Help! My child Is Pigeon Toed

I saw a concerned parent this week who brought her child in to our clinic. She was told that her child had her feet pointing inwards while walking. This is also called in-toe or pigeon-toed walking. (If a child walks with their feet pointing onwards it is called out-toe walking or duck-footed).

These childrens' walking patterns are often termed "rotational deformities" which often cause parents to seek the opinion of podiatrists, physiotherapists or an orthopaedic surgeon for more specialized assessments and treatments.

Often when a baby is born, bowed or curved legs are normal due to the position they may be inside the mother's womb. This sort of bowed or curved legs can remain for a while and seem more obvious when the child starts to walk. It may appear that their feet face inwards (or outwards). Often the child may even trip or fall over their own feet while walking.

There may be different reasons why the child's leg or foot faces inwards or outwards while walking. When a child's leg or foot faces inwards or outwards during walking, it can be due to a number of changes in the leg or foot. If the foot is curved in ('banana' shaped feet ), or when there an inward twisting of the shin or thigh bone (tibial or femoral torsion), in-toe walking can occur.

Tibial torsion occurs when the shin (tibia) bone turns in or outwards. An inward-turned tibia is common in children under the age of 3. It almost always straightens after this age after this age (3) with NO treatment. Sometimes the shin bone even turns slighly outwards as the child grows order. This is perfectly normal. These changes occur in children up to the age of 8.

The are health professionals who will recommend that children with in-toe walking wear a type of orthotics called gait plates. While gait plates may provide some cosmetic effect when worn, there is insufficient evidence they will result in long term change. 

Parents please be very cautious about claims that such devices will fix your child's in-toe walking. Please consider if the expense, time, and your child's well being is worth it for something that will naturally get better on it's own. Do not let these health professionals prey on your fear.

Femoral torsion is when the femur (thigh bone) is turned in or outwards. Children may appear to walk with their feet tuning inwards or outwards. It then looks like their knees point inwards or outwards. 

The femur goes through many changes up to the age of 12 and this inward turn of the of the femur is more commonly seen in girls than boys. Please note that this rotational changes in the femur are a very normal part of growth.

W sitting

This inward turning at the top of the femur and hip sometimes appear in children who W-sit (pictured above) as well. There is however, no research proving that W-sitting is harmful.

There are no shoes, orthotics, garments, stretches etc that have evidence showing them being effective to change in-toe or out-toe walking associated with these rotational changes. Children walk in-toe or out-toe for many reasons. 

Unless your child is tripping often because of the leg position at the ages past 8 years of age, or if one leg turns significantly more in or outwards than the other. Unless one leg seems a lot longer or looks very different compared to the other, there is no reason to be worried. For the majority of children, in-toe or out-toe walking is just part of growing.

Actually, famous athletes like Michael Jordan, Bjorn Borg, Andre Agassi, Andy Murray, Vera Zvonareva, Zinadine Zidane and Ronaldinho are all pigeon toed. There is some anecdotal evidence and indirect research evidence to support that pigeon toed athletes have faster feet reaction times. And that will have to be in another post.

Reference

Mudge AJ, Bau KV, Purcell LN et al (2014). Normative Reference Values For Lower Limb Joint Range, Bone Torsion, And Alignment IN chldren Aged 4-16 Years. J Ped Orthop. 23(1) : 15-25. DOI: 10.1097/BPB.0b013e328364220a

Does Having Different Leg Lengths Cause Injuries?

A runner came to our clinic this past week with a brand new pair of orthotics as he was found to have a leg length discrepancy of half a centimetre (cm). He ran the Singapore Stan Chart marathon last week with them and ended up with a slight injury. 

I had previously written about how it is very common to have a leg length discrepancy (LLD) and that most of the time it did not matter for most people. I had not provide any references to justify my post then so please allow me to do so now.  

Actually, 90 percent of people have a LLD of up to 1 cm (Gordon and Davis, 2019). Knutson et al (2005) also reported that that the most people have an average leg length difference was 0.52 cm and for majority of people this difference does not matter unless there is a difference of 2 cm or more.

What about runners? Would having different limb lengths cause an injury for runners? Many healthcare professionals insist LLD can cause injuries and will often prescribe orthotics to correct this discrepancy.

While running, there is only single leg stance phase (where one foot contacts the ground) and some flight time (where both feet are off the ground) before the other foot contacts the round. At no point is both feet on the ground at the same time when we run (running does not have double leg stance phase unlike walking).

