Barefoot Biomechanics, Barefoot Science

From Primal to Bipedal : Why we must lock in our rolling and crawling with foot to core sequencing

Rolling and crawling are currently some of the hottest trends in fitness and corrective exercise programming.   From Animal Flow to Original, health and fitness professionals are exploring the power of primal movement patterning for correcting movement dysfunction and achieving optimal function.

We actually happened to just do a webinar on this exact topic with Stop Chasing Pain’s Dr Perry Nickelston which we encourage you to catch the archived version on the EBFA YouTube Channel HERE!

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Babies Sitting, Crawling, and Walking

Why rolling and crawling are such powerful stabilization techniques is that they bring us back to our neurodevelopmental origins.   Back when we were first introducing our nervous system to the demands of movement – millions of neuromuscular pathways were being developed.

These neurological pathways soon become the joint stability and coordination needed to sit upright, resist gravity and ultimately put one foot in front of the other.

What movement specialists are starting to realize is that by bringing it back down to the ground and reducing the demands of gravity, clients and patients are better able to restore stabilization patterns.

Test Your Primal Stability 

One example of crawling stability is the quadruped position.  In Animal Flow they call this position The Beast.

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Begin on your hands and knees with your shoulders directly over your wrists, hips over knees, neutral spine and feet flexed.

After creating proper alignment on these 6 points of contacts, engage the deep abdominals and lift the knees 1 cm off of the ground.   Immediately you should start to feel all your stabilizers engage.

Richard Scrivener of Animal Flow recommends holding this 4 point Beast for 45 seconds to test stability.

From Primal to Bipedal 

Despite the current popularity in rolling and crawling I think that it is important for movement specialists to remember that we are still bipedal animals and that simply training primal patterns is not enough to restore the demands of bipedal locomotion.

One of the biggest differences between primal movements and bipedal movements is the degree of impact forces encountered with every step that we take.   When walking each time our foot contacts the ground we are encountering 1 -1.5 x our body weight in impact forces that are entered at a rate of < 50 milliseconds.

To effectively and efficiently load these impacts forces over and over (sometimes over 10,000 times a day!) requires fast and accurate stability.

Now although we were training stability in our primal patterning that stability was not at the rate nor was it specific to the demands of bipedal foot contact.

Foot to Core Sequencing 

This is where foot to core sequencing comes into our programming.

walking-barefoot-298x232I refer the foot to core sequencing we use in the Barefoot Training Specialist® Certification as the critical step in locking in stability.

Why do we want to lock in our stability with foot to core sequencing?

Here are a couple powerful reasons:

  1.  The foot is the only contact point between the body and the ground which means this complex structure is the neurological gateway between impact forces and stabilization.
  2. Fascial sequencing exists via the Deep Front Line connecting the plantar foot with the deep hip and pelvic floor.   Studies have shown that by training the foot to core sequencing you can begin to establish feed forward, pre-activation sequences to enable faster foot to core stability
  3. Thousands of small nerve proprioceptors on the bottom of the foot detect the vibrations of impact forces making the bare foot the gateway to understanding how hard we are striking the ground and how quickly our foot to core sequencing needs to occur

Training Foot to Core Sequencing

The simplest exercise to train foot to core sequencing is via an exercise called short foot.  For those who follow my work probably new I was going to say this!

A few tips with cueing and integrating short foot.

  1.  Start with pelvic floor activation and identification if the client or patient is unfamiliar with how to engage these muscles.   Video on pelvic floor activation is HERE
  2. Stand up and find short foot.  In those clients familiar with short foot immediately begin to cue that they start with the pelvic floor engagement then add in short foot The video on how to do short foot is HERE
  3. Begin to coordinate the breathe with short foot / pelvic floor sequencing ensuring that the engagement happens on the exhalation.   I prefer the breathe to be relaxed and not forced exhalation but natural deep breathing that involves the entire thoracic cavity with lateral ribcage expansion.
  4. Begin to integrate foot to core sequencing in single leg exercises such as those listed HERE

Want to learn more about the benefits of foot to core sequencing and the Barefoot Training Specialist Certification please visit http://www.ebfafitness.com

Finally – as always – stay barefoot strong!

