The eccentric aspect of the shuffle walk

Hey guys, I’m an Osteopath from Australia and am a keen follower of your work. I just had a quick question about your tib ant training via the shuffle gait. I am comfortable with the theory behind it, my only issue is that clinically, tib ants role as an eccentric controller of pronation is significant. Therefore, shouldn’t we develop an exercise which trains it in an eccentric fashion? perhaps there is some controlled pronation in the shuffle gait that I have missed, but i’m interested to hear your thoughts as they are thoughts I respect! Thanks very much for all your work, it’s great to see practitioners using evidence based practice in a creative and practical way. Cheers, D

________

our response:

Hi D. Good question and it is a major point.. If you think about the exercise, you are slowly putting the ball of the foot back on the ground AND maintaining the arch as best as possible. In essence, the arch will drop a bit as your weight is born on the foot, so it will pronate, but you are trying to hold it up, so in a manner of speaking you are controlling the arch descent, so you are eccentrically focusing on the activity. If we were to reshoot the video, this would be part of teh dialogue, because we do have our clients focus on this.  Remember, we are giving this exercise to many folks who have pronation control issues (yes, and ankle rocker issues) so we are kinda hitting the aspect you are questioning.  How this helps a bit.  As they get better, they take bigger steps in the shuffle walk, so that means more acceleration of the prontation, so they will have to try to maintain the arch under greater loads…….hence, more eccentric focus.  That is the way we see it anyways.  

Pain at toe-off; Stopping Big Toe Impingement with the extensor hallucis capsularis.

Photo: note the AET coming off the EHL tendon in the diagram

What if there was a mechanism in place by which to pull structures out of the way of a joint moving to end range ? If you know your biomechanics, you know this is a true phenomenon on several levels. We know of one at the knee, the articularis genu has been written about having function of drawing the suprapatellar bursa and joint capsule/synovial tissue cephalad (upward) during knee extension preventing an impingement phenomenon during full quadriceps contraction in knee extension loading. 

What if there were a similar mechanism in the big toe ? When teaching we are sometimes asked what joint, that when it goes sour, creates more devastation to the entire biomechanical chain than any other joint. I like to choose the big toe/1st metatarsophalangeal joint because failure to fully push off the big toe at full joint range impairs hip extension, stride and step lengths, and creates compensations far and wide ipsilaterally and contralaterally in the body. Most everyone knows about bunions, turf toe, hallux valgus, sesamoiditis and the like, but there are many other things that can make this joint painful. Today we bring you another “clearing mechanism” that acts to pull synovial and capsular tissues out of a joint that is nearing end range.
As seen in the anatomy dissection photo above, the extensor hallucis capsularis (EHC) is an accessory tendon slip off of the extensor hallucis longus (EHL). Interestingly, one study found that 8% of the dissections showed the EHC came off of the tibialis anterior tendon slip. This EHC accessory slip typically originates off the long extensor tendon (EHL) and traverses medially to the dorsomedial joint capsule region. Some studies suggest it is found in 80-98% of people. We propose it is most likely present in everyone because of the critical nature of its function. We propose that perhaps it may be missed on traditional dissections because of its blending with fascial tissues and because of its sometimes trivial size and girth. Just like when we fully extend our knee we want to be sure the articularis genu will draw the synovial capsular tissue up and out of the patellar/femoral approximation, the EHC has been shown on intra-operative testing to exert a pretension on the metatarsophalangeal (MTP) joint capsule similarly pulling the synovial-capsular tissue free from the end range dorsiflexing toe. Without this function, synovial-capsular impingement can occur and create pain and an inhibitory arthrogenic reflex to the EHL, tibialis anterior or any other muscles around the joint for that matter. This can act and feel like an acute “turf toe” (hyper-dorsiflexion event) and yet, not be true turf toe osseous impingement.
So if your client has pain at the dorsal joint on end range extension of the great toe, meaning things like toe-off, doing push ups from the ball of the foot, jumping, kneeling or squatting with the hallux in forced dorsiflexion etc, this tendon slip (and its origin, the EHL muscle) should be on your mind and assessment of the anterior compartment for S.E.S. must commence (S.E.S.= skill, endurance and strength, our Gait Guys mantra). This is why you need to intimately understand this important video (link) and need to know how to do this exercise, the shuffle walks (video link) and build clean ankle rocker ranges of motion via S.E.S. of the anterior compartment.  Pulling on the great toe, twisting it like a radio knob, and forcing end range shouldn’t be the biggest guns in your arsenal, logically restoring all the dysfunctional components should be.

