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Hip to Big Toe!!!

Discussion in 'Biomechanics, Sports and Foot orthoses' started by DMac, Nov 9, 2012.

  1. DMac

    DMac Welcome New Poster

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    Hi all,

    I am a Sports Rehab grad seeking sound advice from you low limb biomechanic geeks! I'll keep this as concise and relevant as possible!

    I have a patient who presented complaining of left anterior hip pain of 2/12 in duration. Questioning revealed a long standing issue with 'achilles tendonitis' (5-10yrs) aggravated by running. Examination showed a postive Thomas test for mobility of psoas, iliacus & TFL (rec fem ok), reduced dorsiflexion and hallux limitus (practically rigidus) on the left. His tib post muscle was like a rope on palpation and this was the source of pain for his 'achilles tendonitis'. Further quizzing found that he used (15yrs ago) to suffer from pain in his left big toe but not anymore. On gait observation I notice he supinates at midstance and can see a firing of the lat soleus and tib post directly preceding this.
    I prescribed 1st ray mobs, plantar fascia t-balling, dorsi mobs, tib post manual Rx and hip mobs.
    The hip is better but the 1st Ray is as stiff, the plantar fascia loosens but tightens again as does his tib post which I am sending him to laser surgery for.
    i believe his issue is his avoidance of his 1st Ray and the subseqent affect this has, he has been to a podiatrist in the past but was given a first ray cut out. I am sending to a podiatrist again and would like to accompany my letter of referral with some form of possible reccomendation.
    What would you reccomend to prevent the tib post from murdering itself trying to lift him off the first ray (assuming my dx is accurate)?

    I would greatly appreciate the considered opinions from the illuminated minds that roam this forum, obviously if you have any questions please fire them out to me.

    Thanking you in advance,

  2. David Smith

    David Smith Well-Known Member

    From the info available I would say that the foot supinates to avoid the hallux rigidus or Functional Hallux rigidus. The STJ axis is probably central to slightly medial (can you assess the position of the STJ axis?) and so the Post Tib has to work hard to supinate the foot. Does the foot pronate a lot in early stance? Is the 5th ray stiff to dorsiflexion by ground reaction force? Is there inhibited STJ eversion RoM? i.e. there may be little actual pronation in early to mid stance but there may be high external pronation moments about the STJ resisted by osseous or soft tissues (maybe, as you propose, the post tib).
    Anyway I find that if there is ITB pain/Gt bursitis including TFL pain (is this the anterior hip pain you mention?) then there is often a early pronation late supinating foot causing alternating (directional) moments about the hip.

    So in terms of the orthotic design treat this like Posterior tibial tendon dysfunction.
    Medial skive, with deep heel cup and high medial flange. Have a 2nd - 5th medial forefoot post to suit the flexibility of the forefoot/lateral column (oe even a lateral post if the lateral column is very compliant to GRF dorsiflexion.

    1st MPJ/ray cut out or dell at the appropriate depth to suit the position and compliance of the 1st ray and in this case I would build in a 4mm drop of anterior to the 1st MPJ so the hallux can drop into it and reduce time and magnitude of the hallux dorsiflexion moments. A rocker shoe such as Sketchers tone ups (but not MBT's as they are to soft and unstable in the frontal; plane i.e they allow or encourage pronation and supination of the STJ)

    Just some ideas to work with

    Regards Dave Smith
    Last edited: Nov 9, 2012
  3. efuller

    efuller MVP

    Pain avoidance for a hallux rigidus is a logical explanation of the PT tendon pain. you could check for some other obscure things as it almost seems as if you describe a PT muscle spasm.

    Laser surgery for a tight plantar fascia that does not hurt or is it for the post tib tendon???? Warming/burning the plantar fascia is not going to fix his hip problem.

    The hip problem could also be caused by pain avoidance from the hallux rigidus. In walking or running you have to make the trailing leg become the leading leg. There are two options for this hip pull or ankle push. With ankle push you will be stressing the 1st MPJ. So to avoid pushing off with the foot/ankle, your patient may have chosen to use more hip pull. Do you reproduce the symptoms when checking hip flexor strength. Of course that is just a theoretical explanation. There are other possible explanations.