Dr Emily

 

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Barefoot Biomechanics

Great Toe Mobility : The Linchpin to Movement Longevity | (Part 1 – Anatomy)

This past weekend I was fortunate to present at the Perform Better Summit in Providence, Rhode Island.   This 3-day educational event is comprised of some of the best educators and most enthusiastic professionals in the industry.   A common theme throughout a couple of the sessions was the association between great toe mobility and function.

The seemingly simple process of hallux dorsiflexion during push-off is actually quite complex and if great toe mobility is compromised it can cause a slew of movement compensations and pain patterns.

In this 3-part blog series we will begin to explore how this joint is stabilized, simple assessment techniques and programming which you can easily implement with your clients and athletes.  Please note that these articles are not all-inclusive of every anatomical detail or compensation pattern – to learn more on this topic please  check out our EBFA Certifications. 

Image_Macias_First_MTP_xrayThe 1st Metatarsophalangeal Joint (MPJ)

Formed by the head of the first metatarsal and base of the proximal phalanx this ginglymoarthrodial or hinge joint allows sagittal plane progression during walking, running, jumping etc.

With the movements of plantarflexion and dorsiflexion, optimal push-off during the gait cycle requires at least 30 degrees of dorsiflexion but having closer to 65 – 75 degrees dorsiflexion is ideal.

Limited hallux dorsiflexion during push-off can be associated with a low-gear push off position, early heel rise, overactive adductors and under active gluteus maximus.

Complexity of Hallux Dorsiflexion

At first glance 1st MPJ dorsiflexion seems quite straight forward and based on the increasing emphasis on the great toe in many fitness and performance lectures – I think it is imperative that professionals truly understand this joint and the complexity associated with hallux dorsiflexion.   Improving hallux dorsiflexion requires much more than simply integrating great toe stretches or putting a wedge under the big toe.

So here we go.  Screen Shot 2015-07-20 at 5.38.06 PM

In closed chain movements such as walking, the propulsive phase of gait is the phase in which maximum great toe dorsiflexion is required.  As the foot prepares for the large amount of power output during propulsion, the flexor hallucis longus (FHL) engages thereby anchoring the distal aspect of the hallux to the ground.

This fixed hallux provides a stable base or lever for propulsion thus allowing the metatarsal head to move relative to the base of the proximal phalynx.  See picture to the right.  

Sliding, Gliding and Jamming

If we break down hallux dorsiflexion even further will find that the first 20 degrees of dorsiflexion – the head of the 1st metatarsal slides over the base of the proximal phalanx.

The next 10 degrees – 50 degrees of dorsiflexion requires the 1st metatarsal to plantarflex relative to the base of the proximal phalynx creating a gliding movement as the foot moves over the hallux.

The final stage of hallux dorsiflexion is a jamming phase which holds the joint in a stable position.

To repeat – with each step we take – hallux push-off requires a timed movement pattern of sliding, gliding and jamming of the 1st metatarsal head relative to the base of the proximal phalanx.   If the timing is shifted or the 1st metatarsal head cannot plantarflex relative to the proximal phalynx, then hallux dorsiflexion will be limited and compensation results.

So how do we ensure proper sliding, gliding and jamming?

1st ray stability!

Of the above phases the most important phase would be gliding phase or the plantarflexion of the 1st metatarsal head relative to the base of the proximal phalynx.

So then the question should be – how do we ensure that the 1st metatarsal head plantar flexes relative to the base of the proximal phalynx?  

To answer this question we must know which muscle plantarflexes the 1st metatarsal.

For those who havFeetSlingsFig1Finale taken my Barefoot Training Specialist courses – especially the Level 2 – you should recall that the muscle that plantarflexes the 1st metatarsal is the peroneus longus.  