LLD actually has a greater effect on double leg stance (both feet contacting the ground) activities. During single leg stance activities, the effect is lessened as the gluteal (or buttock) muscles, especially gluteus medius work to stabilize the pelvis. 

Hence, running is less likely to be affected by leg length differences and studies have shown that LLD was not associated with the development of a running injury (Hespanol et al, 2016). 

Rauh et al (2018) did find that male runners with a LLD greater than 1.5 cm had a greater chance of developing a lower leg (shin/ calf) injury.

Now you know that LLD of up to 1 cm are very common and unlikely to cause pain in many cases, especially runners. There is also insufficient strong evidence when to start treatment and it should not be based solely on the length of the LLD. 

If the gluteus muscle is weaker on the left (pictured), it can cause a functional leg leg difference and cause that side of the pelvis to drop lower. If the difference is above 2 cm, there is a higher chance that biomechanics are affected and can cause problems. Majority of people do not have this.

What about differences of 1 to 2 cm? Personally I believe if it ain't broken, don't fix it. Meaning only if a patient or runner's condition is causing pain then we it may be worth exploring if changing hip or leg strength helps.

References

Gordon J, Eric MD, Davis DE (2019). Leg-Length Discrepancy : The Natural History (And What We Really Know). J Ped Ortho. 39():p S10-S13. DOI: 10.1097/BPO.0000000000001396

Kuntson GA (2005). Anatomic And Functional Leg-Length Inequality: A Review And Recommendation For Clinical Decision-Making. Part 1, Anatomic Leg-Length Inequality: Prevalence, Magnitude, Effects And Clinical Significance. Chiro Man Therap 13,11. DOI: 10.1186/1746-1340-13-11

Hespanhol Junior LC, de Carvalho AC, Costa LO et al (2016). Lower Limb Alignment Characteristics Are Not associated With Running Injuries In Runners: Prospective Cohort Study. Eur J Sp Sci. 16(8): 137-144. DOI: 10.1080/17461391.2016.1195878

Rauh MJ (2018). Leg-Length Inequality And Running-Related Injury Among High School Runners. Int J Sp PT. 13(4): 643-651. PMID: 30140557

Do Orthotics Reduce Kneecap Loads In People With Knee Pain?

Many of our patients wear insoles (or orthotics) as they have been told that it 'corrects' their flat feet while helping to reduce excessive forces on their patellofemoral (kneecap) joint. This then helps to prevent kneecap pain.

Customed made orthotic

Well, if you have been told (by your health professional) that you need insoles/ orthotics for the same reasons, now you can tell them that this latest published systematic review/ meta analyses from the BJSM suggests otherwise. This is a very important study since kneecap pain is very commonly seen in in our clinics (and many others) affecting both the young adolescents and older adults. 

The authors identified 33 eligible studies and did 3 different comparisons during walking and running combined. Using insoles/ orthotics with medial (arch) support versus no insoles, minimalist shoes versus conventional footwear and lastly rocker versus non-rocker footwear.

Arch supports

Analyses by the authors showed that insoles/ orthotics that support your medial arches DID NOT alter kneecap loads during walking or running. This questions results from previous research that suggests the pain reducing effects of insoles/ orthotics. The reduction in pain may have been due to other influences and not the reduction in kneecap loads.

Results also show that mimimalist type footwear reduced peak kneecap loads when compared to conventional footwear during walking and running combined. This systematic review demonstrated an average 9.5 percent reduction in kneecap load in minimalist type footwear compared to conventional footwear over a run of just 1 km. This translates to 1,462 kg for an 80 kg person. This is clinically relevant considering the cumulative load reduction that can occur over numerous loading cycles during running.

I've written about this known fact many times over the years. Using results from Daniel Liberman's study (2010), runners who land correctly in their running technique will have benefits as impact is a lot less (even less than landing on your heels with cushioned shoes on).  If you land wrongly (with minimalist type shoes) the impact is 7 times greater thus greatly increasing the chance of injury. See picture below.

Because kneecap loads are reduced, they are transferred to the ankle and foot bones leading to fractures in the foot bones especially when you do too much too soon. Hence, correct technique and patience is crucial using minimalist type footwear. This is why many podiatrists say minimalist type footwear is not good (for you) since they cause foot  and metatarsal fractures, but bear in mind podiatrists also cannot sell you orthortics to place in your minimalist type footwear. 

