Metatarsalgia

This is a collective term used to describe pain in the region of the metatarsal heads (the ‘ball’ of the foot). Since causes could be vascular, avascular, mechanical or neurogenic, a careful comprehensive evaluation is in order (Cailliet 1997). Some of the most common causes include the following.

Alleviation of pain

Morton’s foot structure

Morton’s foot structure (Morton’s toe, Morton’s syndrome) as described by Dudley Morton, is not to be confused with Morton’s neuroma (see above), as described by Thomas G Morton (Cailliet 1997). Morton’s foot structure is due to the presence of an unusually short first metatarsal or long second metatarsal, which results in excessive weight bearing by the second metatarsal. Cailliet (1997) describes this condition as ‘(1) an excessively short first metatarsal, which is hypermobile at its base where it articulates with the second metatarsal and the cuneiform; (2) posterior displacement of the sesamoids; and (3) a thickening of the second metatarsal shaft’. Because of stress on the ligaments, capsules and muscles that bind the second metatarsal with the cuneiform, its base also becomes hypermobile. Travell & Simons (1992) note extensive compensational patterns associated with a long second metatarsal and describe an examination for its presence as well as patterns of callus development associated with the condition.

Hallux valgus

Hallux valgus describes a deviation of the tip of the great toe toward the outer or lateral side of the foot. The bursa that is located on the medial aspect of the first metatarsal head may become inflamed (usually due to rubbing on the shoe), resulting in the formation of a bunion. There may be pain, crepitus and either restrictive or excessive mobility, which ultimately affects gait mechanics.

Bunion

A bunion is a painful bursa that has responded to repeated pressure and friction by forming a thickening of its wall. Treatment should include removal of pressure by correction of deviant foot mechanics that led to its formation. Although bunions most commonly occur at the first metatarsophalangeal joint, a tailor’s bunion may be noted at the fifth metatarsal, often associated with pressure created on the lateral aspect of the foot by crossing of the ankles.

Calluses and corns

Calluses and corns are natural responses of the skin to external pressure applied against an underlying bony surface. Abnormal foot mechanics are usually the cause of the conditions and must be addressed if treatment is to be successful. Neurovascular corns may be very tender and painful and are best addressed by a podiatric specialist.

Plantar warts

Plantar warts are not usually found over bony prominences and do not usually develop from pressure. Their cause is considered to be viral and treatment varies depending upon the type of wart. Since they may be contagious, gloves are recommended during examination of a foot that has a suspicious wart-like growth.

Gout

Gout is a disorder of purine metabolism, characterized by raised blood uric acid levels that result in deposition of crystals of sodium urate in connective tissues and articular cartilage. Severe recurrent acute arthritis often presents as pain in the first metatarsal.

Hallux rigidus

See also notes on functional hallux limitus (Fhl) below (Mulier 1999, Shefeff & Baumhauer 1998).

Hallux rigidus results from degenerative changes at the first MTP joint.

The widespread negative influences of Fhl (see immediately below) suggest that additional musculoskeletal symptoms of patients with hallux rigidus may benefit from any functional improvement it may be possible to deliver for this structure, via surgery or any other means.

Functional hallux limitus (Fhl)

Fhl describes limitation in dorsiflexion of the first MTP joint during walking, despite normal function of this joint when non-weight bearing (Dananberg 1986). The widespread adaptive and dysfunctional patterns that flow from Fhl demonstrate how imbalances in foot mechanics can affect the rest of the body (see discussion in Chapter 3 regarding Fhl and bodywide postural and functional problems and also below). These potentials may emerge just as effectively from hallux rigidus as from Fhl.

Fhl limits the rocker phase, since first MTP joint dorsiflexion promotes plantarflexion of the foot. If plantarflexion fails to occur, there will be early knee joint flexion prior to the heel lift of the swing limb, which also reduces hip joint extension of that leg. ‘The reduced hip extension converts the stance limb into a dead weight for swing, which is exacerbated by hip flexor activity … resulting in ipsilateral rotation of the spine, stressing the intervertebral discs’ (Prior 1999).

