With Whitney Lowe and TIl Luchau
Episode Transcript
Summary:
In celebration of Til Luchau’s upcoming “Ankle Issues” livestreamed course, Til and Whitney pulled one of their favorite ankle-related episodes (#43) out of the archives. Listen in as they geek out on ankle- and foot-related conditions, anatomy, function, biomechanics and more.
Topics include:
- How the structure of the foot/ankle complex determines function
- Are we over over-pronation yet?
- Plantar fasciitis/fasciosis, bunions, hammertoes, and other things you wouldn’t have thought of as ankle issues.
Episode Outline:
- Structure of the foot/ankle complex
- Medial side deltoid ligament complex
- Lateral side ATF, CF, PTF
- How does structure govern function
- Distal tibiofibular joint & talocrural joint form mortise & tenon
- Primary supporting ligaments
- Mechanics of the region:
- Talocrural motions: dorsiflexion & plantarflexion
- Type I and type II limitations
- Subtalar motions: inversion & eversion
- Pronation and supination (definitions and confusion)
- Phases of gait
- Some common issues/problems
- Valgus and varus angulations (toes and calcaneal region)
- “Overpronation”
- Bunions & hammertoes
- Plantar fasciitis
- Tendon overuse (Achilles tendon etc.)
- Trauma: sprains breaks
- Nerve entrapments mimicking soft-tissue pathology (i.e. tarsal tunnel syndrome, Baxter’s neuropathy, etc.)
Til Luchau:
Hi. This is Til Luchau. This summer I’ll be offering my Ankle Issues course via live stream. This will be the first time this course, which is the latest in my Advanced Myofascial Techniques series, will be available remotely or by recording. You can join us live. You can even bring a client and work on it there’re with us in real time, if you want CAMT credit or certification credit, or the course is affordable enough that you can just sign up and watch the recording later at your leisure. All those options will earn you NCB credit. And for a limited time thinking Practitioner listeners like you can save an extra 15% with the coupon TTP at checkout. If you go to Advanced-Trainings.com and sign up for the ankle live stream, you’ll see all those options there. The Thinking Practitioner Podcast is supported by ABMP, associated bodywork and massage professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, and quick reference apps, online scheduling and payments with Pocket and much more.
Whitney Lowe:
Mr. Luchau, how are you today?
Til Luchau:
I am very well. Thank you. How about yourself, Mr. Lowe?
Whitney Lowe:
Doing well also. Winding down the summertime here in Central Oregon. Looking forward to breathing cleaner air, less fire smoke for us. Have you had bad fires out there this year?
Til Luchau:
We have had fires, but most of the smoke we have is Oregon and California smoke, but it has been worse than ever. And in fact, I’ve turned off my air filter right before I turned on my recording today here in the room because we got smoked too. Yep.
Whitney Lowe:
Yeah. So yep, we’re smoking it up out here this summer.
Til Luchau:
I bet you are.
Whitney Lowe:
It’s been a bad one, yeah.
Til Luchau:
And of course [crosstalk 00:02:00]. Yeah, it’s been bad.
Whitney Lowe:
It has been a bad one, so every year [crosstalk 00:02:01]
Til Luchau:
Maybe we can do a podcast on respiratory something or not.
Whitney Lowe:
Yeah. And with this heat that we’ve had this year, we’ve had some horrendous heat waves out here in the Pacific Northwest that we generally don’t have. And when I just think about those firefighters out there in that equipment, in the middle of a fire when it’s 108 degrees out there, and then something changes with the wind and you’ve got a run for your life, it’s just amazing what some of those folks [crosstalk 00:02:32]
Til Luchau:
I had a client for a couple years who was a smoke jumper out of Bend, out of your area, Sisters or Redmond, whatever their base is there, and she would parachute in and fight fires and then hike out carrying all their gear and stuff. That’s crazy.
Whitney Lowe:
Yeah. And if you are a smoke jumper or a wildland firefighter, you would want to make sure that you don’t have any significant ankle or foot trauma. Right?
Til Luchau:
That’s right. Yeah, absolutely. And you’re probably at risk of developing that as you land in your parachute with your 100-pound duffel bag full of shovels and everything else.
Whitney Lowe:
Yeah.
Til Luchau:
What do you think? Should we talk about that today?
Whitney Lowe:
Why don’t we talk about that? What a great segue.
Til Luchau:
Okay. Where do you want to start? What do you think is a good place to start about talking about the ankle and that kind of thing?
Whitney Lowe:
Well, this is a pretty complex biomechanical region, so maybe we’ll start, we’ll talk a little bit about structure first of the foot and ankle complex, and then we’ll talk about some of the mechanics in there and problems that we see happening, and how we can intervene maybe with some helpful suggestions for people. How does that sound?
Til Luchau:
Great.
Whitney Lowe:
Yeah. So, why don’t we start talking, let’s first off do some maybe definition things. We talk about the ankle joint complex, and there’s really quite a lot to it because we have to remember, we have a distal tibiofibular joint, which is the joint where the fibula and tibia join together distally, and then they’re articulating with the talus that’s down below them.
Til Luchau:
So that joint that you just mentioned, that’s the joint between the two leg bones down at the bottom, end of the leg, and then right below that you say it actually meets the foot proper, at the top bottom of the foot, the talus?
Whitney Lowe:
Exactly. And the distal tibiofibular joint, we consider it to be one called a syndesmosis joint, and that’s one that does not have a great deal of movement to it. It’s bound together by ligamentous tissue, strong, very dense connective tissue that holds those two bones together and then they sit over the top of the talus.
Til Luchau:
To note, joint capsule, per se?
Whitney Lowe:
That’s right, yeah.
Til Luchau:
No joint capsule, but like a boundary, you said ligamentous relationship. And that’s, and maybe I don’t want to divulge too much, but that’s, in my approach, I’m definitely thinking about that movement there, because in my view, you want a little bit of spring there but you don’t want it too much. You want sound not too much.
Whitney Lowe:
Exactly, yeah. And the couple of other relevant mechanical things about that particular joint complex, for those who are into anatomical trivial, we’ll put a little trivia piece in here for those who may not know or have paid attention, the talus is the only bone of the foot that does not have a tendon attached to it.
