Podcast 163: The hip and foot talk to each other. A research paper.

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Today's article link: https://pubmed.ncbi.nlm.nih.gov/32717719/

When one foot is shorter, and smaller. Gait thoughts to consider.

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This person had a congenital “club foot” at birth also know as congenital talipes equinovarus (CTEV). It is a congenital deformity involving one or both feet. In this case it affected the right foot (the smaller one).
Foot size is often measured with the Brannock device in shoe stores, you know, the weird looking thing with the slider that measures foot length and width. In this case, the right heel:ball ratio, the length from the heel to the first metatarsal head, is shorter. The heel:toe length is also shorter, nothing like stating the obvious ! IF they are shorter then the plantar fascia is shorter, the bones are shorter, the muscles are smaller etc.

So, the maximal height of the arch on the right when the foot is fully supinated is less than that of the left side when also fully supinated (ie. during the second half of the stance phase of gait). Even with maximal strength of the toe extensors which we spoke of yesterday will not sufficiently raise the arch on the right to the degree of the left.

Thus, this client is very likely to have a structural short leg. Certainly you must confirm it but you will likely see it in their gait if you look close enough.
Also, you must remember that the shorter foot will also spend fractionally less time on the ground and will reach toe off quicker than the left. This may also play into a subtle limp.
This client may have a mal-fitting shoe, the right foot will swim a little in a shoe that fits correctly on the left. You may be easily able to remedy all issues with a cork full length sole insert lifting both the heel and forefoot. This can negate the shoe size differential, change the toe off timing and remedy much of the short leg issue. You will know that the right foot at the metatarsal-phalangeal joint bending line will not be flexing where the shoe flexes on that right foot. The Right foot will be trying to bend proximal to the siping line where the shoe is supposed to naturally bend. This will place more stress into that foot. This brings up the rule for shoe fit: never size a persons shoe by pinching the toebox to see if there is ample room, the shoe should be fit to meet the great toe bend point to the flex point of the shoe.
Strength of muscles is directly proportional to the cross sectional area of the muscle. With smaller muscles, this right limb is very likely to be underpowered when compared to the left.
All of these issues can cause a failure of symmetrical hip rotation and pelvic distortion patterning.
Altered arm swing (most likely on the contralateral side) is very likely to accommodate to the smaller weaker right lower limb. Do not be surprised to hear about low back pain or tightness or neck/shoulder issues.
A shorter right leg, due to the issues we have discussed above, will place more impact load into the right hip ( from stepping down into the shorter leg) and more compressive load into the left hip (due to more demand on the left gluteus medius to attempt to lift the shorter leg during the right leg swing phase). This will also challenge the pelvic symmetry and can cause some minor frontal plane lumbar spine architecture changes (structural or functional scoliosis…… if you want to drop such a heavy term on it).

Gait plays deeply into everything. Never underestimate any asymmetry in the body. Some part as to take up the slack or take the hit.

post link:

https://thegaitguys.tumblr.com/post/23230149195/we-could-have-easily-made-this-a-blog-post-about

Short leg and Pronation

Dr Allen was ON FIRE on tonites onlinece.com lecture Biomechanics 322). Hope you will join us again (or next time if you missed us). We talked about many of the aspects of a static exam and how it effects weight bearing in the foot. The word "short leg" came up more than once, and yes, from Dr Allen : )

Remember, as the foot pronates more on one side, the center of gravity will move medially. You will often see more toe clenching (and resultant quadratus plantae weakness) on the more pronatory side and more toe elongation on the more supinatory side. You will often also see more splay and elongation on the pronatory side, and less elongation and less splay on the supinatory side. Remember, these are guidelines and not rules, and there are ALWAYS exceptions.

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More foot exercise studies to confuse you.

Don't necessarily believe all that you read. Please to not take away from this study that these 4 exercises: short-foot exercise, toes spread out, first-toe extension, second- to fifth-toes extension are golden goose exercises to rehab your athlete. On first glance if one is not thinking, that could be a mistake in translation.

