foot Pain in Older People: A Randomized Controlled Trial
http://biomedgerontology.oxfordjournals.org/content/early/2014/09/08/gerona.glu169.abstract

Gait Analysis: The Serious Runner’s Salvation
http://online.wsj.com/articles/gait-analysis-the-serious-runners-salvation-1411428069

What Forefoot Running Actually Means
http://breakingmuscle.com/running/what-forefoot-running-actually-means

reader:

I really appreciate learning from you!! I have a bit of a loaded question that I will try to explain clearly to the best of my ability. About 2 years ago, I broke my left shin (hairline-fibula) in a MMA fight. After it healed, a few things have been happening that I assume are connected but can’t quite put my finger on. My ankle mobility on my left ankle is worse than my left. I seem to have permanent turf toe as well. My right glute, ham, and erector are hyperactive.

Additionally, many times when sprinting, pushing a sled, etc, my right quad will become fatigued much more than my left. I believe it’s because I’m not fully extending my left ankle, and relying on my right leg more. Whenever I squat or deadlift, I feel similar too. The right glute and erectors get much more of a “pump” than my left. With all of this, is there anything you would recommend? I truly appreciate it!! It is very frustrating. Thank you again!

Spanking the orthotic: The effects of hallux limitus on the foot’s longitudinal arch.

But the issues do not stop at the arch. If you have been with us long enough, you will have read about the effects of the anterior compartment (namely the tibialis anterior, extensor digitorum and hallucis and peroneus tertius muscles) strength and endurance on the arch.

Here we have a very troubled foot. This foot has undergone numerous procedures, sadly. Today we will not talk about the hallux varus you see here, a virtual unicorn in practice  (and acquired in this case) nor do we want to discuss the phalangeal varus drift. We want to draw your attention to the obvious impairment of the 1st MTP (metatarsophalangeal joint) dorsiflexion range.  You can see the large dorsal crown of osteophytes, a dorsal buttress to any hallux dorsiflexion.  There is under 10 degrees of dorsiflexion here, not even enough worth mentioning.  We have said it many times before, if you lose a range at one joint usually that range has to be accommodated for proximal or distal to the impaired joint. This is a compensation pattern and you can see it here in the hallux joints themselves.

Here you can see that some of the dorsiflexion range has been acquired in the proximal phalangeal joint.  We like to call this “banana toe” when explaining it to patients, it is a highly technical term but you are welcome to borrow it. This occurred because the joint was constantly seeing the limitation of dorsiflexion of the 1st MTP joint and seeing, and accommodating to, the demands of the need for more dorsiflexion at toe off. 

But, here is the kicker. You have likely seen this video of ours on Youtube on how to acquire a foot tripod from using the toe extensors to raise the arch.  Video link here  and here.  Well, in his patient’s case today, they have a limitation of 1st MTP dorsiflexion, so the ability to maximally raise the arch is impaired. The Windlass mechanism is broken; “winding” of the plantar fascia around the !st MTP mechanism is not sufficiently present. Any limitations in toe extension (ie dorsiflexion) or ankle dorsiflexion will mean that :

1. compensations will need to occur

2. The Windlass mechanism is insufficient

3. gait is impaired at distal swing phase and toe off phases

4. the anterior compartment competence will drop (Skill, endurance, strength) and thus injury can be more easily brought to the table.

In this patient’s case, they came in complaining of burning at the top of the foot and stiffness in the anterior ankle mortise area.  This would only come on after a long brisk walk.  If the walk was brisk yet short, no problems. If the walk was long and slow, no problems.  They clearly had an endurance problem and an endurance challenge in the office showed an immediate failure in under 30 seconds (we will try to shoot a quick video so show our little assessment so be patient with us). The point here today is that if there is a joint limitation, there will be a limitation in skill, strength or endurance and very likely a combination of the 3. If you cannot get to a range, then any skill, endurance or strength beyond that limitation will be lost and require a compensation pattern to occur.  This patient’s arch cannot be restored via the methods we describe here on our blog and it cannot be restored by an orthotic. The orthotic will likely further change, likely in a negative manner, the already limited function of the 1st MPJ. In other words, if you raise the arch, you will shorten the plantar fascia and draw the 1st MET  head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … .  but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ……..yes, exactly !  So use your head  (and spank the orthotic when you see it used in this manner.  ”Bad orthotic, bad orthotic !”)