Vleeming et al (1997) note that: ‘Fhl…because of its asymptomatic nature and remote location, has hidden itself as an etiological source of postural degeneration’. They also observe that: ‘Fhl is a unifying concept in understanding the relationship between foot mechanics and postural form…identifying and treating this can have a profound influence on the chronic lower back pain patient’ (see Fig. 3.15 as well as Table 3.2).

Assessment and treatment protocols for Fhl are to be found in Chapter 3. For a summary see Box 14.7.

Circulatory issues including intermittent claudication, restless legs and cramp

Intermittent claudication (IC) refers to cramp-like leg pains, usually affecting the calf muscles. The symptoms are caused by poor arterial circulation (peripheral arterial disease, or PAD) to the leg muscles during exercise, often limiting the individual’s ability to walk more than a short distance. The symptoms are usually relieved by rest.

Cycling and IC (Callaghan 2005)

Aggravating factors related to cycling that may contribute to IC include a mixture of prolonged, repetitive hip flexion, possibly causing trauma to the external iliac artery flow to the lower limbs. There may also be an element of anatomical variation such as extra arterial branches, excessive arterial lengthening, a hypertrophic psoas muscle or associated metabolic disorders such as diabetes mellitus (Schep et al 2002).

Restless leg, cramp & pregnancy (Hensley 2009)

Sleep disturbance is common during the third trimester of pregnancy.

Two under diagnosed sleep disorders commonly experienced by women in the third trimester include leg cramps (LCs) and restless legs syndrome (RLS). LCs may be experienced by up to 30% of pregnant women and RLS by up to 26%. Both usually occur at night, may be described as a ‘cramping’ sensation in the lower leg, which is usually relieved by movement. Leg cramps are most often relieved by dorsiflexion of the foot of the affected leg. RLS is most often relieved by walking.

Although the evidence is weak, the best treatment for LCs during pregnancy appears to be taking supplemental magnesium before bed (Young & Jewell 2002). No evidence exists as to benefits from supplemental calcium, or nighttime leg stretching exercises.

Medical treatment of PAD/IC (Martinez et al 2009)

Adjunctive approaches: stretching and exercise

Therapeutic stretches, such as those involving MET, applied to gastrocnemius and soleus (see Figure 14.38) are suggested as part of the warm-up, before regular exercise therapy for IC (Martinez et al 2009).

Figure 14.38 Alternative position for treatment of gastrocnemius and/or soleus (if knee is flexed to disengage gastrocnemius)

(adapted from Chaitow 2001).

Regular walking exercise (treadmill or in everyday life) is the most commonly recommended rehabilitation exercise to help in improving peripheral circulatory problems related to PAD/IC (Stewart et al 2008).

Soft tissue approaches

Osteopathic soft tissue methods were successfully applied to patients with PAD/IC (Lombardini et al 2009). A controlled study investigated whether osteopathic manipulative therapy (OMT) mainly involving soft tissue methods that have been incorporated into NMT, as described in this book, could be of benefit to patients with intermittent claudication, alongside standard care.

Compared to a control group (no additional manual treatment), the OMT group achieved a significant increase in blood flow and improvement of subjective symptoms, by the end of the study, and at 6 months follow-up.

Salamon et al (2004) suggest that physical manipulation may promote a rapid release of nitric oxide (NO) that might explain the therapeutic vascular effects of OMT. Apparently NO release promotes vasodilation, inhibits platelet aggregation, white blood cell adhesion and smooth muscle cell proliferation, all of which may contribute to profound physiological benefits (Stefano et al 2000).

Other benefits deriving from the OMT approaches, listed below, might relate to a combination of biomechanical, reflexive and circulatory effects, achieved during treatment.

Classifying the muscles of the leg and foot

The muscles of the leg and foot can be functionally classified into those that primarily flex, extend, invert and evert the ankle and subtalar joint and those that act upon the toes. Many of these muscles perform several functions and would appear in several categories. They could certainly be classified as being extrinsic (those arising outside the foot to act upon it) or intrinsic (those arising within the foot structure itself), which has merit when organizing a treatment approach. They could also be classified by innervation as to dorsal and ventral divisions of the plexus. However, the best way to classify the muscles of the leg and foot is by location (Platzer 2004) since the leg is divided into compartments and the foot into dorsal and plantar surfaces.

