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Functional hallux limitus is a theoretical construct. There is no doubt that the phenomenon that is functional hallux limitus exists, but that can often be as far any any agreement or consensus gets with this. There is no doubt that there are some feet when the foot is up in the air that there is a full range of motion available at the the first metatarsophalangeal joint yet when that foot is weightbearing during gait, that joint just does not want to move. That is the definition of what functional hallux limitus is.
I have written about this a lot, speculating that functional hallux limitus has many possible causes and that it may be better to conceptualize it as a nothing more that each person having a variable stiffness range of motion at the first metatarsophalangeal joint and that this may be related to the windlass mechanism. If this is the case then what we typically considered to be a functional hallux limitus is really the extreme of this variable stiffness and that functional hallux limitus probably exists as a continuum and not as an either/or entity.
Concussion is in the news a lot lately and protocols for their acute management have become stricter in most sports as more is known about the long term consequences of repeat concussions. For example, a third of kids who have a concussion develop long term mental health and emotional issues. New laws and rules are being implemented by sporting codes and others are under pressure to do more. I have previously blogged about why I think podiatrists should be concerned about concussion and there is a long thread at Podiatry Arena on concussion.
I see concussion as a major public health issue and podiatrists (and all health professionals) should be concerned and active in advocating on all public health issues (eg smoking, obesity, etc). We should be helping getting all the messages across.
The other reason is that post-concussion is that there is an increased risk for lower extremity injury. More than 30 or so studies now show that.
Finally, we are parents and members of the community and our kids play sport. We may need to step up and use the first aid skills if there is a knock to the head at sport.
I urge all Podiatrists to get involved and interested and become advocates for this public health issue.
This is a common topic I write about often. I wrote here about just how much I learnt about the condition when my own daughter got it and just how much that subsequently influenced my management. We did a PodChatLive on it with Alicia James and I published my unscientific study on it here.
Firstly, it should be called Calcaneal apophysitis and not Sever’s disease, but I still use Sever’s disease as that is way more common in the search engines when you want your writing to show up.
Secondly, as I said in my unscientific study, I not sure we can do much to help it. The big problem with Sever’s disease is that if you take 100 kids with and do nothing, x% will be a lot better next week. If you took another 100 and did something, then x% would be better next week, so did ‘something’ work or was it the natural history that was the reason for the improvement.
I know when you visit Podiatry Facebook groups and other social media and see discussions on Sever’s disease, so many have there views on what should be done. I have to fight myself really hard not to get involved in arguments, but I often want to ask them how do they know the treatment that they are advocating actually works and that the improvement that they are seeing is not just the natural history that you would expect to see. They actually have no way of knowing unless what they are advocating has been tested in a proper well controlled prospective randomized study.
So what do I do for Sever’s disease. Not a lot. Educate them on the nature of the condition and the natural history; discuss how to manage the loads and use a cushioned heel pad.
We call them “thongs” in Australia. The Archies footwear come with an arch support built into them. We sell Archies in our clinic in Melbourne and they sell well. Pretty much everyone who tries on a pair buys them They are that comfortable. What is useful about the Archies is that they can be used by those who need or have foot orthotics but want to occasionally wear this style of footwear.
The other great thing about these is that can be modifiable. I sometime get on the tools and make what I call a MOSI Archie modification for those with a more medially located subtalar joint axis. I made this video on the technique.
I also occasionally answer a question online about them!
I talk a lot during the Clinical Biomechanics Boot Camps about many different design features that get used in foot orthotics such as the MOSI, the Kinetic Wedge and the Cluffy Wedge to name just a few. They are all useful features and have their places depending on what affect you are wanting.
For example, the Cluffy Wedge is deigned to hold the hallux in a slightly dorsiflexed position. This tenses up the windlass mechanism in the foot and brings on that windlass effect earlier. That is only going to be useful if you want to or need to bring it on earlier. If the windlass mechanism is functioning fine, then the Cluffy Wedge is probably not going to make any difference. That does not stop some clinicians using it as a ‘cure all’ and using it in in most orthotic prescriptions. The Cluffy wedge or a similar foot orthotic modification is indicated when it indicated and not indicated when its not indicated.
One big thing I get from running the Clinical Biomechanics Boot Camps is the feedback that I get when clinicians change their clinical practice based on what I teach on the course and its works!