Til Luchau:
Yeah.
Whitney Lowe:
So that’s one that gets moved. It’s an important, really, really important structural bone, but we don’t move that bone by any muscles attaching to it. So it’s an unusual situation in the body where we’ve got a significant bone there with no muscles attaching to it.
Til Luchau:
A significant bone, a very significant joint, but no direct muscular attachments. Yeah, you’re making me think, I wrote an article for Massage and Bodywork Magazine about that joint, an issue or two ago. But I got to refresh myself on the talus trivia. But you said the only bone in the foot, isn’t it the only bone in the body that doesn’t have a muscle?
Whitney Lowe:
It may be.
Til Luchau:
Yeah.
Whitney Lowe:
Well, no.
Til Luchau:
Okay.
Whitney Lowe:
Because there’s the malleus, incus and stapes inside your ear.
Til Luchau:
Actually I was five seconds behind you. Yes, absolutely.
Whitney Lowe:
My mother was an audiologist, so I’m always jumping there to those three.
Til Luchau:
In the ear bones.
Whitney Lowe:
But yeah, other than that, and I just don’t know the rest of anywhere in the body, but it’s probably true that that’s the only ones that don’t have other muscles attaching to them.
Til Luchau:
Yeah, I’m sorry. You got me started, and I got to throw in one more.
Whitney Lowe:
Actually, let’s have it.
Til Luchau:
And I think it’s the only bone that in an anatomical position has its blood flow go from the bottom up. It’s only arterial blood supplies below it, so the blood percolates the talus.
Whitney Lowe:
The talus, we’re talking about?
Til Luchau:
Yeah.
Whitney Lowe:
Really?
Til Luchau:
Yeah.
Whitney Lowe:
Interesting.
Til Luchau:
That’s actually an issue in rehab if you’ve broken it or shattered it from smoke jumping or something like that, then you got to really think about blood flow for it so it can heal because it’s percolating upwards into the bone.
Whitney Lowe:
Interesting, didn’t know that one. Okay. I see. You learn something new every day. So, a couple other things at this joint before we move on from it too, this is, a lot of people don’t hear this term a lot, but this joint between the distal tibiofibular syndesmosis and the talus is called a talocrural joint, hard word to say, T-A-L-O-C-R-U-R-A-L, talocrural joint.
Til Luchau:
Talocrural or talo leg joint.
Whitney Lowe:
Yeah. And it often forms what we call a mortise and tenon type of, not tendon but tenon, T-E-N-O-N, mortise and tenon structure, which is basically a round knob sticking up and a depression for that knob to stick into. Always I learned about mortise and tenon structures when I was in fifth grade. I think it was-
Til Luchau:
Shop class.
Whitney Lowe:
building a model. No, actually this was science fair. I was building a model of stone hinge, and the stones are built with mortise and tenon structures in there. So yeah-
Til Luchau:
So that’s like a-
Whitney Lowe:
… a little bump and a [crosstalk 00:08:11]
Til Luchau:
So it’s like a joint, that distal joint you’re talking about where the mortise of the leg fits around the tenon of the talus, huh?
Whitney Lowe:
Yeah.
Til Luchau:
Cool.
Whitney Lowe:
And we are going to talk about some injury things a little bit later on, but I just want to mention one thing about this, because it’s really relevant here in relation to what we’re talking about, the talus is a little bit wider on the superior side than it is on the inferior side. And when your foot moves in dorsiflexion, that wide branch or the wide surface of the talus rolls up underneath the distal tibia and fibular as you move the foot farther into dorsiflexion.
Whitney Lowe:
And if your foot is forced into extreme dorsiflexion, let’s take our smoke jumper example that we had a moment ago. Talk about somebody who lands from a parachuting accident with extreme dorsiflexion, maybe their weight is imbalanced or something like that, and that talus rolls up underneath the tibia and fibula far enough, it actually can spread them apart and cause a sprain or injury to that distal tibiofibular syndesmosis. And this is an injury called a high ankle sprain because it’s not at the usual ligaments with ankle sprains, but it is sometimes mistaken for them. But usually the cause is extreme dorsiflexion or extreme dorsiflexion with rotation of the ankle.
Til Luchau:
Yeah, and twisting. You can twist that tenon and the mortise too, spread those bones apart and sprain that ligament, that high ankle sprain.
Whitney Lowe:
Right, absolutely.
Til Luchau:
What are some of those ligaments around there?
Whitney Lowe:
Yeah boy, we have a whole mess of ligaments around the ankle joint, but let’s just focus on some of the key ones that are really important to remember. We’ve got, with each of those small foot bones, you’ve got ligaments that are holding them to each other. But we are, mainly when we talk about ankle problems, looking at the ligaments on the medial side of the ankle and those on the lateral side as the primary ones where we see problems occurring most frequently with them.
Whitney Lowe:
On the medial side, there’s a complex of four different ligaments that all blend together. Mostly if you look anatomically, they’re really meshed together and they form a triangle shape, so they’re referred to as the deltoid ligament, complex deltoid meaning like the Greek letter Delta, the triangle shape. And the deltoid ligaments on the medial side of the ankle are quite strong and very resistant to motions. And that’s one of the reasons you don’t see as many ankle sprains on the medial side of the ankles, because that deltoid ligament complex is really quite strong.
Whitney Lowe:
And on the opposite side where you actually need greater stability, those ligaments aren’t quite as large. So I’m not sure why that is the case, but that’s one of the reasons that we see a lot more frequency of lateral ankle sprains, because there’s three key ligaments that resist excessive inversion of the foot on that side. And that’s the anterior talofibular ligament, that’s the main one that gets injured in most ankle sprains, second most common.
Whitney Lowe:
Again, anterior talofibular, those ligaments names always tell you what they connect. So talofibular is going to connect the talus and the fibula. And that ligament goes in an anterior to posterior direction from the fibula down to the talus. And then almost straight up and down superior inferior direction is the calcaneofibular ligament, and that’d be running from the calcaneus to the fibula. And then one running from the fibula in a posterior direction back to the talus also, and that is the posterior talofibular ligament. So those three on the lateral side are trying to give you additional stability mostly against successive inversion movements on that side.
