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Is your 5th toe curled under ? What do you do when “this little piggy” can’t go wee wee wee all the way home.
Have a look at the 4 photos above. You will see this curling of the lesser toes quite often in your practice, and when you know what it means it can help to guide your thinking, both from a diagnostic and treatment perspective.
You should have noticed in the photos that the 4th and 5th toes curl under and are hyper-flexed, and this is at rest. So, what does this mean ?
It means that the long flexors are overactive, the extensors are underactive, and the adduction pull of the long flexors is unopposed by the under appreciated quadratus plantae muscle.
Look at the clinical drawing. The quadratus plantae has 2 heads, a medial head and a lateral head. Being able to clinically test these two heads will give you much insight into the function of the foot and when you see these outer two toes curling under, as you see in the photo, you will always see weakness of the lateral head of the quadratus plantae.
The quadratus plantae arises from two heads separated from each other by the long plantar ligament. The medial head is larger and more muscular, attached to the medial calcaneus; the lateral head is smaller and more tendinous, attaching to the lateral border of the inferior surface of the calcaneus and the long plantar ligament. The two portions join and end in a flattened band which inserts into the lateral, upper and under surfaces of the tendons of the flexor digitorum longus, usually the second, third, and fourth toes.
But this time, if you have studied the drawing, you should notice the oblique line of pull of the long flexors. This should in fact create this undesirable curling effect of the lateral two toes since they are so far out on the oblique line of pull. However, if you look at the insertion of the lateral head of the quadratus plantae you should be able to conclude that this head is designed to offset this oblique pull of the outer two long flexor tendons. The quadratus creates a posterior pull on the outer long flexor tendons ensuring that the curling effect (as seen in the photo) is nullified. Thus, we have a clinical presentation of a weak lateral head of the quadratus plantae (and probably a few others which we will not discuss here so as to not dilute the purpose of today’s post). Now you just have to figure out why it is weak or if there is a biomechanical reason for its insufficiency
- is there a foot type presenting itself that makes it difficult for this muscle to create sufficient posterior pull to offset the tremendous leverage of the long flexors? Maybe a forefoot varus, which gives the flexor tendons a mechanical advantage or a forefoot valgus which puts the quadratus plantae at a mechanical disadvantage? (Taking our National Shoe Fit Certification Program will help you get closer to understanding many of these issues.)
- Are their other anatomical variants like an increased forefoot width or bunions (medial or tailor’s)
- is there excessive rear or midfoot pronation?
- Shoe choice problem ?
Some folks do have adequate function of the quadratus plantae. Note the lovely feet in the last picture … . they must have strong lateral quadratus plantae and abductors of the lateral foot and toes ! And, they have great toe separation, thus great intrinsic interossei muscles, and nice flat toes (great balance between flexors and extensors).
So, what do you do?
- you could do a surgery, amputate or fuse some of the joints to make them look better. Extreme for a problem like this
- you could ignore the issue and hope it goes away. (in all likelihood it will worsen)
- you could give them long flexor, toe scrunching Towel-curling, marble-grasping exercises , like you see all over the internet…and give the flexor digitorum longus even more of a mechanical advantage, and make the problem worse
- you could give them exercises to increase the function of the long extensors, which would increase the mechanical advantage of the quadratus plantae. like the shuffle walk; lift, spread and reach and tripod standing exercises (hmm…sounding better)
- be a real clinician and in addition to looking at the foot, look north of the foot to see what might be causing the problem (loss of ankle rocker, insufficient gluteal activity, loss of internal rotation of the hip, etc) Hmmm; sounding like a good idea too…
The Gait Guys. Hammering it home, day after day, about the importance of gait and giving you clues to be a better _________ (insert athlete, coach, trainer, clinician, shoe fitter, rehab specialist…).
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"… knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position." - The Gait Guys
This video is just the kind of stuff that drives us nuts. We do not have a personal problem with the good doctor, he may know (and most likely does know) far more than he is letting on here but is merely simplifying things for some reason. We merely have a problem with the information that is missing that could make this a valuable addition, or omission, to someone’s care. There are times to simplify things, but when we put out a video on the web where the world can see it, we try to be as thorough as possible even if this means that something will come across seemingly overcomplicated. The fact of the matter is that human biomechanics are in fact complicated and simplifying something, when it is just not possible to do so, really doesn’t help anyone. People, and maybe some medical professionals, who do not know better will see this and not see what is missing, importantly so, here.
