Why the hallux isn't touching the floor and how to fix it

50% of weight bearing through the toes should occur in the hallux aka. big toe. It is an integral structure for balance and gait. When it is not articulating with the floor it can lead to; balance deficits,  falling and gait abnormalities/inefficiencies.

Try standing on one foot then try again while lifting your big toe off of the ground.

I have had several patients with this problem and the way to solve it is to determine if it is due to a structural dysfunction, an anatomical structure that is blocking motion, or a non structural dysfunction. To review non-structural dysfunctions can be due to:

1. Inflammation
2. Alignment
3. Severe Atrophy
4. Upper Motor Neuron Disease or Injury
5. Lower Motor Neuron Disease or Injury

If it is a structural dysfunction, there are several ways to determine what structures are causing the hallux to be stuck in extension.

1. Palpate up the kinetic chain: If a anatomical structure is malalgined it is usually due to forces acting on that structure from its base of supports. Palpating the 1st, metetarsal, medial cunniforms, navicular, talus, and calcaneus for restrictions in the tissues should reveal the cause of the hallux extension.

2. Reposition, Release, and Re educate: Meaning put the toe in the position it should be and see and feel for structural restrictions up the kinetic chain. Then release those and re educate.

3. Diagnostic Motion Evaluation: Doing foot clocks or having the patient perform other types of  movement over a stationary foot in the closed chain will revel dysfunctions at the location of compensation or disjointed motion. This can be done in standing, sitting or hook lying.

The observer must watch for the following; 
a. When and where the motion stops or is no longer sequential or evenly distributed.
b. When the patient compensates for the motion, in the case of the foot the compensation is usually the sole of the foot coming off of the floor.

Case Study: Patient cannot negotiate stairs

I stress in my class to focus on what the patient cannot do functionally to guide your evaluation and treatment by asking “What activity or activities do you have difficulty performing”.

This is beneficial for the following reasons:

1. We now have functional goals which are vital for insurance reimbursement

2. We now can break the activity down into its components and determine where the dysfunction is and what type of dysfunction exists.

3. As a result we will be able to provide the appropriate treatment to restore function.

I was recently given such a case study and asked to evaluate and treat the following functional limitations.

1. Patient is unable to negotiate stairs
2. Patient is unable to balance on one foot to don clothes

Significant patient history is the following:

1. Total toe replacement over 5 years ago on the R.
2. Trendelenberg gait on the right

When we observe this patient we notice the following:

1. Bilateral pronated feet
2. Right hallux extension, approximately 3 degrees in neutral
3. Diminished push off phase of gait.

My evaluation will be as follows: There are u-tube links next to the various evaluations

1. For negotiating stairs I will evaluate:

1. ROM of dorsiflexion with the knee bent in stepping (going up and going down). The knee should come forward over the toes. Going up: http://www.youtube.com/watch?v=-3JxExXQKM0&feature=relmfu Going down: http://www.youtube.com/watch?v=KMCieNrpwfo
2. Pelvic Depression with the leading leg on descending stairs, it should drop 2 inches:http://www.youtube.com/watch?v=047nRKXzBpw&feature=relmfu
3. Hamstring Contraction. You should feel a contraction with your hand. http://www.youtube.com/watch?v=JEyM4as3YRQ&feature=relmfu

2. For Single leg Balance I will evaluate:

4. PROM of the hallux to neutral
5. AROM of the hallux in flexion
6. Observing where motion occurs (motion = instability) Single leg balance

Pelvic stabilization with lower extremity hip/pelvic extension

One of the most challenging movements to achieve is stabilization of the lumbar spine with hip extension. The reason is that virtually every human being lacks efficient hip extension. The compensation for a lack of hip extension results in excessive extension in the spine in younger people and flexion of the spine in older people. This is, in my opinion, one of the major reasons that lower back pathology is a pandemic in society.

Various authors state that normal hip extension is as little as 10 degrees and as much as 50 degrees. (Note that these authors do not state whether the lumbar spine was stabilized when the range of motion measurements were taken.) I believe it to be 30 degrees without compensation of the lumbar spine as this is the amount of hip extension needed to ambulate with a efficient gait pattern.

The following is an awesome activity to do with your clients to disassociate stabilization of the lumbar spine with hip extension. My class and I came up with it in our Balance and Gait Class.

As see in the photo to the left, have your client stand behind a chair and wrap a towel or a strap around the lumbar spine or at the particular segment or vertebrae that you are trying to stabilize. Apply a forward force with the towel so the patient engages their abdominal core stabilizers and the patient can resist without straining. The patient may hold onto the back or the chair for support or on the therapist's shoulders.

In the photo in the right, ask the patient to hold their trunk stationary maintaining the pressure of their back on the towel as they move one leg posterior so that the toes of that leg are parallel with the heel of the leg that is not moving (this is the equivalent of 30 degrees of hip extension). Have the patient repeat or alternate legs moving posterior.