You have also never seen Kipchoge or any elite marathoners wear these minimalist type shoes in a race. The body's muscles will not be able handle absorbing the load (while wearing minimalist type shoes) while running at the high intensities at which these races are contested.  They are good for training definitely, but not for racing, especially if you are not patient enough to get used to them. 

Evidence regarding the effect of rocker-soled shoes (see below) during walking and running were uncertain due to limited studies.

Take home message from the researchers is that minimalist type footwear reduces kneecap loads compared to conventional footwear in people with or without kneecap pain during running. 

Insoles/ orthotics that support the arches do not alter kneecap load during walking or running. Now you know for sure.

References

Liberman DE, Venkadesan M et al (2010). Foot Strike Patterns and Collision Forces in Habitually Barefoot Versus Shod Runners. Nature. Jan 463(7280): 531-535.

Kayll SA, Hinman RS, Bryant AL et al (2023). D Biomechanical Foot-based Interventions Reduce Patellofemoral Joint Loads In Adults With And Without Patellofemoral Pain Or Osteoarthritis? A Systematic Review And Meta-analysis. BJSM. DOI: 10.1136/bjsports-2022-106542

MBT rocker-sole shoes

*Thanks to Hui Meng for getting me the article

No Need To Treat Your Child's Flat Feet

My young patient (only 6 years young then) was told he had flat feet, pronated 'too much' and needed orthotics. He was prescribed the pair of ankle foot orthoses pictured below. His parents ended up a few thousand dollars poorer and they were told to bring him back for more appointments. 

I could not begin to imagine the trauma this child had to go through mentally and physically, having had to wear those *orthotics (picture below) whenever he went out.

Parents with children who have flat feet please take note. This latest Cochrane Review (just published on 14/1/22) states that "in the absence of pain, the use of high cost customised foot orthoses (CFO) for healthy children (from 11 months to 19 years old) with flexible flat feet has NO supporting evidence, and draws very limited conclusions about foot orthoses for treating paediatric flat feet". 

Review articles from the Cochrane Database of Systematic Reviews are highly respected and trusted. Google it if you like.

Not just costly CFO's, less expensive prefabricated (off the shelf) foot orthoses are not needed as well.

This Cochrane review also suggests that there is no further need to research asymptomatic flat feet in healthy children. It is better to focus on other paediatric conditions instead. 

Parents, now you know, do not waste your time and hard earned money on orthotics for your children. Don't worry too much about their shoes too. Email me if you want a copy of the article.

Reference

Evans AM, Rome K, Carroll M et al (2022). Foot Orthoses For Treating Paediatric Flat Feet. Cochrane Database of Systematic Reviews. Issue 1. Art No: CD006311. DOI: 10.1002/14651858.CD006311.pub3. Accessed 18 January 2022

*in my opinion, the orthotics look like they will do a better job limiting ankle movement with the stiff upright medial (inner) and lateral (outer) sections

Arch Supports And Iliotibial Band (ITB) Pain

A patient came in this week after being diagnosed with Iliotibial band (ITB) syndrome. The outer part of his right knee would hurt badly after running about 1.5 km. After stopping to walk, he would be able to run for a few minutes before having to stop again. 

He had been running 4-5x each week, clocking about 50 km weekly. He had just seen a sports doctor who first referred him to a podiatrist to get orthotics as he 'pronated' badly.

After getting his orthotics, he 'pronated' less according to the prodiatrist who filmed him while running on a treadmill. But, alas, his ITB/ knee pain didn't change. Since I'd treated a fellow runner he knew, he came to see me, hoping I could help him run pain free.

The ITB starts from the TFL

I've written previously about the ITB and you can read more about it here (anatomy) and here. If you look at the picture above, you can see it starts from Tensor Fascia Lata (TFL) muscle and runs down the outer thigh before finishing just at the outer part of the knee (picture below). This is usually where runners experience a sharp pain.

Also know as iliotibial tract (bottom R of pic)

Studies show that when the hip rotates medially or drop inwards, a strain is placed on the ITB . This also causes the tibia (or shin bone) to rotate inwards causing the foot to pronate (or ankle eversion). 

Researchers have attempted to correct this by changing ankle pronation to see if this might relieve the strain on the ITB.

In this published paper, 30 runners (15 males, 15 females) with no ITB insertion pain were prescribed orthotic wedges to put into their own running shoes. The wedges were 7 degrees lateral, 3 degrees lateral, no wedges, 7 degrees medial and 3 degrees medial. A total of five running trials were done.

