Forefoot varus

Sid

Barefooters
Jan 1, 2011
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Florida
Since forums are all about sharing personal experiences, this information was helpful for me. Thanks, Gait Guys!

The Gait Guys
We, as clinicians, like to assume that MOST FEET have a range of motion that folks are not using, which may be due to muscle weakness, ligamentous tightness, pathomechanics, joint fixation, etc. Our 1st job is to examine test the feet and make sure they are competent. Then and only then, after a trial of therapy and exercise, would you consider any type of more permanent “shoe prescription”.
If the individual has a rigid deformity, then you MAY consider a shoe that “brings the ground up” to the foot. Often time we find, with diligent effort on your and the individuals part, that a shoe with motion control features is not needed.
Pathomechanics of the Foot
the most clinically common pathomechanical abnormality.
PDF: Pathomechanics of Structural Foot Deformities
A forefoot varus is a very destructive deformity and is encountered frequently in patients with lower extremity dysfunction
Forefoot Varus and Overpronation by James Speck
Forefoot varus is the angling or inverted position of the bones in the front of the foot in relation to the heel. A true forefot varus is a structural deformity involving the shape and alignment of the bones in the foot. A flexible forefoot varus position is more accurately called supinatus. ...

The forefoot varus angle is only going to respond to corrective exercises if muscle weakness and soft tissue tightness are the cause. ...

The goal of any exercise for correcting forefoot varus then is to strengthen the muscles that pull the base of the big toe down to the ground to stabilize the arch, while the heel is held in a stable position to prevent it from everting. ...

In some ways this is what the short foot exercise does.
Forefoot varus
A Pedograph mapping case
Increased heel pressure, Uncompensated forefoot varus (as evidenced by a lack of ink under the first metatarsals (you could even put a Rothbart foot-type on your DDx list), increased clawing of the 2nd-3rd digits on the right, and bilateral Morton’s second toes.
to improve their ability to plantarflex the first metatarsal
This works well on Forefoot varus feet that are flexible and have some skills left in their playbook. Increasing the skill, endurance and strength (our 3 tenants, S.E.S.) of the extensors (both short and long, EHL & EHB) will help to drop the first metatarsal into plantarflexion.

Loss of medial tripod
 
Some interesting information on the foot arches from The Gait Guys.

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe
Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch.
Big Toe Exercise: Regaining Control of the Extensor Hallucis Brevis.
Here Dr Ivo briefly talks about the 1st part of the famous “Extensor Hallucis Brevis” or “EHB” exercise (Part 1) with a patient.
Part 2 of the EHB: Bringing the Extensor Hallucis Brevis of the Foot Back to Life.
Today we show you a proprietary exercise we developed here at The Gait Guys. It was developed out of necessity for those clients who are too EHL dominant (long big toe extensor muscle) and big toe short flexor dominant (FHB). These two muscles are what we call a foot functional pair. Big toes like these will be dysfunctional and will not be able to gain sufficient purchase on the ground to produce stability and power without impacting the joint (1st metatarsophalangeal joint). … These imbalances are also what lead to injuries to the big toe, the arch and other areas of the foot.
The Anterior Compartment: The Necessity for Adequate Extensor Strength
The foot tripod: the importance of the toe extensors in raising the arch.
Here is a little experiment … should also help you to realize 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.
 
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See also the Update:
Migangelo found this great information.
http://www.thebarefootrunners.org/threads/forefoot-varus.15771/page-2#post-172119

Some interesting information on the foot tripod from The Gait Guys.
Is Your Foot Tripod Stable Enough to Walk or Run without Injury or Problem?
The all too common case of the Wobbling Tripod.
The Almighty Foot Tripod
Join Dr Ivo in this brief and informative video demonstrating an exercise that most people with an inadequate foot tripod will benefit from.
The Foot Tripod; Part 2
Pay attention to the subtleties of this simple, yet effective exercise we use on a daily basis.
 
Some interesting toe exercises from The Gait Guys.

The Toe Waving Exercise: Part 1
The short flexors of the lesser digits (Flexor Digitorum Brevis or FDB) are one of the important component sfor creating and maintaining the foot tripod … This is a boon for people with a forefoot varus, as it can help create more mobility of the 1st ray, as well as help descend the head of 1st ray to form the medial tripod (and assist the peroneus longus in anchoring the base of the big toe). It also helps the lumbricals to promote flexion of the toes at the MTP, rather than the distal interphalangeal joint.
The Toe Waving Exercise, Part 2
In this installment, we discuss another important muscle used in this exercise, the extensor digitorum longus (EDL). … The balanced activity of the long flexors and long extensors helps to create harmony during gait. Working the long extensors with this exercise (along with others, like tripod standing, toes up walking and the shuffle gait exercises) helps one to achieve this balance.
The Toe Waving Exercise: Part 3 The Lumbricals
In part 3, we will look at some often overlooked muscles, the plantar lumbricals. Watch the video from the 1st post again. Note the flexion at the metatarsal phalangeal joint.
 
