Separating foot types into supinators or pronators may provide adequate assessment for treatment. However, for a more specific treatment plan it would be advantageous to understand the possible abnormalities and pathomechanics of the forefoot and rearfoot (calcaneus). More importantly, knowledge of these abnomalities/pathomechanics will also prevent deleterious treatment.For example, providing medial calcaneal mobilizations/releases for the overpronator would be great if the patient has a compensated calcaneal varus. But if the patient has a compensated forefoot varus the medial mobilization/release would likely worsen their injury. It may sound complicated, but once you understand these 3 foot abnormalities and pathomechanics it will make sense.Foot Pathomechanics = compensations that occur from foot abnormalities during weight bearing tasks
The 3 Foot Abnormalities
- Calcaneal (Rearfoot) Varus
- Forefoot Varus
- Forefoot Valgus
Basic Foot Knowledge
The foot can be simplified into a structure that has 2 jobs: mobility (pronation) and stability (supination). It requires adequate mobility to adapt to ground surfaces and facilitate shock-absorption. It requires stability to function as a rigid lever for efficient propulsion. Failure of either of these jobs will cause great dysfunction throughout the body.This stability and mobiilty is dependent on an intricate passive and dynamic system. The passive system of bone orientation and joint congruency help to provide static stability when aligned, and flexibility when not aligned. The dynamic system of the muscles help to reinforce stability and allow for controlled flexibility (eccentric loading). When there is an abnormality in the foot alignment or structural, the subtalor joint often compensates by altering the normal balance of stability and mobility.Treating the compensation may provide the patient relief. But for full resolution of the dysfunction you will need to correct and remove the cause.
Normal Foot
Normal neutral foot alignement is compromised of 3 things: 1) Neutral Subtalor Joint 2) Vertical Calcaeus (in line with lower leg) 3) Metatarsal Heads Perpendicular to neutral calcaneus/subtalor joint. This is the position for optimal functioning of both passive and dynamic systems.
Assessment
Postural assessments should be viewed from all angles. An anterior view will show any sagittal plane deviation (forefoot abduction). An oblique view will give a good assessment of the arch and navicular hight. A posterior view will display calcaneal and subtalor positions.Once you have a postural assessment, it is important to determine the foot alignment and structure. There are many ways to accomplish this. Finding talor neutral (anterior palpation), lower leg to rearfoot alignment, unbiased passive dorsiflexion, joint play, postural foot assessment, and gait analysis. I find it best to use a combination of these assessments. If you understand the possible types of pathomechanics and forefoot/rearfoot alignment it will make it easier to determine exactly which foot type your patient has.Finally, you want analyze their gait to see how the patient dynamically uses their foot alignment and structure. The static postural foot assessment will help give you an indication of what you should be looking for during the analysis. You want to not only look for over or under pronation, but try to assess for 3 specific aspects of the dysfunctional motion (compensation). This is of paramount importance because it is the compensations that will dictate which structures you need to treat.
3 Aspects of Dysfunctional Motion
- Amount of Motion
- Speed of the Motion
- Timing of the Motion
Calcaneal (Rearfoot) Varus
This is the most common foot abnormality. However, it may or may not be a clinical problem.Calcaneal/Rearfoot varus is when the calcaneas is inverted with the subtalor joint is in neutral and the forefoot is perpendicular to the lower leg. This foot abnormality is more supinated at heel strike. These patients often present with decreased lateral (eversion) subtalor joint play.Compnesations include overpronation or 1st ray plantarflexion to allow the medial forefoot to contact the ground.
Posture Assessment
Uncompensated
Calcaneus Inverted & Navicular Raised = Supinated
Compensations: Distal = Plantarflex 1st Ray, Proximal = Varus Tibia
Compensated
Calcaneus Vertical & Navicular Collapse = Pronated
Gait Assessment
Abnormal compensatory pronation (amount & speed) will occur at heel strike and continue until heel rise. After the heel is off the ground the foot is able to supinate in time for a fairly normal propulsion. These patients differ from forefoot varus in that the calcaneus does not go into excessive valgus (eversion).http://www.youtube.com/watch?v=5GYI8zA-Rz8
Forefoot Varus
This is the most destructive foot abnormality to the lower extremity. Because of this, it is the most clinically common pathomechanical abnormality.Forefoot varus is when the forefoot is inverted (big toe higher than 5th toe) while the subtalor joint and calcaneus are in neutral. This foot abnormality almost always causes over pronation. Joint play is often excessive.Compensations include calcaneal eversion and navicular collapse to allow forefoot to contact the surface.
