Feet First: Clinical Pearl for the Feet #1
Updated: May 12, 2021
Adapted from my presentation material on the foot and ankle from Orthopedic Integration: Lower Extremity
I made a couple of good decisions during my time in PT school. I always thought the best decisions I made were: working as a care assistant to a lovely woman following her stroke, spending as many hours with my brilliant friends in the anatomy wet lab, and taking a rigorous weekend course at Biomechanical Services (a wonderful source for custom orthotics in Southern California).
During the weekend course at Biomechanical Services, I was able to cast fellow PTs feet, to create therapeutic exercise interventions based on individual foot assessments, and to even craft a simple orthotic device. To this day, I still prefer orthotics casted in non-weight bearing.
The course was one of the most complex courses I had taken (this was before I met Michael and Tim of Folsom PT), as the foot and ankle have so many articulations and moving parts.
I have always thoroughly enjoyed working with and problem solving around the foot and the ankle. I find it to be one of the least understood body parts. In adults, we often do little more than pay our feet the most superficial attention by getting pedicures. Our footwear can be destructive, even as it makes us look good.
Good foot and ankle function is an absolute necessity for healthful functioning of your knees, hips, pelvis and low back (and by extension, your neck, and shoulders) and requires diligent attention.
And so let us embark on a deeper dive into the amazing foot and ankle- developing a sense of awareness for what is required for healthy standing and walking, as well as some problem solving strategies and therapeutic exercises for helping you troubleshoot some common problems.
Each week we will explore one or two pearls to help guide your work with your feet.
Clinical Pearl Regarding the Feet: (#1)
Adult Feet Tend to be Both Stiff and Weak (and what to do about it!)
Somewhere along the line of logic we use when thinking about the body, we created associations between a hypomobile (stiff) area as being strong. Or strength as requiring hypomobility. Though this can sometimes be true, generally loss of mobility (hypomobility) goes hand in hand with weakness. This is most apparent at the foot and ankle. We’ll go over the basics to make sure you have what you need in the mobility and strength departments to function well.
When you look at your feet, don’t they seem spindly and bony? Devoid of muscular and tendinous support?
Prior to studying foot anatomy, I always thought they were just mostly bones. We actually have 4 layers of muscle and tendon in the feet (most layers have 4-7 muscles!).
While bony architecture is an important facet of foot function (we will look at that more when we discuss bunions and the windlass mechanism), muscles are crucial to providing support to the arches of the feet, and determine how well we can use our feet while weight bearing.
Testing basic mobility of the big toe for normal walking:
Start with checking out the available motion at your big toe (the big toe is so important, it has a special term in anatomy- the hallux). It is helpful just to take a look at the posture of your big toe (hallux) to start with. Does the toe line directly up with the first long line of bone moving back toward your ankle (your first metatarsal)? Or is the big toe jutting toward the second toe, and there is a small angle in the way the two bones line up. If so, this is likely the beginning of a bunion. But not to fret! At these early stages, you can absolutely make changes into the progression of this process.
Test your big toe mobility:
Can you draw your big to up away from the ground toward your shin, enough so that you can make a 60-70 degree angle from the floor (brush off those geometry skills! Recall 90 degrees would be perpendicular). This is hallux extension.
When you move the big toe into this extension, does the angle between the toe and metatarsal (the metatarsal is the long bone that starts where your toe ends and projects toward your ankle) change?
Bring your big toe back to the ground. Next check to see if you can move your big toe toward your other big toe (toward your midline)
If all of these mobility tests are clear and easy, move on to checking the mobility at your ankle
If you cannot do either of these, gently work on them by moving exactly the same way you tested. Repeat daily holding for 1.5-2 minutes.
Test ankle mobility:
Sitting with your legs out in front of you (with support for your back), draw your foot back toward your shin. Can your foot make a 90 degree angle between the shin and foot, with respect to the floor?
Next check right and left side differences at the ankle joint. Stand with your right foot an inch or two away from a wall. Bend your knee, letting your knee move in front of the ankle (I know we are REALLY moving away from this habit, but just for this once!). How far can you move your toes back away from the wall, before you cannot keep your foot flat when your kneecap touches the wall? Notice the distance between your toes and the wall.
Repeat on your second side and compare.
Big Toe Stability (this is the most commonly inaccessible motion I see in the clinic)
Remain in your comfortable seat. Rest your foot and place it where it is easy to see. Engage the muscle on the outside of the big toe (if you are using your right foot, it will be the muscles to the left of the big toe, along the midline) and move the big toe away from the second toe. Again, if you are working with your right foot your toe should move out toward the left. Hold for 10 seconds. Repeat 10 times each big toe.
(If this seems impossible, do not despair! You are in good company! About 95% of adults that I test cannot do this. In order to learn: Place your feet together. Get your thick rubber band or theraband and place it around both big toes. Rotating at the ankles, slowly turn the feet a little out (moving the feet away from one another but keeping the heels together). You should feel a stretch and or muscle engagement along the inside of the big toes. Hold for 10 seconds. Repeat 10 times.
Intrinsic Foot Stability: (foot doming)
When you are seated, do you have an arch in your foot? When you stand, do you have the same amount? Many of us who are “flat footed” do not actually have flat feet but a collapsed arch. Our intrinsic muscles are necessary to support the arches of our feet, and ultimately to healthful functioning of our knee, and hip and back.
If you can stand with an arch in your foot when you think about it, but lose the arch as soon as you stop thinking or have difficulty holding the arch, please try the following.
Sit in a chair. Place your towel flat on the floor, lengthwise in front of you. Place your 10 toes at the edge of the hand towel. Spread your ten toes (as above) and then curl them down to pull the edge of the towel under you. Relax, and resume your starting position. Repeat through the length of the towel. Then cast your towel down again and do the whole thing one more time.
Remember that strength building takes at the very least 6 weeks. So stay consistent and work with your right effort on the above activities.
Check out next week for more clinical pearls to support your feet.