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I have been reading and learning more about lower extremity biomechanics from this forum over the last 6 months than I did in podiatry school (that is a shame) or private practice over the past 10 years. Thank you to all that contribute.
I am attempting to be both the patient and the doctor for my own issues and I need some help. Both with a biomechanical explanation and treatment options.
I am 40 yrs old and have been an athlete my whole life. Baseball was my sport but I took up running about 8 years ago when I trained for a marathon (Team In Training). No problems with the training and completed the marathon in about 4.5 hrs. ITB flare ups for the next 2 months shut down my running so I basically started over. Running 12-15 miles per week with no issues until 5 years ago I was running on a treadmill and felt my right foot basically slapping against the ground. The foot felt very stiff and this happened several times over the next 2 weeks until I decided to take an extended time off. At this time no other symptoms while walking.
Over the next 4 years I started to develop a deep ache in my lateral midfoot area (appeared to be in 4th,5th met/cuboid area but moved around some). This would occur at the end of the day or after walking or playing with my kids. There appeared to be a change in my gait at about this time (just did not feel correct with lower extremity balance and push off). My gait felt almost completely normal with no lateral foot symptoms when I was barefoot or walking in vibrams.
The general foot ache I experience on a daily basis now seems to be more lateral plantar with no more 4th,5th met/cuboid symptoms.
I regularly receive chiropractic care and have discussed this problem in detail with him. He does not feel there is a significant limb length or rotational issue.
I would appreciate the expert opinion of this panel to both help a colleague and continue to educate this forum on issues like these. Thanks in advance for your help.

Adam

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Cuboid syndrome ?

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I should add some clinical info to the above description of my lateral overload.
Within the last 6-12 months I have developed what I believe to be a compensated FF and RF Varus-Right foot. When I wear my Vibrams and rock from FF to RF I can feel a lot less pressure under the 1st met head on the right side (symptomatic side). I have had some benign knee pain (once or twice a month on the left side). I have given up on squatting down to catch for my sons for any extended period. Dull ache in the right midfoot/rearfoot area when I have been walking on concrete floors or at the end of the workday.
I also had some success with trying a new running technique several years ago (Chi Running which places more of the initial impact on the midfoot) It allowed me to run with very few symptoms but that has not worked as well over the last 8-12 months and I have stopped any regular running. Thanks again in advance for any assistance. Have a Happy New Year.

Adam

Adam:

Quit the Chi Running, quit the Vibrams, ice the dorsal midfoot, do 3x/day gastroc-soleus stretching exercises and try a 1/8" - 1/4" heel lift in a more traditional running shoes.

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Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

This is a classic example of peroneal inhibition due to a restriction in fibula translation. It would see that this occurred when you slipped off the treadmill. treatment involves a manipulation of the ankle and then peroneal strengthening exercises.

You may also require a cuboid manipulation as well. These can be viewed on You tube by searching Dananberg, manipulation. You may also want someone to evaluate you leg length...the ITB pain post marathon, if unilateral, may be a clue.

Howard

Howard:

As you and I know, we agree on many areas of biomechanics but have elected to approach them differently.
I wonder who has made more 1st ray cutouts you or I?
I wonder which of us has made more 5th ray cutouts for posterior tibial inhibition (possibly useful in this case)?

I believe that you are the most important person in the field of biomechanics in my lifetime as you have fostered your work and findings without trying to damage or degrade others as have The Rootians and The Arena (that means Root and Kirby).
I wish I had your skill and self control.

1. Do you know anyone in the NYC area that is proficient in your manipulation techniques as I have failed to master them (even after your personal demonstrations)?

2. Can you provide some exercises to strengthen peroneus longus specifically?
(especially in closed chain) as this is the root for my Compensatory Threshold Training Program.

Dennis

Hold on a second Dennis. You have patented a method of exercise to promote and accompany FFT and are now asking Howard to provide you the methodology? Isn't that working backwards?