Posture Assessment
Uncompensated (very uncommon)
Calcaneus Vertical & Navicular Raised = Supination (lateral foot weight shift, 1st ray off ground)
Compensated
Calcaneal Valgus (everted) & Navicular Collapse & Forefoot Abduction= Pronated
Gait Assessment
To allow for the inverted forefoot to contact the ground there is excessive compensatory pronation (amount & timing) beginning at the foot flat phase of the gait cycle. This continues for the rest of the stance phase, causing the patient to push-off with an unlocked pronated foot. This is a major clinical problem since push-off requires a rigid supinated foot to use as a lever for propulsion. These patients differ from calcaneus varus because they are not able to achieve any supination prior to push-off.http://www.youtube.com/watch?v=yua1W4GTjAk
Forefoot Valgus
This foot abnormality often presents in patients with rigid and supinated feet (unlike forefoot varus). Since they are already in a supinated posture they are at higher risk for inversion ankle sprains.Forefoot valgus is when the forefoot is everted while the calcaneus and subtalor joint are in neutral. The medial metatarsals lie below the calcaneus (plantar flexed in relation to the calcaneus). There are two different types: total valgus (all the toes slope down) or 1st ray plantarflexion. This foot type often presents with restricted joint play (midfoot, 1st ray, calcaneus).Since the metatarsals lie below the calcaneus it is nearly impossible not to compensate. The patient must supinate to accomodate this abnormality. This may lead to a calcaneal varus compensation.
Postural Assessment
Uncompensated
Very uncommon - would cause a significant amount of increased pressure on the first ray
Compensated
Calcaneal Varus (inverted) & Naviclar Raised = Supinated
Gait Assessment
Excessive compensatory supination occurs (amount & timing) after heel strike due to premature loading of the forefoot. Pronation is insufficient, but may occur at the end of stance phase to allow for knee flexion. This foot abnormality has trouble attenuating loading forces, thus proximal joints are forced to accomodate.http://www.youtube.com/watch?v=Q0zLo420j2A
Bottom Line
It is important to note that these abnormalities and pathomechanics are not black and white. They exist on a continuum and are often times combined. Being able to further assess your pronators and supinators into a specific pathomechanical foot type will improve your plan of care and allow you to provide your patients with specific interventions to fix the culprit of the problem.Supinators (Pes Cavus)
Uncompensated Calcaneal Varus & Compensated Forefoot Valgus
Pronators (Pes Planus)
Compensated Calcaneal Varus & Compensated Forefoot Varus
While this post focused specifically at the local foot and ankle joint, it's important to consider regional interdependence. Remember that the height and rigidity of the arch can be affected by tibial internal and external rotation (in closed chain). And this tibial motion is further influenced by it's proximal structures.
Dig Deeper
Running Injuries - Foot TypesPhases of GaitSomastruct - Forefoot Varus - Overpronation - Intrinsic Foot Strengthening - Arch StrengtheningPhysioblogger - Plantarflexed 1st Ray
References
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Keys to Achilles Tendon Repair Rehab
Achilles tendon ruptures can be a very frustrating rehab for both the patient and the clinician. The patient has to wear a boot of shame for 4-8 weeks and are very limited in the amount of activity they can perform. Clinicians are often frustrated since these surgeries require a very particular rehab protocol and are limited as to which interventions they can use. However, one good thing about treating a achilles tendon repair is that you really only have to be worried about two things:
- Protecting the passive tension and integrity of the repaired Achilles tendon to prevent an insufficiency of the muscle-length tension relationship (avoid stretching past neutral for 3 months)
- Strengthening end-range plantarflexion strength
Avoid Insufficiency of the Achilles Tendon
Remember taking of the rubber bands off that new baseball glove that you have been trying to break in? They didn't exactly recoil back to their normal shape. In fact, you had to throw them away most of the time because they lost their function. They were stretched out too much and the elasticity was now only mildly useful with a object much larger than your baseball glove.Achilles tendon repair rehabilitation is very similar to this rubber band. The surgeon and the patient go through a lot of trouble to regain the passive tension and viscoelastic properties of the newly repaired tendon. The worst thing you can do as a physical therapist is to compromise the surgery by lengthening the achilles tendon in the first 3 months when the structure is vulnerable.
