Short foot

Liberacion fascial con pelota

Activacion tibial posterior: pelota en los malolos, de puntillas
Activacion cadera profunda: tumbado, pierna de arriba 90 grados,
doblada hacia atras apoyada en foam roller, pierna de abajo, 90 grados al
frente, tirar pie de pierna de adelante hacia el techo.
Activacion suelo plvico y core: intentar llevar suelopelvico al medio,
tumbado boca arriba, mantener 10 segundos.
Apoyar un pie en la punta o levantarlo, moverlo hacia un lado desde la
cadera, dejarlo caer a un lado desde la cadera.

A navicular drop of > 10 mm would be considered

pathological.

1.

Short Foot Short foot is one of the best

exercises for someone with navicular drop as
one of the functions of the abductor hallucis
is the pick up the navicular. I often refer to
this sling effect of the abductor hallucis
during BTS Level 1
2. Ball between heels Performing a calf
raise with a ball between the heels (behind
the medial malleoli has been shown to have
some of the highest posterior tibialis muscle
activation. This exercise is also a great way
to integrate the posterior tibialis function all
the way up into hip external rotation.
3. Single leg glute exercises Everyone
knows Im a big fan of barefoot balance
exercises for the reason that it is a highly
functional exercise for glute activation.

Studies have shown that 6 weeks of glute

strengthening can create a neutral STJ in a
mildly everted foot.
FitnessRx for Increased STJ Inversion:

To neutralize the excessive inversion you will want to address both the foot
and the hips. Start with mobilization via Self Myofascial Release (SMR) of
the STJ invertors:
Tibialis anterior
Posterior tibialis
Soleus
Abductor hallucis / plantar fascia
Next, move up to the hip and mobilize (via SMR) the hip external rotators:
Gluteus medius
Piriformis
Compensation: Increased STJ Eversion

If STJ inversion means rigid and locked, then STJ eversion is going to mean
unstable and unlocked. If you notice your client striking the ground on an
unstable foot that is already unlocked, proper dissipation of ground reaction
forces is going to be compromised. Remember when we discussed how the
foot and lower extremity absorbs impact forces? It was the STJ inversion to
eversion that drove the body spirals and efficiently loaded impact forces.
If this step is compromised then efficient movement is also compromised.
Your goal is to get the client or athlete foot back into a position in which they
can strike the ground in an inverted STJ position.

FitnessRx for Increased STJ Eversion:

To neutralize the excessive eversion you will want to address both the feet and
hips. For correcting excessive STJ eversion your program will include both
mobilization and activation or strengthening.
Start with mobilization of the STJ evertors:
Peroneus brevis / longus
Gastrocnemius
Next, move up to the hip and mobilize the hip internal rotators:
Adductors
TFL
Rectus femoris
After mobilization, focus on activating / strengthening the STJ invertors:
Abductor hallucis
Tibialis anterior
Posterior tibialis
Soleus
As well as to activate and strengthen the hip external rotators:
Deep lateral rotators
Gluteus medius
Common Compensations Seen During Midstance
Compensation: Knee Valgus

The presence of knee valgus during midstance means that there is a lack of
control of the body spiral. Since midstance marks the point of peak
deceleration, knee valgus typically denotes poor eccentric control of either the
glutes and/or the foot invertors (namely the posterior tibialis).
There are two types of knee valgus which can be observed:
with STJ eversion
without STJ eversion
Compensation: Knee Valgus with STJ Eversion
Knee valgus with STJ eversion can be characterized as both a proximal and
distal spiral issue. The STJ eversion is often a compensation for weak
eccentric deceleration by the foot invertors (namely posterior tibialis). The
STJ eversion drives the knee into valgus requiring increased deceleration by
the posterior gluteus medius.

