Let’s Talk Toes

When it comes to bunions, hammer, and mallet toes, the most common questions that I get most from athletes are how can I keep training and is surgery really my only option? Both of these are completely understandable questions, especially when you look at the typical article written about toe deformities. They offer a list of potential causes and then talk about surgical options for when “symptoms become unbearable”. Some will talk about toe spacers, pads, and taping, but most solutions are geared at symptom relief versus a long term solution. The good news? This article isn’t one of those. Instead of focusing on a list of causes, we are going to talk about toe deformities and what the different types all have in common from a biomechanics stand point.

Types of Toe Deformities

 

 

 

 

 

 

In normal anatomy, all toes are made up of little bones called phalanges. Every toe except the big toe has three of them (the big toe only has two). These phalanges create three joints called interphalangeal joints or more simply IP joints. The furthest is called the DIP (distal IP joint) and the middle is called the PIP (proximal IP joint). The closest phalange then connects to the metatarsal (long bone of the foot) at the MTP joint. Think of this one like the knuckle in the hand. Why is all of this anatomy important? Toe deformities occur when these three joints (MTP, PIP, DIP) get stuck in a position, creating inflammation and permanent changes to the bone.

Bunions – these can occur on either side of the foot although the big toe is the most common. A bunion occurs when the MTP moves away from the second toe. Over time this forces the phalanges in towards the other toes.

Hammer Toe – these are most common in the second toe (directly next to the big toe) but can happen in any of the smaller toes. This deformity occurs when the PIP joint gets stucked in a bent position. Over time this can grow to include extension at both the MTP and DIP joints.

Mallet Toe- like hammer toes, these can affect any of the smaller toes. The deformity occurs when the DIP gets stuck in a bent/flexed position.

Hallux Limitus/Rigidus (not pictured above) – this deformity affects only the big toe. The MTP joint becomes increasingly limited in motion. In the early stages this is known as hallus limitus. If this loss of motion continues, bone spurs can grow as the result of prolonged inflammation and will make the motion loss rigid as it is now blocked by bone on bone contact.

How Do They Happen?

The most important thing to realize about these types of injuries is that they all result from a progression of changes. You don’t just wake up one day with a bunion or hammer toe. These types of injuries start with a simple loss in mobility that over time results in joint breakdown and permanent bone change. Here’s a visual:

Loss of Motion > Contracture (muscle/tendon/ligaments get stuck short) > Breakdown of cartilage/bone > Bone spur/bunion formation

When you think about the different types of toe deformities in this regard, they become more like an overuse injury. Improper shoes, genetics, and prior injuries can all contribute to this type of injury by creating or exacerbating an underlying mechanical problem. This could be mobility loss in the foot, ankle or hip, decreased strength, or even coordination/muscle imbalances. Whatever the original restriction, the damage to the toes is the result of the body compensating and ultimately working in a way it isn’t designed to. Eventually, it will result in something breaking down under the strain produced by that compensation. In the case of toe deformities, the joints of the toes are what eventually breakdown.

So what can you do about it now?

While the actual changes to the bone and joint are irreversible without surgical correction, it’s important to realize that you still have a lot of control over your feet and the underlying mechanical causes. By improving mobility to the foot and ankle, you can normalize how you walk and run and take pressure off of the toes. This will allow the recurrent inflammation to calm down and help prevent further degenerative changes from happening.

In the video below, we are going to talk about some of the contributing mechanical factors at play and go through a little self test to see how your mobility stacks up:

In the self test at the end, we went through four movements. Here’s a breakdown of the test + next steps:

Self Test Walk through Result How To Fix
Toe Flexion
  1. start seated
  2. keep ankle in neutral position
  3. bend one toe at a time, joint by joint
  4. stop when you feel a pull
Ideally, you want to be able to flex (bend)your toe completely at all three joints.

If you can’t do this, the next test will help determine if the restrictions are above the ankle or below it.

  • If your toe mobility was normal? Nothing to fix!
  • If your toe was limited with just this movement? Start with the foot basics course. If you have a premium account and are looking for more, the toe deformity course will streamline this for you.
Toe Flexion with Ankle Plantarflexed
  1. start seated
  2. point ankle down (plantarflex it)
  3. bend one toe at a time, joint by joint
  4. stop when you feel a pull
How did your toe mobility change? Did it stay the same or did it get worse?