"The intrinsic foot muscles maintain the medial longitudinal arch and aid in force distribution and postural control during gait."  That is a pretty bold statement by the study's authors. We would argue that a far less misleading statement would be that "the intrinsic foot muscles are a piece of the puzzle, just a piece, and to dismiss the powerhouse tibialis anterior, tibialis posterior, long and short toe flexors and particularly the extensors is a glaring oversight".  Yes, I know, the authors just wanted to study the intrinsics, I get it, -- one just has to be careful of the conclusions made when the study is so microscopic compared to the global perspective at hand.  Please, read on.

This study tried to correlate the effects of these 4 exercises: short-foot exercise, toes spread out, first-toe extension, second- to fifth-toes extension on activation of the foot intrinsics muscles they chose to observe (abductor hallucis, flexor digitorum brevis, abductor digiti minimi, quadratus plantae, flexor digiti minimi, adductor hallucis oblique, flexor hallucis brevis, the interossei, and lumbricals).

They looked at the activation before and after exercise in just 8 athletes. They did not look at non-athletes and yes, this is a terribly small N sampling and the study only used T2 weighted MRI to make these conclusions.

The study's conclusion was "Each of the 4 exercises was associated with increased activation in all of the plantar intrinsic foot muscles evaluated.".  

Here is my concern*. 
Did they consider the various foot typings ? (*Caveat, I have not read the entire study, I am trying to get it). There are many variables to consider including arch integrity, forefoot type, rearfoot type, foot flexibility, step width, step length, client weight amongst other things. Yes, that makes for a near impossible study, I get it. And, it does not appear they had a control study that looked at what happened right after walking. Wouldn't it be fair, and wise,  to see what the study showed after barefoot walking for 1-2 minutes ? I bet many of these muscles show significant activation there as well, after all, they were weight bearing and stepping down on the foot which requires the muscles to be activated and utilized.  So, does that then mean these 4 exercises are any better than walking ? Does that mean they will suffice for homework for your client ? Does that mean they will strengthen these muscles ? And, does activation mean proper pattern utilization of these muscles, meaning, is there functional translation over to functional use ? Yes, that is not what the study was looking at, but for darn sure that would have been nice info to know. Just take the study for what it found, and do not step beyond those tiny boundaries. We hope that is what they will go for in the next stage of study.  To be fair, they also concluded, "These results MAY have clinical implications for the prescription of specific exercises to target individual intrinsic foot muscles."  Safe words. Yes, I capitalized the word MAY.

- Dr. Shawn Allen, one of the gait guys.

Thomas M. Gooding, Mark A. Feger, Joseph M. Hart, and Jay Hertel (2016) Intrinsic Foot Muscle Activation During Specific Exercises: A T2 Time Magnetic Resonance Imaging Study. Journal of Athletic Training In-Press. 
http://natajournals.com/doi/abs/10.4085/1062-6050-51.10.07
http://dx.doi.org/10.4085/1062-6050-51.10.07

Podcast 112: Strengthening the foot's arch


Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 

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Show notes:

Job security, become so good and so unique that Ai cant replace your skills as a doctor
http://www.techinsider.io/age-of-ems-machines-will-take-over-all-jobs-2016-8

How prosthetics are working now, and will in the future
and why you should be scared
http://thenextweb.com/insider/2016/08/04/researches-think-we-may-have-to-protect-our-brains-from-hackers-in-a-few-years/

Open talk about how coordination is the first strength changes someone notes. It comes before true strength is achieved. It is neurologic, and its can feel decievingly safe, but it is a lie.

Foot Strengthening ?
https://drjohnrusin.com/advanced-strength-training-for-feet/

http://www.jospt.org/doi/abs/10.2519/jospt.2016.6482?platform=hootsuite&

Impaired Foot Plantar Flexor Muscle Performance in Individuals With Plantar Heel Pain and Association With Foot Orthosis Use

Tags:
foot arch, foot intrinsics, short foot, yoga toes, gastrocnemius, soleus, heel pain, hammer toes, correct toes, foot exercises, thegaitguys, squatting, gait, gait analysis, gait assessment,  orthotics, prosthetics
 

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Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

- another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. Shawn Allen, one of the gait guys