Til Luchau:
And maybe tell me if this is accurate, you can think of them as radiating off of that distal end of the fibular, like your lateral malleolus are splaying off of that in three directions.
Whitney Lowe:
Exactly. Yeah, that’s good. And mechanically too, just another thing to note here about the ankle and its stability is, probably the majority of people have at some point twisted their ankle or stepped down funny in doing something that they call turning their ankle or something like that. And that most of the time that’s, we’re going to talk about some of the foot mechanics in a moment here, but most of the time that’s twisting your foot inward or into inversion. One of the reasons, the other reason is if you don’t twist your foot out into eversion anywhere near as much, is that the tibia extends farther distally than the fibula does. So it prevents excessive inversion movements where the fibula doesn’t have that same bony limitation to movement.
Til Luchau:
And there’s another reason I’m thinking of too, and that is that you have, most of us have another leg on that side. So this is the kinesthetically, it’s more of a covered direction or that falling outward or even having to stabilize that, we don’t have anything out there to catch it, so that ends up rolling the foot [crosstalk 00:13:13]
Whitney Lowe:
Yeah, right.
Til Luchau:
Cool.
Whitney Lowe:
So, tell us a little bit about, let’s talk about some motions here. What motions do we have that we’re mostly looking at here in this area?
Til Luchau:
Well, you’ve mentioned dorsiflexion and plantar flection. So dorsiflexion is pulling your toes up towards your knee, plantar flection would be pulling your toes down away from your knee. And that’s the movement that happens, essentially of the talus moving between that tibia and fibula, is that little, you mentioned it being wider and front. So when you point your toes to the narrow parts there and your ankle is pretty loose, that’s great for toe off when you need to adapt. And then when you pull your toes up towards your knee in dorsiflexion that actually gets snugged up real tight there because of the wide part of the talus between those two bones, that mortise and tenon locks down like a spring stabilizer. And so then you have a lot of stability and actually, sorry, I might’ve said it backwards. In tow off in that phase of the gait, it’s like when you’re pushing off the toe, there’s lots of stability if you’re in dorsiflexion.
Whitney Lowe:
Yeah.
Til Luchau:
Did I say that right, Whit?
Whitney Lowe:
Yeah.
Til Luchau:
Okay, great. You’re my fact checker here. Thank you. So we don’t get too much hate now.
Whitney Lowe:
All right, yeah.
Til Luchau:
And then-
Whitney Lowe:
Yeah, so think about the position that your foot is in, and so you can envision that your toes are extended in that push off phase, the toes are extended and the foot is moving in the direction of plantar reflection, but it’s dorsiflexed for the most part to give you that spring load and the power in forward compulsion.
Til Luchau:
Now a lot, we’re going to talk about problems, but there’s two things that could make it hard to dorsiflex. Dorsiflexion is hugely important, and people will really notice it when they don’t have much dorsiflexion, even more than we don’t have plantar flection for various reasons. But there’s two things that can make it hard. And in my book, I call them type one or type two. I don’t think that’s any kind of official designation. Type one is where something in back of the leg is making it hard to dorsiflex. Basically the sero complex, the soleus, the gas jog, et cetera, posterior coral fascia, not able to allow that lengthening you need to dorsiflex. Any other?
Whitney Lowe:
So this would be a muscular or soft tissue restriction to dorsiflexion because those tissues are not elongating fully, that’s the idea on that?
Til Luchau:
Yes. Contractile tissue let’s say, because the other one is soft issue too. Type two would be an inability of the tibia and fibula to adapt around the talus. So they don’t widen enough. They don’t spring enough to allow the talus to go to full dorsiflexion. And you get like a jamming sensation there on the front for that.
Whitney Lowe:
Yeah.
Til Luchau:
Okay, so the two things that can keep you from having full dorsiflexion is structurally. And then you had some thoughts about subtalar motions?
Whitney Lowe:
Yeah, so we talked about the talocrural joint being that joint between the talus and distal tibia and fibular and the next important joint in the foot ankle complex is called the subtalar joint. So that’s sub meaning below and talus referring to the talus. So this is the joint down below the talus where it’s articulating with other foot bones there. And this joint, very important also for foot mechanics, and the two motions that primarily occur at the subtalar joint are inversion where the plantar surface of your foot turns in a medial direction, and eversion where plantar service is turning outward in a more lateral direction. So inversion and [crosstalk 00:16:48]
Til Luchau:
Those are mostly happening right below the talus?
Whitney Lowe:
Yeah.
Til Luchau:
Now, I actually get excited about this stuff. We’re so deep in the geek dumb here, that especially once you get into the foot joints, those little movements get really arcane and very cool because they explain a lot of stuff. So that, turning your foot in and turning the foot out, you’re saying a lot of that’s happening right there at that joint between the calcaneus and the talus, and between the talus and the other bones below it. Very cool.
Whitney Lowe:
Yeah. And I do want to reiterate, as we talk about this, that these are not absolutely pure motions, meaning there’s really some different planes of movement that are occurring at each one of these things. It’s not straight only sagittal plane movement or only frontal plane movement. There is really some kind of altered dynamics of that movement, which is absolutely necessary because your foot is trying to adapt to differences in ground surface and walking on rocks and stepping in holes and doing all kinds of things, your foot has to be adaptable to changes in the ground surface down below. So you can’t just have these pure single plane movements that don’t have some other degrees of. And we’ll get into this in just a couple minutes as we begin to talk about pronation and supination, because those are some confusing topics, but they help illustrate why these are not pure motions.
Til Luchau:
Yeah, sometimes it’s drawn out as being run in a bleak axis that goes through all three planes. But even that might be an abstraction because if you, [inaudible 00:18:23] does a cool thing where he draws the joint surfaces as little barrels and knobs, and you see that that surface there is so complex between those two bones. It’s not going to move just like a plane hinge in any one direction, there’s all sorts of little permutations. It does.