Why Not to Stretch
Stretching the tendon too early will cause the collagen to heal in an insufficient length. More specifically, pre-mature anatomical lengthening will increase tendon compliance, decrease viscoelastic properties, and a shift the muscle length-tension relationship to the right. Thus, the muscle would be unable to produce adequate force at shorter lengths. This increased tendon lengthening would also cause greater muscle shortening during muscle contraction, further preventing an optimal muscle-length tension relationship for force production.Given the nature of the surgery and rehabillitation, I feel it is important to opt on side of caution when considering dorsiflexion ROM. You can always add ROM later in the course of recovery when the structure is completely healed, but you cannot put back the passive tension and elasticity in the tendon once it is over stretched.This conservative approach will help keep the surgeon and the patient satisfied in the long run. Two keys to avoiding insufficiency and decreased function of the achilles tendon are:
- Do not stretch the achilles tendon past neutral for 3 months
- Add a heel-lift to footwear
Strengthen End-Range Plantarflexion
End-range plantarflexion strength goes hand in hand with the muscle-length tension relationship mentioned above. You can help to further accelerate your patients outcome by strengthening the gastroc-soleus complex in the end-range, shortened position. This is not only a safe intervention due to the absent passive tension placed on the structure, but it is a very functional ability for everyday activities (walking, stair negotiation, landing from a jump, etc.).Mullaney et al studied the strength of end-range plantarflexion in 20 patients post-operatively after an Achilles tendon repair (mean 1.8 years). They found that there was a decrease in passive stiffness in dorsiflexion (see above) as well as a weakness in end-range plantarflexion strength. Testing end-range plantarflexion with a decline heel raise, they found that 14 out of 20 of the patients could not perform this task. The authors hypothisized that this was due to anatomical lengthening, increase tendon compliance, and insufficient rehab.
Interventions for End-Range Plantarflexion
To ensure that you are not apart of the "insufficient rehab" variable, strengthen your patients plantarflexors in the end-range position. There are two ways to do this: toe walking and decline heel raises. Toe walking may be a more advanced technique due to increased amount of weight bearing and stability required. Therefore, I would begin with a small angle of decline heel rises and progress as tolerated.
Bottom Line
Achilles tendon repair rehabillitation can be a difficult process for both the clinician and patient. Preventing anatomical lengthening of the Achilles tendon will lead to greater satisfaction and function for your patient in the long run.
- Do not stretch past neutral into dorsiflexion for the first 3 months
- Add a heel lift into footwear
- Increase end-range plantarflexion strength (decline heel raises, toe walking)
References
Mullaney MJ, Mchugh MP,Tyler TF, et al. Weakness in End-Range Plantar Flexion After Achilles Tendon Repair. Am J Sports Med. 2006 Jul;34(7):1120-5 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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How To Pick Your Kicks (Part 3 of 3)
Assessing your static and dynamic foot type can be difficult, but it seems simple when compared to the complexity and confusion associated with selecting the right shoes for your feet.This post will be focused on shoe selection and how to use information from the parts 1 & 2 to help you choose the right shoes.
Shoe Selection
Basic selection starts with finding which “group” your feet belong to. Using the previous 2 posts you can attempt to classify your foot type as either a supinator, neutral, or pronator. Within each category there is a continuum from minimal, moderate, to severe. Each different foot type is going to have a corresponding shoe type.
Shoe Characteristics
Shoe companies have come a long way since the one-size-fits-all flat soled shoe. While Converse still has a place in punk-rock bands and hipsters, it is fairly conclusive that these type of flats are not the best for athletic activities. Today there is a plethora of shoes available to accommodate just about every possible foot types. Walking into a shoe store can be confusing with all the different companies and characteristics. But to attempt to keep it simple, just look at 2 characteristics: pronation control and features.
Pronation Control
This is the most important characteristic to consider when choosing footwear. You want enough support to prevent any ankle instability or over-pronation, but not too much support to where it limits your normal foot motion. The midsole of the shoe is usually the predictor of how much support/control the shoe provides.Pronation control ranges from minimal (neutral foot types) to maximal (severe pronators) support
- Neutral shoes are for neutral foot types that have no over-pronating tendencies
- Support shoes helps maintain a neutral position of the foot during dynamic activities and prevent mild-mod over-pronating
- Motion control shoes will have a more aggressive support against severe over-pronating or severe ankle instability
Features
This is where the shoe companies often times try to separate themselves with the "latest technologies and innovations". Regardless of what the shoe companies are selling, the function of the features is always the same. It comes down to how much and what type of cushioning system the shoe has. The trade off here is that the more cushioning a shoe has, the heavier it is. Therefore, it is important to find the right amount of cushioning for your comfort and support, but not too much to where you care carrying unnecessary weight.Like pronation control, features can be considered on a continuum from minimal to maximal cushioning/features
- Minimal feature/cushioned shoes will usually be lighter and are best for athletes who don't need shock support and are not big heel strikers
- Maximal feature/cushioned shoes will usually be heavier and are best for athletes who require a great deal of shock support, have a strong heel strike and/or are over-supinators
Foot Type and Possible Shoe Type
This table will hopefully provide an idea of what shoe type might be best for you. Each individual has a unique foot type and therefore simply categorizing yourself into a 1 of 3 category is not always the answer. It all comes down to the proper fit, support, and comfort. Hopefully this table will give you a place to begin your search.