In the next section, the extrinsic muscles (those arising in the leg) will be considered first, followed by the dorsal and plantar intrinsic muscles of the foot.

The leg can be conveniently divided into three compartments – anterior, posterior and lateral – although some authors offer only anterior and posterior by including the fibularis muscles in the posterior compartment (Fig. 14.24).

Figure 14.24 Transverse section of the right leg

(adapted with permission from Travell & Simons 1992).

The extrinsic muscles are discussed first in the following section, organized by their compartmental location. The intrinsic muscles are then discussed more briefly and organized as to dorsal or plantar location. Although the discussion of the intrinsic muscles may be brief, this in no way diminishes the tremendously important role they play in maintaining the integrity of the foot.

Posterior compartment of the leg

The muscles in the posterior compartment of the leg form superficial and deep groups, separated by the deep transverse fascia. They are all plantarflexors as well as inverters of the foot, some offering medial stabilization to the ankle, especially important on rough terrain.

Muscles of the superficial layer of the posterior leg

The superficial layer of the posterior leg is composed of gastrocnemius, plantaris and soleus, which together form the bulk of the calf (Fig. 14.25). They constitute a powerful muscular mass, with their large size associated with ‘one of the most characteristic features of the musculature of man, being related directly to his upright stance and mode of progression’ (Gray’ anatomy 2005). Gastrocnemius and plantaris act on both the knee and foot positioning, while the soleus acts only on the foot.

Figure 14.25 Muscles of the posterior compartment of the right leg. Gastrocnemius is reflected to show soleus, plantaris, and the course of the neurovascular structures through the soleus canal beneath it

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Gastrocnemius (Fig. 14.26)

Figure 14.26 Trigger point target zone for gastrocnemius. Other trigger points in this muscle also refer to the medial and lateral posterior knee (not shown)

(adapted with permission from Travell & Simons 1992).

Soleus (Fig. 14.27)

Figure 14.27 Soleus and gastrocnemius relationship from lateral perspective

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Venous pumping

Travell & Simons (1992) describe the venous pumping action of the soleus muscle.

The soleus provides a major pumping action to return blood from the lower limb toward the heart. Venous sinuses in the soleus muscle are compressed by the muscle’s strong contractions so that its venous blood is forced upward toward the heart. This pumping action (the body’s second heart) depends on competent valves in the popliteal veins. Valves in the veins to prevent reflux of the blood are most numerous in the veins of the lower limbs where the vessels must return blood against high hydrostatic pressure. The popliteal vein usually contains four valves. Deeper veins that are subject to the pumping action of muscle contraction are more richly provided with valves.

Travell & Simons further note that when seated for long periods of time, such as when traveling, ‘spontaneous’ thrombosis can occur in the deep veins of the legs. The pumping action of the soleus can be employed (using the pedal exercise) to prevent this occurrence, as mentioned in Chapter 4 and illustrated in Figure 4.9.

Since the blood vessels that serve the leg and the tibial nerve must course deep to the soleus, the soleus canal, formed by a tendinous arc at the proximal end of the muscle, provides a passageway. Travell & Simons (1992) suggest that entrapment of these structures is possible by the plantaris muscle belly or by taut bands of myofascial tissues that are often associated with trigger points. ‘Obstruction affects mainly the soft-walled veins, causing edema of the foot and ankle’.

Trigger points in the soleus muscle primarily refer to the heel, Achilles tendon and ipsilateral sacroiliac joint (Fig. 14.28). Additionally, a rare and ‘exceptional’ trigger point (not illustrated) is known to refer to the ipsilateral face and jaw, possibly altering occlusion of the teeth (Travell & Simons 1992).

Figure 14.28 Trigger point target zones for soleus. A rare trigger point in soleus refers to the face and jaw (not illustrated)

(adapted with permission from Travell & Simons 1992).