So think of all of this the next time you see a turf toe / hallux rigidus/ hallux limitus. Rattles your brain huh !?

This is not stuff for the feint of heart. You gotta know your biomechanics.

Shawn and Ivo … .the gait guys

Addendum for clarity:

a Facebook reader asked a question:

From your post: “if you raise the arch, you will shorten the plantar fascia and draw the 1st MET head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … . but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ” I always thought when the plantar fascia is shortened, it plantar flexes the 1st metatarsal (1st ray) and extends (dorsiflexes) the 1st MTP joint….

Our response:  

We should have been more clear, our apologies dear reader.  Here is what we should have said , ” The plantar fascia is non-contractile, so it does not shorten. We meant conceptually shorten. When in late stance phase, particularly at toe off when the heel has raised and forefoot loading is occurring, the Windlass mechanism around the 1st MET head (as the hallux is dorsiflexing) is drawing the foot into supination and thus the heel towards the forefoot (ie passive arch lift). This action is driving the 1st MET into plantarflexion in the NORMAL foot.  This will NORMALLy help with increasing hallux dorsiflexion. In this case above, there is a rigid 1st MTP  joint.  So this mechanism cannot occur at all. In this case the plantar fascia will over time retract to the only length it does experience. So, if an orthotic is used, it will press up into the fascia and also plantarflex the 1st MET, which will carry the rigid toe into plantar flexion with it, IN THIS CASE.”

Podcast 53: Debunking Treadmills & Recovery Strategies

A. Link to our server:

http://thegaitguys.libsyn.com/podcast-53-debunking-treadmills-recovery-strategies

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

________________________________________

* Today’s show notes:

By this time next year, you could be 3D printing custom comfortable inserts for your shoes
http://gigaom.com/2014/01/26/by-this-time-next-year-you-could-be-3d-printing-custom-comfortable-inserts-for-your-shoes/

_______________

LeBron James, Kevin Durant Help Spearhead NBA Popularity of Legs Recovery System
http://bleacherreport.com/articles/1932257-lebron-james-kevin-durant-help-spearhead-nba-popularity-of-legs-recovery-system#articles/1932257-lebron-james-kevin-durant-help-spearhead-nba-popularity-of-legs-recovery-system

_________________

Mechanism of orthotic therapy for the painful cavus foot deformity
http://www.jfootankleres.com/content/7/½/abstract

___________________

The influence of incline walking on joint mechanics

http://www.gaitposture.com/article/S0966-6362(14)00002-2/abstract

__________________

Biomechanics Expert Debunks Treadmill-Running Myths
http://www.runnersworld.com/treadmills/biomechanics-expert-debunks-treadmill-running-myths

_____________

Ice baths:

http://www.theactivetimes.com/cold-hard-truth-about-ice-baths

____________

8:38am Jan 21

Hi guys,

I’m hoping you can help.

I have a severely arthritic 2 MTPJ on my left foot.

It seems to trigger extreme hip flexor tightness which has twisted my whole body, right up to my neck and jaw.

I can’t seem to get any definitive answers as to how to turn off this protective hip flexor tightness. I’m concerned if it goes on much longer I’m going to develop bone spurs throughout my body. This would destroy my life.

Is there any surgery you recommend?

Or any type of Rocker soled shoe? I’ve tried MBT’s but I think the forefoot is stiff enough and my Hipflexor hasn’t calmed down properly.

Thank you so much if you decide to answer this

Richard

____________

Blog reader: moham17

How does subtalar supination/pronation affect plane deviations farther up the chain, specifically at the pelvis? I was going over some notes and found something saying that increased pronation leads to increased frontal plane motion at the pelvis during gait, and increased sup leads to increased transverse plane motion. However, in this video I was watching, the clinician states that increased sup will lead to increased frontal plane motion. Is this not a contradiction? Can both be true? Thanks

______________

Fighting falls with feedback: Virtual reality training improves balance | Lower Extremity Review Magazine
http://lowerextremityreview.com/issues/january/fighting-falls-with-feedbac-virtual-reality-training-improves-balance

_____________

Brooks Transcend and Altra Olympus: Max Cushioning In a Lightweight Package Appears To Be The New Trend in Running Footwear

http://runblogger.com/2013/08/brooks-transcend-and-altra-olympus-max.html

Orthotics and Foot beds, What’s the Difference?