Til Luchau:
And that joints adaptability, the subtalar joint features prominently in a lot of different systems. It’s not a whole lot of movement typically, but it’s essentially the first joint up from the ground. If you look at the weight bearing of normal standing or landing position, that’s the first joint that’s adapting. And so people like Gary Gray and his calves method, and then people that have riffed off of his system like James Earls, things like that, see it as the joint that sets up the potential for the rest of the body’s adaptation in walking or running.
Whitney Lowe:
It’s almost like that idea of stack of blocks, and you get that first block a little bit tilted, and that’s going to magnify some of those effects throughout the rest of the body. The higher up you go, just because of the way forces and torque works, those things will be exaggerated later on through the [crosstalk 00:19:35]
Til Luchau:
I’m going to underline that tilted part, because it could be tilted or it could be inadaptable, but that’s when we get to pronation myths and such, the tilted one is relevant there.
Whitney Lowe:
Yeah. Well, let’s dive into that a little bit about pronation and supination because these are some terms that are, my experience has been in trying to teach people about these concepts for many years, is that there’s a great deal of confusion out there about pronation and supination and what they are and what they, how they’re defined and what actually happens there. So, let’s look at that a little bit.
Whitney Lowe:
So, first thing is pronation, let’s start with pronation because that’s the big one everybody hears about a lot. Are you overpronating? Are you hyperpronating or that sort of term, and whether that [crosstalk 00:20:24]
Til Luchau:
Are you a pronator or do you need these shoes because you’re a pronator, or do you need [inaudible 00:20:27] because you’re a pronator, et cetera.
Whitney Lowe:
Yeah, something like that, right. Yeah. So, the first thing to remember is that everybody pronates when they move with their foot and ankle complex, hopefully yes. In normal gait mechanics, pronation is normal. The problem is overpronation or the potential problem is overpronation. But what does that actually mean? So, let’s explore that a little bit.
Whitney Lowe:
Pronation is a combination of movements in different planes. So we’ve talked about two of those planes of movements, dorsiflexion and plantar flection happen in that sagittal plane. And then we’ve also talked about inversion and eversion where the foot rolls inward or the foot rolls outward. But as you mentioned a moment ago, that the motion of the foot is on a diagonal plane, and we talk about it being in an oblique axis. And there’s actually another component to that movement, which is, and this one’s hard because it uses terms that don’t seem to work at the foot the same way. But if your foot, if you’re standing straight with your body, and in anatomical position your foot is pointing forward, if you simply, with your foot on the ground, turn your foot out to the sides, your toes are now pointing more laterally in your foot. This is what we frequently call turnout. That motion is called abduction.
Whitney Lowe:
So, abduction of the foot is when your foot turns out. And likewise the opposite of that abduction would be when it turns in often what we refer to as a pigeon-toed gait, for example.
Til Luchau:
Pigeon-toed, bear paw.
Whitney Lowe:
So, pronation-
Til Luchau:
I’ve heard it called [crosstalk 00:22:08] that bears do or duck foot, pigeon or duck foot turning out the other way.
Whitney Lowe:
Yeah.
Til Luchau:
Yeah.
Whitney Lowe:
Yeah. Right. So, go out walk in the snow or the sand or something like that and you can often see indications of those. Because I have a very significant abduction turnout, and especially on one side of my feet, very evident when I walk in the snow, but any event. So, pronation is a combination of dorsiflexion, eversion and abduction. So if you envision your foot pulling up toes toward the knee turning a little bit out with plantar surface turning a little bit outward, and the toes pointing out a little bit away from the body, that is the dynamic direction or movement or pronation. So we think about, talk about pronation being a dynamic movement as opposed to a static position.
Til Luchau:
I was about to say that. But just to-
Whitney Lowe:
Yeah, so really important concept there.
Til Luchau:
… give you an animal analogy, maybe you have a duck with its toes pulled up and a little bit facing outward with the sole too.
Whitney Lowe:
Yeah.
Til Luchau:
But yeah, like you’re saying, it’s a movement. It becomes useful when you think about it as a movement as opposed to a static position.
Whitney Lowe:
Yeah, that’s really important.
Til Luchau:
And I just had a thought. We have this outline that we should put in this show notes so that people can really follow along, but I’m thinking maybe a diagram or two, or for sure, a link to like a druse, a trail guide to movement books, a discovery book that has some really cool stuff about all these motions in there.
Whitney Lowe:
Absolutely, that’s a great idea. Yeah, so we’ll put that in there and include that as well, so you can get a sense of that. So, overpronation is when you are moving either too far or too fast during the gait cycle through those motions. So pronation is a normal part of your foot mechanics. When your heel hits the ground first, then the weight goes onto the flat surface of your foot and then to your toes and you push off, there’s a natural rolling towards the inside of your foot that is perfectly normal, and that is the pronatory movement. That’s natural pronation. But if you roll too far toward the inside of your foot or too fast toward the inside of your foot during that gait cycle, that would be overpronation.
Til Luchau:
And some of the debates are around, how do you define too far or too fast? Is it a certain amount of number of degrees or a certain number of, that kind of question. How do you approach that one, Whit?
Whitney Lowe:
Yeah, I have seen a lot of different discussions about that, and I don’t have a rule that I rigidly adhere to. It’s like that thing about, what is it? A similar thing like, it was in relation to the law, I know it when I see it, kind of thing. There’s all kinds of things, like looking at wear patterns on the bottom of the shoe, looking at a person’s gait cycle. A lot of people can compensate for degrees of overpronation and not ever have a problem with it. So it’s like, it’s a hard thing to actually measure and look at. But you can see sometimes, and we’re going to talk about this too, that there are some other things that do likely result from overpronation because it definitely changes the mechanics and the weight distribution and the force distribution to the [crosstalk 00:25:27]
Til Luchau:
All right. I think it’s, can I share with you my thoughts on that really quickly?
Whitney Lowe:
Absolutely. I was going to ask you that.