Deep vein thrombosis

CAUTION: Deep vein thrombophlebitis is a serious condition to which applications of massage, and other forms of soft tissue manipulation, are contraindicated.

Symptoms include constant pain even when the muscles are not active, warmth and redness but these symptoms are not always present. A positive Homan’s sign is noted, in which pain is elicited when the foot of the fully extended leg is placed forcibly in dorsiflexion, especially when accompanied by tenderness on deep palpation of the calf (Hoppenfeld 1976). Difficulty arises in achieving an accurate diagnosis from these last two symptoms alone, since these may also be characteristic of myofascial dysfunction. Travell & Simons (1992) further note that ‘clinical examination alone is unreliable for detection of thrombophlebitis’ and that ‘contrast venography remains the standard’.

While both muscles of triceps surae produce plantarflexion when the knee is extended, as the knee is progressively flexed the gastrocnemius becomes less effective and the soleus becomes successively more responsible for plantarflexion. The force created by these two muscles can lift the body during gait as well as during stance, their strength is most obvious when one is standing on the toes.

Regarding the postural roles of the triceps surae, Gray’s anatomy (2005) notes:

In normal walking, gastrocnemius restrains the tibia from rotating on the talus as the weight is shifted from the heel to the ball of the foot during stance phase (Travell & Simons 1992). It is effective in plantarflexion of the foot when the foot is free to move and, since plantarflexion forces applied to the calcaneus are transmitted through the cuboid to the 4th and 5th metatarsals, supination simultaneously occurs with plantarflexion movements (Travell & Simons 1992). Its flexion forces on the knee are weak when the knee is extended, resulting in a strong plantarflexion force instead.

Achilles tendon

The Achilles tendon is the thickest and strongest tendon in the human body, beginning near the middle of the calf, receiving additional fibers almost to its lower end and attaching to the posterior surface of the calcaneus at its mid-level. A bursa usually separates the tendon from the bony surface of the tibia and another separates the tendon from the skin (Cailliet 1997). The tendon spirals as it descends so that the gastrocnemius tendinous fibers insert on the lateral calcaneus and the soleus fibers more medially. Regarding tendons, Gray’s anatomy (2005) notes that: ‘A tendon stretches elastically by 8% before breaking, and its recoil returns 93% of the energy used to stretch it. This high energy return is important, not only because it reduces the work required from the muscles, but also because the lost mechanical energy becomes heat: leg tendons with poor energy return would overheat in running, and be damaged.’

Plantaris (see Fig. 14.27)

NMT for superficial layer of posterior leg

Gastrocnemius

• Lubricated gliding strokes are applied to the most lateral segment of the gastrocnemius 7–8 times.

• The thumbs are moved medially 1–2 inches and the gliding strokes repeated on the next section of muscle.

• The gliding strokes are repeated in sections until the entire posterior surface of the leg has been treated.

• As the thumbs glide over the tissues, attention is focused on the consistency and quality of the tissues being palpated. There should be a pliable and somewhat elastic quality and they should have no taut bands or thick or fibrotic congestion.

• If dense or taut tissues are found, repetitive gliding, trigger point pressure release (as described in Chapter 9) and myofascial release techniques may be applied to reduce ischemia and enhance blood flow and lymphatic drainage of the region.

• The gastrocnemius can often be lifted in a pincer-type grasp as each head is examined by rolling or compressing it between the fingers and thumb. This may be accomplished more easily if the knee is flexed to at least 45–90° (Fig. 14.29). Residual oil or lotion may need to be removed in order to grasp without slipping.

• During this type of examination, nodules associated with trigger points may be revealed and assessment can easily turn into treatment, as applied compression is used to release the taut bands.

• Stretching of the tissues housing trigger points is recommended after their release as well as home application of the stretching techniques to help prevent reoccurrence.

Figure 14.29 The gastrocnemius can often be lifted and compressed between the thumb and fingers as its fibers are examined for taut bands or ischemia.