Considerations
Shoes are Made for Specific Athletic Activities
◊ Running shoes give anterior-posterior (sagittal) support
◊ Cross-Training shoes give more medial-lateral (coronal) support
◊ Always consider which event you are performing as you will need a shoe that can meet the specific demands of that activity
Where to Buy
◊ There are many specialty running stores and shoe stores that have a knowledgeable staff that can help you (please don't waste your time and money by going to the mall or a corporate chain store)
◊ If you have any injuries or pain it is best to be evaluated and fitted by a trained professional
◊ It helps to bring in your old shoes so that they can be assessed for the wear and tear
Wear Them in First
Wear your shoes in slowly. Try wearing them around some before going for a long run in a brand new shoe. This can possibly prevent some pain with the change in footwear.
When to buy new shoes?
General acceptable range is between 300-500 miles
Summary
Hopefully this 3 post series provides some information and understanding to the confusing world of footwear. As mentioned above, there are many factors to consider when choosing which shoes are right for you. Even if these posts do not lead you to the perfect shoe, I hope that it will at least prevent you from running in the wrong shoe.Part 1 - Static Foot AssessmentPart 2 - Dynamic Foot Assessment
Dig Deeper
www.runnersworld.comwww.runnerswarehouse.comhttp://www.wilkpt.com/Articles/Singles/buyingtherightshoe.htmlhttp://chrisjohnsonpt.com/defective-running-shoes-as-a-contributing-factor-in-running-injuries/
Update 2015
While this blog post series may provide some helpful knowledge, it should be known that static foot posture and selecting shoes based off of this foot type is not the best option. For more information please read this article on pathomechanics and refer to the GaitGuys for the most up to date information on shoes, feet, and gait.
How To Pick Your Kicks (Part 2 or 3)
In the last post we discussed how to assess your foot type in static positions. Knowing your static foot type gives you a good place to start, but you really want to be choosing your footwear based on the dynamic support it can provide for your athletic activities. However, for a true dynamic assessment you should seek the help of a trained individual.Hopefully this post will give you some useful information to help you understand more about your possible dynamic foot type.
Assess Your Foot Type
3 Foot Types
Remember this is a CONTINUUM and an oversimplification.
- Supinators (pes cavus, high arching feet)
- Neutral
- Pronators (pes planus, flat feet)
3 Ways to Assess Your Dynamic Foot Type
- Balance on 1 Foot (Barefoot) - Try to balance for 30sec-1min to allow the possible instability to display itself. Placing a camera behind to view the heel and subsequent movement will provide the best assessment
- Check Your Kicks - Look at the soles of your old shoes (supinators wear on the outside toes, pronators wear more on the inside toes)
- Film Yourself Running on a Treadmill - Of course a 30 sec clip of a quick jog won't provide the most accurate assessment of how your running gait, but may show some possible tendencies. A proper gait analysis involving the whole body from various positions would be required to truly assess for foot type and preferred footwear.
Results
Pronator
◊ If your foot has the tendency to “roll in” ( inner ankle goes towards the ground)
◊ Heel is angled outward (rear foot eversion, calcaneovalgus)
Chris Johnson has a great post and video of someone who dynamically pronates ("runner's wobble").http://chrisjohnsonpt.com/the-wobbly-runner-and-recurrent-injury/
Neutral
◊ If your foot has minimal movement and stays in neutral position
◊ Heel is angled vertically
Supinator
◊ If your foot has the tendency to “arch up” (outer ankle goes towards the ground)
◊ Heel is angled inward (rear foot inversion, calcaneovarus)
Example of Gait Analysis at the Foot/Ankle
This picture shoes an oversimplification of what a video analysis of running gait may show at the foot and ankle.
Now What...
Having an idea of your static and dynamic foot type will give you a better idea of what type of shoe is best for you. Again, it's best to get a professionals opinion, especially if you are experiencing injuries or pain. But hopefully these last 2 posts will provide some information to help you understand your foot type.The next post will deal with the types of shoes available and how they correlate with foot type.Part 1 - Static Assessment of Foot TypePart 3 - Shoe Selection
Update 2015
While this blog post series may provide some helpful knowledge, it should be known that static foot posture and selecting shoes based off of this foot type is not the best option. For more information please read this article on pathomechanics and refer to the GaitGuys for the most up to date information on shoes, feet, and gait.
