Friday, December 9, 2011

The popliteus muscle and functional hallux limitus

This is just a quick post for myself before I go for a new and welcome appointment tomorrow. I think I have clarified a lot of my thinking lately and I want to see how right I am. The really really good news is that in the last post I wrote about a doctor who I was told I should go see. I got an appointment, but he is so busy that my appointment wasn't going to be until the end of April. Well he found my blog post and emailed me to offer me an appointment this Saturday as he was going to be in the office doing paper work. Well, isn't that the greatest? I also had a running friend email me as he has been a patient and he also says that he is the best and definitely who I should see! I can only say that I am very fortunate to find a doctor who is very eager to fix problems and to make time to see a new patient. That is quite exciting. The rest of this is more boring stuff, and mostly for my reference, but you never know who may read this and offer some insight or get some ideas to help figure out their own biomechanical problems!
So my hip has been fixed and an MRI ruled out a back or nerve problem so what is up? And what is the etiology, or cause, of my messed up mechanics and problems running. I am going to write what I now think and I then want to compare it to what the doctor says tomorrow, but most important for me is what to do about it all and I think I have found the right doctor to do that!

Last week (after a month of feeling my left lower leg was pointing out more to the side and creating instability on my whole left side) I did some massage on the back of the knee and upper calf. It started feeling better and lining up better. I asked my PT about this and she said it is the popliteus muscle and that muscle can rotate the lower leg out. She then did Graston and deep tissue massage on this and the surrounding muscles. My leg felt better than it had in over a month. I also noticed, however, that when I stand or walk, my big toe really doesn't touch the ground and when I walk or run that left foot awkwardly shifts from from the outside to the inside rotating my foot and lower leg out to the side to try to get that toe on the ground. I also noticed that I have no foot tripod on my left foot (I was aware of this before) as when I  pronate forward the 1st MTP joint gives way and collapses without supporting my foot. The joint and toe is there, but it is almost like it is cut-off and doesn't do what is supposed to do and just gives way.There is a name for this phenonena and it is called functional hallux limitis and I do have orthotics for this, but they seem not to work correctly anymore. So I took out the orthotics ( a cutout under the 1st MTP joint is supposed to preload the joint so this doesn't happen) and instead put a wedge under the big toe which is supposed to do the same thing for the toe joint but in a slightly different way. It is called a cluffy wedge and I bought a set before I got the orthotics made, but I never really used them as I had orthotics. I used them and had a great 8 mile run on Saturday (my only run of the week) and my foot felt much better (of course I got sore muscles from going so far with a change in what I had inserted in my shoe and using a regular insole instead of an orthotic).

So I think that my big toe is the source of my problem.s With functional hallux limitis the big toe joint doesn't work and the foot can't propel itself over the toe, so it finds an new way to do this through pronation. Over time the pronation then forced my foot to point out and that created havoc with my knee (the poplietius muscle). This created the inward rotation at my hip which caused the hip not to work correctly which led to the back pain on the left side for the past 25+ year and the labral tear in the hip. In other words I think the problems start in my toe. Now the question is can we finally fix it and retrain my muscles to work properly. I will be most interested to see what the doctor says tomorrow.

I was also supposed to see the podiatrist who is renowned for his work with functional hallux limitis and made my orthotics this week. I somehow got lost and missed the appointment, which is too bad, because I was looking forward to his thoughts and to get the manipulations on my feet. I have an appointment next week if I need it.

This is my podiatrist showing one of his manipulations for the popliteus:

soft tissue treatment of the popliteus

more on the popliteus and its role as a knee rotator- also ways to strengthen the popliteus

how the cluffy wedge works

My current orthotic works like this with a first ray cutout:

Here is my PT showing a big toe mobilization that I have started doing:

Here is a TRX guy showing some toe joint manipulations:

Here is his explanations for the big toe joint and if I am right explains a lot of the compensations my body has created over the years:
Often overlooked, the big toe is not a big joint (metatarsophalangeal joint) but vital for performance and non dysfunctional movements. Mobility is key in locomotion and reciprocal patterns with the feet like the lunges in all planes of motion. Compensations will happen when motion can't occur in this part, which can give other dysfunctions higher up in the chain, muscle or joints or both. Proper gait pattern requires ability to flex the knee to 40 degrees, the dorsiflex the ankle at minimum of 20 degrees, and to be able to extend the first MTP joint to a minimum of 65 degrees (Oatis, 2004). The inability to extend the first MTP joint due to joint degeneration, structural change, or general restriction is commonly known as hallux limitus and is often seen in running athletes who wear traditional running shoes (not all but many of them). This range of motion is very important in the grand scheme of the "Windlass Mechanism" , which is a passive loading mechanism that occurs as the calcaneus clears the ground in late stance and the weight transfers over the heads of the metatarsals. Combined, these motions load the plantar fascia and intrinsics of the foot that help to transform the foot into a stable lever off of which to push (Fuller, 2000). As demonstrated by Carlson, there seems to be an incremental, linear relationship between hallux dorsiflexion and increased tensile strength of the plantar fascia (Carlson, 2000). As you know, the plantar fascia and Medial Longitudinal Arch are capable of producing a great deal of elastic return in running, so imagine the detrimental effects when this mechanism cannot function well. Those with reduced hallux extension and pronated feet often have diminished effects of this mechanism and ultimately less efficient (Dananberg, 1986). When the big toe does not extend well during late stance, plantar flexion torque decreases and occurs in a delayed fashion (Hall, 2004), knee flexion increases (potentially as a result of tension from the distal end as the calcaneus raises early), and hip extension decreases. To compenstate, there must be an increased drive of the hip flexors to advance the leg. When the foot is fixed upon the ground, this contraction creates potential for lumbar rotation and lateral flexion can occur stressing the intervetebral disks and potentially leading to low back pain and dysfunction (Kapandji, 1974). Add to that the possibility of the body compensating with an anterior tilt to facilitate hip flexion and you have a gamut of issues that sounds a lot like the makings of Janda's lower crossed syndrome with excessively toned hip flexors, inadequate gluteal strength, and possibly an increased full body anterior tilt placing the plantar flexors under excessive load. It is very common in the running world. Additionally, the early knee joint flexion and limited extension of the hips can beget a loss of transverse plane stability possibly as a result of ineffective use of the "screw home mechanism" at the tibiofemoral joint and ineffective activation of the hip extensors. Put all of the above together and you have a recipe for increased forces at the PFJ, shearing across the iliotibial band, potentially increased contact pressures at the anterior hip capsule, excessive activation of the deep hip rotators forcing the hip into a hyperextended position causing decreased sacral rotation during gait, low back pain, and SIJ instability. Clearly, limited hallux extension/flexion/abduction is not something to be ignored.


Frank Lilley said...

Good luck to you! Hope you can quickly find the fundamental problem . . . sounds like you're close!

Bry said...

The foot issues sound very similar to what I've noticed on my left foot as well. As I've gotten older, it's become harder to run and that seems to have been the main cause.

Interested in hearing more as you figure things out!

Jim Hansen said...

Do you find that your leg compensates for the foot? and is that what makes it harder to run?

Bry said...

I'm definitely compensating for it. I'm pretty convinced the tibial stress fracture I had in high school on that leg was at least partially caused by it.

The main problems I've had is that I creep mileage up to a certain point and get injured. I've done this several times since high school.

Anonymous said...

Hello I hope you see this message as you have written this long ago. It sounds like we may have the big toe issue in common but want to hear your thoughts. I had a bunionectomy on my r foot and the toe now does not lay flat on the ground. My legs , hip, back has been in severe pain since then. My doctors came to the conclusion that's it a biomechanical problem from walking in a surgical boot so long after surgery. I'm beginning to think its the big toe not laying flat that is causing the extreme pain. (we came to the bio issue by trying some pretty heavy duty injections which did not work) I look forward to your thoughts I cannot thank you enough !

Jessica from MD

Jim Hansen said...

Hi Jessica,
Sorry to hear about the pain, I know how that goes. I know there is a connection between the toes and the hip, but I am still working on getting to the perfect fix. This is a good article a friend sent me last week: It also has some references at the bottom. Are you able to do flexibility exercises for the feet? Have you checked out Somatics yet? You might find some answers at Martha Peterson's site: for retraining your body's movement patterns and for getting out of pain. Good luck and let me know if you find something to work.

Unknown said...

Increased femoral anteversion or retro version

Unknown said...

Dr. Buly in NYC at the Hospital for Special Surgery is the world's leading expert. I have surgery scheduled for next month.