We wonder how many of the videos online of people demonstrating big toe mobilizations, toe distractions, fancy exercises and various toe circus tricks to regain motion and function and reduce pain actually truly know about the anatomy and function of the big toe and how ankle rocker and other things can impair its function.  We wonder about these kinds of things.  

Please just remember, the average uneducated viewer is merely looking for solutions to their painful parts. Those in the know have a responsibility to deliver as complete a package as possible, within reason. 

“With great powers (and knowledge) there must also come, great responsibility.”-Stan Lee  

Dr. Shawn Allen

the gait guys

Photo credit link: http://www.wisconsinfootandankleinstitute.com

www.wisconsinfootandankleinstitute.com/img/research/The-Accessory-Extensor-Tendon_fig1.jpg

references:

Foot Ankle Surg. 2014 Sep;20(3):192-4. doi: 10.1016/j.fas.2014.04.001. Epub 2014 Apr 16.
The extensor hallucis capsularis tendon–a prospective study of its occurrence and function.Bayer T1, Kolodziejski N2, Flueckiger G2.

Foot Ankle Int. 2006 Mar;27(3):181-4.
Extensor hallucis capsularis: frequency and identification on MRI.
Boyd N1, Brock H, Meier A, Miller R, Mlady G, Firoozbakhsh K.

Foot Ankle Int. 2004 Jun;25(6):387-90.
The accessory extensor tendon of the first metatarsophalangeal joint.
Bibbo C1, Arangio G, Patel DV.

If you work in a shoe store, you better understand the real problem behind this frequent shoe breakdown. You have seen it, but do you truly understand it ?

Stripping of the heel counter: a naughty problem. (note the foam break down at the inside heel of the shoe in this photo of an almost new pair of shoes)

Has the inside of the heel counter of your shoe ever looked like this?

Do you know why ? We will tell you why !  * #4 is the lightbulb moment for most people,. 

1. you may be lazy and not tie your shoes and try to slip  your foot into/out of your shoe without unlacing and re-lacing. This will often fold the top of the counter over upon its self and start some breakdown. Kids are lazy, but so are some adults.

2. your laces may be laced to loosely and your heel is excessively slipping/riding up and down on the heel counter foam/material.  

3.  you have a nasty Halglunds deformity that is just so big it is creating too much friction.

4. However, there is often a better and more logical reason and it just so happens that it is the one that no one thinks of or understands.  Loss of ankle rocker (AKA loss of ankle dorsiflexion.  You see, the heel counters job is to gently create counter pressure against the back of the heel/calcaneus so that when the person moves into terminal stance phase of gait (when the heel begins to rise) the heel rise will pull the heel of the shoe up AT THE SAME TIME !  If there is a differential in this time stamp event, then the heel will rise abruptly against a shoe that has not had time to finish forefoot rockering at toe-off through the normal forefoot siping on the outsole.  In other words, if ankle rocker/dorsiflexion is less than sufficient the restricted range will necessitate that the  heel rise BEFORE it is technically supposed to do so, AND thus, before the shoe will reach its build in rocker that enables the heel rise. The two events  have to occur at the same time ! When a person has impaired ankle rocker and thus goes into premature heel rise, the shoe will essentially still be attempting to get to the forefoot rocker built into the shoe (which will lift the heel of the shoe passively). So, if the heel rise is premature, before the shoe gets to the forefoot rocker, the heel will abruptly, yet subtly, slide up the heel counter and shear the foam on the inside of the heel counter. Keep in  mind that once the heel slide and the shoe heel counter engage together the shoe will be suddenly thrust into its (the shoe’s) forefoot rocker. But, you should understand that this is premature forefoot loading response, and it has a host of clinical problems that go along with it (ie. metatarsal stress fractures, premature or excessive forefoot pronation, toe clenching etc). 

