Normal gait requires at least 10 degrees of ankle dorsiflexion, with maximum dorsiflexion occurring closed chain during late midstance. Limited ankle dorsiflexion can result in a myriad of compensations both proximally and distally.

From knee hyperextension to midfoot over-pronation, the deforming forces caused by tight calves is enough to make any Movement Specialist cringe. I refer to this lack of ankle joint dorsiflexion as a "Podiatric Epidemic" as a majority of people assessed lack adequate ankle joint range of motion.

For clients or athletes who have adequate pelvic flexibility but demonstrate decreased gastrocnemius range of motion, we want to integrate posterior group stretches.

When recommending posterior group stretches some classic stretches include the wall stretch, downward facing dog and dropping a heel off of the step. When performing theses stretches have you ever considered the role rearfoot position may have on the effectiveness of each stretch?

Impact of Rearfoot Position on Stretching

A 2009 study by Jung et al. evaluated the impact of rearfoot position on the effectiveness of gastroc stretching. Due to the prevalence of tight gastrocs in an over-pronated foot type, Jung et al. wanted to determine if the everted calcaneal position altered the effectiveness of the stretch.

Jung et al. evaluated 30 patients with both a neutral foot type and an over-pronated foot type with increased calcaneal eversion (average 4 degrees). Subjects performed a gastrocnemius wall stretch both in their relaxed calcaneal stance position and while wearing orthotics which placed the calcaneus in a neutral position.

Ultrasound technology was used to evaluate the degree of stretch as determined by the change in myotendinous length. It was observed that rearfoot position had a significant impact on the effectiveness of posterior group stretching. A 3mm difference in gastroc lengthening was achieved while stretching with the everted rearfoot shifted into a neutral position.

Considerations for the Movement Specialist

When considering articles to review and share on the EBFA Blog, I like the above study for several reasons:

1. It emphasizes the impact subtle adjustments in body positioning can have on stretching effectiveness. As evidence-based fitness professionals, if we can apply research studies such as this into our client's programming we may begin to see better results.

2. It re-emphasizes the concept of foot-specific programming which I integrate into my Barefoot Training Specialist workshops. In an over-pronated foot type with increased calcaneal eversion you want to consider the impact ankle stretching may have on the weakened posterior tibilais tendon.

3. When the calcaneus is brought out of the excessive eversion the stretch becomes more isolated to the Achilles tendon and gastrocnemius/soleus - with little stress to the posterior tibialis.

Want to integrate this evidence into your client's programming?

1. For any clients with an over-pronated foot type, isolated gastroc stretching should be performed preferably non-weight bearing to minimize the impact of rearfoot position during the stretch.

2. If a client uses orthotics that control rearfoot motion, perform closed chain gastroc stretches while wearing the orthotics and then remove the shoes for the barefoot training exercises.

3. For any clients with an over-pronated foot type and wear Vibrams or minimal footwear for daily use and training, frequent evaluation of the posterior tibialis tendon should be performed.

To learn more about this, make an appointment online or visit a podiatrist at one of our convenient locations.

By: Dr Emily Splichal, DPM

It is believed that many factors play a role in the development of athletic performance. From cardiorespiratory capacity to skeletal muscle function, can our genetic and musculoskeletal makeup predict our talent as an athlete?

With many sports performed in closed chain environments our foot is highly integrated in lower extremity kinematics, postural stability and force production. Exactly how important is the foot type in determining athletic skill? With most attention on the association between foot types and risk of injury, what if instead we took a moment to look at certain foot variances and the advantages each may have on athletic performance?

Foot-Typing

Due to the variances in foot type and arch height we need to begin with a classification system that is reliable and consistent. Simply classifying a foot as a high arch or low arch does that reflect the dynamic biomechanics of an athlete's foot-type.

One such foot-typing system that does provide validity and reproducibility is the Foot Posture Index. The Foot Posture Index is a 6 point static foot assessment performed in multiple planes which is used to classify foot-type and degree of severity (Cornwall 2011).

A 2011 study by Cornwall et al. evaluated the reliability of the Foot Posture Index to predict dynamic foot function. After evaluating 203 subjects it was concluded that the Foot Posture Index can predict dynamic foot mobility. Those subjects with the greatest foot mobility correlated with the over-pronated or low arch foot type. Conversely those with decreased foot mobility were associated with a more supinated or high arch foot type.

Over-Supinated Foot Type

In the over-supinated foot-type the heel and subtalar joint are in an inverted position with a lateral shift in body weight and slight adduction of the forefoot on the rearfoot. Typically we think of an over-supinated foot type as more rigid with an increased risk for stress fractures, tendonitis and plantar fasciitis. But could there be any advantages to this supinated foot position?