Fitness Rx for Knee Valgus with STJ Eversion:

To correct the knee valgus with STJ eversion, eccentric strengthening is a key
component to the corrective exercise programming. Before integrating the
eccentric exercises, mobilization and activation must first occur.
Start with mobilization of the STJ evertors:
Peroneus brevis / longus
Gastrocnemius
Next, move up to the hip and mobilize the hip internal rotators:
Adductors
TFL
Rectus femoris
After mobilization then you want to focus on activating / strengthening the
STJ invertors:
Abductor hallucis
Tibialis anterior
Posterior tibialis
Soleus
As well as to activate and strengthen the hip external rotators:
Deep lateral rotators
Gluteus medius
Finally, begin to integrate the eccentric exercises such as:
Negative heel lifts
Walking backwards on a treadmill
Negative step downs

Compensation: Knee Valgus without STJ Eversion

Knee valgus without STJ eversion would indicate a proximal glute issue only.
All correctives would focus on mobilization, activation and strengthening of
the hip muscles only.
Compensation: Tibial:Femoral External Rotation (TFER)

TFER is characterized by an external rotation of the tibia on the femur at the

knee joint. This is typically observed at either midstance or during the
Propulsive Phase. TFER forces the client to push-off in an altered position
which stresses proper foot alignment and creates a counter movement of the
body spiral.
The muscles which are typically over-active in TFER include:
Gastrocnemius (lateral head)
Bicep Femoris (long head)
TFL / IT band
FitnessRx for Tibial:Femoral External Rotation:
To correct for TFER, it again involves mobilization followed by
strengthening.

Begin with mobilization of:

Gastrocnemius (lateral head)
Bicep Femoris (long head)
TFL / ITB
After mobilization, progress to strengthening the muscles which will begin to
de-rotate the TFER:
Gastrocnemius (medial head)
Semimembranosis / Semitendonosis
Gluteus medius (posterior fibers)
Common Compensations Seen During Late Midstance
Compensation: Abductory Twist
The abductory twist (cigarette twist) occurs as the foot is attempting to move
through the ankle joint while the STJ is in a neutral position. A limitation in
ankle dorsiflexion will create this compensation mechanism.

Every time the foot abducts there is an activation of the hip external rotators,
namely piriformis.
FitnessRx for Abductory Twist:
To correct for the abductory twist the focus should be on restoring proper
ankle joint dorsiflexion. Focus on mobilization of both the soleus and
gastrocnemius.
Compensation: Early Heel Lift

Another common compensation for limited ankle dorsiflexion is an early heel

lift. This early heel lift causes the client to enter Swing Phase too early, which
disrupts efficient movement but also places the adductor longus at increased
risk of overuse injury.
In those clients or athletes with a true limitation of ankle dorsiflexion,
barefoot work, drop shoes and midfoot-strike running should be avoided as
this increases the stress placed on the achilles tendon.
FitnessRx for Early Heel Lift:
To correct for the early heel lift the focus should be on restoring proper ankle
joint dorsiflexion. Focus on mobilization of both the soleus and
gastrocnemius.

Common Compensations Seen During Propulsion

Compensation: Altered Push-Off

Altered push-off can be the result of limited ankle mobility, poor deceleration
of the body spiral, STJ eversion at heel strike or STJ eversion on relaxed
stance. This common push-off position compromises the activation of the
plantar fascia, the efficiency of gait and elastic recoil at push-off.
Without correcting push-off, gait can never fully be optimal.
FitnessRx for Low Gear Push-Off:
To correct for a low gear push-off we need to go back to what is driving this
compensation pattern in the first place. Is there limited ankle mobility? Is
there tibial:femoral external rotation?
The answer to these questions will determine how to address your corrective
exercise programming. See the above compensations for the
appropriate FitnessRx programming.