Running along the lateral aspect of the lower leg, behind the lateral malleolus and under the cuboid, this muscle attaches to the base of the 1st metatarsal and to the medial cuneiform.

If we look closer at the peroneus longus insertion we see that it inserts 90% on the base of the 1st metatarsal and only 10% on the medial cuneiform.   Together this insertion controls the metatarso-cuneiform joint – or the 1st ray.

Joining the peroneus longus tendon on the medial side is the tibialis anterior, with both of these muscles together contributing to the Spiral Fascial Line.  

1st Ray / Met-Cuneiform Stability

hypermobility1With the tibialis anterior and peroneus longus as direct antagonists of each other, balance between these two muscles is critical for 1st ray stability or hallux dorsiflexion.

If for some biomechanical or neuromuscular reason the tibialis anterior is more active or dominant compared to the peroneus longus then the 1st metatarsal (1st ray) begins to dorsflex.  Elevatus

If the 1st metatarsal is dorsiflexed then the gliding phase of hallux dorsiflexion cannot occur and we get premature jamming of the 1st MPJ, limited dorsiflexion and compensation.

So how do we ensure balance between the tibialis anterior and peroneus longus?

To answer this question we must go to the rear foot where we will find the subtalar joint (STJ).   STJ position greatly dictates
the stability of not just the rear foot, but the entire foot in general.

STJ eversion is often associated with a hyper mobile, flexible and unstable foot and often has trouble locking or stabilizing in a timely mannefootblogr.   STJ eversion as indicted in the picture to the left also causes the peroneus longus tendon to go on slack thus giving a mechanical advantage to the tibialis anterior.

Once the tibialis anterior is given an advantage, the 1st metatarsal begins to dorsiflex, the stability of the 1st ray is compromised and hallux dorsiflexion is limited.

But what if you have a client with limited hallux dorsiflexion and they have a neutral STJ position?   This is where understanding both open-chain and closed-chain assessment techniques is important.

In Part 2 of this blog series we will explore how to begin to assess for both structural and functional causes of limited hallux dorsiflexion.

Until then…..stay barefoot strong!

Dr Emily Splichal

Founder EBFA Fitness

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Barefoot Biomechanics, General

Biomechanics of the Stiletto Strut

stilettoAnyone who has followed by work since before 2012 knows that I love shoes!

I may be barefoot strong but come Friday night, I, like most women across the world, am strapping on my sexiest stilettos for a night out on the town.   Blame it on fashion and living in NYC for over a decade, but I can’t deny that my knees get weak as I walk through the Shoe Department at Bergdorfs!

Associated with power, confidence and sex appeal nothing ruins a perfect pair of pumps like a young fashionista stumbling around in her 5 inch platforms.   If you are looking to improve your stiletto strut, understanding the biomechanics of the foot & ankle may be the ticket to the perfect stride.

In today’s blog I’m going to combine two of my passions – stilettos & biomechanics – to give you a scientific approach the catwalk and why biomechanics play a bigger role than we realize when achieving the perfect stiletto strut!

The Case of the Stiletto Duck Walk

I’m sure we’ve all seen the woman walking in heels with her feet turned out – or every time she takes a step the foot drops down into pronation.   The cause for this “stiletto duck walk” is related to the biomechanics of the great toe joint and the extreme heights of today’s heels.  Big toe

Normal walking on flat ground requires at least 30 degrees of great toe dorsiflexion.  Slide into stilettos and the demands on great toe dorsiflexion increases – often requiring up to 90 degrees dorsiflexion!

If you have limited great toe mobility (whether it be in flats or heels) and you are trying to enter the propulsive phase of gait but do not have the joint mobility – you will compensate!

Two of the most common compensations for limited great toe mobility is to turn your feet or pronate during push-off – leading to the stiletto duck walk.

So what can be done to avoid the stiletto duck walk?

1.  Lower the height of your heels.

photo-2Heels that exceed 3 inches start to defy natural foot biomechanics which is why the higher height of heels must have platforms and a forefoot rocker built into the shoe (see picture to the left)

For women with flat feet I often recommend keeping the heel height lower as this foot type is inherently unstable which compromises great toe mobility.