    On prescription device. I would not add a medial heel skive unless I saw a medially positioned STJ axis. Methods for determination of positional variations in the subtalar joint axis. Kirby KA. J Am Podiatr Med Assoc. 1987 May;77(5):228-34. The PT is working harder to avoid pain, not necessarily because there is a medially positioned STJ axis. If there was a slightly medial axis then I would give him a varus wedge type orthotic like a medial heel skive. The risk of a medial heel skive is creating peroneal tendonopathy if your device provides too much supination moment.

    Other things that may help a hallux rigidus: Rocker bottom shoes or a stiff plate in the shoe to prevent attempted flexion of the MPJ.

  4. Dananberg

    Dananberg Active Member

    I would like to give you a bit of a different take on this problem. Hallux limitus co-exists with peroneal inhibition. When the post. tibial muscle is unapposed due to this inhibited peroneal status, it must overwork in an attempt squeeze against its dysfunctional antagonist. Post tibial tendonitis often results.

    Hallux limitus blocks heel lift. When this takes place, the effect is to limit hip extension. It is further accommodated via knee flexion. The more the knee flexes during single support phase, the less hip can extend (the closed kinetic chain effect). It becomes a vicious cycle. The flexed knee gait causes gluteal overuse as it must function to support the hip in the 2nd half of single support phase (and thus out of phase for the gluts) and pain in and around the hip results.

    The most telling part of the history is the limitation of ankle joint dorsiflexion. This is associated with a restriction in fibula translation. As the fibula head is the origin of the peroneus longus, there is a responsive inhibition in the peroneus longus (although I do not know why this happens, but have seen in countless times). Manipulation of the fibula head and talo-crual joint can return ROM to normal and restore the peroneus longus to a facilitated status.

    I would STRONGLY recommend against using a carbon fiber plate to prevent hallux dorsiflexion. This only compounds the issue. Instead, try an orthotic with a large
    1st ray cutout. This permits some decompression of the 1st MTP joint. If accompanied by ankle manipulation and restoration of peroneal function....the outcomes can be excellent. I would also look carefully for LLD and add this correction to the orthotic. Since this subject is likely limping quite a bit, I would see weekly or every other week to reassess the situation. The amount of heel lift used at the start will likely decrease over time as gait smooths.

    Hope that this helps.

  5. David Smith

    David Smith Well-Known Member


    Your explanation sounds good but I am confused by the initial statement:

    What do you mean by Peroneal inhibition? Do you mean constrained in its action potential or completely blocked from operating? Are you saying the peroneal group is in tonic spasm or firing at the wrong time or the muscle is not firing at all?

    Inhibition seems to infer the muscle is not able to work, it cannot be an agonist or antagonist, if this is so how is it that the Post tib must work harder against an antagonist that isn't firing?

    Do you mean that the Post tib must contact to a resting position that is more contracted than normal in order to balance against the passive tension of the peroneal group?

    So I'm thinking (uh oh! now things get dangerous :eek:)

    Wouldn't this result in an inverted STJ position in open chain that is stiff to eversion moments? This inverted position at foot strike would result in a greater pronation moment integral, probably increased magnitude and time.

    Therefore at midstance the supination moments from the force of the shortened post tib may balance the pronation moments due to GRF and at this point the foot starts to supinated under the increased reaction of post tib.

    This may be concomitant with active hip external rotation attempting to avoid saggital plane progression perturbation from the hallux limitus/ rigidus.

    Regards Dave Smith
  6. Dananberg

    Dananberg Active Member


    Muscles are normally facilitated or inhibited by the CNS in the course of normal function. Imagine trying to perform a biceps curl exercise if the triceps were fully active and pulling in the opposite direction. When inhibited, they act....although weakly, against the opposing muscle. In the case of the peroneals, they loose sufficient "strength" to maintain a plantarflexed and stable 1st ray against ground reactive forces. Hence, the 1st met dorsiflexes and jams during
    1st MTP joint dorsiflexion.

    Once facilitated, normal strength returns to the muscle and it can 1) oppose the post tibial while trying to compress the midfoot during midstance and 2) act to keep the 1st met head against the floor.

    Muscles act to protect the joints about which they function. When specific muscles function inhibited, those joints affected by it may be painful. Restoring normal facilitation goes a long way to producing asymptomatic function.

    Try reading Yanda's work on muscle action. He was a Czech physiatrist (who is now deceased) who explored muscular imbalance (which is often attributed to a sub-clinical CP) to a host of chronic musculoskeletal conditions.