Til Luchau:
I have a proof. In that past bunch of years I’ve avoided the term overpronation, because it does imply there’s some ideal amount. And that’s very debatable, just based on anatomical studies of averages and things like that, it’s pretty hard to say this amount is okay and that amount is not, or even this shoe wear pattern is good and this shoe pattern is bad, because it depends on how you’re measuring it. Is it symptoms. It turns out that symptoms don’t correlate with pronation in a significant way. And there has been a huge debate, because most of our coaching and thinking about gait and stance and the ankle has to do with let’s control pronation, not overpronate, but it turns out when you really look to see, “Okay, so what problems are these people having?” It’s, there’s not many in particular. [inaudible 00:26:25] doesn’t seem to be associated with symptomology. And any measurement is basically postulated over an ideal anatomical neutral, which may or may not have much relevance to actual life anyway. So I’ve started, here’s, I’m skipping to the punchline, is that okay?
Whitney Lowe:
No, I want to hear that. That was going to be my next question. And so how do you-
Til Luchau:
How do you frame it?
Whitney Lowe:
How do you frame it? Yeah.
Til Luchau:
I frame it, and this is actually a philosophy I’m playing with in a number of areas in my life. Maybe the problem isn’t overpronation, it’s a lack of ability to go the other way. Yeah, maybe it’s not that you’re stuck in pronation, which as the classic model says that it’s, the foot has a position that it can’t get out of. Maybe it’s just that you don’t have enough supination available to you.
Whitney Lowe:
So, in terms of gait mechanics, when a person lands at foot strike, because one of the primary muscle that’s given as functionally resisting overpronation is tibialis posterior. And because of its angle of pull, [crosstalk 00:27:34] it puts on the breaks, and keeps you from rolling too far over on the inside of your foot. So are you suggesting then that, how do we frame that or look at that in terms of like, well, if a person is, you can see sometimes people walking and they’re really rolling over onto the inside of their foot and there’s other mechanics things that are not happening in the foot, is that necessarily because they’re not supinate enough or maybe their tibialis posterior isn’t putting on the brakes enough, or how do you [crosstalk 00:28:03] that?
Til Luchau:
Enough compared to what? Is compared to an anatomical ideal, yeah. If we see it rolling in, that’s already assessed according to [inaudible 00:28:13], and listen, that’s my background. And I’m not saying that position does nothing, I’m just saying it’s not everything. And our conventional models say, “Let’s look at the alignment and if we get it aligned, we’re good.” And sometimes that’s the case, but it turns out that a lot of people aren’t good even after you do manage to teach them or correct them or put inserts to keep them in an anatomical alignment. A lot of people still have symptoms, so it’s not that alignment is everything. And so often what does seem to make a big difference is the ability to adapt as you mentioned. So it’s not like they don’t have, they’re not supinating enough in that weight-bearing phase, it’s just that we don’t have enough supination available in the overall cycle, the overall ability to stand and balance.
Til Luchau:
Now, my job, and that’s strategic to my job as a manual therapist, because I don’t stack bones up and get them all balanced and then push people out the door, hoping they’ll stay there. That’s not my way of thinking about my work. I’m giving people options to move and then enough awareness and body awareness and encouragement to move and use it, that hopefully that they stay healthy and keep those things going.
Til Luchau:
But that’s not, it’s not to say the job is done. If someone does have a situation where there’s so much movement there that they’re hurting themselves, which could happen after an injury. Say, if you sprain your ankle that way immediately and you have a pathological amount of movement, I’m not going to say, “Now you go make that pathological amount of movement the other way,” I’m going to say, “Maybe that’s a place for some odd classic strengthening or some alignment awareness training,” or those kinds of things, which we actually work into, a lot of the hands on therapists do, but we for sure do in my approach where we’re at, and then they structure integration. That’s, we’re educating as much as we are repositioning, maybe even more. So that’s where the role of education really comes in.
Whitney Lowe:
Yeah, and I think that’s so patent there because this is the thing we have oftentimes defaulted to try to look for, like the simple answer to many of these types of very complex biomechanical challenges. And one of the things that I really have shifted my thinking about over the decades really is that, a lot of what we do with our manual therapy is not necessarily making those kinds of very significant tissue changes in the therapy session that all of a sudden then, like you said, the person walks out the door and then they are corrected. Something like foot mechanics is really hard to change because you’re reinforcing it with every foot strike and everywhere you go.
Whitney Lowe:
And so those kinds of things are often a very complex multi-factorial problem. And maybe we can address certain components of that. Like you said, find some good ways to move and find some ways that encourage more, a functional movement in combination with shoe inserts, and all those other kinds of things as a complex picture that might change some things. But a lot of these problems lead to things that are difficult to undo. And we’re going to talk about this in a moment when we talk about bunions and hallux valgus and things like that, if you’re over pronating, you’ve already done a lot of the biomechanical damage that’s really hard to undo.
Til Luchau:
Somehow I want to take the other side of the debate. What is it? It’s, I think patterns are hard to change and maybe we can do mechanical damage by spending too much time in one extreme granted, and yet sometimes just a small change makes a whole lot of difference. And it’s often waking up of someone’s possibility or their awareness like just finding out that I can weight bear a little differently through my foot, or just the meditation of walking and pushing off as tightly with a different awareness, can really shift the way that someone’s foot moves. But then also those kinds of symptoms you were mentioning too. So just to, I want to put in a plug for the hopefulness as well as the difficulty of the situation.
Whitney Lowe:
Well, and I think yeah, we’re really on the same track of talking about those things that reinforce changing, for example, motor patterns or motor awareness or appropriate receptive awareness in the body to change those things, and they get repeated by doing them over and over again and correcting those things. And that’s why it’s so necessary to do something like that, as opposed to having this idea that a person can come in and we’re going to do something to their foot that’s going to change it and that’s going to make their mechanics magically work great. [crosstalk 00:32:51]
Til Luchau:
Oh, I still hope for magic, but there’s lots of ways to get it. There’s lots of ways to get. Sometimes it’s slow magic, sometimes it’s quick magic.
Whitney Lowe:
Yeah. I really like a lot of those ideas that you’ve talked about of enhancing proprioceptive awareness to then tap into changes in motor patterns and things like that because of that increased awareness. And so you’re getting the person working with you, as opposed to you working on them, just a different mindset about that whole process or the way that’s being done.
Til Luchau:
Yeah. And I can’t help but do a little semi-commercial.