In this video there is no regard to the pre-positioning of the metatarsal to that big toe. This is a very unique joint, it has an eccentric axis that changes with metatarsal plantarflexion and dorsiflexion. This eccentric axis is shifted by the shifting position of the relationship of the metatarsal head with the base of the hallux. Here, at this joint, we have a concave-convex joint interface which with all said joint types, has a roll-glide biomechanical rule. This rule at this joint is unique in that the axis of roll-glide is eccentric meaning that the joint has a shifting axis during the motion of dorsi and plantarflexion. This is dictated and dependent upon the posturing of the sesamoid bones properly beneath the metatarsal head. You can hear more about this premise here, in a video we did a few years ago. It is long, but it is all encompassing. What is important, that which is not noted here, is that with more metatarsal plantarflexion there is opportunistically more dorsiflexion at the joint. (This is precisely the joint range loss that occurs in “turf toe”, hallux limitus.) Thus, in the above video, to properly mobilize the big toe into dorsiflexion, the foot must be taken into full metatarsal plantarflexion (pointing the foot) where greater amounts of joint dorsiflexion will be found (because of the eccentric axis shift) and the joint should be also mobilized in full ankle and metatarsal dorsiflexion, but the therapy giver must know, and be expected to find, that less toe/joint dorsiflexion will ALWAYS be found in this position. Knowing this will not mistakenly leave one with the interpretation that the joint is suffering restriction, that the joint is merely showing its limitation because of the return shift of the eccentric axis to a less mobile position.
* Here is a little experiment you can do to teach yourself this principle. It should also help you to realize the gait cycle.
Sit in a chair, cross one ankle over the opposite knee and see what happens to the joint ranges as you proceed.
- dorsiflex the ankle and big toe. With your muscles only, not your hands, actively pull back the ankle and toe striving to get the most amount possible of dorsiflexion at both joints. You should see that there is some toe dorsiflexion of the big toe.
- now keeping that big toe dorsiflexed as strongly as possible, begin to plantarflex the foot, thus moving the 1st metatarsal into plantarflexion as well. You should note that the relative amount of toe-metatarsal dorsiflexion DRAMATICALLY increases !
- you can also do this passively. This time start at full foot plantarflexion (foot pointed) and passively pull that big toe back into dorsiflexion. A huge range is likely to be found if you have a cleanly functioning foot. Now, try to hold that significant range while you push the ankle into dorsifleixon. At the end of the metatarsal and ankle dorsiflexion range you should feel the big toe start to resist this range you are trying to maintain, the big toe will forcibly start to unwind the dorsiflexion. This is because of the eccentric shift of the joint and tension building in the passive tissues in the bottom of the foot.
- You want, and need, these relationships to occur properly and timely in the gait cycle and there are milliseconds to get it right and that means the entire kinetic chain must be clean of flaws, otherwise compensation will occur. (Note: Blocking or trying to control these issues with a foot bed, shoe type or orthotic can either be helpful therapeutically, or harmful to the chain.)
This is precisely what happens in the gait cycle. During swing phase the foot/ankle is in dorsiflexion to create foot clearance and to prepare the foot tripod for the contact phase with the ground. There is some big toe (hallux) dorsiflexion represented in this swing phase, but it is not a significant amount you likely learned from your own self-demo above, mainly because it is not possible, nor warranted. But, once the foot is on the ground and moving through the late stance phase of gait into heel rise, the ankle is plantarflexing. Thus, the metatarsals are plantarflexing, and this is causing the slide and climb of the metatarsal head up onto the sesamoids. This causes the requisite shift of the axis of the 1st MTP joint (metatarsophalangeal) and affording the greater degree of toe dorsiflexion to occur to allow full foot supination, foot rigidity to sustain propulsive loading and also, never to forget, sufficient hip extension for gluteal propulsion. At this point, the range of the big toe in dorsiflexion is far greater than the dorsiflexion of the joint at ankle dorsiflexion. Impairment of this series of events is what leads to turf toe, hallux limitus as it is called. And when that becomes more permanent, even mobilizing the joint, as seen in the video above or otherwise, is not likely to get you or your client very far in terms of normal gait restoration. And forcing it, won’t made it so either.
Remember this, the kinetic chain exists and functions in both directions. If you are starting with a hip problem that limits hip extension, and thus full range toe off during gait, in time you will lose the end range of the toe-off dorsiflexion range. And any attempts to try and regain it at the foot will fail long term if you do not remedy the hip. ”If you don’t use it, you will lose it”. So to gain it back actively, sometimes you have to restore all of the functional losses of the entire kinetic chain to get what you are hoping for. And for all you people doing “activation” to the glutes on your athletes, finding you are having to do it over and over and over again…….day after day after day, well … . . we hope you take this blog article to heart and put this thought process into action.
Remember, if you do not have the requisite strength, skill and endurance of the 2 toe extensors and 2 toe flexors as well as sufficient strength of the tibialis anterior (as well as many other components) you are likely to see impairment of this joint. In this environment, do not expect joint mobilizations to offer you anything functionally lasting.