2.  Shorten your stride

Another great tip for decreasing the demands on great toe mobility when in high heels is to keep your stiletto stride short.   The longer the stride, the greater the demands on great toe mobility.

Learn more about wearing high heels with flat feet – http://www.howcast.com/videos/500316-How-to-Walk-in-Heels-with-Flat-Feet-High-Heel-Walking

The Forward Lean

The next common mistake I often see in the stiletto strut is the forward lean.  This dropping of the chest is often associated with the stiletto strutter trying to walk faster than the heels are biomechanically allowing.    Biomechanical studies have shown that when walking in heels the woman is forced to shorten her stride length and increase stride frequency.

Increased stride length not only requires great toe flexibility (see above) but also hip extension flexibility.   As soon as we slide into our heels the ankle assumes a plantar flexed position forcing the pelvis into an anterior tilt.   This anterior tilt shortens the hip flexors thereby limiting hip extension.

What can be done to avoid the forward lean when walking in heels?

1.  Minimize the heel height 

The higher the heels the greater the shift in the pelvis.   Each additional inch in heel height is further shortening the hip flexors and reducing hip extension flexibility.   If your pelvis already naturally gravitates towards an anterior tilt then keeping the heel height 3 inches will not only save your stiletto strut but it will also dramatically decrease the load to your lower back.

2.  Keep the hip flexors flexible 

If you are going to wear heels often then make sure to keep the hip flexors flexible.   Repeated stiletto wear will overtime shorten the muscles on the front of the hip making successive high heel wear more difficult.    I encourage women to do at least 5 minutes of hip mobility exercises (stretching) before and after wearing their heels.

To learn more stiletto recovery tips –

To experience my Stiletto Recovery Workout DVD please visit – http://www.amazon.com/Stiletto-Recovery-Workout-Emily-Splichal/dp/B009ZXGLU6

3.  Own the shorter stride 

This final tip is often difficult for me sometimes as I’m always moving and walking super fast, however if the heels force you to shorten your stride you might as well own it.    The shorter stride gives you time to spice up your walk and add a little sex appeal or personality to the walk!

 The Weafalls-off-high-heels-2k Ankles

The final common mistake seen in the stiletto strut are the weak or wobbly ankles.   Again blame it on biomechanics and foot type as the extreme plantar flexed and inverted foot position can be difficult for certain foot types to control.

If you find yourself weak in the ankles and pitter pattering around in your heels out of fear of falling then the below tips should help you build some ankle strength and confidence in your strut!

1.  Minimize heel height

Just like the previous two stiletto strut errors, decreasing heel height is probably one of the best ways to correct all stiletto strut errors and compensations.   Remember that for every inch you increase heel height you drastically change the demands placed on the foot and body.

For the novice stiletto lover I suggest not going above 3 inches.   In addition, the thickness in the heel can greatly help build confidence in your walk with many women stating the greatest stability in wedges / espadrilles.

2.  Barefoot training

Another tip that I love and have built my Catwalk Confidence Workout around is barefoot training for foot, ankle and core strength – all necessary components to walking confidently in your heels.

Studies have shown that our feet and core and deeply integrated and that the stronger the feet are the faster the core / hips can stabilize when walking.   This translates to a more graceful walk (think tango dancer)!

To learn more barefoot training tips for improving your stiletto strut please check out my DVD – Catwalk Confidence.

http://www.amazon.com/Catwalk-Confidence-Workout-Emily-Splichal/dp/B009ZXBEUS/ref=sr_1_2?s=movies-tv&ie=UTF8&qid=1425976693&sr=1-2&keywords=Dr+Emily+Splichal

In closing a few final tips for keeping your feet and body stiletto strong :

1.  Recover your feet daily by standing on a golf ball

2.  Keep your hips flexible by do hip flexor stretches or foam rolling your quads

3.  Weekly barefoot training keeps the small muscles of your feet and core working together

4.  Never compromise in shoe fit as the damage it can do the feet is not worth the fashion

To learn more about feet and stilettos please check out my recent segment on The Meredith Viera Show!

