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Lateral forefoot striker in elite runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Oct 20, 2009.


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    hi need some help.

    Ive been treating this patient for variuos problems for the last 3 years.

    two main are stress reaction left > right 3rd and 4th met heads

    achilles and soleus pain right > left.

    She is runs 5000 and 10 000 for Sweden and during heavy training can run up to 140 km weeks.

    With regards to her forfoot pain she is now painfree.

    Her achilles pain is now ok due to the fact that she is only running 70-85 km weeks at the moment. but as soon as the km´s go up the pain returns.

    I have constructed 3 different device for her flats, racing flats and spikes. She is a feel runner and does not like to be over controlled.

    ff valgus
    plantarflexed 1st
    reduced triceps surea rom
    slightly reduced 1st ray and 1st mtp joint rom
    toe gripping
    slightly increased rom stj and mtj
    reduced hip flexor and lower core strenght

    running mechanics
    lateral forefoot striker
    up right running position
    ´sits´at hips ie not good forward hip position

    eccentric program for achilles
    heel lifts on and off.( if forefoot is slightly painful then out )
    stregthening core and hipflexors.

    She is about to go into heavy training in spain for 5 weeks and am wondering about changing the forefoot postion.

    She tends to have problems when I change the device so will need to be alittle conservative.

    My question is varus or valgus posting for the forefoot.

    If I Valgus post the forefoot will be better balanced, but the load on the 1st ray and mtp will increase and so will the soleus load.

    If I varus post it will more load on the lateral forefoot but reduced load on the soleus and will go against her natural forefoot position.

    Im thinking ff valgus post with self mobs for 1st ray and 1st mtp at the moment anyone got any other suggestions ?
  2. Sammo

    Sammo Active Member

    Hi Michael,

    Quick question: If you valgus post the forefoot, wont you increase the force acting on it as the forefoot must rotate further in the frontal plane before the 1st mpj loads?

    How about trying a 5th ray cut out.

    The 5th ray has it's own axis of movement and I've used it very successfully in people with mainly limited calcaneal eversion where the 5th ray loads to much and causes pathology (4-5 IM muscle/ligamentous strain, 5th met-cuboid dorsal compression/impingement). This will mean the 5th isn't under as high a pronatory moment/dorsiflexion force. Works similar to a forefoot varus wedge..

    Either that or try the ankle Rom Mob shown on the front page, as it is calf pain??

    Just some ideas....

  3. A forefoot Valgus pad will increase force on the forefoot yes which is my concern since the hx of 3rd and 4th met head problems. It will help transfer more load to the 1st ray and 1st mtp and it should also occur faster by everting the forefoot. This should increase the windlass effect which will I hope reduce the load on the soleus the problem with this patient is the plantarflexed 1st ray and reduced 1st mtp and 1st ray rom. Thats what I´m thinking.

    Sorry it is part of her treatment plan I lost my original post and must not have put it in the 2nd time.
  4. Sammo

    Sammo Active Member

    Whoops, I meant lateral forefoot.

    Why does she get the 3-4 MPJ problems, is it capsulitis? If so is it due to a "low gear" type gait? I don't think it's mentioned but I'm guessing she has a supinated/cavoid foot type?

  5. Michael:

    My guess is that your runner-patient is a forefoot/midfoot striker and as such is landing mostly on the lateral metatarsal heads (3rd and 4th metatarsal stress reactions) which then increases the eccentric load on the gastroc-soleus (calf pain) during the first half of the support phase of her running gait. Rather than use forefoot valgus/varus wedging under the metatarsal heads, I would try putting in soft heel lift that tapers to end just at the metatarsal neck level. This modification would accomplish the following:

    1. Decrease the bending moment at the 3rd and 4th metatarsal necks.

    2. Decrease the eccentric load on the gastroc-solues by having her strike more on the heel and less on the forefoto during the initial half of support phase.