This past weekend I was fortunate to present at

the Perform Better Summit in Providence,
Rhode Island. This 3-day educational event is
comprised of some of the best educators and most
enthusiastic professionals in the industry. A common
theme throughout a couple of the sessions was the
association between great toe mobility and function.
The seemingly simple process of hallux dorsiflexion
during push-off is actually quite complex and if great
toe mobility is compromised it can cause a slew of
movement compensations and pain patterns.
In this 3-part blog series we will begin to explore how
this joint is stabilized, simple assessment techniques
and programming which you can easily implement
with your clients and athletes. Please note that
these articles are not all-inclusive of every
anatomical detail or compensation pattern to
learn more on this topic please check out our
EBFA Certifications.

The 1st
Metatarsophalangeal Joint (MPJ)
Formed by the head of the first metatarsal and base of
the proximal phalanx this ginglymoarthrodial
or hinge joint allows sagittal plane progression
during walking, running, jumping etc.
With the movements of plantarflexion and
dorsiflexion, optimal push-off during the gait cycle
requires at least 30 degrees of dorsiflexion but having
closer to 65 75 degrees dorsiflexion is ideal.
Limited hallux dorsiflexion during push-off can be
associated with a low-gear push off position, early heel
rise, overactive adductors and under active gluteus
maximus.
Complexity of Hallux Dorsiflexion
At first glance 1st MPJ dorsiflexion seems quite
straight forward and based on the increasing emphasis
on the great toe in many fitness and performance
lectures I think it is imperative that professionals

truly understand this joint and the complexity

associated with hallux dorsiflexion. Improving hallux
dorsiflexion requires much more than simply
integrating great toe stretches or putting a wedge
under the big toe.

So here we go.
In closed chain movements such as walking, the
propulsive phase of gait is the phase in which
maximum great toe dorsiflexion is required. As the
foot prepares for the large amount of power output
during propulsion, the flexor hallucis longus (FHL)
engages thereby anchoring the distal aspect of the
hallux to the ground.
This fixed hallux provides a stable base or lever for
propulsion thus allowing the metatarsal head to move
relative to the base of the proximal phalynx. See
picture to the right.
Sliding, Gliding and Jamming

If we break down hallux dorsiflexion even further will

find that thefirst 20 degrees of dorsiflexion the
head of the 1st metatarsalslides over the base of the
proximal phalanx.
The next 10 degrees 50 degrees of
dorsiflexion requires the 1st metatarsal
to plantarflex relative to the base of the proximal
phalynx creating a gliding movement as the foot
moves over the hallux.
The final stage of hallux dorsiflexion is
a jamming phase which holds the joint in a stable
position.
To repeat with each step we take hallux push-off
requires a timed movement pattern of sliding,
gliding and jamming of the 1st metatarsal head
relative to the base of the proximal phalanx. If the
timing is shifted or the 1st metatarsal head cannot
plantarflex relative to the proximal phalynx, then
hallux dorsiflexion will be limited and compensation
results.
So how do we ensure proper sliding,
gliding and jamming?
1st ray stability!

Of the above phases the most important phase would

be gliding phase or the plantarflexion of the 1st
metatarsal head relative to the base of the proximal
phalynx.
So then the question should be how do we ensure
that the 1st metatarsal head plantar flexes
relative to the base of the proximal phalynx?
To answer this question we must know which muscle
plantarflexes the 1st metatarsal.

For those who hav

e taken my Barefoot
Training Specialist courses especially the Level 2
you should recall that the muscle that plantarflexes the
1st metatarsal is the peroneus longus.
Running along the lateral aspect of the lower leg,
behind the lateral malleolus and under the cuboid, this
muscle attaches to the base of the 1st metatarsal and to
the medial cuneiform.

If we look closer at the peroneus longus insertion we

see that it inserts 90% on the base of the 1st metatarsal
and only 10% on the medial cuneiform. Together this
insertion controls the metatarso-cuneiform joint or
the 1st ray.
Joining the peroneus longus tendon on the medial side
is thetibialis anterior, with both of these muscles
together contributing to the Spiral Fascial Line.
1st Ray / Met-Cuneiform Stability

With the tibialis anterior and

peroneus longus as direct antagonists of each other,
balance between these two muscles is critical for 1st
ray stability or hallux dorsiflexion.
If for some biomechanical or neuromuscular reason
the tibialis anterior is more active or dominant
compared to the peroneus longus then the 1st
metatarsal (1st ray) begins to dorsflex.