Some of you may have read about my adventures in improving my bunions and forefoot valgus. Interestingly, afterwards I developed an unusual callus pattern on my left foot (the one that had the worse bunion), shown below as B. These calluses were quite uncomfortable and limited my running, and they kept growing back despite filing them off! I was unable to prevent them, despite adjusting my landing (forefoot, midfoot, lateral, medial).
card-24714657-back.jpg
After doing some reading below, it dawned upon me that perhaps, I was unconsciously plantarflexing my left big toe on landing. That toe was a bit stiff from the bunion, and I’m still working on improving the range of motion with the exercises above.

So, I tried dorsiflexing my left big toe a bit more on landing. Amazingly, that solved the problem for me!

It seems that a healthy foot is quite important to barefoot running, and that foot problems can significantly affect gait. Sometimes, it seems, that foot and gait problems can be addressed with exercises and conscious effort. I’m definitely thankful for all of the great information from The Gait Guys!

Forefoot Valgus or Plantarflexed 1st ray?
We remember that Forefoot valgus is a condition where the forefoot is everted with respect to the rearfoot.
With a plantar flexed 1st ray, the forefoot is actually in varus (ie inverted) and the the 1st ray is dropped (thus, plantar flexed).
"I’ll plead the 1st … ." More foot geek stuff from The Gait Guys.
1st rays can be elevated or depressed.

Update: After just a few days, I can tell that I'm now landing on the correct part of my foot. I'm no longer hammering away at those two spots with each footfall. The area that I am landing on now is going through the conditioning process. (This is similar to what happened when I straightened out my bunions, when the calluses diminished on the side of my toes and the pads started to become thicker.)
 
So, this is an update. I've tried several things to address problems with my left foot (see the callus pattern above).

Dorsiflexing the toe did help a bit, but it wasn't the complete solution. The callus pattern improved, but didn't go away completely. I kept filing down the callus, but that's just a temporary fix. Landing with my weight on those two points was still a problem.

So I tried relaxing the feet, and maybe that helped a bit. I also tried plantarflexing and planting the big toe firmly enough to lift the 1st met, and even supinating the foot for a lateral forefoot landing. That helped take some pressure off the 1st met, but it felt awkward and exaggerated, as if just another temporary fix. Plus, supinating the foot was making the medial side of my calf sore.

Eventually, I tried different ways of lifting the foot and putting it down while standing in place, just to see if I can find a comfortable position at all. I found a decent position, and it wasn't too bad. So, I tried jogging in place, and it wasn't too bad either. I tried jogging forward slowly, and it was pretty good.

So, I've shortened the stride length, and things feel like they are going in the right direction. I can't say that I was overstriding, because the right foot felt fine, but maybe? It even feels like I might even be shuffling a bit. If I had access to a gait lab, I think that this would have been fixed a long time ago, but that's ok, because my left foot feels a lot better now. That's all that counts!
 
I uped my mileage a bit today, and the problem showed up again towards the end of my run. It seems that weaknesses show up when I'm tired.

I thought back to a blog post I had read.
http://yelling-stop.blogspot.com/2011/12/bent-big-toes-and-genesis-of-metatarsal.html
I didn't fully appreciate the diagram, when I first saw it. Now, I understand.
(Edit: This image shows pressure during walking.)
uploadfromtaptalk1401030894997.jpg
If you're not engaging your big toe (the highest pressure point in the bare foot), your body needs to bear that weight somewhere ...
In my case, it's on the first met, hence the discomfort and callus!
So, I had the right idea plantarflexing the big toe. However, I think it's going to take a combination of all of the above.
 
careful. i tried plantar flexing my big toe a few years ago. changed my form and has tightened up my anterior and side leg compartments. my peroneals and extensors are constantly tight. i've been trying to change my form but it's hard once you set a different pattern. i've been trying that dorsi flexing and short footing. check your iliopsoas as well. there's a lot of compensation that will happen up the chain that can't be ignored.
 
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Thanks for the thoughtful feedback and suggestions! I'm sorry to hear about your situation and hope that you're able to resolve them.