Whitney Lowe:
Well, let’s hear it.
Til Luchau:
Will you allow me that? Okay. So not only are we about to start our leg, knee and foot principles class in a few weeks here, this is being September, you can join all the way through September of this year, and there’s going to be recording later, so where you do a deep dive into foot biomechanics. But if the world’s situation allows, we’re hoping to go back to Spain and walk along section of the Camino de Santiago next year. And that, talk about a walking workshop.
Whitney Lowe:
Oh, that’s cool.
Til Luchau:
That’s what that is. It’s a walking workshop where you get the repetitive, long-term opportunity to really play with different dynamics. So we do little morning mini classes in these different dynamics, and then you go walk for the day with some companions and study that. And then we gather a debrief, usually over a glass of wine or something along that too.
Whitney Lowe:
I might have to sign up for that. That sounds pretty nice.
Til Luchau:
It’s pretty amazing. Knock on wood, still will stay tuned to see what the world’s situation allows, but that’s what we’re hoping for next May. Anyway, thanks for that commercial break, back to our show.
Whitney Lowe:
Well, I want to talk just briefly about a couple other, well, biomechanical terms that we’ve mentioned a couple of times, and define them a little bit and talk about how they play in relation to some of the things that the things, the foot and ankle complex, in particular, the terms valgus and varus, which are oftentimes confusing for folks.
Whitney Lowe:
So a valgus angulation is one in which the distal end of a bone deviates in a lateral direction. The distal end of a bone deviates in a lateral direction. And a varus angulation would be the opposite one where the distal end of that bone deviates in a medial direction. So you can talk about valgus angulations of the elbow, of the knee, of the calcaneum region, of the toe, lots of different places where you may see those. But in the foot and ankle, they’re pretty relevant, because those forces then are not oftentimes moving ideally through the rest of the bone and connective tissue structures.
Whitney Lowe:
So we’ve been talking a lot about overpronating in a person who rolls over toward the inside of their foot during gait, will most likely have a calcaneum valgus foot position during their weight bearing stance, where the distal end of the calcaneus is deviating laterally and that’s making them roll toward the inside of their foot. And that would be a calcaneum valgus that leads to an overstress on some of those other soft tissues trying to help stabilize and support the foot and ankle complex. And we talked, I’m going to mention a few things too, because there are some other problems like bunions and hammertoes, and bunions often-
Til Luchau:
Well, I just-
Whitney Lowe:
Go ahead.
Til Luchau:
Well, just in terms of valgus and varus, your explanation is so clear. I even hate to touch it, except to say that it’s the same question that is, do those correlate with symptoms? And it turns out not as much as we thought. Especially it depends on the degree of load and the amount of repetition, like the level of performance people are at, but there’s been a lot of research into say Q angle of the knee and how it might correlate with knee injuries. Of course, it seems like it only makes sense that if you got really valgus knees, like really knocked knees, you’re going to have more knee injuries, it turns out that doesn’t seem to be the case, and that some high-level athletes have some pretty strong valgus or varus patterns there. So it’s back to the same asterisks if they were, that alignment isn’t everything anymore in terms of my approach and I don’t think in a lot of people’s.
Whitney Lowe:
And that’s, I think a really important takeaway to emphasize. And I agree with you there, that we’ve, in the past, looked at these things as pathologies. And the way I like to look at it now is that, it could be a factor that’s relevant, but just because it’s there doesn’t mean it is something that needs to be fixed or changed or corrected. So like lots of other things that could be factors, we want to put that in the mix and think about, “Well, this might be playing a role in this. Let’s see if it is.” For some people it’s going to be a prominent factor and for other people it’s not going to be as much.
Whitney Lowe:
But I did want to, as we were talking about those concepts, touch base a little bit about some things with the toes in the foot, you were going to talk to us more about some other things here. I’m going to mention bunions and some other things that happen, and that’s often a result of something called hallux valgus, which is the great toe or hallux. Especially when your foot moves into excessive pronation that forces the distal end of the toe in a more lateral direction, as does often wearing of really narrow toe box shoes. That causes the distal end of that hallux to be deviating in a lateral direction. And that pushes the proximal end toward the middle side of your foot, which often rubs on your shoe and produces a bunion. So those things are often related, although there’s, again, a lot of questions in some of the literature about how much these are causative factors, like the shoe wear being causative factors, how much genetics is a causative factor, and I think we’re recognizing it’s not as simple as we may have once thought.
Til Luchau:
It’s not as simple, but certainly I was getting tired of wearing my pointy cowboy boots because they were pulling my toes in and giving me a big bunion there. So I started wearing my ballet slippers at night and that didn’t help at all, they were pulling out too. But certainly shoes could be a factor in that and genetics and the bunion thing. But I’m thinking, there’s also, as you mentioned, a connection between pronation and bunions, and if you stand up, you can feel it.
Til Luchau:
Listeners and you too Whit if you want, if you stand up you can feel it. I’ll just guide you through a little of [inaudible 00:39:40] or a sensate experience of that. If you stand up and you put your feet straight ahead, and then you lean forward, your feet basically keep you from falling on the nose, your feet are more or less straight. And a lot of that weight, for most people, a certain amount of that will be in that head of the first metatarsal there. So that’s it’s like the base of the big toe is what takes a lot of that weight when you lean forward with straight feet. Now, if you go ahead and turn your feet out, like the duck foot thing, and then you lean forward, you find that something different happens. You have to pronate a little bit. And that head of the first metatarsal takes even more weight. In fact, it tries to migrate toward the midline to act like a big toes that where to keep you from falling forward.
Til Luchau:
So that leg rotation, knee rotation, hip rotation, tibial torsion, the foot talar tibial movements, all those things, if they don’t allow your foot to come somewhat toward the midline, that bone will to try to support you there, and that’s may be part of the functional contributions to that bunion pattern. And then if it wasn’t complex enough, have a seat, if you’re standing up, when you, if you can’t dorsiflex, if you have either that type one or that two limitation where you can’t bend your ankle very much into dorsiflexion, you can cheat by pronating. It’ll essentially force the movement down a joint or so, so that your knees come in toward the midline and you get lower in your squat, but you’re essentially pronating instead of dorsiflexion there. And like you said, that can be assumed. Biomechanically, it can be a force that will push you toward a bunion situation too.