The runners were analyzed by video motion analysis while running at their self selected running pace to calculate motion forces and ITB strain.

The orthotic wedges significantly changed ankle eversion (or pronation) angles compared to no wedges. However, the strain rates did not differ between conditions. There was no change in knee joint angles and tibial rotation under all orthotic wedge conditions. 

The researchers concluded that orthotic wedges may not change forces acting on the ITB, even though they altered foot pronation while female runners had greater strain forces acting on their ITB's potentially due to increased internal hip rotation.

It is interesting to note that the female runners demonstrated significantly greater peak ITB strain and strain rates compared to the male runners, potentially due to increased hip internal rotation (because of wider hips and pelvises for child bearing purposes). I have written at length before that for female runners, their knee pain is coming from their hips. Always treat the cause of the problem. Do not treat the pain alone.

Take home message is that even though orthotic wedges can correct your foot's pronation, it may not alter forces acting on your ITB. This means that your knee pain may not get better using orthotic wedges.

Of course any one reading this may say that these off the shelf orthotic wedges are not customized and that the subjects were all wearing different running shoes. Personally I feel that the different shoes are not an issue as these orthotic wedges used in the study did significantly change ankle pronation so they did what they were supposed to do. 

Would this then be fair to say that using orthotics to change ankle pronation or eversion angles does not seem to benefit those with ITB pain at the knee? Perhaps any podiatrists reading this would like to comment.

Reference

Day EM and Gillette JC (2019). Acute Effects Of Wedge Orthoses And Sex On Illotibial Band Strain During Overground Running In Nonfatiguing Conditions. JOSPT. 49(10): 743-750/ DOI: 10.2519/jospt.2019.8837

ITB attachments at the knee

Towel Scrunching Exercises For Your Feet?

Have you ever been asked to do foot strengthening exercises? A patient who saw me this week was asked to do foot strengthening exercises by another health professional who saw him recently. This included some towel scrunching exercises for his "collapsed arches" so as to strengthen the muscles supporting his arches. 

My patient was quickly bored and I told him just walking in minimalist footwear would be just as effective as doing strengthening exercises for the foot.

We know from published evidence that weakness in our intrinsic foot muscles can lead to a variety of load related injuries. And supportive footwear can contribute to intrinsic foot muscle weakness since these muscles tend to switch off (since they aren't absorbing forces and controlling foot movement) while walking and running.

Researches randomly assigned runners into three different groups. One group wore minimialist shoes (Vivo Barefoot), another group did foot strengthening exercises and the third was a control group. All groups maintained their running mileage throughout the study.

The minimialist footwear group increased their walking step count weekly while the foot exercise group did progressive resistance exercises at least 5 days per week.

Foot muscle strength and size were measured via ultrasound at the start of the study, week 4 and at the end of  the study (week 8). Researchers found all foot muscle sizes and strength had increased significantly in both the minimalist footwear and foot strengthening exercise group. There were no changes in the control group.

The researchers concluded that walking in minimialist shoes is just as effective as doing strengthening exercises for your feet. It is definitely way more convenient changing footwear rather than doing specific foot exercises. This may result in better compliance with patients.

So definitely don't throw away your Vibrams or barefoot style/ minimialist type shoes. They are definitely still useful. Vibram ended up with a bad reputation after they were sued. 

However, I feel minimalist type shoes were unfairly criticized as the evidence for barefoot or minimalist type shoes are actually sound provided your running technique is correct. 

*Much less impact if technique is correct-see below

If you walk with barefoot style/ minimalist type shoes instead or running (to strengthen your intrinsic foot muscles) there will be a much lower risk of injury.

Definitely still useful. And much less boring than doing towel scrunches.

Reference

Ridge S, Olsen M et al (2019). Walking In Minimalist Shoes Is Effective For Strengthening Foot Muscles. 51(1): 104-113. DOI: 10.1249/MSS.0000000000001751.

Liberman DE, Venkadesan M et al (2010). Foot Strike Patterns And Collision Forces In Habitually Barefoot Versus Shod Runners. Nature. Jan 463(7280): 531-535.

*Using results of Daniel Liberman's study, runners who land correctly in their running technique will have benefits as impact is a LOT less (even less than heel striking with cushioned running shoes). If you land wrongly (with barefoot style shoes), the impact is 7 times greater thus greatly increasing the chance of injury. See picture above.