Advantage #1 - Rapid Re-Supination

In sports such as soccer, changes in direction and cutting maneuvers require rapid activation of the posterior tibialis in order to create a rigid foot lever and push off. Although it is purely anecdotal, perhaps a more supinated foot type allows the athlete to quickly change direction and push off of the ground.

Advantage #2 - Decreased Contact Time

For a runner or athlete the ability to decrease contact time, not only makes them faster but also decreases the risk of injury. In endurance sports, time spent in contact with the ground is when the athlete gets injured.

A 2007 study by Hasegawa et al. found that when comparing different foot strike patterns, running speed and contact time, those runners with a midfoot and forefoot strike had a shorter contact time when compared to runners with a rearfoot strike.

In addition it was observed that regardless of foot strike pattern, those runners who had the greatest degree heel inversion at foot strike also had the shortest contact time. Because an over-supinated foot type has increased calcaneal inversion this may provide an advantage in reducing contact time when running (Hasegawa 2007).

Over-Pronated Foot Type

In the over-pronated foot-type the heel and subtalar joint are in an everted position with a medial shift in body weight and abduction of the forefoot on the rearfoot. This foot type is typically associated with increased plantar pressures and force distribution over the plantar foot. Typically we think of an over-pronated foot type as more mobile with an increased risk for posterior tibial tendonitis, knee pain and bunions. But could there be any advantages to this pronated foot position?

Advantage #1 - Improved Balance

A 2002 study by Hertel et al. compared balance and stability in different foot types. Interestingly it was found that the over-pronated foot type had better balance when compared to the over-supinated foot type. It was hypothesized that eue to the increased plantar contact in an over-pronated foot type there was an increase in plantar cutaneous feedback which is critical in stabilization. Sports requiring balance, such as karate, boxing or gymnastics may benefit from this foot type.

Outside of increased plantar distribution, the over-pronated foot type may not be as advantageous when it comes to athletic performance. Since many athletics are dependent on force, speed and agility - all of which relate to rapid foot contact time - the delayed strength and activation of the posterior tibialis may put this foot type at a disadvantage.

Conclusion

Although much of this information is anecdotal due to the lack of research, it does provide important considerations for the coach or parent of an athlete. We are all born with a specific foot type, so it is up to us to understand our foot type and use it to our advantage whether it be for agility or balance & stabilization!

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To learn more about foot-typing and how to create a foot-specific program for your clients and athlete's – consult a podiatrist at Midtown Podiatry, or make an appointment online.

By: Dr. Emily Splichal 

HOW TO PREPARE FOR FOOT SURGERY

Now that you and your doctor have decided on surgery as the treatment for your condition, there are some things you can do to get yourself ready for a comfortable and quick recovery.

Get your mind ready: It has been shown that attitude can effect the outcome of medical care and the perception of pain. Have confidence in the course of treatment and your doctor. If you are unsure, get a second opinion before proceeding. Learn some relaxation techniques such as deep breathing or meditation. Know that pain is expected after surgery. Relaxation techniques have been shown to reduce the need for pain medication. Have a positive attitude and focus on the intended outcome of the surgery. After the recovery, you will be glad of your choice.

Get your body ready: Proper nutrition is essential for recovery following surgery. If your diet is not the best, consider consulting a nutritionist for dietary advice. Supplements to consider include calcium and vitamin D for bone health, vitamin C and zinc for skin and soft tissue and extra protein for muscle support are good starting points. Hydration is important. Be sure to drink plenty of water. Be aware that some post-operative medications can cause stomach upset or constipation. Make sure you take the medication as prescribed and eat and drink normally. Extra fiber should reduce the incidence of constipation. Should antibiotics be prescribed, a pro-biotic vitamin can reduce the incidence of diarrhea. Yogurt or Kefir can be used as an alternative. If you will need to be on crutches post-operatively, make sure your arms and non-operative leg are strong enough to support you. Simple arm and leg strengthening exercises should be performed to get you ready. You can consider a consultation with a physical therapist or personal trainer to help get you ready for crutch walking.

Get your life ready: Your mobility will be temporarily restricted after surgery. Make sure you take care of chores prior to the surgery. You will want to do as little as possible in the first few days after surgery.

Make sure you have what you need on hand, including food, water and post-operative medications. Consider having a friend or family member stay with you to help out.

Get your house ready: Much like child proofing, you will want to fall proof your house or apartment, especially if you are going to be on crutches. Take a look around for things that can impede walking or trip you up, such as furniture, rugs, cables, etc. You may not want to use stairs right away, so temporary one level living should be considered in homes with stairs. Make sure the bathroom is accessible. Some accessories that can make toileting and showering easier are: a commode that can be used as a toilet riser, a shower seat, suction grab bars and a cast/ bandage cover to keep the operated foot dry.