One of these is the treatment of anterior compartment syndrome. My previous clinical experience in dealing with this problem is an almost 100% failure in its treatment. It really was a challenge. Anterior compartment syndrome is when the muscles expands its volume as it normally does on exercise and the fascial compartment that the muscle is in is particularly tight, so it hurts. Nothing really used to seem to help except the surgical outcomes were always pretty good.
In 2013, this study was published and I immediately started doing it in clinical practice and teaching about it in the Clinical Biomechanics Boot Camps. By changing from a heel strike to a more midfoot or forefoot strike with a lower touch down angle meant the activity in the anterior tibial muscle did not have to work so hard (but keep in mind that to do this requires other muscles to work harder and put them at increased injury risk if this is not done carefully).
This means the rationale was there. Even more surprisingly was that the results were often quite dramatic clinically. It worked. I enjoyed the feedback from course participants who went back to their clinics and tried it and contacted me to tell me it worked.
So much of the use of foot orthotics is based on compromises. The ideal foot orthotic and the ideal foot orthotic prescription is often modified away from that ideal to take into account the footwear that they are to be used in. This is particularity a problem in things like tight football boots or ballet flats when you need some form of arch support. These types of shoes are not designed for any sort of support or foot orthotic to go into them. They are minimalist by design. Often what I do for these types of patients is use a self adhesive silicon gel arch support which takes up very little room, but does give some support. There is a little bit of trial and error to get the placement in the shoe right for comfort. It is less than ideal, but better than nothing.
This is one of those pet peeves and annoyances. Arthur Lydiard was probably one of the greatest or most influential distance running coaches. I often see his name used in many ways and miss-quoted or have things credited to him that he did not say.
I knew Arthur Lydiard. I did some work with him. This means my ears pick up when people say what he might of thought of something related to running.
On running shoes I have seen him quoted as saying that minimalist running shoes are better. I seen it said that he would have supported barefoot running if he was around when that fad took hold. Wrong. He never said anything like that.
Here is what he wrote about running shoes:
In most of his books he advocated for the use of padding in running shoes to reduce impacts: “…check that they have good rubber soles that will protect you from the impact..” (pg 7; Run, the Lydiard Way; 1978) and “Well-rubbered shoes are essential to eliminate jarring effects” (pg 212; Run, the Lydiard Way; 1978). He also believed that forefoot strikers were “more susceptible to foot troubles” (pg 116; Run, the Lydiard Way; 1978) than those who flat-foot or heel strike. In an interview with the website RunWashington, he went on to say “We like flexible shoes, to let your foot function. Shoes that let your foot function like you’re barefoot – they’re the shoes for me, as long as they have some rubber underneath to alleviate the jarring.”http://irunningshoe.com/2021/03/18/what-did-arthur-lydiard-thing-about-running-shoes/
Arthur Lydiard also collaborated with Converse and EB Brutting to make well padded running shoes. He was not a minimalist – he wanted padding in running shoes. He thought forefoot striking was problematic.
It may be somewhat voyeuristic, but I periodically head over to YouTube to check out if there are any new videos of athletes getting an Achilles tendon rupture. They hurt you to watch them. Here are a few:
For more on the Kevin Durant rupture, see this write up. One thing I do find interesting about Achilles tendon ruptures is that if you follow the literature, the outcomes between surgical outcome versus conservative care outcomes are about the same; so how does clinician make a decision as to which is the best approach? There is this very log thread on Podiatry Arena with all that literature (you can sign up to watch that thread and get notified of new updates). Some research can be followed here.
The mechanism of action in all these videos is similar. There is a simultaneous extension of the knee and flexion of the ankle as they accelerate.
There is no doubt that Abebe Bikila is a legend. He was a late selection for the Ethiopian team for the marathon at the 1960 Rome Olympics. Because of his late inclusion the teams sponsor, Adidas did not have shoes in his size, so he decided to run barefoot. On September 10, 1960 he got the gold medal. It was no fluke as he then went on to win the 1964 Olympic marathon in Tokyo. He ran faster in this one wearing running shoes.
My interest in him is two-fold: Firstly, he really is a legend and his running achievements are legendary.
Secondly, it has been interesting to follow the use of that legendary status by the barefoot running community during the fad on barefoot running. He was held up as a hero of that community for his barefoot achievements. He was used to promote the benefits of barefoot running. That is fine and he is anecdotal evidence that a marathon can be run barefoot. What you never see mentioned in that barefoot community that he subsequently ran faster to win the Tokyo marathon wearing running shoes. I did point that out on a number of occasions and all I got in response was hate mail. What does that tell you?