If it got worse, that likely means that you have restrictions both in the foot and up along the shin as well.

  • If your mobility was unchanged and looked normal? Perfect!
  • If your mobility got worse with this test, you will want to add in work on the shin itself where the long toe extensors are located.
  • For free users, check out the foot basics course in addition to the shin basics course. For premium users, the toe deformity course will streamline this for you.
Toe Extension
  1. start seated
  2. keep ankle in neutral
  3. pull one toe back, one joint at a time
  4. stop when you feel a pull
Ideally, you want to be able to extend (bend back) your toe completely at all three joints.

If you can’t do this, the next test will help determine if the restrictions are above the ankle or below it.

  • If your toe mobility was normal? Nothing to fix!
  • If your toe was limited with just this movement? Start with the foot basics course. If you have a premium account and are looking for more, the toe deformity course is the one for you.
Toe Extension with Ankle Dorsiflexed
  1. start seated
  2. pull ankle up (dorsiflex it)
  3. pull one toe back at a time, one joint at a time
  4. stop when you feel a pull
How did your ankle mobility change? Did it get worse with the knee straight or did it stay the same?

If it got worse, that likely means that you have restrictions deeper in the calf where the long toe flexors are located.

  • If your mobility was unchanged and looked normal? Awesome!
  • If your mobility got worse with this test, you will want to add in work on the calf where the long toe flexors.
  • For free users, check out the calf basics course in addition to the foot basics course from above. For premium users, the toe deformity course will streamline this for you.

 

Stay tuned: next week we will dive into what toe deformities mean to you as an athlete in terms of shoe selection, problem areas and recovery!

Ankle Range of Motion

When it comes to overuse injuries it is really easy to see them as an isolated event. The problem, however, is that overuse injuries are not an isolated thing. In fact, overuse injuries are the result of a mechanical problem. This could be mobility loss, decreased strength, or even coordination/muscle imbalance. Whatever the restriction, the injuries that happen are a result of the body compensating and ultimately working in a way it isn’t designed to. Eventually, it will result in something breaking down under the strain produced by that compensation.

The reason I bring all of this up is to point out that a single mechanical problem can actually manifest in a number of ways. Let’s take a look at ankle dorsiflexion for example:

Ankle dorsiflexion is your ability to bring the shin/tibia over the foot. Walking around normally doesn’t doesn’t require that much, but when moving at effort, the demands increase as you load the foot and ankle in prep for more propulsion. Restrictions here will limit that load period and in some cases stop your ability to push off of the foot completely. This means your body has to find a new way to move forward or you will fall over your own two feet. Depending on how your body tries to compensate, a number of injuries are possible.

That is why I wanted to do a blog series about normal mechanics and mobility. There is a reason certain treatments are seen across multiple injuries. It’s because even though what broke is different, the mechanical problems that led to it are likely the same.

With that in mind let’s get started. Up First? The Ankle Joint

In a lot of ways the ankle is the gateway to normal walking, running, etc. Our foot is the first thing to hit the ground and the mobility our ankle provides is what allows us to move over and push off of that foot. Without it, compensation is required to keep you from falling over your own foot. Let’s take a closer look! (note: the last minute is a self test. pause as you need to!)

 

In the self test at the end, we went through three movements. Here’s a breakdown of the test + next steps:

Self Test Walk through Result How To Fix
Dorsiflexion
  1. start in half kneeling position
  2. keep heel perfectly flat on floor
  3. lunge forward so that your knee comes over your toes.
  4. stop when you feel your heel start to come up
Ideally, you want to be able to keep you heel down and move your knee comfortably over the toes.

If you can’t do this, the next two tests will help determine if the restrictions are above the ankle or below it.

  • If your ankle mobility was normal? Nothing to fix!
  • If your ankle was limited with just this movement? Start with the calf basics course.
  • If your ankle was limited in all movements? You will need to address multiple areas. Combine the calf, knee and foot basics courses. If you have a premium account, the chronic tight calves course will streamline this for you.
Dorsiflexion with toes on stretch
  1. place something under the toes. in the video I am using a massage stick. 1-2 inches of height is plenty.
  2. relax the foot and repeat the first test.
How did your ankle mobility change? Did it stay the same or did it get worse?