Whitney Lowe:
So those are, we’re seeing those more complex biomechanical compensations when people might have some movement limitations or movement restrictions, and then they orient you in those directions away from those. And some of that may be pain avoidance. I’m thinking in particular of like, backpacking trips that I’ve been on early on when you start to get a hotspot or a little bit of blister on your foot, and then you have to change foot mechanics because you’re trying to avoid the pressure from your shoe, from a friction blister, and that really changes those foot mechanics. And then all of a sudden, some other things start like, “Hey, this isn’t how we’re supposed to be walking,” kind of thing.
Til Luchau:
Is the structure a determining function at that point or is the function determining the way you’re using your structure?
Whitney Lowe:
Yeah.
Til Luchau:
So I guess back and forth, that’s great. Yeah, and then hammertoes we should mention too. And hammertoes, again, can be, it’s complex, and I’ll go into it a bunch in that course I mentioned there, but it’s, you could think of it as the soft tissue pulling the digit, pulling the toe from both above the foot and below the foot. And since it can’t both flex and extend at the same time as a whole toe, it buckles. It can’t telescope either. It can’t just shorten itself so it ends up buckling. And then that loss of adaptability in the flexors and extensors of the toes means that it will get more or less fixed in that position, and then the all kinds of things can come from it. But that, and all the longer structures there that is buckling the toes cross the ankle, so certainly they can be related to ankle stabilization, ankle dynamics as well. What are your thoughts on that?
Whitney Lowe:
And again, hammertoes become another significant problem because your footwear and everything isn’t really designed for your toes to be flexed inside your shoe. And you lose the capability for, especially proper force distribution during the push-off phase of gait, and so you’re losing some of that mechanical push that you’ve got from the toes, as well as, they’re now squinched up inside shoe where you oftentimes see friction problems with that that are not designed for the way your foot’s in the footwear.
Til Luchau:
Yeah, right. And so we used to think about it like, [inaudible 00:43:44] those things, this could stretch them out like there were bend. And probably, again, the evidence doesn’t support we’re changing down to the molecular level, those collagen molecules, but there’s certainly a lot we can do to help people have a sense of greater movement through their toes in that situation. And no matter what stage in the hammertoe story, because once some time goes on, it gets tougher and tougher to say, “Make them straight again,” but you can always get some kind of movement and get some kind of relief. And then there’s lots of creative things people do. You mentioned the shoe problems with the top of the toes in the shoe, walking on the ends of the toes and they get sore, there’s probably thoughts of different sorts of splinting and things like that, that seem to have a great effect in people.
Whitney Lowe:
And when we talked about to the alignment challenges of the hallux valgus or the other toes not being ideally aligned, there are some other really good tools out there to help the yoga toes and the spacers that you put inside in between your toes and things like that. If you have shoes that are wide enough in the toe box to allow for that, or you got sandals or something like that, that you can wear that won’t squish your foot while those things are in there-
Til Luchau:
Or you can spend some no shoe time with those.
Whitney Lowe:
Yeah, for sure. I’ve worked with some of those things in the past and found them to be really, really helpful and valuable, because I have, what’s called a tailor’s bunion, which is, really, it’s a bunion on the opposite side of the footwear, the little toe. The small toe is deviating toward the midline. And I found those things to be really quite helpful. And I wear these tennis shoes all the time that, from a company, this is an already paid endorsement, but from a tennis shoe company called Altra, A-L-T-R-A, and they look-
Til Luchau:
And a nice wide toe box.
Whitney Lowe:
… a little goofy because they got a huge really wide toe box. But man, they are the most comfortable shoes I’ve ever put on my feet and I feel really great. So just, I wear these. I wear these tennis shoes around inside. And they’re like running shoes. I wear these running shoes inside my house when I’m working and even at my computer because they give me this kind of spring in my step and they make me feel alert and ready to jump up and do things. And believe it or not, that has an impact on mental function if I’m wearing the right shoes.
Til Luchau:
No doubt, no doubt. And then certainly the way that feet in general, footwear being a part of that story, but the way the feet’s comfort and adaptability and support under, this changes the way we do all kinds of things, including the way we look at the world and thinking and act.
Whitney Lowe:
Yeah.
Til Luchau:
Right on.
Whitney Lowe:
That whole thing about where the connection with the base of the ground and all that kind of stuff, there’s some relevance and all that. But what else have we got there?
Til Luchau:
Well, we’ve got a couple of issues, problems we didn’t touch on before we wrap things up. Plantar fasciitis/fasciosis, what should be said about that?
Whitney Lowe:
Yeah, this is, boy, that’s another one that’s in-
Til Luchau:
In foot dynamics.
Whitney Lowe:
Yeah, this is a messy thing to get into with plantar fasciitis. And obviously we could spend a whole episode on that because there’s-
Til Luchau:
We did. That was number 24.
Whitney Lowe:
I was going to say, I thought we had done that once before we got into that.
Til Luchau:
Episode 24, we talked about that whole problem. How does it relate to ankle mechanics?
Whitney Lowe:
Yeah. Again, I think a lot of times we may see chronic overuse in that connective tissue complex. And you talked earlier about that type one limited dorsiflexion. This is a good example of the critical importance of what we frequently refer to as the plantar flexor, sling. I’ve heard that term talking about the gastroc and soleus complex down to the calcaneus down to the whole bottom surface of the foot. And then-
Til Luchau:
Something to extend that out up the hamstrings.
Whitney Lowe:
Exactly. The whole-
Til Luchau:
[crosstalk 00:47:31] or whatever, yeah.
Whitney Lowe:
… fascial connectivity through those tissues there that can get pulled from other different regions or impact other regions by not being appropriately transmitting their tensile loads through those areas. So, that’s why it’s important, I think, to address a lot of tissues of the entire lower extremity when we’re trying to address something like plantar fasciitis, because there are tensile loads that are transmitted through many of those other tissues in there. So we’re seeing this as more of a chronic overuse degenerative problem with that connective tissue, as opposed to its term indicating more of an inflammatory type of reaction there. But there certainly could be inflammatory components to that from the tissue irritation, tissue overuse, especially, where it’s pulling on the attachment to the calcaneus.