How To Pick Your Kicks (Part 1 of 3)
Shoe shopping can be a very complicated and confusing process. Choosing the proper shoe can ensure injury protection and provide proper distribution of forces. Whereas choosing the wrong shoe can lead to injuries and under performance. To add to this problem, there are many stores out there with self-proclaimed “professionals” giving out the wrong advice.This post will hopefully clear up some of these concepts and begin to lead you in the right direction in choosing your next shoe.
3 Foot Types
Keep in mind that this is a CONTINUUM and that each individual has a unique static and dynamic foot type. This is a simplification to help people categorize themselves into selecting proper footwear. It is always best to seek help from a professional when selecting the proper footwear for your activities.
- Supinators (pes cavus, high arching feet)
- Neutral
- Pronators (pes planus, flat feet)
Assess Your Foot Type
3 Ways to Assess Static Foot Type
Be sure to stand with both feet pointed forward and try to distribute weight equally during assessment
- Stand in front of a mirror - look at space under arches and inner ankle position (stand at 10 o'clock and 2 o'clock to the mirror to change the angle to get different views of the inside of your arch)
- Take a picture of both feet at foot level - from behind (heels) and from the front (toes)
- Wet Test - wet feet and stand on cardboard or paper bag, then look at foot print
Results:
Supinators
◊ Increased space under the longitudinal arch (middle of foot is far off the ground)
◊ Greater curvature on the inside of the foot print
Neutral
◊ No exaggerated flattening or arching of midfoot
Pronators
◊ Decreased space under longitudinal arch (middle of foot is close to ground)
◊ Lesser curvature on the inside of the foot print
Now What...
Unfortunately most of us buy athletic shoes for athletic events and a static assessment doesn't always translate well for the dynamic demands of sports and activities. However, having an idea of your static foot type will provide a good base knowledge for what type shoe your feet may need.Part 2 - Dynamic Foot AssessmentPart 3 - Shoe Selection
Update 2015
While this blog post series may provide some helpful knowledge, it should be known that static foot posture and selecting shoes based off of this foot type is not the best option. For more information please read this article on pathomechanics and refer to the GaitGuys for the most up to date information on shoes, feet, and gait.
The Best Posterior Chain Stretch
Inflexibility of the hamstring muscle is often a prominent kink in most people's posterior kinetic chain. It's the reason why we have to sit down to tie our shoes, can't sit up-right with our legs straight out in front of us, and the reason why most of us would be very pathetic at martial arts. Having a tight hamstring is a major concern as it can lead to increased risk of injury, decrease athletic performance, and cause pain and symptoms both proximally and distally (low back pain, achilles pain, etc.).
A possible cause of this common impairment could be that the majority of the population spends a substantial amount of their time in the seated position (jobs, communting, watching tv, reading this post, etc.). This seated position puts the hamstring in a shortened position. The body responds and adapts to this habitually shortened position by decreasing the hamstring muscle length.To further complicate the problem, hamstring tightness is not just a result of muscle tightness. Fascia and neural tension are a major component of posterior leg tightness. So how can we address all of these aspects of hamstring tightness without spending 30 minutes of stretching a night?
90-90 Active Hamstring Stretch
This stretch will hit the entire posterior kinetic chain from your plantar fascia to your low back. It also works all 3 aspects of hamstring tightness (muscle, fascia, neural tension).
How to Perform
- Start on your back and grab the back of your thigh with both hands
- Your thigh should be at 90° throughout the entire stretch
- Slowly use your quadriceps to kick your leg up while flexing your foot towards you at the same time
- Pause for a second when you reach your limit
- Slowly relax your foot and drop your lower leg back to the starting position
- Repeat for 3 sets of 10-15 reps
http://www.youtube.com/watch?v=s4wgP4wjeDc
Other Considerations:
- If you are very tight and not getting much motion at all, start off with your other knee bent (in hooklying) instead of straight
- Try not to flex your neck and upper back up during the stretch, use a pillow to support your head if you need to
- Best time to stretch is within 15 minutes after working out while your body is still warm
- 3 sets of 10 a day is not a limit - adjust to what your mobility needs are
Of course there are many other considerations when addressing hamstring tightness (posture, ergonomics, muscle weakness, compensations, etc.). But I hope this article will at least give you a new way to stretch your hamstring and posterior kinetic chain. Just taking a few minutes a day for this exercise can help improve your hamstring flexibility and possibly decrease your risk for injuries. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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