If the 1st metatarsal is dorsiflexed then the gliding

phase of hallux dorsiflexion cannot occur and we get
premature jamming of the 1st MPJ, limited
dorsiflexion and compensation.
So how do we ensure balance between the
tibialis anterior and peroneus longus?
To answer this question we must go to the rear foot
where we will find the subtalar joint (STJ). STJ
position greatly dictates
the stability of not just the rear foot, but the entire foot
in general.
STJ eversion is often associated with a hyper mobile,
flexible and unstable foot and often has trouble locking

or stabilizing in a timely manne

r.
STJ eversion as indicted in the picture to the left also
causes the peroneus longus tendon to go on slack thus
giving a mechanical advantage to the tibialis anterior.
Once the tibialis anterior is given an advantage, the 1st
metatarsal begins to dorsiflex, the stability of the 1st
ray is compromised and hallux dorsiflexion is limited.

But what if you have a client with limited hallux

dorsiflexion and they have a neutral STJ position?
This is where understanding both open-chain and
closed-chain assessment techniques is important.
In Part 2 of this blog series we will explore how to
begin to assess for both structural and functional
causes of limited hallux dorsiflexion.
STJ eversion = tibial / femoral internal
rotation
STJ inversion = tibial / femoral external
rotation

Step 1 General 1st MPJ Appearance

Always start by looking at the 1st

MPJ non-weight bearing.
Do you see a bunion? Depending on the size of the
bunion this can greatly effect the integrity of the joint
as well as alter push-off position.
Do you see spurring dorsally? In the presence of
arthritis and altered joint function, the body starts to
create spurs or osteophytes along the dorsal aspect of
the joint.
These are easiest seen on X-ray but you can often see
them or palpate them along the dorsal joint line.
Depending on the degree of osteophytes they can begin
to limit hallux dorsiflexion during push-off.

Step 2 Joint Integrity

Next you want to assess the health of the joint to
determine if any arthritic changes are present. By
moving the toe up and down you are not only assessing
mobility but are more so looking for the presence of
crepitus or bone on bone.
In this step you also want to determine if there is
limited dorsiflexion open-chain. If there is a
limitation in open chain dorsiflexion you will surely
see a limitation on closed chain!
Step 3 Load the 1st Metatarsal
In Step 2 we are simply looking for joint integrity but
not getting an accurate representation of functional
hallux dorsiflexion.

If you look at the picture on the right you will see that

as I am dorsiflexing th
e hallux the 1st
metatarsal head plantar flexes greatly. This degree of
plantar flexion is not possible when standing on the
ground as it would be blocked by the ground when we
walk. This means that Step 2 assessment doesnt
really translate to closed chain dorsiflexion.
To get a more accurate representation of closed chain
mobility you want to load the 1st metatarsal head like I
am doing in the picture to the left. This mimics the
ground when closed chain. Now dorsiflex the hallux
and determine your mobility.

Step 4 Heel Rise Assessment

Next we want to have our client stand up and begin to

compare the above findings with closed chain function.
The first assessment we want to look at is a heel rise.
Not only is this a great assessment for determining the
foots ability to lock and become a rigid lever but it
also allows us to look at the clients forefoot lever.
When coming up to a heel rise you are looking for the
height the client is able to lift as well as the ability to
stay even across all 5 metatarsal heads of MPJs.
On the picture above Id like to see this client stay a
little more medial on the hallux during her heel rise.
This assessment finding will be compared to the gait
assessment and walking push-off position below.
Step 5 Walking Push-Off Position
Walking push-off position and hallux dorsiflexion is
probably the most important assessment you can do