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Adam,

Your symptoms of ITB inflammation and lateral midfoot pain are indicative of lateral overload. This lateral overload could be the result of a limb varus condition which could result from a femoral anteversion, genu varum, or tibial varum, or an uncompensated or partially compensated rearfoot varus.

Alternatively this could be the result of a functional problem resulting in the transfer of weight to the lateral forefoot instead of rolling over the big toe. This is one of the common compensations of functional hallux limitus.

This seems to be a unilateral problem so I would doubt that you have a physiologic varus in one leg and not the other. Particularly since you state you do not feel you have a leg length discrepency. My guess is, you have a functional hallux limitus. To see how I test for this codition, search you tube, cluffy wedge, how to test for FHL or stiffness in the big toe, this is a short 2 minute video.

There are three main arches in the foot, the medial longitudinal arch, the lateral longitudinal arch, and the transverse metatarsal arch. When excessive pressure is applied to the lateral column in the foot, over time, the lateral arch will break down just like the medial longitudinal arch will do. This results in the so-called forefoot valgus deformity. This will also incidentally break down the transverse metatarsal arch.

I find that most of these forefoot valgus conditions can be corrected by simply pushing the fourth and fifth metatarsal down as a cast of the foot is obtained. A forefoot valgus post will only jam the fourth and fifth metatarsal's upward more, and I find is very uncomfortable. A cut-out underneath four and five is not a bad idea, but this is going to destabilize the foot laterally and potentiate the problem of lateral instability, by messing with the lateral tripod of support (essentially raising this).

The solution I would recommend would be a pad underneath the cuboid to support the lateral arch, and a Cluffy Wedge to overcome the limited motion dynamically of the first MTPJ. Because of the functional hallux limitus, you most likely have an equinus. I do not know for sure, but I suspect the fibular glide issue may be related to this. If these modifications do not work on an OTC insole, then a custom orthotic would be indicated making sure to plantarflex the fourth and fifth metatarsals and not apply any fill to the lateral arch of the cast.

I think the reason your barefoot running pattern has helped you, is because you have less limb varus. This is what I have observed with this running pattern. When running I would make a concerted effort to try to widen your stance and roll over your big toe joint. This will engage your windlass mechanism and result in stability of your midfoot particularly your cuboid as described by Dr. Hicks in the 1950s. I would suspect that manipulation of your cuboid by bringing the fourth and fifth metatarsal's down and pushing up on the cuboid may also be helpful. I would recommend that after you address the mechanical deficiencies you see an ART provider to work on your IT band, flexor digiti minimi, abductor digiti minimi, flexor digitorum brevis, and your peroneus longus and brevis. Modalities and ice may help the soft tissue inflammation.

I hope you find this information helpful, and would be anxious to see how you do with these recommendations.

Adam, I think what Kevin is getting at is there is a lot of propaganda and rhetoric associated with Chi running, Pose running, barefoot running, or whatever is the flavor of the month running is.

What gets missed in all the propaganda and rhetoric is that you can not change running form without loading more some tissues that were not loaded as much before ... if the tissues can not take it then that "form" is not for you. Yes Chi, Pose, Barefoot and Minimalist all eliminate the load associated with heel strike, but those forces have to go somewhere (Newton's law on conservation of energy) ... in those techniques of forefoot/midfoot strike, the dorsiflexion moment of the forefoot on the rearfoot is one of the loads that have increased. The symptoms you are describing reflect the tissues not being able to take it ....hence Kevin's advice to get back on the heel. That is the best way to lower that moment and give the tissues a chance to heal. .... after that you can (if you want to!) transition back to Chi slowly giving the tissues time to adapt .... HOWEVER .. if could be that the moments are so high, the tissues can never adapt to that load...