  7. efuller

    efuller MVP

    Howard, I would agree that I would not use a carbon fiber insert for a functional hallux limitus (Non weight bearing there is normal range of motion of the Hallux, but upon weight bearing it is very difficult to dorsiflex the hallux or in gait little dorsiflexion of the MPJ is seen.) However, the poster did mention nearly rigidus. I think that there is no problem using a carbon fiber plate if there is struturally no range of motion of the 1st MPJ. In fact you could use an orthotic with a first ray cut out on top of a carbon fiber plate. I would agree that the orthotic and cut out will help decrease compression at the joint and this could relieve pain. However, I don't understand how a carbon fiber plate would compound the issue. Which issue?

  8. Lorcan

    Lorcan Active Member

    Heres a link to the Janda institute;

    and this is a recent blog by Leon Chaitow,Osteopath discussing Recipricol Inhibition and Post Isometric Relaxation and their use in MET to treat hyper and hypotonic muscles.

    http://chaitowschat-leon.blogspot.ie/search?q=reciprocal inhibition

    Hope it helps.
  9. drsha

    drsha Banned

    Dr Dananberg presents Sagittal and Transverse plane biomechanics treatment for this Sagittal and Transverse plane problem.

    The rearfoot frontal plane diagnosis or treatment regimen focused on the STJ Axis and its frontal plane care with varus posts and medial skives are reactions to biomechanical changes that are primarily caused by vault, forefoot, FHL and HR biomechanics in DMacs case.

    Like wise, focus on the compensatory muscles such as PT instead of the exhausted, inhibited or aphasic primarily pathological peroneus longus in this case reflects old school biomechanics band-aids.

    I remain convinced that the bulk of the future of biomechanics care and research will live on the sagittal and transverse planes as foot surgery currently exists.

    IMHO, the frontal plane of the rearfoot and the STJ Axis, like STJ Neutral will occupy a back seat in most cases.

    Kudo's Howard.:drinks

  10. Dananberg

    Dananberg Active Member


    My experience has shown me that even a few degrees of available MTP joint dorsiflexion is better than none at all. Added to that, is that over many years, I have seen completely immobile (but not yet fused joints) gain ROM when the joint is decompressed with a 1st ray c/o and the inhibited peroneals are facilitated. Changes in hip extension are almost immediate with this, and for D-Mac's patient, it is this condition with which he is clinically challenged.

    Once one goes the route of using a carbon fiber plate, they will forever chase the symptoms caused by sagittal plane restriction....although the pain MTP joint may resolve. Doesn't sound like a successful outcome to me.

  11. Dananberg

    Dananberg Active Member


    I am not talking about peroneals as one sees in CMT. In that case, there is NO MOTOR SIGNAL to the muscle, and complete atrophy results. If, however, the muscle is receiving an inhibitory signal from the CNS, there is no atrophy, just a muscle being "weakened" in its inability to respond to its antagonist in a normal facilitated manner.

    In the case D-Mac presented, the post tibial tendon is described as "rope" like and would fit the type of situation I am describing.

    I have viewed midfoot stability as in large part related to the equal and opposite compressive forces created by the post tibial and peroneals as they cross under the foot. This serves to stabilize the midfoot to the forces present in the 2nd half of single support phase.

    When the post tibial tries to compress against an inhibited peroneus longus, it is going to overwork as proper compression is never achieved. I have seen this in young athletes countless times in post tibial tendonitis (shin splints) which occur following ankle sprain. Ankle sprain creates an environment in which the fibula translation is lost, and secondary peroneal inhibition occurs. Simple ankle manipulation can resolve the entire process.

    We have tended to try to explore biomechanics without understanding the effects of muscular activity. Moments are effected by neurological events.....and having the tools to manage these opens an entirely different treatment tool bag with which to manage these otherwise difficult cases.

  12. efuller

    efuller MVP

    A few extra degrees compared to.... relaxed stance. I'd agree with that. My own foot does that when comparing stance without orthotics to relzxed stance with orthotics. The force required to dorsiflex my hallux is much less, but I don't get more range of motion than I do non weight bearing as that is a structural issue. At least for my foot, the decompression makes more comfortable to get more weight on the ball of the foot, wich would theoretically allow more hip extension of the trailing leg.

    I sill think that the functional hallux limitus type gait is a pain avoidance type gait rather than a purely mechanical effect. Yes I know, we've been around that stump. So, if the first MPJ is acutely painful, I'd have no problem with adding a carbon fiber insert. I'd have nor problem taking it out when symptoms at the first MPJ resolve.