If it got worse, that likely means that you have restrictions in the foot itself. This can be the small muscles within the foot, the long tendons coming from the deep calf, or a combination of both.

  • If your mobility was unchanged and looked normal? Perfect!
  • If your mobility got worse with this test, you will want to add in work on the foot itself. For free users, check out the foot basics course in addition to the calf basics course from above. For premium users, the chronic tight calves course will streamline this for you.
Dorsiflexion with knee on stretch
  1. keep your heel perfectly flat
  2. straighten the knee so that it is locked straight and repeat the first test
How did your ankle mobility change? Did it get worse with the knee straight or did it stay the same?

If it got worse, that likely means that you have restrictions behind the knee where the gastroc and hamstring tendons criss cross each other.

  • If your mobility was unchanged and looked normal? Awesome!
  • If your mobility got worse with this test, you will want to add in work on the back of the knee. For free users, check out the hamstring basics course in addition to the calf basics course from above. For premium users, the chronic tight calves course will streamline this for you.

 

How To Loosen Up Stubborn Areas

question mark on a sticky note against grained wood

Today we kick off our weekly Q&A session with the most common question I get:

“I have been working on _______ EVERY day and it will not loosen up. What do I do?”

We have all been there on this one. For some of you it may be the calves or hamstrings, and for others maybe it’s a hip or a persistent shoulder issue that just won’t let up. Whatever the area, the problem just won’t go away despite consistent work with the roller or massage ball. So what’s going on and why won’t it go away??

The first thing to realize is that our bodies are not like cars. If something breaks down, we can’t just swap that part out and carry on our merry way like it never happened. This is even more true when it comes to overuse injuries. For most of us, the start of symptoms and the start of the injury are not one and the same. There is a gap between the two and that gap is where we learn how to compensate around the problem so that we can continue training , racing, competing, etc.

This means we need to step back and stop focusing our efforts just on the area that hurts. Instead, we need to think about what other areas are contributing to the problem. Here’s an example:

Shoulder Pain (front of the shoulder to be more specific):

  • You start your self treatment using the Anterior (Front of) Shoulder Basics Course. This will take you through a progression of treatments targeting that area over the course of a few days. You want that time to see what works and to allow recovery between treatment sessions. However, at the end of that program, your shoulder still hurts. Now what?
  • My next step would be to include work on the opposite side of the shoulder. Why? Muscle groups work in pairs. These pairs allow controlled movement of a joint in opposite directions.  If the front side is having problems, then its safe to assume that the back side is as well. Head over to the body map and pull up the back of the shoulder. Add those techniques into your self treatment and reassess how things are feeling.
  • If working both sides doesn’t help, then it’s time to expand the areas we are working on. Why? Most major muscle groups work to move more than one joint. If there are problems at one joint, that muscle group will likely be compromised in how it moves the other joint. This is why the next step is to move up one joint and move down one joint. Using the shoulder as an example, this means that it is time to see how the neck and upper arm (biceps/triceps) are feeling. Back to the body map and pull up those basics courses to learn those techniques.

To put it more simply:

  1. Start with the problem area.
  2. Expand the area you are working on to include the opposite side as well.
  3. Add in the areas directly above and below the problem area.

Sound complicated? It’s not at all! This is where the interactive body map comes in. It doesn’t require you to know muscle groups or names. Simply start with your problem area and then flip the map over to find the area on the other side (this option is on the left hand side of the map). If you are moving up or below, use your mouse to select the areas directly above and directly below.

ATA Turns 6 (and gets a big makeover!)

iStock_000002119649_Small

It’s hard to believe that this past January the ATA website turned six years old! For those of you who have been along for the ride from the beginning, you have seen a few different versions of the site now. What started as a little clinic wordpress blog has grown into a virtual warehouse of pictures, videos and content. In fact, managing all of that content and keeping it organized, user friendly, and time efficient has been my biggest challenge so far! Thankfully, you have all been a wonderful feedback loop over the years.
That’s why when I sat down to plan out the next phase for ATA, it was with your suggestions and feedback in mind.
  • Problem #1: Site Navigation. Let’s be honest, there is A LOT of information on the site. The body map was a great start in terms of organizing all of it by region, but it still made for large amounts of clicking around to find stuff. Despite my attempts to organize and reorganize, I never really could find a good fix for this until now. The new site is truly an educational site, complete with “courses”. These courses allow me to not only deliver the content in a streamlined way, they allow me to keep everything all in one place, on one screen. The new site is essentially an “app”. It’s simple and incredibly easy to use.
  • Problem #2: Information Overload. The new course setup allows me to keep things short and to the point. Even the videos have a whole new look. There are little timers built in and directions so that you can literally watch and let the video do the rest. Each treatment will take you less than 10 minutes from start to finish.
  • Problem #3: Not mobile device friendly. The new site is more mobile friendly than it is desktop friendly. Why? Because I want you to be able to pull this stuff up on your phone or tablet while you’re on your family room floor using the treatment techniques.

