Big toe drop

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Lady 46 years old - Arthritis knees and wrists. hypothyroid (but doesn't admit to thyroxine) auto immune disorder unspecified - meds, sertraline and Rebeprazole (antacid)

She has plastic orthoses made by osteopath.

Complains of lateral column pain left

Only pain elicited in clinic is by pressure to distal end of 4th metatarsal. maybe slight pain to pressure plantar cuboid left.
left lateral column very stiff, mob and manip lateral column and cuboid complex = much improved compliance to dorsiflexion. She reports reduced pain on walking now.
in walking the left knee sometimes flexes excesively and prolonged thru stance phase - left foot toe in - with rectus foot and hallux adducted, suspect to resist pronation moments - foot pronates rapidly and early and appears to now bear weight thru medial column (NB did not view barefoot walk before mobs on left) NB both feet rectus.
Good ankle roms both - left foot has elevated 1st ray /mpj. good hip roms external and int roms. no LLD noted in stance or sitting.
both feet f/foot supinatus flexible right a little stiffer left, stiff 5th lateral column and midfoot roms both when stabilising STJ open chain. left had very medially rotated STJ axis with projection from mid lateral heel to distal shaft 1st Ray. right has central stj axis. heavy supination test both
AM3 pressure mat scan shows both have FncHL and left foot CoPP progresses very quickly to forefoot and lateral.

Take coach's eye vid walking in clinic - tends to keep left foot pronated thru swing - probs to avoid lateral instability and heel strike. Sometimes has foot drop and drags the hallux on floor.

Podotrack prints-

Temp till new orthoses - Add poron 1st ray ext to met toe sulcus to left.
Goto bespoke orthsoes - probs salts - maybe eva. plenty of volume in hi top shoes.

Query: See attached/linked vid and pic - she sometimes drag the left big toe thru swing phase - any ideas as to why? I'm thinking perhaps she adducts the hallux to increase supination moments by GRF from the ground and she also supinates the foot early in swing phase, probably to reduce lateral instability at heel strike. Both these action also tend to plantar flex the 1st ray and hallux and so sometimes it catches on the ground and the frictional force plantarflexes the hallux more. Also excessive knee flexion thru stance phase may not allow enough time for the CoM to get high enough or enough hip flexion for foot ground clearance.
https://www.coachseye.com/v/f23dac1ed3e347afacb7e334c8cc84f8

 

You can also see the low gear push off concomitant with the CoPP lateral excursion seen on pressure mapping. I think this might be contributing to the toe drop/drag. The supinating foot and the internal ttibial rotation causes the toe to rotate toward the ground.

 

Did you ask her why her knee flexes during stance.
Hallux adducted to resist pronation moments?
When does the rapid pronation occur. Immediately after lateral forefoot strike. Or after medial forefoot loading?

Heavy supination test? = hard to supinate in supination resistance test?

What was muscle strength? One cause of the first toe staying down in the video would be EHL muscle weakness.
Any spasticity? Prolonged activity of FHL muscle is another cause of plantar flexed hallux in swing.

I'm not clear on your thinking on hallux adduction and supination moments from ground reaction force.
I'm also not clear on how supination in swing affects lateral instability. Why do you think this person has lateral instability when they have a medially deviated STJ axis?
I don't think hallux adduction nor supination in swing phase will necessarily plantar flex the first ray and hallux.

 

Hi Eric - thanks for your input
"Did you ask her why her knee flexes during stance. Yes but she didn't know she did it
Hallux adducted to resist pronation moments? Ah should read abducted (in terms of foot midline)
When does the rapid pronation occur. Immediately after lateral forefoot strike. Or after medial forefoot loading?" early midstance here's a link to the whole video https://www.coachseye.com/v/1e8944c308bd4306aeb687cd83cfd1b7

"Heavy supination test? = hard to supinate in supination resistance test? yes
What was muscle strength? One cause of the first toe staying down in the video would be EHL muscle weakness.
Any spasticity? Prolonged activity of FHL muscle is another cause of plantar flexed hallux in swing". didn't do muscle testing - time restraint and only noticed toe drop at last minute and then when assessing video later. The full toe drop/drag only happens once in a while but the right does do it also to a lesser extent.

"I'm not clear on your thinking on hallux adduction and supination moments from ground reaction force.
I'm also not clear on how supination in swing affects lateral instability. Why do you think this person has lateral instability when they have a medially deviated STJ axis? ah that should read active pronation in swing. She has medially rotated STJ axis so that the posterior projection is lateral to the calcaneal centre. therefore as she lands on the heel the rearfoot experiences a supination moment about the stj, therefore pronating the foot in swing loads the peroneals to resist supination moments by GRF. another strategy can be to supinate the foot to land on the lateral side of the stj axis resulting in a small pronation moment about the stj at heel strike. The problem with this strategy is that if you hit an uneven surface tending to supinate the foot then the pronator muscle group is not primed to react in time to stop lateral instability.
I don't think hallux adduction (edit abd) nor supination (edit pronation) in swing phase will necessarily plantar flex the first ray and hallux."
Apologies for typing errors