Barefoot Biomechanics, Foot Function & Fascial Lines Series

The Windlass Mechanism: A Powerful Addition to your TFL / ITB Stretches

Tensor fasciae latae (TFL) / iliotibial band (ITB) over-recruitment and tightness is one of the most common contributors to movement dysfunction observed in the lower extremity.   Whether it is a dancer with an over-supinated foot or a runner with tibial femoral external rotation, hypo-mobility in this muscle (connective tissue) can be a strong deforming force.

For today’s blog we will continue to explore how integrated the foot is with the rest of the human movement system.   Below I will demonstrate how to use the foot (or more specifically the windlass mechanism) to enhance your TFL/ITB stretches.

Introducing the TFL / ITB

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Arising on the anterior part of the iliac crest and inserting as the iliotibial band on the lateral aspect of the femur, the patella and Gerdy’s tubercle (lateral tibia) this muscle:

  • concentrically moves the hip into flexion, abduction and internal rotation (on a fixed leg it is anteromedial rotation of the pelvis)
  • stabilizes the knee for single leg stance (gait)

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I prefer the corrective exercise approach of self myofascial release (SMR) prior to stretching as this allows a better increase in tissue mobility.   (Click to see video on TFL SMR)

When stretching the TFL / ITB the hip should be moved into extension, adduction and external rotation.  This can be done either open chain with a yoga strap or closed chain in a variety of poses including:

Revolved Triangle Pose (Parivrtta Trikonasana)

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Standing Forward Bend, variation (Uttanasana)

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Enhancing the TFL / ITB Mobilization

The one aspect of the TFL / ITB stretch that I believe is the most overlooked would be the rotation element.   In my practice I find that it is primarily the internal rotation or transverse plane moment of the TFL that causes the most lower extremity dysfunction.

So how can we enhance the external rotation that is occurring during our TFL / ITB stretch?

The technique to increasing the external rotation moment during a closed chain TFL stretch is associated with the windlass mechanism.

Introducing the Windlass Mechanism

If you have attended one of my EBFA courses you should recall the windlass mechanism – however for those who are unfamiliar with this biomechanical phenomenon it is a powerful addition to your TFL / ITB stretch

To understand the windlass mechanism you must understand the plantar fascia.

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Originating on the plantar medial tubercle of the calcaneus, the plantar fascia runs across the plantar aspect of the foot before fanning out into 5 slips and inserting into each of the digits.

To better understand your plantar fascia or for a great way to demonstrate this concept to your clients, here’s a little activity I encourage you to try right now:

  1. Keeping the digits relaxed, touch the bottom of your foot. You should feel the most superficial plantar intrinsic muscles.
  2. Now dorsiflex your big toe and feel the bottom of your foot again.  You should feel the plantar fascia is now a tight band of connective tissue.

This dorsiflexion of the big toe (or rather all your digits) and the subsequent tightening of the plantar fascia is referred to as the windlass mechanism.

But wait – there’s more!

Because our plantar fascia inserts onto the calcaneus, and the calcaneus is part of the subtalar joint – the windlass mechanism must create a moment in the subtalar joint (STJ).  Remember that any muscle or tendon that inserts or originates on the medial aspect of the foot or STJ axis is going to create inversion.

If you recall, all STJ movements are coupled with tibial and femoral counter-rotations in the transverse plane.

STJ eversion = tibial / femoral internal rotation

STJ inversion = tibial / femoral external rotation 

Since we need to externally rotate the hip to enhance the TFL / ITB stretch this is where the windlass mechanism will come into play.

Enhancing your TFL / ITB Stretch

If we return to our two stretches above – Revolved Triangle Pose & Standing Forward Bend – to increase the external rotation moment in the hip all we need to do is activate the windlass mechanism.   This is done by dorsiflexing our digits during the stretch.

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Try it now!

Integrating into Client Programming

As you consider the application of the windlass mechanism in your TFL / ITB stretches remember that proper loading an unloading of impact forces during gait occurs through this deep hip internal / external rotation.

If you prefer more dynamic stretches this dorsiflexion of the digits and activation of the windlass mechanism can be applied in a variety of ways and in a variety of stretches.

To learn more about the functional foot and from the ground up programming please visit http://www.ebfafitness.com 

Are you barefoot strong? 

