technique

BodyReading the MeRidians | @woRk | essential skills | Myofascial

techniques

working with hammertoes: the Foot

By Til Luchau
My grandfather loved to hunt quail, walking the fields and thickets of his native western Oklahoma prairie. At some point toward the end of his life, he switched from walking to driving, hanging his shotgun out the window of his old sedan, slowly cruising the back roads, still looking for quail. Its my hammertoes, hed say. Just cant walk around like I used to.
A hammertoe is bent downward (Images 1 and 2), resulting in painful pressure on the end of the toe or its upper side where it rubs or hits the shoe. Common causes and risk factors include: Wearing narrow or tight-fitting shoes. Imbalanced muscle strength, tonus, or flexibility in the foot or leg. Direct trauma or injury to the structures involved. Genetic influences such as Mortons toe, in which the second toe is longer than the great toe, making it more likely to hit the end of the shoe. Neuromuscular diseases (e.g., cerebral palsy, Charcot-MarieTooth disease, multiple sclerosis), inflammatory diseases (e.g., psoriasis, rheumatoid arthritis), and the nerve damage sometimes accompanying diabetes. The second toe is most often affected (Image 2), though hammertoe can be found in any of the toes. In a true hammertoe, the joint at the base of the toe (the metatarsal phalangeal joint, or MTPJ) and the next joint (the proximal interphalangeal joint, or PIPJ) are fixed in a bent position. Variations include mallet toe (when the contracture is primarily at the most distal interphalangeal joint, or DIPJ); claw toe (flexure at all three toe joints); crossover toe; and clinodactyly (congenitally curly toes). Although our discussion will focus on hammertoes, the principles and techniques here can be adapted to address these other conditions as well. Although seen in all ages, hammertoe incidence increases with maturity, eventually affecting about one in 10 people over the age of 60. Hammertoes are about five times more likely in females than males (perhaps because women tend

3 4
Hammertoes range from moderate (Image 1) to severe (Image 2). Remedies include spacers and splints (Images 3 and 4), exercises, and surgery (Image 5). Images 1 and 2 courtesy Primal Pictures; Image 3 courtesy CorrectToes. com; Image 4 courtesy PediFit.com; Image 5 courtesy James C. Mutter, Kamran Jamshidinia, MD. All used by permission.

112

massage & bodywork

may/june 2012

6
to wear tighter shoes than men studies claim that nine out of 10 women wear shoes that are too small).1 There are racial differences too, with hammertoes about three times more frequent in African-Americans under the age of 60 than in whites of the same age (though there is much less racial difference in people over 60).2 Nonsurgical care of hammertoes involves using more spacious shoes; padding points of contact; using special braces, spacers, or splints (Images 3 and 4); physical therapy; and exercises such as using just the toes to gather and ungather a towel on a hard floor. Whatever the root cause or factors involved in hammertoes, the result is that the soft tissues are too short to allow natural alignment of the toe bones. Surgeons address this by one or more of these methods (Image 5): 1. Lengthening the contracted connective tissue by cutting toe tendons, capsules, or ligaments. 2. Shortening bones to fit the contracted tissues by removing articular heads or other parts. 3. In advanced cases, performing arthrodesis (fusion) of the bent joints via wires or other means in combination with the two methods above. Although some consider hammertoe surgery easy to perform (it is often the first surgery new surgeons are allowed to do),3 complications do occur, most commonly pain and discomfort related to the loss of movement in the toe, especially when joints have been excised or fused. As manual therapists, there are many ways we can effectively release the shortened soft tissues involved in extensors hammertoe and related conditions. Sometimes this is corrective, reversing the curling of the toes, and other times Flexors it is palliative, meaning that it helps relieve pain and other symptoms. It also is reasonable to imagine that soft-tissue lengthening could, at least in some In normal movement, toe flexors and extensors cases, delay or prevent hammertoe take turns contracting and lengthening (Image surgery, and so avert the resulting 6). In hammertoes (Image 7), both flexors and loss of mobility that patients often extensors remain contracted simultaneously, experience after corrective surgery. buckling the toe. Over time, the ligaments and joint Ida Rolf, the originator of Rolfing capsules shorten, further fixing the joint. Image structural integration, said, In a 6 courtesy Primal Pictures; used by permission. balanced body, when flexors flex, Image 7 courtesy Advanced-Trainings.com. extensors extend (Image 6). Nowhere is this more obvious than in the toes. When toe flexors contract without Watch Til Luchaus technique reciprocal lengthening of the extensors, videos and read his past the toes are pulled short from both above and below. The toes cant collapse Myofascial Techniques articles like a telescope, nor is it easy for them in Massage & Bodyworks digital to bend sideways, as the great toe does edition. The link is available at in hallux valgus, or bunions; therefore, the middle toes shorten by buckling Massageandbodywork.com, at into a hammer, mallet, or claw shape ABMP.com, and on Advanced(Image 7), depending on the shape of Trainings.coms FaceBook page. the joint involved, and on the structures that are responsible for the pulling.

ABMPtv.com Extensor & Flexor Digitorum Brevis Technique

MyOFAscIAL TEchnIquEs

8
Use active or passive client movement to lengthen contracted toe flexors in the Flexor Digitorum Brevis Technique. Image 8 courtesy Advanced-Trainings.com. The short toe flexors are shown in green. The long toe flexors (red) will be discussed in the next installment. Image 9 courtesy Primal Pictures; used by permission.