Are You Choosing Running Shoes Based On Comfort?

Picture by Oyvind Solstad from Flickr

Don't we all love shoes that are comfortable? Especially when it comes to our running shoes. As runners, we all love that ahhhh sensation of our first steps in an exceptionally soft and comfy shoe. I couldn't believe how soft an Adidas NMD (not really running shoe though) felt when I first slipped it on. 

A more comfortable (or cushioned) shoe is usually preferred by new runners or for runners who are prone to injury and want extra protection and support.

The shoe companies know that subjective comfort is an essential factor in sport shoe development since this definitely helps them sell shoes. This comfort paradigm is based on an assumption that perceived comfort will lead to a path of least resistance (while running) and potentially reduce injury and improve running economy. (Luo et al 2009; Mundermann et al, 2001).

We've definitely been sold on advertisements selling us the softest, bounciest and energy return shoes that propel us forward and saves us energy and prevent injuries.

One study showed reduced oxygen consumption levels during running at submaximal speed while running in shoes that were rated subjectively as most comfortable (Luo et al, 2009). This may support the fact that running economy improves due to reduction of muscle activation (which decreases oxygen consumption or metabolic demand). 

Another study on military personnel showed some evidence supporting the use of comfortable shoe inserts (or orthotics) reduced injury rates of the foot, ankle, hip, knee and lower back compared to a control group.  However, two studies are not credible enough to know what actually helps and what are the mechanisms of reduction in oxygen consumption and preventing injuries. (Both studies count Professor of Biomechanics Benno Nigg, known for his work of running shoes as one of the authors).

In this latest paper I read, the authors aimed to investigate how shoes of differing comfort affects differences in oxygen demand along with potential mechanisms associated with injury risk. 

Fifteen male runners who ran at least 20 km per week with treadmill experience were recruited for the study. Testing includes an incremental lactate threshold test, a comfort assessment and treadmill running trials for biomechanical and physiological assessments. 

The researchers did not find any decrease in oxygen consumption in the most preferred shoe. Potential biomechanical contributors to changes in oxygen consumption (or metabolic demand) showed some differences in stride rate between the most preferred and least preferred shoe. Personally, it was interesting for me to note that stride frequency was actually lower in the most preferred (or comfortable) shoe compared to the least preferred (or least comfortable).

Based on the findings of this study, previous suggestions (derived from two other studies) regarding positive effects of enhanced footwear comfort during running cannot be supported. Neither on running economy nor on preventing injuries.

Should we then choose our running shoes based on comfort alone? This study suggest maybe not since the most comfortable shoes were not better or worse off with regards to oxygen consumption and not enough data to show any real change on injury risk.

Comfort is just one of many factors when we choose running shoes (compared to the more common foot type option like overpronators, supinators etc). Of course I definitely would not suggest running in shoes that are uncomfortable. 

I'm also feeling appalled that only 15 male runners (and no female  runners) were selected for the study. Remember I write previously how difficult it is to recruit runners to participate in a running research.

Athletes will want shoes that give them absolute efficiency that helps that run faster while your average runner would want the least discomfort while running to get fit.  

Of course there are some runners that will choose based on colour! *facepalm*

References

Lindorfer J, Kroll J and Schwameder H (2019). Does Enhanced Footwear Comfort Affect Oxygen And Running Biomechanics? Eur J Sport Sci. 20(4): 468-476. DOI : 10.1080/17461391.2019.164028

Luo, G, Stergiou P et al (2009). Improved Footwear Comfort Reduces Oxygen Consumption During Running. Footwear Sci. 1(1): 25-29. DOI: 10.1080/194242809002993001

Mundermann A, Stefanyshyn DJ and Nigg BM et al (2001). Relationship Between Footwear Comfort of Shoe Inserts and Anthropometric And Sensory Factors. Med Sci Sport Ex. 33(11): 1939-1945. DOI: 10.1097/00005768-200111000-00021.

Notes on the shoes in this study provided by Adidas

Five different shoes based on criteria previously reported in another study (Luo et al, 2009) were provided for this study. The shoe conditions showed variations in total mass (80 grams), heel lift (3.7mm), forefoot cushioning, rearfoot cushioning forefoot bending and rearfoot bending. The shoes in this study includes a standard neutral running shoe, shoes equipped with non standardized features like carbon fiber plates for increased longitudinal bending stiffness, exaggerated arch support and a cross training shoe.