Welcome to rewind Friday Folks. Here is an oldie but a goodie, with lots of great information. Rememeber; if you use or prescribe orthotics, hopefully you are using exercises as well and hopefully, the prescription is changing over time and you are removing correction from the device!

Orthotics and footbeds, they’re the same thing, right? This is a question that is often posed to us.  No, they’re not the same, but oftentimes one or the other can be appropriate. To explain the difference, we need to understand a little bit about foot mechanics.

The foot is a biomechanical marvel.  It is composed of 26 bones and 31 articulations or joints.  The bones and joints work together in concert to propel us through the earth’s gravitational field.  It is a dynamic structure that is constantly moving and changing with its environment, whether it is in or out of footwear.  Problems with the bones or joints of the foot, or the forces that pass through them, can interfere with this symbiosis and create problems which we call diagnoses.  They can range from bunions, plantar fasciitis, shin splints, TFL syndrome, abnormal patellar tracking, and lower back pain just to name a few.

Before we go any further, we should talk a little bit about gait (ie walking pattern). Normal walking can be divided into 2 phases, stance and swing. Stance is the time that your foot is in contact with the ground. This is when problems usually occur. Swing is the time the opposite, non weight bearing foot is in the air.

 

The bones of the foot go through a series of movements while we are in stance phase called pronation and supination. Pronation is when your arch collapses slightly, to make your foot more flexible and able to absorb irregularities in the ground; this is supposed to happen right after your heel hits the ground. As your foot pronates, the leg rotates inward, which causes your knee to rotate in, which causes your thigh to rotate in, which causes you spine to flex forward. Supination is when your foot reforms the arch and makes your foot a rigid lever, to help you propel yourself; This is supposed to happen when you are pushing off with your toes to move forward. It is at this time that the entire process reverses itself, and your leg, knee, and thigh rotate outward and your spine extends backward. When these movements don’t occur, or more often, occur too much, is when problems arise. This can be due to many reasons, such as lack of movement between your foot bones (subluxation), muscle tightness, injury, inflammation, and so on.

Many people over pronate, due to incompetence of the intrinsic musculature of the lower kinetic chain, genetics, environmental factors or injuries. This means that their arch stays collapsed too long while in stance phase, and they remain pronated while trying to push off. As we discussed, during pronation the foot is a poor lever. This means you need to overwork to propel yourself forward. This can create arch pain, inflammation on the bottom of the foot (plantar fascitis), abnormal pressure on your foot bones (metatarsalgia), knee pain, hip pain and back pain.

Lets look at skiing. Skiing is a stance phase sport. While skiing, your foot stays relatively immobile in a ski or snowboard boot (i.e. it is not moving through a gait cycle). A footbed is designed to create a level surface for your feet and keep them in a neutral posture. It accomplishes this by “bringing the ground up to your foot.” They are generally custom designed to an individuals foot through many different methods. They work incredibly well (as long as the foot remains in a static posture) and many people extol the benefits and improvements in their respective sports when using these.

Orthotics are always custom made devices. They actually improve the mechanics of your foot (or give you mechanics you didn’t have before) and make it function more efficiently by altering the shape and function of the arch as the foot moves through various activities. They act like a footbed but have the added benefit of functioning while dynamic (i.e. moving) as well. This works as well or better than a footbed, and is usable in other sporting activities, such as Nordic skiing, snow shoeing, hiking, running, or biking. Many people use their orthotic in their everyday shoes, to help prevent some of the problems and symptoms they are experiencing. It should be emphasized that an orthotic IS NOT a substitution for competent musculature. We view them as an aid to assist the rehabilitation process; slowly pulling out correction as the biomechanical competence improves.  We like to call this “Orthotic Therapy”.

In summary, a footbed supports the foot in a neutral posture. It is great for activities where your foot is static or held in one position. An orthotic supports the foot in a neutral posture and improves the mechanical function of the foot. It can be used in static or dynamic activities. Remember to always consult with a professional who is well versed with the mechanics of the feet, ankles, knees, hips and back, since footbeds and orthotics have a profound effect on all these structures.

Orthotics and footbeds; they can be great assistive devices along the road to foot competence. And they can be great doorstops when you are done using them!