Til Luchau:
Go listen to episode 24. If you want to know more about that, we get into that in detail.
Whitney Lowe:
Exactly, yeah.
Til Luchau:
Any of those others you want to make sure we mention, Whitney?
Whitney Lowe:
Well, one of the things I wanted to call attention to also is that, and again, this is sort of model lens of looking at things, is trying to often see likely what are called nociceptive drivers? What are the things that are causing pain in these different regions? And so frequently I see instances where people have pain on the bottom surface of their foot and immediately jump to ideas that they have something like plantar fasciitis happening, when in fact there a lot of other possibilities such as nerve entrapment problems. Like in the tarsal tunnel, the nerves feeding down to the bottom surface of the foot can give pain in the exact same places as plantar fascia problems.
Whitney Lowe:
And some of those more distal cutaneous nerves can get entrapped by just like the quadratus plantae muscle underneath there and Baxter’s neuropathy. So these are a couple of different nerve entrapment problems that may also exist around there. So, I always like to look for a variety of different solutions and see if they fit a particular pattern of what might be really driving the nociceptive sensations coming out of there, so we can make a treatment approach that will address that appropriately.
Til Luchau:
That’s great. And yeah, I remember you talking about Baxter’s neuropathy and those kinds of things in that episode 24 too. So that’s relevant to this foot pain question we’re doing today, and the ways that the ankle can affect the foot mechanics there.
Til Luchau:
And so, I don’t know, I’m just thinking in summary, a lot of what I’m doing is making sure, I mean, a dorsiflexion is so key. Dorsiflexion is like the king or queen of the foot movements. And if people have dorsiflexion, they end up moving in a way that the foot’s happy with often. And a lot of the compensations people do where there’s a lot of pronation or a lot of things with the toes, sometimes they, just to way around, lack dorsiflexion, so many times. I don’t want to say that for everybody, but that’s certainly the place I start with where people’s like, “Do they have dorsiflexion?”
Til Luchau:
And then similar is true in terms of recovery from a bad sprain, or you mentioned a high ankle sprain up in the leg, or breaks, boot top breaks, different foot injuries or ankle injuries, a lot of the recovery process involves finding movements that we didn’t have. And protecting, as you mentioned, the body protecting against the movement that was painful. Oftentimes it is that inversion sprain rolling out in the ankle. So often giving people options for movement, helping them realize they have a whole foot under them and they don’t have to just rely on one part of the foot, opens up a lot of possibilities for people that are recovering from an injury as well, too.
Whitney Lowe:
Yeah. Right.
Til Luchau:
What do you say what’s important for you for people to take with them?
Whitney Lowe:
This is one of those places where I think it’s really valuable to have just, even a fundamental understanding of some of the key principles of mechanics of this region, because of our weight bearing and the way in which the loads are transmitted from the foot and ankle complex through the rest of the body, in terms of what we tend to see as primary problems in this area, I do think it’s really valuable to have at least some basic conceptual ideas of how the whole foot and ankle complex functions biomechanically and how some of those forces might be altered or not working in an ideal fashion to see what tissues might be absorbing a lot of those stresses inappropriately. So that’s the kind of plug for, learn some biomechanics and learn some kinesiological fundamentals about this area because it’s relevant to what we’re doing there.
Til Luchau:
Awesome.
Whitney Lowe:
Yeah. Well, we’ll wrap up there for today with our foot and ankle complex topic, and probably revisit this and some other things a little bit down the road. But we do want to say a big thank you to our closing sponsor today who is Books of Discovery, and they have certain been a part of the massage therapy education field for over 20 years with thousands of schools around the world teaching with their textbooks, eTextbooks and digital resources. And in these trying times, this beloved publisher is dedicated to helping educators with online friendly digital resources that make instruction easier and more effective in the classroom or virtually.
Til Luchau:
And they like to say, learning adventures start here. They, Books of Discovery, use that same spirit here on The Thinking Practitioner podcast and they’re proud to support our work, knowing we share the mission, to bring the massage and bodywork community and livening content that advances our profession. Check out their collection of eTextbooks and digital learning resources for pathology, kinesiology, anatomy, and physiology at booksofdiscovery.com, where Thinking Practitioner’s listeners save 15% by entering “thinking” at checkout. And we’ll put a link into that Trail Guide to the Movement book, which is a great way to go and see those kinds of movements that Whitney and I were talking about.
Whitney Lowe:
Yes, absolutely. And we do want to say, again, thank you to all our sponsors. So stop by the sites for handouts, show notes, transcripts, and any extras over there. And again, we do thank all of you listeners for hanging out with us today as well and picking up hopefully some valuable tips for you there. You can find links to those resources on our sites over at my site at academyofclinicalmassage.com, and Til where can they find that for you?
Til Luchau:
Advancedtrainings.com. Advancedtrainings.com with a dash or without. If you have questions or things you want to hear us talk about, email us at [email protected] or look for us on social media just my name, Til Luchau. How about you, Whitney?
Whitney Lowe:
Also over on social, under my name or on Twitter @whitlowe. And if you will rate us on Apple Podcasts, as it helps other people find the show, and you can hear us on Spotify, Stitcher, Google Podcasts, or wherever else you happen to be listening, please do share the word and tell a friend about the show. And of course, if you’re unable to find us in any of those locations, you can tune your kitchen microwave to 450 gigahertz and pick us up right there.
Til Luchau:
That explains that popping sound I hear in the background there, popcorn back there. [crosstalk 00:54:59]
Whitney Lowe:
Exactly. Yeah, at 450 gigahertz also. That’s right.
Til Luchau:
Cool.
Whitney Lowe:
Yeah. All right, so we’ll see you again, I think in two weeks, right?
Til Luchau:
Two weeks, right. And you can check out those show notes. We’ll put those links in there. Thanks everybody. Thanks, Whitney.
Whitney Lowe:
Very good. Thank you, sir.