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Barefoot Biomechanics

Understanding (Subtle) Peroneal Subluxation: Treating the Cause vs. Symptoms

Welcome to another post in the Barefoot Strong Blog!   Today’s post is a great example of why all health and wellness professionals (including those that are specialists) must always consider the greater picture and consider integrated movement systems.

Although I am a Podiatrist and am presented with patients complaining of foot & ankle pain or dysfunction, I take great pride in approaching all my patients with a holistic and functional approach.   Each patient I see is assessed for foot function as it relates to the entire body and integrated movements such as walking, squatting and landing.

Below is is a summary and explanation for an often misdiagnosed cause of lateral foot pain in runners.  

Female Runner with Chronic Lateral Ankle Pain

I was recently referred a patient with chronic lateral ankle pain which was not responding to current conservative treatment and physical therapy (which is always a signal that we need to delve deeper into the actual cause vs. symptoms).

Patient is a 29 yo female, avid runner who was training for a marathon last year when she began to experience lateral ankle pain.   Pain is greatest during push-off and is described as dull and aching.   Patient reports no history of ankle sprains or ankle instability.   No acute injury associated with this pain.

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Patient has seen several doctors including two Podiatrists and one Orthopedists, all of which diagnosed perineal tendonitis and the recent diagnosis of subluxing peroneals.   In the past year the patient has done several courses of physical therapy consisting of ankle mobility and strengthening.  In addition she has tried orthotics and two steroid injections to the peroneal tendons which provided mild relief however the pain eventually returned.

Patient recently had a diagnostic ultrasound done which demonstrated “subtle subluxing peroneals”.  The radiologist reported being able to reproduce the subluxation when plantarflexing and everted the foot.  The Podiatrist who ordered the US recommended surgery to correct the peroneal subluxation.

The patient seeks a second opinion as she believes surgery is extreme for her foot pain.

Patient Examination

On examination a few things that stood out included:

  • Pain on palpation along peroneal tendons posterior fibula right foot
  • Mild pain on resisted eversion
  • Limited ankle mobility right foot < 5 degrees
  • On stance mild calcaneal eversion noted 5 degrees
  • Gait assessment demonstrated increased eversion on late midstance, low gear push-off and tibial femoral external rotation (TFER)

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TFER right foot            Abducted right foot in mid stance

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Abducted right foot           STJ eversion and knee valgus

A Closer Look at Lateral Ankle Anatomy

When considering lateral ankle pain and possible peroneal subluxation a detailed understanding of lateral anatomy is of course important.  The lateral compartment of the lower leg is comprised of the peroneus longus and brevis muscles.  Distally, they both travel posterior to the fibula within the fibular groove.   At this level both tendons are in the same fascial sheath with the peroneus brevis anteromedial to the peroneus longus.  Below the fibula, the peroneus longus and brevis muscles form separate sheaths to prepare for the longus turn under the cuboid towards its medial foot insertion.

Inferiorly, the peroneal tendons are bound by the calcaneofibular ligament (CFL) and the inferior peroneal retinaculum.   While superiorly they are bound by the superior peroneal retinaculum.

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The pathoanatomy of peroneal subluxation lies within the integrity of the superior peroneal retinaculum, its contents and the ability to maintain those contents within the retromalleolar groove.

The superior peroneal retinaculum has a lateral, non-osseous roof and a floor comprised of an osseous retromalleolar groove and medial non-osseous posterior intermuscular septum of the leg portions.

Understanding Peroneal Subluxation / Dislocation

Often considered an issue related to the fibular groove, the pathomechanics of peroneal subluxation and dislocation is in fact not related to the fibular groove but rather to fibular position and rotation.

When the fibular is externally rotated (as in the case of pronation and TFER) it causes a relaxation of the superior peroneal retinaculum and allows the peroneal tendons to roll on each other and possibly sublux over the lateral malleolus.   In an acute setting the mechanism of injury is commonly a dorsiflexed foot and sudden or heavy contraction of the peroneal muscles on an everted subtalar joint and externally rotated fibula.

Acute symptoms of snapping or popping with pain and feelings of instability are common with a true peroneal dislocation or subluxation, and often times the peroneal tendons can be seen snapping over the fibula.

Subtle Peroneal Subluxation

When we consider subtle peroneal subluxation the pathomechanics are similar to that of an acute or true peroneal dislocation, however to a lesser degree.   The same mechanism of plantarflexion and on everted STJ and externally rotated fibula is present but instead of snapping over the fibula, the tendons roll on each other causing irritation to the tendons and surrounding tendon sheaths.