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I want to thank all of you for your thoughtful responses to my lateral overload issue. I would like to add some clinical details so we can all learn together albeit from different trains of thought.
I no longer experience any type IT Band problems and have not had dorsal lateral foot pain over the past 4-6 months. What I am experiencing on somewhat of a daily basis is a dull ache in the right plantar cuboid/peroneal region. A heaviness sets into my plantar lateral foot after walking on concrete floors or at the end of the workday. I coached my son's basketball team last night and felt that "feeling" on the bottom of my foot with a change in my gait. I still had that feeling this morning walking down the hall at work. After looking closer at the area I was not pushing off my great toe hardly at all (thanks Dr. Danenberg and Dr. Clough). I placed a cuboid pad in my shoe and the gait quickly seemed to normalize with a more pronounced push off of my right hallux.
Yesterday while riding the stationary bike I noticed my right lower extremity had to reach for the pedal a lot more than my left. I moved the seat back and forth and made sure my posture was correct and there was definitely a difference.
I would love to hear from any of you about strengthening and stretching that can allow this problem to be resolved without long term orthotic use.
I shouldn't like being a guinea pig but I am starting to enjoy this process. I will keep all informed of my progress so we can learn together. Thanks again for all the shared knowledge.

Adam

Question for abfootdoc

No disrespect intended but are you a podiatrist or a patient looking for advice?
These guys are posting a lot of stuff that you should really already know - where did you train?

respectfully

Steve Wells

Hi Steve
No disrespect taken, but actually I did extremely well in school and did a 3 year surgical residency in foot and ankle reconstruction. You are correct that I should have learned a lot more clinical biomechanics but I can assure you that after talking to many colleagues I did not get the same responses as I have gotten from the podiatrists involved in this forum. I consider myself astute and I am constantly reading trying to further educate myself.
I have been dealing with this lateral overload issue for several years (its really more of a nuisance than an injury that stops me from being active). As I have seen on this forum there are many different opinions and ways to treat the same symptomatology. I hope you have accrued clinical biomechanics knowledge that you will be able to share with me and the rest of the podiatry forum. Looking forward to it.

Adam

Good response, Adam. Thanks for being humble enough to ask questions. We are all still learning, and those that are not will simply never improve their clinical skills. Good day.

Craig,

To this point, many years ago, I treated a patient with the following history. He was and had always been a midfoot striker. He was told by a friend that he would do much better if he ran "heel--toe". He tried it. Ruptured his plantar fascia on the second day out running in his NEW style.

Howard

Adam, There are two foot types that tend to have high lateral loads. They should be treated differently. One type is the easy to supinate foot with a laterally positioned STJ axis. The other is the partially compensated (forefoot or rearfoot) varus foot that lacks eversion range of motion. Are you familiar with the Coleman block test? That is one way to differentiate these foot types. On other threads I've described a maximum eversion height test that is another way of differentiating these foot types. It is also possible to have a laterally deviated STJ axis and a partially compensated varus.

In the partially compensated varus foot a forefoot varus wedge will usually help to increase the load on the medial forefoot and decrease the load on a lateral forefot. This wedge will make lateral instability, or peroneal muscle symptoms worse in the foot with a laterally positioned STJ axis.

Eric

Howard:

I did a free screening at a running shoe store here in Sacramento a few months ago. The last 5 people I saw with new running injuries had all admitted to trying to "run more on their midfoot and forefoot, and avoid heel-striking" soon before their injuries had begun running with their NEW style.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Without giving reasons for my offerings and using my best Arena language, so as not to divert this thread, here are my suggestions.

Casting Suggestions:
Correct for excess supinatory moments in the rearfoot
Utilize Forefoot Vaulting Technique
Reduce dorsiflectory stiffness moments under 5th met

Foot Bed Adjustments:
Reduce frontal plane corrections of the rearfoot.
Full contact vaulting with low durometer crepe over the shell
Aggressive 1st ray cutout
Aggressive 5th ray cutout
5-7 mm 2-3-4 Bar Post in forefoot
Consider a temporary heel lift

Kinematics:
Strengthen PT
Strengthen P. Longus
Leave T Achilles alone
Set up a Compensatory Threshold Training Program

good fortune

Dennis