    Hope this helps.
  6. The only thing I would perhaps add to Kevin's suggestions and your treatment list above would be mobilizations for ankle as seen in the video Bruce did, you might find this helps with ankle RoM and to bring the heel down. Also, what are the hamstrings like length wise? If you dont' get sufficient knee extension and /or ankle dorsiflexion, runners will often "drop in" onto their forefoot. I use a modified PNF stretching technique to help with this. Basics of this: Take target muscle to stretch barrier; isometric contraction in target muscle held for about 10 seconds followed by concentric contraction of the target muscles antagonist. The premise being that we get post-isometric relaxation / latency and reciprocal inhibition in the target muscle by stretching in this way- this may or may not be true, but the results I've had with it seem to be good and the low number of repetitions and instant, observable results generally goes down well with runners.

    Overview on facilitated stretching here:


    Book here:

    Nice little "how to" book. I was once asked by a student (who was peering at my book collection at the time) which was my favourite book, I told him it was the one above as it was cheap and gave me something I could use clinically the day I got it. Moreover, the guy on the front cover of the second edition has got a tremendous mullet. I note second hand copies available from $1.77- got to be worth it, you couldn't even buy a pint for that much!!!
  7. Thanks Kevin we have tried heel lift but then have been from a harder eva and finish more posterior than you suggested. The softer longer makes a bit more sense.
    Thanks again
  8. How high a heel lift have you tried? Also, a no-brainer really, but you can loose weight by drilling out holes in the underside of the foam that you make the heel lift out of, if you wish. Although increased weight might well help to bring the heel down- catch 22 when dealing with elite runners.
  9. thanks for those Simon.
    Her physio and I have her doing a huge range of different stretching. Im a huge fan of PNF and other facilitated stretching use it most days at the clinic.

    Still might have to buy the book love a good mullet or hockey hair as its called over here. Business on the front, party on the back.

    I missed writing about the ankle mobs in the original tx plan, but they are being used too.

    Thanks again
  10. We have been from 10 mm down to 5 mm tappered It was dense material but she would complain that her 3-4 met pain would return. But ive got some 10 mm very soft material at work that is very light and spoonge which I think would work well. The material would compress under load which will reduce the forward moment of COP when compaired to the harder eva.
  11. I have used Spenco insole material (neoprene) in my runners with good results. Just don't think you want a forefoot extension of any type under the metatarsal heads due to the stress reactions at the metatarsal necks and her tight gastroc-soleus complex.
  12. CraigT

    CraigT Well-Known Member

    Hi Michael
    A couple of quick questions...
    What material are your orthoses made from?
    Does she have much of a lat long arch when NWB?
    The reason I ask is that I have found some good success with midfoot and forefoot runners who load the 5th mtpj heavily by ensuring there is good lateral midfoot contact through the cuboid region and using a shell device.
    My rational is that you are decreasing the pronatory force by decreasing the length of the lever arm that is the forefoot at foot strike. This does not mean you don't still use a heel lift, but you may not need it to be as high.
  13. Hi Craig.
    We have used ever type of material for her orthoses. We have now settled on 4 mm copolymer for her flats and full length thin eva for her racing flats and spikes.

    I went down the cuboid notch/high lateral arch in a earlier model for her but she hated them could not run in them hated the feel.

    Runners give me a dog walker any day for less of " I DON´T LIKE THE FEEL OF THIS"
  14. matthew malone

    matthew malone Active Member

    Hi Michael

    I have had similar problems with fell runners i see where there fell shoes are so shallow, you can only just squeeze in a thin plastic / carbon device..trying to add a raise in these shoes is just a nightmare. I have been working with some orthopods for the past few years doing lots of mods to shoes - i have taken this into the sports side of things and have recently seen a fell runner where i sent his fell shoe off to a specialist orthopaedic shoe company - i requested that they split the sole unit of the shoe in half and sandwhich in a 10mm tapered through raise to just behind the met heads as kevin suggested. The shoe came back and you couldnt even tell the raise had been done, and it worked a treat! it maybe worth trying something like this becuase then you have more room for the orthotic?

    Of note - does anyone think there would be a difference in function of a sole unit raise compared to the raise being on an orthotic?

  15. Hi Matthew, I think that is defintley something to try thanks for the idea.

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