for the gre

at toe. If a client has
great hallux dorsiflexion in all other assessments but
then doesnt push-off properly all other assessments
are irrelevant.
Remember our goal is to optimize function not just
seeing if our clients pass static assessments.
When walking we need a minimum of 30 degrees of
hallux dorsiflexion. If there is less than 30 degrees
dorsiflexion or the dorsiflexion isnt occurring at the
right time during the gait cycle then compensation
results. The most common compensation is that we
will see our clients begin to assume what is called
a low gear push-off position.
A low gear push-off position looks like the image to the
right and is associated with an unlocked and unstable
foot. If you recall during push-off we need maximum
foot rigidity to allow power output. In Part 3 of 3 of

this blog series we will be focusing on the low gear

push-off.
Step 6 Finger Under Toe / STJ
Assessment
Im sure I could come up with a more technical name
for this assessment but I think the finger under the
toe is easiest to remember! In this assessment I like
to demonstrate to clients and professionals the impact
that the STJ has on 1st ray stability and hallux
dorsiflexion.
In the above client we saw through the different
assessments that she had good dorsiflexion open chain
with good joint integrity (no crepitus). When we had
her stand up though and do a heel rise we begin to see
a deviation off of the body weight away from the
hallux. In addition during gait she assumed a low
gear push-off position all indicating a compromise in
functional hallux dorsiflexion.
The next assessment we want to do as to determine if
the limitation in hallux dorsiflexion is driven by a lack

of 1st ray stability would be the finger under the

toe test.
Have the client stand with the feet in a relaxed
calcaneal position. In the case of our above client you
can see that she is mildly pronating or in an unlocked
position. Remember that we ideally want to
assess STJ position from behind not anteriorly
like in the picture to the right.

When the client is in this unlocked,

relaxed position we then want to assess the hallux
dorsiflexion by trying to put our finger under the great
toe. Advise the client to stay relaxed and to not fight
or assist you in any way.
In the picture to the left you can see I can barely get
my finger under her big toe. This is an insufficient

amount of hallux dorsiflexion. We should be able to

get the entire finger under the toe.
What you want to do next is put the foot in a neutral
position. This neutral STJ position will shift the 1st
ray into a stable position and engages the

peroneus longus or spiral line which

we learned in Part 1.
From here you want to re-assess the hallux
dorsiflexion with the finger under the toe test.

You can see in the picture to the

left that stabilizing the STJ and 1st ray led to a large
improvement in hallux dorsiflexion.
This assessment begins to guide my approach to this
client.

My focus must go back to STJ stability and function if I

ever want to optimize her hallux dorsiflexion during
closed chain movements.
In Part 3 we will begin to explore the most effective
programming to improve client hallux dorsiflexion.
Please remember that the above assessment
techniques are designed to get your thinking. They
are not intended to be a be all end all to diagnosis of
great toe dysfunction. A complete great toe
assessment would also include images such as X-rays
so that we can get a true perspective on joint health.
ver the past couple days we have been reviewing the
anatomy and functional assessment for great toe
mobility. Again I am very happy by the positive
response and interest by so many professionals in this
topic. It shows this increasing awareness to the
importance of the foot and foot function which makes
me so proud!
In Part 3 of 3 of this blog series we will begin to
explore the most appropriate programming for these
clients and when is surgery really the best option.
I do want to emphasize that the biggest take-away
from this blog series should be that great toe
mobility is not just a local issue but is globally

interconnected to rear foot, core and hip stability.