In the case of my patient complaining of lateral ankle pain, understanding her functional movement is important in determining the true cause of her symptoms.  Isolated examination revealed localized pain along the peroneal tendons posterior to the lateral malleolus and the US confirmed subtle subluxation reproducible during plantarflexion and eversion of the foot.

Knowing my patient’s diagnosis, pathomechanics of this diagnosis and having assessed her gait it became quite apparent that the driving force behind her pain was the tibial femoral external rotation present during her gait cycle.

Understanding TFER

I was first introduced to the concept of TFER in Shirley Sahrmann’s book Movement System Impairment Syndromes of the Extremities.   Sahrmann describes TFER as an external rotation of the tibia / fibula relative to the femur.

This external rotation is often associated with overactive:

– gastrocnemius (lateral head)

– bicep femoris (short head)

– TFL/ITB

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Note the left foot external rotation at swing phase

Most often observed during the propulsive phase of gait this TFER impacts alignment during midstance (causing knee valgus) and propulsion (abducted push-off on an everted foot).   This push-off in an abducted and everted foot is the movement that reproduces subluxation of the peroneals.

Correcting the Cause

When treating TFER always start with mobilization or inhibition of the overactive muscles.   If knee valgus is present with the TFER then much focus should be on the TFL/ITB.

Step 1 – SMR or trigger point release gastroc, BF and TFL everyday for at least 5 – 10 minutes

Step 2- Dynamic mobilization / stretches to gastroc, BF and TFL

Step 3- Lock it in with strengthening medial or internal tibial / femoral rotation with pigeon-toed hamstring curls as well as hip external rotators with reverse clam shells

Further Considerations

I hope that this case presentation leads to a deeper appreciation for the importance of looking at functional movements and integrated systems when assessing patients with localized pain.

I’ve been seeing a large number of patients with over-pronation syndrome presenting with lateral ankle pain and subsequently finding out through MRI that they have peroneal tears.   I believe that the driving force behind these peroneal tears in the over-pronated foot are due to overlooked subtle peroneal subluxation secondary to TFER and pushing off (plantar flexing) on an everted STJ.

I am doing a small study to further evaluate this concept and appreciate any feedback and interest in this topic that you may have!

Dr Emily Splichal

To learn more about TFER, performing gait assessment and rehab programming similar to this, please visit http://www.ebfafitness.com

Are you barefoot strong?  

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Barefoot Science

Five Tips to Protect Your Peripheral Nerves

As a Podiatrist, I frequently treat patients complaining of numbness in their feet and legs.   From the top of the foot to the lateral aspect of the heel, we typically associate loss of protective sensation with our diabetic clients – however this is not always the case.

We all, regardless of age need to consider our peripheral nerve health!

Through years of treating various nerve entrapments and idiopathic peripheral neuropathies, I have become quite passionate about educating patients and professionals on the importance of protecting our peripheral nerve health as we age.

The Nervous System

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Comprised of both the Central Nervous System (CNS) (brain & spinal cord) and Peripheral Nervous System (PNS) (nerves & axons), our nervous system is responsible for coordinating voluntary and involuntary actions.

Our PNS is a complex network of spinal nerves and plexuses branching from the spinal cord and includes the cervical spinal nerves, brachial plexus and lumbosacral plexus.     In all of our peripheral nerves there is an afferent (signal to CNS) and efferent (signal to PNS) pathway which controls our movements and actions.

What’s unique about the PNS, as it relates to the foot, is this is where the smallest nerve branches exist.  Nerve branches that will have either a sensory (skin) or motor (muscle) function.

Those small nerves that have a sensory function to the skin are referred to as cutaneous nerves or in the bottom of the foot they are our plantar cutaneous receptors.   These small plantar cutaneous nerves are responsible for processing information that allows us to maintain quiet stance, manipulate uneven terrain and absorb impact forces.

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Foot Fact:   Did you know that we have both small nerves and large nerves in our foot?      Small nerves can be found in our plantar skin and provide a faster response when compared to large nerves.

Aging and Nerve Health

You have probably read at least a dozen articles advocating the benefits of protecting cognitive function as we age.   From exercise to crossword puzzles, there are many ways to keep your brain sharp as you age.

But how much do you think about your peripheral nerve health?

Our ability to maintain an active lifestyle and participate in the activities we enjoy is just as dependent on a strong, healthy peripheral nervous system as it is to cognitive function.