To see a video of this activity, click the link: http://www.youtube.com/watch?v=OPwJaiiuRqI&feature=youtu.be

Just a footnote, if your client is not able to perform the activity without compensation, there is either a structural or non structural dysfunction of the thigh, pelvis, sacrum or a non-structural dysfunction in the lumbar spine that needs to be addressed first.

Home Program Stabilization for the pelvis and lower extremity in supine

Pictured to the Left:

1. In this example the patient has one towel under is lumbar spine and he is trying to pull that towel out laterally. He is, therefore, stabilizing his lumbar spine by holding the towel stationary against his own resistance.

2.The second towel is wrapped under his lower thigh and the patient is pulling it upwards. He is resisting this challenge by activating his hamstrings and foot stabilizers. He is stabilizing with the hip, knee and foot stabilizers.

Pictured Below:

3. The patient now begins to move his free leg and a variety of positions to challenge the stabilization at the lower back and his left leg.

Stabilization for Balance

For Balance the key spots that require stabilization (a isometric contraction, ideally with a rotational bias) are:

1. The pelvis, because it houses our center of gravity.

2. The hips, knees, and feet because these structures act as our base of support in standing.

Remember that balance is control and falling is a uncontrolled displacement of the body that occurs when our center of gravity moves beyond our base of support (tripping) or our base of support moves beyond our center of gravity (slipping). For maximum stability our center of gravity should remain equidistant within our bases of support.

After we have determined the cause of our pt's instability (refer to previous entry for the list of reasons) and the location (through the diagnostic motion evaluation, DME). We will treat the instability and provide home program for carry over.

The following post will provide examples of treatment and home program stabilization techniques.

These are also great exercises for your lower back, hip and SI patients!

How to train individuals with Balance Deficits

Balance is the ability to control one’s body either in a stationary position or while moving

Therefore:

Balance = Control

The muscles that are in charge of controlling our bodies and movement are our core muscles.

Therefore:

Balance = Core muscle control

Our Core muscles are stabilizers

Therefore:

Balance equals Stability

Note that we have core muscles in every joint they are:

1. Deep
2. One Joint muscle
3. Oriented in a diagonal fashion
4. Rotators

Reason’s why core muscles stop working:

1. Inflammation/Trauma: For every cubic centimeter of inflammation a muscle shuts down by 1 percent.
2. Alignment: “Alignment dictates function” due to the Length Tension Ratio which states that a muscle will contract with greatest vigor when it is at a particular length.
3. Upper Motor Neuron Disease/Injury: Including; Stroke, Parkinson’s Disease, Dementia, TBI, etc…
4. Lower Motor Neuron Disase/Injury: Including; Radiculopathy, Neuropathy, Compression
5. Severe Atrophy: Someone who has been severely weaken by immobility due to coma, bed rest, inactivity, disease.

The key to treating Balance is to identify the factor or factors causing your patient to have poor core muscle function:

1. Inflammation/Trauma: Exercise to train core muscles, (see below)
2. Alignment: Release, Reposition, Re educate or Reposition/Re educate
3. Upper and Lower Motor Neuron Disease/Injury: Remove Cause of disease if possible, treat symptoms with facilitation techniques, address possible alignment and inflammatory issues, and re educate.
4. Severe Atrophy: Re education and training (see below)

To train these muscles appropriately we are required to perform an isometric contraction ideally in a rotational direction for a sustained period of time

To train Core muscles (Balance) we should perform exercises that:

1. Are isometric in nature
2. Resist a rotational movement
3. Sustain a contraction for a period of time, up to a minute

Next entry will provide examples for Core muscle training of the lower extremities and abdominal core in Standing, Sitting and Supine.

Grandpa Treamtn Day 6

This day was all about function and functional exercises. I took advantage of the good weather and treated on the deck. It is an optimal location as there are many places to hold on while walking. What I observed was that when my grandfather walked with the cane in his right hand and held on with his left hand, he was able to assume a normal gait pattern. This was not the case while walking with the cane in the left hand and hand rail on the right. Therefore, I had him walk holding on with the left and cane in the right walking forward, backward and side stepping.

I also had him perform his home exercises of hip abduction and extension having his back to the railing of the deck and holding on to his side and rear rather than forward so that he would not compensate with flexion.

I also incorporated another exercise that was recommended to me by a student in my class to reinforce pelvic motion in sitting and it is to perform seated pelvic clocks on a commode and drop a small object ( I choose cereal ) into the bucket. The benefit to doing this on a commodes is that you can obtain the appropriate seat height to maximize range of motion. I had him work on moving his pelvis into anterior rotation.

Finally, I decided to have him try walking with 2 canes. He walked better than I have seen him walk in years and he comment on how his walking felt normal. We practiced taking a few steps with the wheelchair behind him and called it a day.