 

Here’s a video to show you how it all works:

So what does all of that mean for you as the user??

To access the courses, you will need to create an account and sign up for a membership plan. 🙂

Here’s what you can expect with your membership:

  • Access to all of the courses. As of today, there are 18 courses currently on the site. This number is only going to grow over the next few weeks as I start loading up the injury specific courses. Once those are done, you can expect 1-2 courses per month on average. My plan is to have three types of courses per region:
    • Basic- these courses are region specific and focus on how to use the different self treatment techniques on that area only.
    • Intermediate- these courses are more in depth and take a more total body approach by working on areas above and below the symptom area.
    • Advanced – these are injury specific courses. Like the intermediate courses, these are more in depth and designed to not only cure your symptoms, but also help you identify the cause behind them.
  • Access to monthly webinars and Q&A’s. These will be announced on the blog and also through member emails. Each will be recorded so if you miss one? No problem. You will be able to download it when you have the time.
  • Access to me for questions, feed back etc. As things get rolling I will be posting “office hours” for you to reach me on skype.

In addition to individual plans, the new site layout also gives me the ability to create custom courses for teams and groups. Coaches? Need an offseason maintenance plan for your athletes or a post workout recovery routine? This is the option for you. Simply use the contact page to tell me what you are looking for!

Sounds pretty good doesn’t it?

 

 

Shoulder Treatment Part 3 (aka elbow and forearm)

Hi everyone! Sorry for the massive m.i.a but it has been a tough few weeks in the Boyle household between an epic battle with the flu and more recently 50 fire ant bites on my hands. Lesson learned the hard way on that one! 🙂 Anyhow..

This week we dive back into the treatment portion of our shoulder series. To recap: in part one we really focused on the large stabilizer muscles to build some slack down into arm, as well as, up into the trunk muscles. In part two, we then added in some more aggressive mobilization techniques to target the busy intersections in the front and back of the shoulder where the biceps and triceps attach.

This week we’re shifting to the other side of the biceps and triceps into the elbow, forearm, and hand. While that may seem far away from where you’re symptoms are, remember- there are four fascial chains of muscles in the arm. The two deep/stabilizing lines run from the biceps and triceps all the way to our hands. On top of them, the superficial lines connect the power muscles of the chest and back to the ones in our forearms. Whichever way you look at it, restrictions here will impact your shoulders ability to function normally. If you’ve been battling shoulder symptoms for any length of time, you can also guarantee that your elbows and wrists have been doing a hefty amount of the compensating.

Here’s the breakdown:

  • Roller: forearm + hand (1 minute each of flexors, extensors, drinking muscles, thumb and pinky finger)
  • Stretches: 30 seconds x 1 of each (flexors, extensors, thumb + hand)
  • Total time = 6-8 minutes

Forearm and wrist massage from Athletes Treating Athletes on Vimeo.

Shoulder Treatment Part Two

Hi everyone! This week we continue to dive into the treatment portion of our shoulder series. In part one, we used the foam roller to target the large musculature below the shoulder. When tight and immobile those muscles (aka the lats, the pecs, the serratus…) can act like weights that pull down on your shoulder joint. Not only does this force the arm to work harder to get overhead, it also keeps the shoulder joint unstable and out of position. In that treatment post we also worked on the neck muscles that attach to the top of our shoulder blade (aka the levator and upper trap).

This week we’ll be moving closer to the shoulder to start restoring balance between the front and back of the shoulder. To that you’ll need a massage ball or tennis ball!