In my case, I'm trying to rehab my left foot, which has been weakened by a bunion related to a pair of tight shoes from my 20's. My big toe has been particularly problematic, and I'm working on strengthening the muscles. I've noticed in comparison to my right foot, my left big toe has weaker plantarflexion, so I'm trying to restore some strength. My goal is not to plantarflex the toe all the time, but rather at the right time. It seems that proper functioning of the foot involves using the right muscles at the right time in the gait cycle.
(I don't have to have as much problem adjusting my gait.)

The diagram above showed the pressures for walking. This diagram below shows the pressures during running.
http://trainingclinic.vivobarefoot....oception-Making_Sense_of_Barefoot_Running.pdf

walkrunsprint.jpg

Regarding your thought of examining the iliopsoas, I've noticed that my hip flexors are tight. I think that it's in large part due to sitting during my job. I've been trying to stretch them, and strengthen the glutes. Is this what you mean, or did you have something else in mind? Thanks!
 
partly, yes. siting is not good for us. those muscles could be bound by trigger points which will have to be released first or they'll just tighten the trigger points more if you just stretch them.

i also was only engaging my big toe while running. still caused problems. trying to sort them out with the help of those vids you posted.
 
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partly, yes. siting is not good for us. those muscles could be bound by trigger points which will have to be released first or they'll just tighten the trigger points more if you just stretch them.
I felt out the trigger points for the iliopsoas, and I don't think that they need releasing. I suspect that over a year of not running, probably left my glutes in crummy condition. I think that this will improve over time.

i also was only engaging my big toe while running. still caused problems. trying to sort them out with the help of those vids you posted.
So, I tried engaging the left big toe, first for a 1 mile walk, just to get the feel of it. It felt awesome! Then I ran, and it still felt awesome for 3 miles. :D Then my toe got fatigued when I picked up the pace, and my foot was smashing into the ground again. I feel really encouraged, that I've found the problem. In my case, I think that the bunion put my toe out of alignment, limiting proper functioning, leading to weakening of the muscles over years. My right big toe engages automatically, and I'd like to see my left one do the same eventually.

Do you have bunions also?
 
Update: Activating the big toe flexors really is working well for me. I'm also able to engage the abductor as well, which helps with my bunion.

Apparently, it is hard to change one's gait. I walk/jog each morning, and somehow was forgetting the new gait after 24 hours (maybe due to being in shoes for work?) So, I've ended up doing it twice a day now, and it has really seemed to help.
 
No bunions. Just weak feet. Still.
 
As an update, in terms of gait, my left foot was all sorts of messed up. All that time trying to spread the big toe, to target the bunion, I somehow "forgot" that the toe goes through progressive extension and flexion during gait. I'm sure having a weak toe, due to having a bunion didn't help.

So I tried extending the toe, and that helped a bit. I also tried to activate the other toes, which helped a bit.

Since I've been walking with a backpack and now a weight vest, I've noticed that my gait has improved substantially. It's really helped to strengthen both feet. In particular, on my weaker left foot, the big toe is stronger and more firmly planted. The abductor hallucis is stronger. My gait has improved, and I'm utilizing the entire forefoot pad now.

I think that I'm almost there! :D
 
I've continued to work on developing strength and flexibility. It seems that activating the appropriate muscles during the right time in the gait cycle is important.

I've been working on toe splay, as shown in the video below around 10:43. It seems to be helping!

The Gait Guys: Some strategies in Controlling the Foot Arches and Big Toe
Dr. Shawn Allen of The Gait Guys speaks about proper stabilization of the medial foot and arch.
 
As an update, in terms of gait, my left foot was all sorts of messed up. All that time trying to spread the big toe, to target the bunion, I somehow "forgot" that the toe goes through progressive extension and flexion during gait. I'm sure having a weak toe, due to having a bunion didn't help.

So I tried extending the toe, and that helped a bit. I also tried to activate the other toes, which helped a bit.

Since I've been walking with a backpack and now a weight vest, I've noticed that my gait has improved substantially. It's really helped to strengthen both feet. In particular, on my weaker left foot, the big toe is stronger and more firmly planted. The abductor hallucis is stronger. My gait has improved, and I'm utilizing the entire forefoot pad now.

I think that I'm almost there! :D
Sid, you are the most "foot-aware" person I know. This post is just one example of that. ;)
 
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Using YogaToes, I've been working on developing flexibility and range of motion today. While walking the dogs, I found out that short, quick strides help with toe extension and splay. This all seemed to helped with my evening run. Nice and springy, and my left foot stopped making the slapping sound. Progress! :D
 

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