12 10 11

The Extensor Digitorum Brevis Technique. By anchoring into the short toe extensors on the top of the foot, you may use active or passive toe flexion to lengthen the short toe extensors. Image 12 shows the extensor digitorum brevis (green), as well as the extensor digitorum longus (red), covered in our next installment. Images 10 and 11 courtesy Advanced-Trainings.com; used with permission. Image 12 courtesy Primal Pictures; used by permission.

FLEXOR DIGITORUM BREVIS TECHNIQUE When contracted, the short toe flexors in the sole of the foot (Image 8) contribute to hammertoes by curling the PIPJ and DIPJ, the two distal joints of the toe. The flexors are found just deep to the plantar fascia, in the most superficial muscle layer of the bottom of the foot. Before attempting to work with this muscle layer, warm up the superficial and plantar fascia of the sole. These tissues can also contribute to toe flexure. Use any broad, superficial technique for this preparatory work. (One example is the Plantar Fascia Technique described in Working With Ankle Mobility, Part 1, Massage & Bodywork, March/April 2011, page 113.) Avoid using oil or cream, at least at this point, since reducing friction makes it more difficult to work with the soles distinct tissue layers. Instead, slow down and let the tissues melt. Once youve prepared the superficial and plantar fascia, use the tips of your curled thumbs to anchor the short, strong flexors in a heelward direction, as your client lifts the toes in active toe extension (Image 9). You can also use passive toe extension, gently stretching the toes into extension with your free hand. This combination of anchoring into the short flexors and adding movement is very effective in lengthening contracted or shortened lines of strain in the underside of the

Celebrate ABMPs 25th anniversary and you may win a refund on your membership. ABMP.com. 115

MyOFAscIAL TEchnIquEs

foot. Be thorough, working the entire sole from toes to the origin of the flexors on the anterior calcaneus.

EXTENSOR DIGITORUM BREVIS TECHNIQUE The extensor digitorum brevis (Image 12, page 115), the only muscle (along with its hallucis head) on the dorsal surface of the foot, complements the short toe flexors by pulling the MTPJ (the joint at the base of the toe) into extension or dorsiflexion. When tight, this up-bent dorsiflexion becomes the resting position of the toe joint. Use your fingertips, as in Images 10 and 11 (page 115), to release any contracted tissue here, this time using toe curling or flexion as active or passive client movements. Isolate each toe in turn, feeling for the specific head of the brevis thats involved in that toes extension. TOE TENDONS, CAPSULES, AND SHEATHS It will be important to spend some time working slowly and deeply right around the joints of the toes themselves. Both the extensors (dorsally) and the flexors (on the plantar surface) merge with their longer counterparts (the flexor and extensor digitorum longus) into tendinous hoods within the toe (Image 13). In a hammertoe pattern, these fibrous sheaths become contracted on the concave sides of the joint (in the crease of the bent toe, Image 7). The joint capsules are also involved in maintaining a bent joint, as are the collateral ligaments of the toes, found at the sides of all three toe joints. They are largest and strongest at the MTPJ, lying between the base of the toes. These ligaments, and other structures between the long metatarsals of the foot, such as the adductors and lumbricals, will need to be gently lengthened before normal alignment is possible. As with our other

techniques, use active and passive client movement, along with your direct pressure, to lengthen these shortened tissues. If your client has already The flexor tendon sheaths (orange) are some of the fibrous connective had hammertoe tissue structures that surround the toe joints. They can contribute to toesurgery, working joint fixation. Work these structures combining pressure with active and the ligaments passive movement. Image courtesy Primal Pictures; used by permission. and tissues of toes can help Be sure to have a look at the next reduce pain once the surgery has column, where Ill talk about the long healed (after at least 68 weeks). toe flexors and extensors and the role Although the toes and their of the lower leg in toe deformities, as ligaments are painful, sensitive, well as the whole-body implications of or ticklish on many people, if you hammertoes, bunions, and more. take your time and stay in close communication with your client, Notes the sensation will be well tolerated. 1. Remedy health Communities, hammer The normalization of hypersensitive toe Remedies, accessed april 2011, www. areas can itself be very therapeutic. healthcommunities.com/hammertoesclawCombined with the tissue changes toes/hammertoe-remedies.shtml. from your work, it will yield 2 anthony watson, hammertoe deformity, gratifying changes in flexibility and accessed april 2012, http://emedicine. pain reduction. At this point, youve medscape.com/article/1235341-overview. worked the short toe flexors and 3 w. Fishco, emerging Concepts in extensors, as well as the capsules, hammertoe surgery, Podiatry Today 22, no. ligaments, and sheaths of the toe joints 9 (september 2009): 349. accessed april themselves. Although there is more 2011, www.podiatrytoday.com/emergingto do, and you may need repeated concepts-in-hammertoe-surgery. visits to see a visible change in the resting position of the toes, in many cases, your client will already notice greater toe flexibility and comfort.
Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the united states and abroad. he is also a certified Advanced Rolfer and has taught for the Rolf Institute of structural Integration for 22 years. contact him via info@ advanced-trainings.com and Advanced-Trainings.coms Facebook page.

13

Celebrate ABMPs 25th anniversary and you may win a refund on your membership. ABMP.com. 117