We are and remain..The Gait Guys.

Podcast 47: The Thigh Gap & Medial Tibial Stress Syndrome

Podcast 47 is live !

Topics: Lots of cool stuff for your ears and brains today. Don’t miss this show on Allen’s Rule Part 2, ankle biosensors, Parkinson’s syndrome gait disorder, Medial Tibial Stress Syndrome, The Thigh Gap disorder, and the ever confusing and much debated Abductory Heel Twist in walking and in runners. Don’t miss this show !

A. Link to our server:

http://thegaitguys.libsyn.com/podcast-47-the-thigh-gap-medial-tibial-stress-syndrome

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

________________________________________

* Today’s show notes:

Neuroscience piece

1. Update on Allen’s Rule blog post:

http://thegaitguys.tumblr.com/post/68094426145/allens-rule-is-this-why-the-kenyans-are-better

2. Could a simple ankle sensor help with parkinsons symptoms ?

http://www.scientificamerican.com/article.cfm?id=could-a-simple-ankle-sensor-help-with-parkinsons-symptoms

3. Probiotics Boost Running Performance in Heat

http://www.runnersworld.com/nutrition-for-runners/probiotics-boost-running-performance-in-heat

4. http://thenextweb.com/gadgets/2013/11/26/thalmic-labs-gearing-ship-first-myo-gesture-control-armbands-weeks/

5 Gait Factoid:  the foot abductory twist

6.  Note from melissa on her 9 month leg pain.

Disclaimer 

7 . National Shoe Fit Program

8 . medial tibial stress syndrome

http://lowerextremityreview.com/cover_story/medial-shin-pain-in-runners-evidence-for-orthosis-use

9. from a blog reader:

The thigh-gap obsession is not new but it’s the most extreme body fixation yet

http://www.theguardian.com/fashion/2013/nov/04/thigh-gap-obsession-most-extreme

Does this foot look like your foot ? 

There are a few subtle issues here. At first glance this foot looks half-way decent but upon further observation you should note the subtle drift of all of the toes.  In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit is the reference digit.  

In this foot, look at the shape of the 2nd and even the 3rd digit, they have a curve to them. Remember, form follows function and the dead give away here is that the hallux (the big toe) is drifting into adduction towards the 2nd digit. This is referred to as early hallux valgus and it is accompanied by early evidence of a bunion at the medial foot at the metatarsophalangeal joint.  When the shaft of the hallux is not in line with the shaft of the metatarsal long bone we get the angulation between the two causing the hallux valgus.  This is often from excessive pronation (either rearfoot, midfoot and/or forefoot) that collapses the tripod, splays the distal MET head via its dorsiflexion, and the development of complicated long and short hallux flexor muscle dysfunction as well as abductor hallucis (transverse and oblique head) disfunction further driving the hallux pull medially.  When the distal toes are engaged on the ground and there is still forefoot pronation occurring through the medial tripod support, the toes will be forced into a twist or spin, and in time you will get toes that appear drifted or windswept like these toes appear.  A similar phenomenon occurs at the lateral foot and a Tailor’s bunion begins to occur there as the forefoot begins to widen as the MET heads separate and the toes funnel medially (often provoked to do so by pointed footwear).  

We can also see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL). See this post here for an explanation of this phenomenon.  

This is a fairly typical foot that we see in our practices.  This is not a far-gone foot but one has to catch this foot at this stage or it is rather difficult to resuscitate back to a healthy foot. Like a spinal scoliosis, once a bunion and  hallux valgus gets too far, it becomes an issue of symptom management rather than repair.  Hallux abduction must be retaught, tripod skills must be retaught, intrinsic foot muscle strength must be regained as well as strength and endurance of the tibialis anterior and toe extensors to help raise the arch again and control pronation. Sometimes a temporary orthotic can help the person to passively regain some degree of competent tripod while homework earns the changes. In some cases, an orthotic needs to be a permanent intervention if tripod stability cannot be adequately achieved.  But, we never give up and neither should you or your client, amazing things can happen over long periods of time when correction is forced.

There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box.  Support the midfoot with an orthotic or built up foot bed, if necessary, but don’t leave it there. It is a crutch, and even crutches are intended to be put aside at some point. 

Shawn and Ivo, The gait guys