 

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Barefoot Biomechanics

The Functional Impact of Bunions

When you hear the word “bunions”- what comes to mind?

Do you picture the foot of a young athlete or that of a stiletto-loving woman?

bunions

Often associated with high heels or blamed on “genetics”, bunions are actually more often due to improper biomechanics and faulty movement patterns.

In the below article we will explore the impact bunions have on functional movement – from the way we stabilize our core to the way we push off with each step!

To fully appreciate the functional impact of bunions, we must first understand both the biomechanics of the first ray as well as the fascial lines crossing the bottom of the foot.

The First Ray

hypermobility1 

The formation of bunions is associated with the stability (or rather instability) of the first ray and the balance of muscles around the 1st MPJ.   The bones which make up the first ray include:

  • medial cuneiform
  • first metatarsal
  • hallux (great toe)

When our foot loses stability of the 1st ray, specifically at the metatarsal / cuneiform joint, the long metatarsal is able to swing out medially forming the structure we recognize as bunions.

bad xray sesamoid

As the metatarsal / cuneiform joint deviates medially, the soft tissue structures around the 1st MPJ begin to deviate laterally.

What causes first ray instability? 

If you guessed pronation or calcaneal eversion you are correct.

Some additional drivers of first ray instability include tibial:femoral external rotation or TFER.  This was discussed in the blog post Subluxing Peroneals.    In my office I find this TFER to be highly over-looked but one of the strongest drivers of bunion formation and foot dysfunction.

The First MPJ

To further understand the impact of bunions we must now explore the stability of the 1st MPJ or great toe joint.

Transverse plane stability of the 1st MPJ is a balance between the adductor hallucis muscle laterally and the abductor hallucis medially. What is unique about these two muscles is that they both share a tendon with another intrinsic muscle – the flexor hallucis brevis.

The flexor hallucis brevis muscle is unique in that it has two small sesamoid bones lying in the tendons.

If we take a closer look at the picture below we can appreciate how the medial tendon of the flexor hallucis brevis shares a tendon with the abductor hallucis, and the lateral tendon of the flexor hallucis brevis shares a tendon with the adductor hallucis.

conjoined tendon

How 1st MPJ transverse plane stability impacts function has to do with what’s called sesamoid position.   In the above picture we can see that the flexor hallucis brevis (and therefore sesamoids) are sitting directly under the 1st metatarsal head or 1st MPJ.   This allows a perfect balance between the abductor and adductor hallucis.

If we go back to the bunion picture (below).   We can appreciate that the sesamoids have shifted laterally away from the 1st metatarsal head.

How does this affect functional movement?    The answer has to do with our fascial lines and how we stabilize proximally!

bad xray sesamoid

Foot Function and Fascial Lines

In the plantar foot the Deep Front Line (which is our deep stabilizing fascial line) consists of the deep posterior leg compartment including the posterior tibialis, flexor hallucis longus and flexor digitorum longus.   For the purpose of this article we are going to focus on the posterior tibialis.

PTtendon

Running posterior to the medial malleolus and along the medial aspect of the foot, the Posterior Tibialis inserts onto the navicular.   After attaching to the navicular the Posterior Tibialis fans out and has 9 osseous and fascial attachments which includes:

–       every tarsal bone (except the talus)

–       every metatarsal (except the 1st)

–       peroneus longus tendon

–       flexor hallucis brevis muscle

In EBFA education and programming we focus on how short foot specifically strengthens the intrinsic muscles of the foot and activates this stabilizing Deep Front Line.

 

Short Foot and the Deep Front Line 

short foot

Short foot is a foot activation exercise that was first introduced by Janda et al.

This exercise targets the abductor hallucis on the medial side of the foot.

Because the abductor hallucis shares a tendon with the flexor hallucis brevis, and the flexor hallucis brevis has an attachment to posterior tibialis – we are able to tap into our Deep Front Line through short foot!

