Movementthinker post 73

WELCOME BACK MY FRIENDS TO THE SHOW THAT NEVER ENDS…I’M SO GLAD YOU COULD ATTEND…COME INSIDE…COME INSIDE. 

Today’s lesson is about feet. That’s right…feet. Not that I have a fetish or anything, but I was intimidated by feet after meeting the oh great guru of feet (that’s right…there is a feet guru) Dr. Tom McPoil. I didn’t have much of an interest in feet to begin with, but after meeting this guy, I had even less interest (not that he was boring, but I didn’t share his passion for feet). Not that feet aren’t interesting, but seriously…they’re feet. Making a career on feet wasn’t my cup of tea. I chose spines…or more romantically…spines chose me. Dr. McPoil was intimidating. He one of the best PTs in terms of the biomechanics of feet and foot pain. I demand a lot of my students and he was demanding of us. I took some of the information that he gave us and applied it to my career, but it had nothing to do with feet. He spoke of how to achieve excellence. Do what the others aren’t willing or able to do.

Fast forward about 10 years (I now have some greys) and I am a little more interested in feet. Not that I want to treat them all day mind you, but a little more interest than none. I mean when the foot hits the ground is when the machine can start to move. I might as well get a little better understanding of the mechanics of the foot.

Like I said…COME INSIDE…COME INSIDE.

This weeks article will again be a learning lesson for both you and me. I knew little about the feet (compared to my knowledge of the systems above the feet), but now I know just a little bit more than nothing.

“Hallux Valgus is a common foot deformity, presenting in 35% of women over 65 years of age…hallux shifts laterally and the first metatarsal medially. Other alterations may include collapse of the arch and rolling of the hindfoot”

Do you know what this means yet? When I hear collapse of the arch, I think of the Greek dynasty and the collapse of the building. It sounds dramatic, but when the arch of the foot collapses (that is what the author is talking about, but a Greek…or maybe Italian arch…sounds more dramatic) the machine starts to break down. 

When the toe shifts laterally and the long bone of the foot medially, this is commonly known as a bunion (DUM DUM DUM!) These are no good! 
“Hallux deformity is typically accompanied by an overgrowth of bone (exostosis) and tissue that develop on the dorsomedial eminence of the first metatrsal head…called bunion…painful”

I already like this author. First they talk about collapsing of the arches…so dramatic and now they talk of overgrowth of bone. This is usually not good either. I picture something out of a horror film with the overgrowing of bone.

Stated simply, when a tissue is stressed the tissue grows. We typically apply this principle to muscles, but when applied to bone, it is called Wolf’s law. Bone gets stronger (grows) when it is stressed. Sometimes good in the case of osteoprorosis, but sometimes bad in the case of BUNIONS!.

“…its prevalence is highest in females with symptoms of deformity exacerbated by fashion shoe wear”

Story time: I am open and honest with my patients. I tell them that “anything that you do I have either done or am willing to try.” I had a patient that wanted to wear high-heeled shoes to church. She was very stylish and who am I to tell a person that they are stuck wearing flats for the rest of his/her life. She turned my saying around and needless to say, I wore high heels for the first time in my life (at least that I will admit to).

Why do this to yourself? Cramming 10 pounds of sh..potatoes…into a 5 pound bag doesn’t usually go well. Why cram a foot that naturally spreads out during the gait cycle into a shoe that doesn’t allow spreading? Especially those pointy shoes? What gives?

I don’t get it. You keep wearing those shoes and I will keep going CHA CHING$$$! Because at some point, you will end up in the clinic…unless you learn better from reading this.

“The foot may be divided into local regions called the hindfoot, midfoot, and forefoot”

Simply stated, the foot is divided into the back foot, the front foot and the middle foot. I had to go through 7 years of college to understand the above sentence. Not only that, but I had to pay about $70G to understand the same sentence. I gave it to you for free. 

“The hindfoot comprises the calcaneus and talus. The midfoot contains the navicular, cuboid, and 3 cuneiforms. The forefoot has 5 metatarsals and the attached phalanges.”

 The back foot has the heel and part of the ankle joint. The middle foot has the arch bones and the front foot has the toe bones. I love how things can sound so complicated, but be so simple at times!
 Are you a professional? Do you have your own language? We were once told in school that the reason why everything sounds so complicated is so that others don’t try to break into our profession without going through the actual schooling to learn the language. Other professions do this also. Ever try reading all of the screens that I blindly click “accept” to during updates? Legalese. They have their own language.
 “The extrinsics power gait accelerations, while the intrinsics, having both attachments within the foot, act to stiffen the arch and assist in holding the toes on the ground”

 Again, I am not a foot guy, but this makes it easier for me to understand. Foot muscles control the arch and toes and shin muscles control movement of the body. It’s simple, but sometimes simple is best in order to get a base to learn from.
 “Pronation, in the context of poture, indicates a flat or planus foot, and supination indicates a high or cavus foot. Because overpronation accelerates the hallux valgus process, treatment generally bolsters the hindfoot and arch to limit pronation”

 This is a long winded way of saying that treatment for bunions typically emphasizes preventing a flat foot. Now go back and read #6 and you will have the basics of the exercises that will be proposed for treatment of bunions.
I want to touch on this for a second. There is also research, I believe out of Harvard…for some reason I remember the name Lieberman…that indicates that barefoot running could work to hypertrophy the intrinsics of the foot also. I am curious if one takes the exercises proposed in this article in combination with a barefoot walking/running protocol if there will be a change in not only hypertrophy, but also arch height and injury rate of runners. Just a thought.
“Approximately 50 (degrees) of first MTP joint motion is required for walking, whereby the hallux serves as the fulcrum of forward propulsion”

For those that don’t understand this, this means that your big toe must bend backwards about 50 degrees (halfway to completely upright) in order to walk. For those with bunions, or have had bunion surgery recently, this number is a dream. This means that another joint(s) will have to make up for that loss.

“As deformity progresses, overpronation culminates in rolling the first metatarsal off the sesamoids. The hallux follows, turning onto its side…Weight now borne on the medial aspect of the hallux contributes to a lateral push…the hallux and sesamoids may sublux or even dislocate. This releases tension from the plantar fascia”

In short order, if the above happens…you’re up the creek without a paddle. This means that your arch has collapsed. When your arch collapses, you are putting weight more on the inside of the foot. When this happens, you are shoving the big toe towards the pinky toe. If this happens to an extreme, you will dislocate the big toe and it’s all downhill from there. There are some major attachments at the base of the big toe, which support the bottom of the foot. If this gets disturbed…you will have to see a surgeon.
There is a large chunk of the article that goes into origins and insertions of muscles. This is important for your PT to understand, but it is boring, wrote memorization and the layperson doesn’t need to know all of the details (in other words, I don’t feel like typing all of the names of the muscles of the foot. Just know that I read it and if need be, I could restate it.)

 The exercises can be found at http://www.jospt.org/doi/pdf/10.2519/jospt.2016.0504

 I have already used these exercises with some patients with awesome results. The patients, both high and low level note cramping of the muscles of the foot and a better awareness of arch height and great toe extension requirements for walking and running. The foot is not my forte, but at least I now can say that I learned (I don’t really remember learning this in PT school) the biomechanics of the foot and feel more comfortable treating and educating if/when I see this in the clinic.
Excerpts taken from:
Glasoe WM. Treatment of Progressive First Metatarsophalangeal Hallux Valgus Deformity: A Biomechanically Based Muscle-Strengthening Approach. JOSPT. 2016;46(7):596-605.