* clinical pearl: this problem often presents with the runner having dorsal foot pain across the top of the foot. The runner will naturally think it is the tightly tied shoes, so the natural solution is to lace the shoes looser and looser (or skip lace) until the point they no longer stay on the foot because of the heel counter sliding. Neither one fixes the dorsal foot pain, because the lacing is not the issue. The astute shoe fitter will realize that this dorsal foot pain is directly related to the loss of ankle rocker, but that is a blog post for another time. 

It is natural for runners to try to tie their shoes tighter to stop the feeling of the heel slip but this is not the solution.  Ankle strangling is not the solution.

Either the shoe is:

1. not fit properly matching the person’s natural forefoot rocker phase to the shoe’s natural rocker or

2. they have a narrow heel (and thus also need a more appropriately fit shoe)

3. need to learn to lace the shoes properly (this does not mean strangle the ankle, any shoe that needs to be tied that tightly to prevent this phenomenon is not the correctly fitted shoe).  Shoe tie tension should be modest, comfortable and not constrictive…… ie hardly noticeable.

OR:  

the person needs more ankle rocker !  Which does not necessarily mean more calf stretching. It means EARNING posterior length through anterior strength. Watch one of our solution exercises here  .  Earn the changes you need, no one wants to have to performs stretches before every run for the rest of their lives.  Who has that kinda time ?! 

Better yet, why not take our National Shoe Fit Certification Program and learn the truths about shoe fit and clean biomechanics.  Or, you can leave the pathology alone and support your friendly neighborhood shoe store and local running injury guru more frequently than usual or than is necessary.  Its your money and your time.

Links to the National Shoe Fit certification program:

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

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

other web based Gait Guys lectures:

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

Shawn and Ivo, The gait guys

Sharing the secrets of gait and walking/running biomechanics that you are not taught elsewhere.

What do you do with these Dogs?

Take a good look at these feet. Hard to not cringe, we know. In this photo, the gentleman’s feet are relaxed! Imagine what it they will look like with some additional long flexor tone!

So, keeping in mind his tibial varum (bend in the tibia) and uncompensated forefoot varus (inability to get the head of his 1st ray down to the ground), what can we do?

• how about we increase extensor strength? He could do the lift, spread, reach exercise while tripod standing. He could do the toe waving exercise.   He could do shuffle walks.
• teach him to stretch his long toe flexors. Frequently. 20-30 mins minimum; daily
• you could manipulate his feet to ensure better biomechnics
• you could massage his feet to improve mobility and circulation
• you could facilitate his long toe extensor muscles
• you could inhibit his long toe flexor muscles
• you could improve ankle dorsiflexion by showing him how to stretch the calves, 20-30 mins daily
• you could improve ankle dorsiflexion by making sure he has adequate hip extension
• he could wear correct toes, to improve the biomechanical advantage of the long toe extensors
• he could wear shoes with a wider toe box
• he could wear shoes with less ramp delta (or drop)
• he could wear shoes with less torsional rigidity

and the list goes on. There are many simple things you teach a person with feet like this. many of them we have introduced you to here on the blog. Spend some time. Learn some cool stuff. Read the blog. Follow us on Facebook. Attend a Biomechanics class we teach the 3rd Wednesday of each month on onlinece.com . Check out our Youtube Channel. Consider furthering your education and taking the National Shoe Fit Program.

The resources are there. All you need to do is dig a little deeper.

We are The Gait Guys and we are all things gait.