One interesting point was that the researchers glued lead to the heel counters of the shoes that were lighter (since shoe mass influences oxygen consumption by about 1% per 100 grams of additional mass).

What Supports The Medial Arch

I've been trying to keep myself busy during the CB and catch up on my reading and watching. Not watching Netflix, mind you. I don't have a Netflix account. At the risk of sounding like a dinosaur, I have never watched anything on Netflix.

Anyway, I've been trying to learn about the human body and how to best treat it when it's under duress. So here's sharing what I've learnt about the medial (or inner) arch and also by putting whatever I've learnt down, I can always refer back to this.

The human medial arch has a four muscles supporting it. Namely, Tibialis Anterior, Tibialis Posterior, Flexor Flexor Digitorum Longus  and Flexor Hallucis Longus (the last 3 are also known as Tom, Dick and Harry).

Back of R leg

Tom, Dick and Harry start from the back of the leg as seen in the picture above. Flexor Hallucis Longus (FHL), or Harry goes under the talus to the bottom of the big toe. This muscle carries the whole weight of the body while we push off while walking. This is also the same muscle that can cause bunions, as it puts undue pressure between the sesamoid bones under the big toe. But that will have to be another much longer post.

FHL goes in between the sesamoid bones under the big toe

I'm especially fascinated with the Tibialis Posterior muscle, especially how it attaches at the bottom of the foot in the picture below. See how wide and diverse the attachments are. It attaches to the calcaneus, the navicular bone, the 2nd - 4th metatarsals and also the cuboid.

Bottom of R foot

Other than the muscles, there is also the plantar fascia, helping to support the medial arch. Much more important than the muscles are the deeper arch support consisting of the Long Plantar Ligament (which attaches to the base of metatarsals and cuneiforms) and especially the Spring Ligament.

a = plantar fascia, b = long plantar ligament

The spring ligament is also known as the calcaneonavicular ligament (c in the picture above). It goes from the sustentaculum tali to the talus. It really acts like a trampoline to prevent your talus from flattening when you weight bear. This is most important for lifting or supporting our arches.

Typically, when we talk about arch support, we would think of taping the arch, changing our shoes, putting arch supports or orthotics into our shoes. But as you can see from the picture above that none of them can really help the spring ligament in supporting our arches.

We can really only affect/ or treat the muscles and the plantar fascia. Remember this. You may not need to buy anything fancy to support the spring ligament.

Another look at the dissected medial arch. 9 is the Long plantar ligament, 10 is the plantar fascia and 11 is the spring ligament.

Now you know.

PS Sim - Winner Of The Cameron Ultra-Trail 100 Km Race

Picture from PS Sim

PS kindly agreed to not remain anonymous anymore so I can finally write here that she is the runner who won the Cameron Ultra-Train 100 km race despite having plantar fasciitis (for the past six months at least). She came back to our clinic today to allow me to finish assessing her and treat the cause of her pain.

Actually, after my previous post, I've had questions from some readers already asking me what I did for PS and her plantar fasciitis.

Here's a summary of what I did for those asking. No ultrasound, no ESWT (shock wave) needed, no orthotics and no other gimmicks.

Just plain old accurate body reading and thorough assessment after the body reading pointed to clues around her hips being one of the main reasons to her pain in her plantar fascia. Other contributing factors also suggest that changing shoes and her foot type may have triggered it.

So, of course I started treating her hip first and also taught her what to do to prevent it from recurring. She needs to work at this still for the time being.

 I wrote in my last session with her that I only had time to treat parts of her foot along her Superficial Back Line (SBL) and The Spiral Line.

Superficial Back Line

I did more work on her SBL and also treated fascia along her Superficial Front Line today. After that I had to change her pelvic rotation and suggested she may want to try taping her foot (in case she was planning on starting training again).

Happy to discuss if anyone has questions.

Spiral Line

Congrats to PS once again for a race well won and to Melvin for winning PS.

"Collapsed" Arches And Tibialis Posterior Muscle Pain

I had a really interesting case involving a triathlete/ runner recently. She had terrible pain in her arches and couldn't even walk around barefoot at home. It had started after she increased her run training recently. The orthopaedic surgeon she consulted had prescribed two pairs (yes two, you read correctly) of orthotics. And he said if they failed she would require surgery. A soft pair for her training and a hard pair while she was wearing her work shoes for her "collapsed arches".