As we know everything is integrated!
Structural Limitations in Hallux
Dorsiflexion

Hallux Limitus / Rigidus

One of the most important causes for limited hallux
dorsiflexion is structural and progressive arthritis
Often associated with older age great toe arthritis is
actually quite common among runners, dancers,
athletes or any client who has an unstable foot (overpronation).
This loss of joint mobility is structural and cannot be
corrected with functional training. Great toe
arthritis can be managed or slowed down with
correctives but it cannot be reversed.
To the left is an X-ray of a patient with structure
changes to the great toe joint. Joint space narrowing

and spurring or osteophytes can be appreciated both of

which greatly reduce the range of motion.
If we look at the lateral X-ray we can see that
osteophyte development can become quite

impressive dorsally its no

wonder these clients have no dorsiflexion.
I must emphasize that in these clients doing aggressive
manual joint mobilization can fracture these
osteophytes leading to bigger issues than they started
with.
You must always know the health of the joint before
you start manually manipulating a great toe joint.
So what can you do with this client?
Surgery is always an option with the ideal procedure
(which of course depends on the health of the joint) is
a decompression-type procedure with removal of the
osteophytes. I personally try to avoid joint fusion at
all costs if possible but sometimes the condition of the
joint requires fusion.

If surgery is not an option

or desired by the client then I often recommend using
a rocker forefoot bar or shoe.
A forefoot rocker is a graphite bar that allows the client
to dorsiflex over the shoe improves function and can
eliminate pain. This type of shoe allows the client to
achive proper hip extension and propulsion despite
having less than 30 degrees DF. (Think Sketcher
Shape-Up shoes).
Functional Limitations in Hallux
Dorsiflexion
This is the area where most of you will be able to hep
your clients improve their great toe
mobility. Functional means it is driven by a loss of
stability elsewehere in the foot (or body).
This type of limitation in hallux dorsiflexion will
generally demonstrate good mobility open chain but
then lose that range of motion as soon as they enter a
closed chain environment.

Where we want to first look for instability would be

the first ray.
Loss of first ray stability typically presents in those
patients with decreased medial arch, excessive STJ
eversion or inversion, navicular drop and under-active
glutes. For the sake of the article not all of these
issues will be covered however in all EBFA
Certification workshops we cover each in detail. To
find a workshop near you click HERE
Excessive STJ Eversion
In Part 2 we briefly demonstrated how STJ eversion
can cause 1st ray instability. To review this unstable
STJ position puts the peroneus longus tendon on slack
causing a delay in or insufficient plantarflexion of the
1st metatarsal head realative to the base of the
proxmiaml phalynx. (If you have not read Part 1

please clickHERE)
In this client our goal is to improve STJ positning
through posterior tibialis strengthening, short foot
activation and glute strengthening. One of my favorite

exercises for this client is the ball between heels

exercise (see picture on right).
Excessive STJ Inversion
For the client who has limited hallux dorsiflexion due
to an inverted STJ and dorsiflexed 1st metatarsal our
goal is to increase foot mobility and neutralize the STJ.

For this client we want to

mobilize the platnar foot, tibialis anterior and deep hip
rotations.
Combination Structural &
Functional Limited Dorsiflexion
Hallux Valgus
Similar to hallux limitus, the client with bunions often
presents with joint space narrowing and coral spurring
which can begin to block hallux dorsiflexion.
With bunions structure is not the only contributor to
limited joint mobility. Bunion formation is also
greatly associated with foot type specifically eversion
/ over-pronation and generalized foot instability.

For this client we must consider both structural

limitations (need X-ray) as well as our ability to slow

the format
through corrective exercises.

ion of the bunion

In addition to the foot and hip strengthieng exercises

mentioned above for the STJ eversion, we also want to
include a medial stretch to the great toe with either
tape or a Bunion Bootie (www.bunionbootie.com).
This medial pull will mildly stretch the adductor
hallucis muscle as well as position the abductor
hallucis for better intrinsic activation.
Final Key Tips & Pearls
A few additional paddings and modifications to inserts
and shoes which may benefit your client include:
Reverse Mortons Extension
Cluffy Wedge
LA Pad & Varus Posting
Finally my last tips of advice:

 Please know why you are doing what you are doing.
I am seeing too much of cluffy wedge for everyone!
and l dont think everyone fully understands who and
when this is the most appropriate.
Remember sometimes its best to refer out.
When in doubt get a copy of your clients X-rays