  13. Dananberg

    Dananberg Active Member


    Patient #1 that I identified with functional hallux limitus 30 years ago did NOT have any 1st MTP joint symptoms....only ipsilateral anterior tibial (AT) muscle pain.....and only at night. Since it was AT inversion to avoid the locking MTP joint that was etiologic to her symptoms, treating the Fnhl cured it (basically a rohadur device with large 1st c/o). The puzzle was she was compensating for something which DIDN'T HURT, and there was never any history of 1st MTP joint pain. Yet, on EDG, she inverted on one step and then jammed on the next, repeatedly.

    I would agree that pain avoidance could explain a small portion of the compensatory maneuvers....but there are actually many more who never have pain yet adjust from "toe to head". It is clearly avoidance.....yet not necessarily due to pain. Most intriguing.

  14. HansMassage

    HansMassage Active Member

    I just commented on another board about nerve entrapment by pressure on the septum between the flexor and extensor inhibiting movement of a joint. This patient as described has built up multiple layers of such possible entrapment.

    Patient myofacial reduction of agonist/antagonist conflict pressure on the nerve has been successful with clients with similar complaints.
  15. DMac

    DMac Welcome New Poster

    Thank you to everyone,
    The PT is referred for the tib post laser and has been prescribed dorsi and hip mobs. I would agree with David Smith's interpretation (the PT does pronate early in WB only to supinate - there is a visible firing of FHL and Tib Post). So in my humble opinion (and spoken without the eloquent tongue of a podiatrist) I believe that the problem is one of pain avoidance where the PT is placing and undue stress & overload on the Tib Post in mid stance to supinate the foot off the 1st MTJ. This has caused a restriction in Dorsiflexion as he never fully dorsiflexes in WB due to a poor Windlass toe off and a Hip problem further up the chain due to a 'dragging' of the limb rather than a proper toe off.
    So my revised question would be, would you write off the 1st MTJ as useless and aid the Tib Post in avoiding it and is a deep heel cup, rear foot varus posting, forefoot 2-5 posting with a drop in the 1st Ray the best way to achieve this in terms of orthotic intervention?
    Thank you again & kind regards to ye all.
  16. DMac

    DMac Welcome New Poster

    "I believe that the problem is one of pain avoidance where the PT is placing and undue stress"

    Should read: "the PT is placing an undue stress!
  17. David Smith

    David Smith Well-Known Member


    Its difficult to give you a definite prescription because we don't have the patient in our hands. You have been given lots of alternatives that may apply to your patient and it is for you to work thru that.

    So this may be a good prescription but even so it is not writing off the 1st MPJ it is facilitating its operation in terms of the windlass action, while at the same time off loading the PTib. However you say that there is a severe hallux limitus, which tends to stop the windlass action of the 1st MPJ anyway and potentially cause saggital plane progression perturbation (block). I suggest a drop off under the Hallux to optimise the saggital plane progression. Dr Danaberg suggests the Hallux RoM can be increased to facilitate the windlass action and engage the windlass and optimise saggital plane progression. Eric suggests the hip pain may be due to trick actions of the hip to avoid using ankle propulsionand so if your orthosis allows the ankle propulsion because the avoidance was due to hallux limitus joint compression pain the you may find that is the best route, its your call :eek:
    Keep up the good thinking, hope you get a eureka moment - Good Luck

    Regards Dave Smith
  18. Tkemp

    Tkemp Active Member

    Hi Danny,

    You've been given some excellent advice here.
    I would also check for functional leg length difference. If the patient is experiencing unilateral lower limb pain there can be a tendency for the trunk muscles to become unevenly contracted as the patient subconsciously tries to reduce body weight placed through that limb in gait.
    In which case, referral to a physio or soft tissue specialist for assessment and treatment would be beneficial.
  19. efuller

    efuller MVP

    What is a tib post laser and why was the patient referred for it?

    Are you referring to an ankle restriction in motion or a MPJ restriction of dorsiflexion? Supination of the STJ by the posterior tibial muscle will tend to make dorsiflexion of the hallux easier.

    I'm not happy with your wording on the windlass. I'm not sure that a poor windlass has ever been defined. I'd change the "proper toe off" to propulsive toe off. If the foot doesn't propel the leg forward, then the hip has to drag leg forward, as you said.

    If you can reduce the load on the MPJ then the body may decide it doesn't need so much posterior tibial activity. So no, don't write it off.


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