We are not saying that joint mobilizations are useless and unnecessary, not by any means. We are saying that you have to know what you are doing when you do them, so you can get the results you desire or, to realize why you are not getting the results you desire.
Treat your clients with clear biomechanical knowledge and you will get the results you desire. If you go in with limited knowledge, results may speak for themselves.
Gait analysis and understanding movement of the human body is a difficult task. It takes many years to learn the fundamental parameters and then many decades to implement the understanding wisely and with effectiveness. Here at the gait guys, we hope to someday get to this point. We too, are students of gait and gait pathology. It is a journey.
"Once you understand the way broadly, you can see it in all things." -Miyamoto Musashi
Shawn and Ivo, The Gait Guys
Can you see the problem in this runner’s gait ?You should be able see that they are heel impacting heavy on the outside of the rear foot, and that they are doing so far laterally, more than what is considered normal.This is a video of someone with a rear foot varus deformity.These folks typically have a high arched foot, typically more rigid than flexible, and they are often paired with a forefoot valgus.Q: Do you think it might be important as a shoe fitter to know this foot type ?A: YesQ.Should they be put in a shoe with a soft lateral crash zone at the heel ?A: No, absolutely not. Why would you want to keep this person deeper and more entrenched on the lateral heel/foot ?!This foot type has a difficult time progressing off of the lateral foot. The lateral strike pattern and the tendency for the varus rear-foot (inverted) keeps this person on the lateral aspect of the foot long into midstance. This eats up time when they should be gradually progressing over to the medial forefoot so that they can get to an effective and efficient medial (big toe) toe off. This gait type is typically apropulsive, they are not big speed demons and short bursts of acceleration are difficult for these folks much of the time. Combine this person with some torsional issues in the tibia or femur and you have problems to deal with, including probably challenges for the glutes and patellar tracking dysfunction. What to see some hard, tight IT Bands ?These folks are often the poster child for it. Good luck foam rolling with these clients, they will hate you for recommending it !They are typically poor pronators so they do not accommodate to uneven terrain well. Because they are more on the outside of the foot, they may have a greater incidence or risk for inversion sprains. You may choose to add the exercise we presented on Monday (link here) to help them as best as possible train some improved strength, awareness and motor patterns into their system. In some cases, but only when appropriate, a rear foot post can be used to help them progress more efficiently and safely.These foot types typically have dysfunction of the peronei (amongst other things). A weak peroneus longus can lead to a more dorsiflexed first metatarsal compromising the medial foot tripod stability and efficiency during propulsion while also risking compromise to the first metatarsaophalangeal (1st MTP) joint and thus hallux complications. Additionally, a weak peroneus brevis can enable the rear foot to remain more varus. This muscle helps to invert the rearfoot and subtalar joints. This weakness can play out at terminal swing because the rear foot will not be brought into a more neutral posture prior to the moment of heel/foot strike (it will be left more varus) and then it can also impair mid-to-late midstance when it fires to help evert the lateral column of the foot helping to force the foot roll through to the big toe propulsive phase of terminal stance. (* children who have these peroneal issues left unaddressed into skeletal maturity are more likely to have these rearfoot varus problems develop into anatomic fixed issues…… form follows function.)You can see in the video the failed attempt to become propulsive. The client speeds over to the medial foot/big toe at the very last minute but it is largely too late. Sudden and all out pronation at the last minute is also fraught with biomechanical complications.One must know their foot types. If you do not know what it is you are seeing, AND know how to confirm it on examination you will not get your client in the right shoe or give them the right homework.* caveat: the mention of Monday’s exercise for this foot type for everyone with Rearfoot varus is not a treatment recommendation for everyone with the foot type. For some people this is the WRONG exercise or it might need modifications. Every case is different. The biomechanics all the way up need to be considered. Medicine is not a compartmentalized art or science.Shawn and Ivo, The Gait Guys
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Approaching joint assessment from the perspective of “cylinders”.
Our approach to every joint assessment has long been to visualize and assess the joint(s) as a cylinder since the body parts are cylindrical in form. This has been our approach, and they way we teach, for many years. At each number on the clock (cylinder) there is a theoretical muscle that provides stability to the joint in that vector during loading. The most accurate assessment would be one that investigates the ability of each muscle around the clock (cylinder) to see if it has sufficient S.E.S. (Skill, Endurance, Strength) as well as how well that muscle(s) participates with the synergists, antagonists and agonists (ie. motor patterns for stability and mobility). We do this at each joint along the kinetic chain when assessing someone with a clinical or functional problem.