Here’s the breakdown:

  • Muscle mobilizations: 3 reps nice and easy of the pecs (3 arm positions) and 3 reps nice and easy of the back of the shoulder (two rotations and across the chest)
  • Stretches: 30 seconds x 2 of each (bicep and tricep)
  • Total time = 8 minutes

Shoulder Treatment Part One

Hi everyone! This week we are back to dive into the treatment portion of our shoulder series. Over the past month, we’ve talked about how the shoulder functions, what joints are responsible for moving it, and last but not least how the different layers of muscles are connected. The big take away should have been that the shoulder is the least stable joint of the body and that there are actually four joints responsible for moving are arm. What does that mean to you as an athlete?? That we need to keep those stabilizers healthy and mobile.

In this video we are going to be using the foam roller on those stabilizers (lats, serratus, pecs, triceps, and the big intersection that is our armpit). From there we’re going to shift to stretching out our neck. Yes, you read that right! In particular we want to loosen up the upper traps and levator.

Here’s the breakdown:

  • Foam roller: 1 minute of each (armpit, tricep, pecs)
  • Stretches: 30 seconds x 2 of each (levator, upper trap)
  • Total time = 5 minutes

shoulder massage pt 1 from Athletes Treating Athletes on Vimeo.

Superficial Back Arm Line

In our previous three posts, we talked about the two deeper muscle lines in the arms, as well as, the superficial chain in the front of the body. This week we’re going to introduce the last muscle/fascial chain- the superficial back arm. If you think of the deep lines as our stabilizers, the superficial lines are the real power behind reaching overhead, reaching out to the side, and pushing/pulling. It’s important to realize that these muscle chains/lines all work together. If the deeper lines are restricted/stuck, they will compromise the more superficial muscles and vice versa.

SBAL

In terms of function, this muscle chain is responsible for controlling the movement of our arm behind us, as well as, out to the side. To do that we need larger muscles which we get in the Trapezius and Deltoid. Both of these muscles feature multiple functional parts capable of moving the arm in multiple directions. This makes them powerful abductors. From the Deltoid, this arm line travels down the lateral septum (which separates the muscles in the front of the arm from the back of the arm). It then connects to the common extensor group (purple in the picture above). The extensor group originates on the lateral epicondyle and travels down the back of the forearm and hand to our fingertips.

Here’s a video to walk you through the muscles in this chain and to show you how to stretch them:

 

Superficial Front Arm Line

In our previous two posts, we talked about the deep arm lines. These muscle chains both included smaller muscles that were designed to help position our elbow and orient our hand. This week we’re going to build on those muscles by looking at the larger more superficial muscles that lay on top of them. If you think of the deep lines as our stabilizers, the superficial lines are the real power behind reaching overhead, pushing, and pulling.

The Superficial Front Arm Line

superficial_front

 

In terms of function, this muscle chain is responsible for controlling the movement of our arm out in front of us as well as to the side. To do that we need larger muscles which we get in the Pectoralis Major and the Latissimus Dorsi. While one muscle is found on the front of the body and the other on the back, both share a common attachment point on the inside front of the humerus. This makes them powerful adductors and internal rotators as they pull the arm back to our side. From that common connection on the humerus, this muscle chain then follows the intermuscular septum (green in picture above) down to the medial epicondyle where it attaches to the forearm flexors (aka the muscles responsible for flexing our wrists and fingers).

Here’s a video to walk you through the muscles in this chain and to show you how to stretch them:

 

Deep Back Arm Line

In last week’s post we started digging into the functional arm chains by looking at the deep front line. This week we’re going to build on that by looking at it’s partner in the crime- the deep back line. An easy way to visualize the difference between the two is to lift your arm out to the side as show in the picture below. You want to make sure your hand is point down to the floor and that your elbow is pointing backwards. In this position, the deep front line is on the front and the deep back line is on the back.

The Deep Back Line

deepbackline

In terms of function, this muscle chain works in two ways. When the arm is moving freely out away from your body, it works to position the scapula and rotate the humerus while also working with the front line to determine how much elbow flexion/extension is needed.  In weight bearing (push up/plank) position, it provides stability from side to side. In total there are 8 individual muscles in this chain. Here’s a video to walk you through each and what they do. You will also find ways to stretch each one of them.

Remember! Don’t push through pain with the stretches. Just go until you feel a pull. If you’re bringing a lot of tightness in terms of posture, expect to feel these in a few different places! 🙂 20 to 30 second hold of each.