She was advised not to run but was given the green light to bike and swim. Unfortunately, both times she wore her soft orthotics for cycling (and not evening running) her arches hurt after only fifteen minutes and she had stop riding. Even after icing her foot after the ride, her foot still felt sore the next day.

Pretty high eh?

Upon further questioning, she told me she didn't use the orthotic  and was able to walk pain free for 2-3 hours a few days ago in her Havaianas flip flops (or slippers).

However, after she biked again yesterday morning for only ten minutes, the pain came straight back with a vengeance.

When I examined her, her foot was was fairly flat and she had no arches. Her pain was mostly on her navicular bone and it was very tender to touch. I took a quick look at her soft pair of orthotics and noticed that the medial (inner) side of the orthotic was highly built up.

I told my patient I thought it was probably the orthotic irritating her navicular bone since it flared up within such a short time of using it while riding her bike.

Here's how the Tibialis posterior irritates the navicular bone

Other than her navicular bone tenderness, her tibialis posterior muscle was sore upon palpation all the way up her shin. Yes, the tibialis posterior muscle is the very same muscle that causes the much dreaded shin splints in runners.

L tibialis posterior

To make the long story short, I treated her and she's back running happily with no pain. What did I do? I treated her lateral, spiral and superficial back line.

Spiral Line

Arches And Orthotics

Picture from article Scientific Reports

I've often been asked by my patients about whether they need orthotics. The following article I read will explain some of the research behind orthotics on how they can affect your running rather than just my opinion.

Each time we land on our arches when we run, energy is stored in our arches. This is free energy that doesn't require anything to activate. The researchers wanted to measure wanted to find out specifically how much energy is lost if they restricted the arch with orthotics.

Orthotic that was used

The researchers made two types of custom orthotics. One completely blocked the arch from collapsing while the other allowed the arch to compress (or collapse) halfway. Only runners who did not use orthotics were recruited for their study. The runners ran on a force plate treadmill. The shoes had sensors inside which measured energy expenditure.

In order to have a baseline measurement, the runners ran in just the shoes (that were similar for all runners, pictured below) first followed by the same shoes at the same speed while testing the home made orthotics.

Picture from Scientific Reports

The runners tested the orthotics while walking as well as running.While walking, there was virtually no difference in energy expenditure. However, while running significant energy loss occurred.

In the orthotics that blocked all compression, researchers measured an energy cost of six percent (or less efficient by six percent) while the orthotics that allowed for 50 percent compression lost four percent.

Before you throw away your orthotics (if you're wearing them) the authors suggested don't throw them out yet as many runners get custom made insoles to prevent injury. They felt this is more important than saving energy without the orthotics. In fact the authors were very diplomatic and said that "We don't want to say orthotics are good or bad."

Likewise, if you are considering wearing orthotics (but may not need them), then maybe you shouldn't especially if you wanna run faster.

Reference

Stearne SM, McDonald KA et al (2016). The Foot's Arch And The Energetics Of Human Locomotion. Scientic Reports 6, Article number: 19403. DOI: 10.1038/srep1940.

A Podiatrist's View on Overpronation

Podiatrist Ian Griffiths feels the word "overpronation" should be banished. In fact, he feels the term "overpronation" should be erased from current day usage in both the medical and lay communities. Surprised that this is coming from a podiatrist? Please read on.

Overpronation has often been blamed for causing injuries.  In fact, there is little evidence that excessive pronation causes injury for that matter. Griffiths' view (and yours truly as well) is that pronation is only one of many factors to consider when assessing an injured patient.


In truth, pronation is completely normal. Majority of data collected suggests that the average normal foot position is actually mildly to moderately pronated and not "neutral". In fact, some studies even suggest that a pronated foot type can be protective against injury.

This does not mean that you will not suffer from pain or injury associated with your foot movement or pronation patterns. This means that the relationship between pronation and injury is not consistent or predictable and poorly understood at best.


Most of my patients who wear motion control shoes have always been told by their Physiotherapist/ Podiatrist/ Sports Doctor/ running shoe shop assistant that they go to telling them they have flat/ low arches and that they need to control their "overpronation".  Well, now you know that there is actually very poor evidence that these motion control shoes achieve this. Based on what you now know, if the shoe store you go to (or physiotherapist/ podiatrist etc) tell you to choose shoes based solely on how flat your arch looks or how much you pronate then you'd better leave.... pronto.

*Here's the Ian Griffith's article.


Have a look here to read Griffith's view on running shoe selection.

I've also written about running shoes here and here.