When dealing with a frontal plane drift, as in the 3rd photo above where you see the person’s (black shorts) pelvis drift laterally outside the perpendicular foot line, one could naturally assume that the gluteus medius is weak (9 o’clock) but the wise clinician would also look at the other side of that cylinder to see if the adductors were involved (3 o’clock) since that is 180 degrees through the joint axis. (Note: Runners are sagittal athletes so frontal plane weaknesses are often seen. This is not desirable however, this is a perfect example why runners should cross train more into lateral and angular sports to ensure that the sagittal plane does not dominate.) Obviously the foot and the knee also need a similar cylindrical assessment approach. We have spoken loudly many times here and on our podcasts over the years that quite often there are multiple flaws in a presentation, typically a focal cause and one if not several compensations as a functional adaptation strategy around that central flaw. In this runner’s case there could be medial knee weakness or foot weaknesses that are affording too much medial drift and spin of the limb resulting in the lateral pelvic drift compensation. But, just because the gluteus medius shows up weak does not mean that it is the focal point of clinical intervention. If one facilitates the gluteus medius and does not address the causative lower cylinder issues then they are quite possibly empowering the compensation and enabling the aberrant activity to continue. Knowingly or unknowingly layering armor or inappropriate strength to a pathologic compensation pattern at a focal joint level that is not the focal cause should be a clinical crime, but it is done every day by people who do not know better even though their efforts are well intended.
Ok, we got on a bit of a soap box rant there, sorry. Back to the case at hand.
Your assessment should not stop at the frontal plane in this case. If there is an imbalance in the sagittal plane in this sagittal athlete this can be a causative problem as well, which is why the cylinder approach should not stop at the frontal plane or when you find that first major weakness. In frontal pelvic drift cases, there is quite often an anterior pelvic tilt where the lower abdominals can be weak, the low back is slightly extended and the paraspinals are more active. This is the classic “impaired hip extension pattern” and sets up a Janda/Lewitt style “Layered Syndrome”. Most of the time, resolving this sagittal flaw will show immediate improvement of the frontal plane deficits. But, do not think it is as simple as re-facilitating these 2 patterns. Remember, neuromotor reprogramming and patterning takes 8-12 weeks by some sources. And remember, the initial strength gains in the first few weeks are from neuroadaptation (ie, skill gains in coordination), these gains are not the true physiological endurance and strength gains that we desire for an athlete. Those gains take time but they are the ones that we need for sport performance and joint power.
And then there is the rotational or axial component, which we did not even begin to discuss here. We have briefly talked about the frontal and sagittal cylinder aspects, and yes, we have just skimmed the surface as there are multiple patterns and issues which we have had to leave out here so that this doesn’t turn into a full fledged chapter for our next book. This stuff gets complicated and can leave you running in mental circles at times. But these concepts will help you better understand why you often see neuro-protective tightness 180 degrees on the other side of the cylinder from tightness, and when you address the weakness the other side of the cylinder some of that neuro-protective tone is eased. But again, it is not nearly this simple because you must remember that if your assessment is static or on a table then your findings will be functionally imprecise. And, not stopping there, there are multiple joints below the joint you are focusing on, and multiple joint complexes above as well. Plus, there are 3 other limbs that can play into the function and dysfunction of a given limb and its joints. There are breathing patterns, postural patterns and many other issues. This is not an easy game to play, let alone play it well or wisely for your athlete.
In today’s photos we wanted to show you 3 runners. One a distance runner with good joint stacking and one sprinter with amazing joint stacking. And then the runner in the black shorts, who cannot stack the foot, knee or hips even remotely well. This runner in the back shorts will have the cross over gait and likely have the medial ankle scuff marks to prove it. But remember, there is one component that we often talk about, one we did not discuss here … . . are there also torsional issues in this runner ? Do they have femoral or tibial torsion(s) ? What is their foot type ? Are they in the right shoe for their foot type ? Are some of these components playing into their visibly flawed mechanics ?
Below is an article we have put up here on the blog previously. It is a study where the investigators examined hip abductor strength (watch this video here ) in distance runners with iliotibial band syndrome comparing injured limb strength to the unaffected limb to determine whether correction of the strength deficits in the HAM’s (hip abductor muscles) correlates with successful outcomes. The study showed the obvious, that runners with ITBS have weaker HAM strength compared to the asymptomatic leg.
But here is our question, did they just strengthen the compensation for an apparently successful outcome, or did they address the problem ? Only time will tell if you actually fixed something or merely enabled the dysfunctional motor pattern by layering it with more armor for the next battle. If it is fixed the problem and all of its associated problems should go away. But if the runner comes back weeks later with knee complaints, foot pain, back pain or the like … . . then the message should be loud and clear.
Shawn and Ivo, The Gait Guys……today with soap on the bottom of our feet.
Clin J Sport Med. 2000 Jul;10(3):169-75. Hip abductor weakness in distance runners with iliotibial band syndrome. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N,Sahrmann SA. Department of Functional Restoration, Stanford University, California 94305-5105, USA.