 

How bunions impact proximal stability has to do with the abductor hallucis and sesamoid position.

Remember we said in a bunion the sesamoids begin to shift laterally away from the head of the 1st metatarsal.   As the sesamoids shift laterally they bring along the flexor hallucis brevis muscle (as well as the abductor hallucis!)

This lateral shift of the abductor hallucis pulls the muscle under the 1st metatarsal making it now a sagittal plane muscle (not a transverse plane muscle as it should be).   It is this shift in the sesamoids driven by the bunion formation that impedes integrated proximal stability – from the ground up!

As we interfere with Deep Front Line stability, we subsequently interrupt Spiral Line and Lateral Line stability (since they are all integrated through the posterior tibialis muscle).    All movement is integrated – integrated movement that starts with the foot!

So what can we do? 

Short foot is one of the exercises I recommend to keep the foot strong and integrated with the core proximally.   But what do we do if our clients have bunions and we cannot get them to activate the abductor hallucis through short foot?

I often talk about a product called Bunion Bootie.   http://www.bunionbootie.com

bootie

This snazzy little product slips over the great toe and pulls it medially, allowing better engagement of short foot.   By frequent use of Bunion Bootie – along with short foot exercises, your client will hopefully be able to restore foot to core integration.

Will this correct a bunion? 

Not necessarily.

After a certain progression in bunion formation no bunion can be “cured” with exercises and/or toe stretchers.  Since a bunion is actually an imbalance around the metatarsal / cuneiform joint or first ray – the only way to re-stabilize proper alignment is through surgery.

However, for those clients who never want surgery but want to remain functionally integrated with their foot – Bunion Bootie and short foot is your answer!

To learn more about the sesamoids, 1st MPJ and fascial lines please check out my other blog on Foot Function & Fascial Lines!

Are you barefoot strong? 

 

 

 

 

 

 

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Barefoot Biomechanics

Functional Implications of the Cavus Foot

With the growing popularity of foot fitness and barefoot training within the health & fitness industry, professionals are beginning to appreciate the impact that improper foot function can have on lower extremity alignment and total body function.

To truly understand the connection between feet and function, an understanding of the different foot types and foot imbalances is imperative.   In all EBFA courses and Certification workshops we educate professionals on the basics to performing both open-chain and closed-chain foot assessments.

The goal of these assessment techniques is to build an appreciation for the unique differences each person can have in foot mobility, structure and function.

To date, most of my EBFA Blog posts have been about the pes planus or flat foot. But the impact that a caves or high arched foot type can have on alignment and functional movement is just as important to understand.

The Cavus / Inverted Foot 

When we look at a true cavus or high arched foot there are some characteristic joint alignment issues that should begin to jump out at you.

1.  Inverted STJ

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As we look at the cavus foot from behind, it is quite apparent that the heel is turned in or inverted. This STJ position causes the navicular bone to sit in a position that is superior to that of the cuboid – causing the mid foot to excessively lock.   Remember that it the unlocking of the mid foot that allows our foot to loading impact forces and use them for potential energy and efficient movement.

This increased STJ inversion can be the result of an imbalance between the muscles on the inside of the ankle (posterior tibialis and anterior tibialis) and the muscles on the outside of the ankle (peroneals) – or it could be a compensation for a plantar flexed 1st ray in the forefoot (more on this soon).

2.  Increased calcaneal inclination and metatarsal declination

ped_cavus_before

As we look at the foot from the side what gives this increased appearance of the high arch is what called the “pitch” or inclination of the heel bone relative to the declination of the metatarsals.

In the Xray below we see the altered pitch in both the calcaneus and metatarsals.   Not only does this alter the osseous or bone structure of the foot, but soft tissue compensations and contractures are going to follow.

CMT-Lateral-X-ray-Figure-2A_thumb

This increased metatarsal declination angle along with weakened foot intrinsics alters the muscle balance of the extensor digitorum longus (EDL) allowing hyperextenion and contracture of the digits.  Furthermore the plantar flexed metatarsals lead to plantar fascia shortening which further locks the foot and impairs the foots ability to load and unload impact forces.