These items can be obtained at a surgical supply store or through catalogs. Some items may be covered by health insurance as well. Make the kitchen accessible as well. Make sure frequently used items are easily within reach. Consider preparing meals in advance for easy microwaving. Using disposable dinnerware temporarily will reduce clean up. If you will be on crutches, take a dry run around the house. You may be surprised at obstacles that you never thought of. You may want to consider crutch alternatives such as a knee walker or scooter if crutch walking is difficult for you.

Get ready to go: Depending on where your surgery is taking place, you may be required to have pre-operative testing and a medical exam done prior to the surgery. Make sure these are done at least 1 week before the surgery. Follow up with your doctors offices to make sure that the facility has all the results ahead of time. Follow pre-operative instructions to the letter. If you are having anesthesia other than local alone, make sure you don't have anything to eat or drink within 8 hours before surgery. You should continue to take prescribed medications unless otherwise directed by your doctor. Plan to arrive at the surgical facility in advance. Most hospitals and surgical centers require their patients to arrive 2 hours prior to their scheduled procedure time to allow for intake. For office procedures, 15 minutes is sufficient. Arrange for transportation home in advance. An escort is required for discharge by hospitals and surgical centers and is recommended for office surgery. Don't forget to arrange for transportation to your post-operative visits as well. Don't hesitate to call your doctor for any reason post-operatively. We are all here to make sure your recovery is safe and rapid.

If you have any questions prior to surgery, call the doctors of Midtown Podiatry.

Another New York team has been affected by a serious foot/ankle injury. New York Yankee pitcher Joba Chamberlain recently sustained a serious ankle injury while having fun with his young son. He has been on the disabled list this season after having elbow surgery. His rehab was progressing as planned before this latest incident in which Joba sustained an open dislocation of his ankle.

This is a very severe injury, where the bones become separated due to ligaments tearing. An open injury refers to the fact that the skin over the area was torn as well, exposing soft tissue and bone to the outside. These types of injuries are most commonly seen with motor vehicle accidents or falls from heights. These injuries require emergent care by a foot and ankle specialist. Most will require some form of surgical treatment to relocate the joint and clean and repair the wound. Fixation of the joint to allow for healing can be accomplished with a cast, but commonly pins, wires or external fixation devices are used, especially with open injuries, in order to tend to the wounds. Usually several months of non-weight bearing immobilization will be needed for healing. This puts Joba's return to the team this year doubtful. We wish him the best for a speedy and complete recovery.

If you or a family member ever suffers an injury to your ankle, make an appointment with the qualified professionals at Midtown Podiatry with locations in Midtown, Union Square, Gramercy Park, Wall Street and Glen Cove.

By: Paul J. Betschart 

Diabetes has become a prevalent disease in our society today. According to the American Diabetes Association, 8.3% of the population has been diagnosed with this disease. Diabetes does not limit itself to race, class or gender; affecting celebrities like Halle Berry, Bret Michaels, Nick Jonas, Paula Deen, Salma Hayek and Bears Quarterback Jay Cutler.

As podiatrists we see the impact that diabetes can have on a person's mobility. Many serious foot complications and other medical complications can be reduced or eliminated with control of blood glucose (sugar) levels. This control of blood glucose is not easy to accomplish as evidenced by the explosion of numbers of people with type 2 diabetes in this country and in the world. Type 2 Diabetes has become a major public health concern in the United States, as 26 million people in this country alone have type 2 diabetes. A large number of these cases are caused by or worsened by obesity.

Weight loss has been shown in research studies to reduce blood sugar levels and reduce need for medication and insulin for control. Weight loss is usually difficult to attain, especially for those significantly overweight, who have difficulty exercising. Two recent studies have garnered new hope for those with diabetes caused by obesity. These studies examined the surgical treatment of obesity and it's relationship to diabetes. The studies followed patients who underwent gastric bypass weight loss surgery. This type of surgery reduces the size of the stomach and redirects some of the intestine to cause weight loss. These studies showed that, not only did patients lose weight and keep it off, but their diabetes significantly improved! These studies showed over 80% of patients no longer need to take medication to control their diabetes.

Weight loss surgery has been shown to significantly improve other obesity related health problems as well, such as high blood pressure, cardiovascular disease and sleep apnea to name a few. Current NIH standards still only recommend weight loss surgery for those significantly overweight that have failed other approaches at weight loss. Recent advances in surgical techniques have made the procedure safer, with complication rates lower than other common abdominal surgery, such as gall bladder removal. Hopefully, the increased safety and the demonstrated effectiveness in managing disease will widen the NIH recommendations to give people better access to this life saving treatment.

Should you or a loved one need a recommendation for a weight loss surgeon, we can help you! Through our affiliation with Gramercy Surgery Center, we can refer you to some of the best Bariatric surgeons in New York. Give the office a call or mention it on your next visit to Midtown Podiatry, with locations in Midtown, Gramercy Park, Union Square, Wall Street or Glen Cove.

By: Paul J. Betschart, DPM