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Foot Fact:   Did you know that 80% of our plantar mechanoceptors are sensitive to vibration?   The sensitivity of these mechanoceptors peaks at age 40 and by age 70 requires twice the stimuli to create the same response.

Tips to Protecting Peripheral Nerves

Tip #1Keep blood sugar under control

Although we typically associated elevated blood sugar levels with diabetes, we can all experience fluctuations in our blood sugar levels (think Ben & Jerry’s ice cream).

Elevated glucose in our blood stream is converted to AGEs (advanced glycation end products).   The myelin that surrounds our peripheral nerves is sensitive to these AGEs – which cause demyelination and disrupts signal transport.

The formation of AGEs stimulates an increase in oxidative stress, free radical formation and an up-regulation in our pro-inflammatory markers.   Or essentially elevated blood sugar levels (even in a non-diabetic) causes aging and degeneration of peripheral nerves (with the foot nerves going first!).

Tip #2 – Consider Nerve Protective Vitamins

When I was in Graduate School a big part of my focus was on vitamin supplementation and diabetic peripheral neuropathy.   Having spent so much time researching this topic I became a firm believer in the benefits of the appropriate vitamins in protecting nerve health as we age.

Everyone can benefit from nerve protective supplements – especially if we consider that elevated blood sugar levels (even in a non-diabetic) can start to damage our peripheral nerve function.

Vitamin #1 – L-Methyl Folate

This is not your mother’s folic acid!

L-methyl folate is the activated form of folate (folic acid) which has been shown to increase nerve growth factor. When taken over a period of 6 months studies have shown an increase in epidermal nerve fiber density (or in other words more peripheral nerves!).   Link to study 

Dosage: 1000 ug X 3 times day

Vitamin #2 – Acetyl-L-Carnitine

ALC is another powerful nerve protective supplement.

ALC has been shown to decrease painful nerve symptoms, as well as increase vibratory sensation. Remember that we maintain balance and absorb impact forces based on our ability to detect vibration so this is extremely beneficial as age!

Dosage: 500mg x 2 times day

Vitamin #3 – R-Lipoic Acid

This is probably my favorite supplement! (Yes I do get that excited over a vitamin)

Touted as one of the most powerful anti-oxidants, ALA has been shown to improve micro-circulation to peripheral nerves while decreasing oxidative stress.   A key point about ALA is that it must be taken in the R-LA form. “R” form is one that is biologically active (vs. “S” form).

Dosage: 600mg x 1 time day

Tip #3 – Cardiovascular Exercise

Cardiovascular exercise has many benefits, one of which is related to peripheral circulation.   The vascular system, just like the nervous system, is very intelligent meaning that if there is a loss in circulation to one area of a muscle the vascular system will create what’s called collateral circulation (or in other words form new blood vessels).   This is why cardiovascular exercise is beneficial for those with peripheral arterial disease.

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So just like the collateral circulation formed in muscles, our vascular system can create new micro-vascular pathways to our nerves. The more blood and oxygen to our nerves the healthier they are!

Tip #4 – Myofascial Release

When I have a patient with idiopathic nerve symptoms I often include myofascial work into their recovery program.   Our complex network of superficial and deep fascial is intertwined with just as complex of a network of arteries, veins and peripheral nerves.

As our peripheral nerves course from the spine down to the foot it is only inevitable that they may get “stuck” or “sticky” at some point.   From muscle adhesions to a loss in fascial flexibility, our inflexibility can often impede nerve conduction.

Just like when you sleep on your arm and wake up with it tingling, to a smaller degree this is what’s happening to our peripheral nerves when they get caught in fascial tissue.

I often recommend to my patients to release their plantar foot, up the back of the calf to the hamstrings and into the glutes and piriformis.   For those with nerve symptoms this should be done daily.

Tip # 5 – Go Barefoot!

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This one pretty much goes without saying!     If our small nerves are on the bottom of the foot we want to keep them sensitive and awake through frequent barefoot stimulation.

Our nervous system is very plastic – which means that it can be shaped, challenged and molded based on the stimuli it encounters.   Conversely, if you do not stimulate your peripheral nervous system it will begin to weaken, fade and atrophy.

Whether your barefoot routine includes vibration training, standing on different textures or simply walking around your home – daily barefoot stimulation is enough to keep these small nerves on point!

Want to kick it up a notch?   Workout barefoot!

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To learn more about foot health, barefoot training and EBFA Education

please visit http://www.ebfafitness.com

 

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