3.  Plantarflexed 1st Metatarsal

The final characteristic of a cavus or high arched foot can be a plantar flexed first ray.   The 1st ay includes the great toe, first metatarsal and medial cuneiform bone.    If we load the foot in an open chain assessment we can see how a plantar flexed first ray would present.

wedge-tarsectomy-with-dorsiflexing-lapidus-05

In the case of a plantar flexed first ray when the foot tries to establish a tripod, the plantar flexed 1st ray shifts the bodyweight onto the lateral aspect of the foot causing compensatory inversion of the heel or STJ.   This STJ eversion and over-activation of the tibialis anterior further locks the foot and adducts the forefoot relative to the rear foot.

One of the tests that can be done to see if the plantar flexed first ray is driving the STJ inversion is called a Coleman Block Test.

coleman block test

In this test, the client / patients stands with just the first ray off of the block.   If the STJ neutralizes during this test then it is confirmed that – 1. the plantar flexed first ray is in fact driving the STJ inversion and 2. that it is a flexible and correctable deformity (often with orthotics).   This test is covered in advanced EBFA workshops.

Foot-Specific Programming for Functional Movement

So what do you do if you have a client or patient with this foot type?

Understanding the unique imbalances presented in this foot type are important to correcting the efficiency of movement and restoring balance in the cavus foot type.

1.  Improving foot mobility 

Because the invertors play an important role in shock absorption, over-activity of these muscle make this foot type a poor shock absorber.  Clients with this foot type may tell you they have a history of stress fractures or shin splints.

Fitness Rx:   To relax the over-activity of the inverters, integrate myofascial release into your client’s program.   I like to address the posterior tibialis muscle by going to the bottom of the foot.   Remember that the posterior tibialis has 9 attachments that fan the bottom of the foot.   Standing on a golf ball is one of my favorite release techniques for the plantar foot.

Reccommended 5 minutes every morning, evening and before working out.

golf-ball-exercise-to-strength-the-arches

2.  Improving lateral ankle stability 

Normal walking and running require our foot to strike the ground in an inverted position. With the over-supinated heel already in an inverted position, the chances of twisting or rolling an ankle are even greater in this foot type.

Typically the muscles on the outside of our ankle (peroneals) function to stabilize and prevent the ankle from rolling, however in the over-supinated foot type they are already eccentrically loaded and therefore cannot function properly to prevent ankle sprains.

Fitness Rx: To relax the eccentrically active peroneals integrate myofascial release into your client’s programming.  Because the peroneals are elongated in a cavus foot type you do not want to stretch an already elongated muscle.   Stretching an elongated muscle can increase the tension placed on the tendon leading to further instability or tendonitis.

I would follow the myofascial release of the peroneals with intrinsic strengthening.   This intrinsic strengthening should be done in a controlled setting as to avoid over-activation and further locking of the foot.   I recommend integrating balance exercises and movement patterns with short foot activation during the concentric phase of the exercise.   For examples of these exercises please visit:  YouTube Video

3.  Increase LPH Mobility

Ensuring proper foot mobility also requires an assessment of lumbopelvic hip mobility. Through the lateral myofascial highway, the taut peronals in an over-supinated foot type will begin to pull on the iliotibial band.   With its attachment to the tensor fascia lata on the anterior hip, an over-supinated foot type can cause secondary pelvic immobility.

I often tell professionals in my workshops that the foot and hip are like a marriage.   If someone has a locked foot and ankle you can usually assume their LPH complex will also be restricted.

Fitness Rx: To increase LPH mobility in a cavus foot type, integrate TFL myofascial release into your client’s programming.  I recommend following TFL, anterior hip release with dynamic stretches.  This can be locked in with pelvic floor activation and deep hip stabilization.

To learn more about the implications of different foot types please visit http://www.ebfafitness.com 

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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

F5.large

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)

Gymnast_Faeryan

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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