Soleus

• Deeper pressure applied with gliding strokes or static compression, if appropriate, may influence the soleus, which lies deep to the gastrocnemius. The soleus may also be treated by displacing the gastrocnemius medially and laterally to gain access to a part of its belly on each side (Fig. 14.30). This is more easily accomplished if the foot is passively plantar-flexed.

• To treat the medial and lateral aspects of the soleus simultaneously, the practitioner places one thumb on the medial side of the exposed portion near the distal end and the other thumb on the lateral side of the exposed portion. The thumbs will be deep to the tendon of gastrocnemius and opposite each other on the sides of the leg (Fig. 14.31).

• With lubrication, the practitioner glides the thumbs proximally, while simultaneously pressing them toward each other. This ‘double thumb’ technique will entrap the soleus between the thumbs as pressure is applied.

  Page 544 

• Mild tension can also be applied to the triceps surae by bracing the foot against the practitioner’s abdomen, thigh or hip in such a way as to create slight dorsiflexion, which will tighten the gastrocnemius and lift it slightly from the soleus. Since this movement will also stretch the soleus, care should be taken to avoid excessive stretch and/or excessive thumb pressure on the tissues while repeating the gliding process (from the distal end to the knee) 7–8 times.

Figure 14.30 The gastrocnemius can often be displaced so that a portion of the underlying tissues may be palpated on each side of the leg.

Figure 14.31 The medial and lateral portions of the soleus are pressed toward each other while a gliding stroke is applied with both thumbs simultaneously.

Plantaris (and gastrocnemius attachments)

• The medial thumb will also be treating the long tendon of the plantaris muscle. A similar compressive ‘double thumb’ glide can also be applied to the gastrocnemius.

• The knee is now supported at 70–90° of passive flexion, to relax the hamstring tendons. Palpation of the attachments of plantaris and the lateral head of gastrocnemius is sometimes possible by placing a thumb between the biceps femoris tendon and the iliotibial band and directly onto the lateral condyle of the femur (Fig. 14.32).

• The procedure can be repeated for the medial head of gastrocnemius by working either between the semimembranosus and semitendinosus tendons or around them (in the medial edge of the popliteal space) on the medial epicondyle of the femur.

• Palpation may reveal a tender attachment but plantarflexion of the foot to assess muscular contraction of the tendon will not produce the desired effect, since these two muscles only plantarflex the foot when the knee is extended. Caution must be exercised to avoid pressing into the mid-portion of the popliteal fossa due to the course of a neurovascular bundle.

• The plantaris muscle belly can sometimes be palpated just medial to the lateral head of gastrocnemius. This is best and most safely accomplished with the knee flexed to 90°. The practitioner stands beside the knee and wraps her caudad arm around the medial aspect of the leg so as to ‘cradle’ the leg with the tibia resting on her forearm (not shown in illustration). The thumb of that wrapping arm is placed diagonally across the back of the knee so that it lies directly over the course of the plantaris muscle (see Fig. 14.33).

• A short, transverse snapping stroke can be repeatedly applied to the belly of plantaris with that overlying thumb while caution is exercised to avoid intruding on the popliteal fossa, especially when applying strong compression for trigger point pressure release, due to the neurovascular structures. When positioned correctly and if the plantaris is present, the thumb should ‘flip’ across the muscle when appropriate pressure is being used.

Figure 14.32 Avoid the neurovascular structures during palpation for the lateral attachment of gastrocnemius as well as the attachment of plantaris.

Figure 14.33 Transverse snapping palpation can be precisely applied to the belly of plantaris.

NMT for Achilles tendon

CAUTION: If evidence of bursitis or tendinitis is present, the following treatments should be postponed until the inflammation has been reduced. If partial tear of the tendon is suspected, a clear diagnosis should be sought before application of these or any other techniques that may stress the possibly damaged tendon, especially stretching techniques. All forms of strain (including stretching and possibly walking) that could further tear the tissue should be avoided until the extent of damage is known.

Figure 14.34 Slight dorsiflexion of the foot will assist in maintaining tension on the Achilles tendon as gliding stokes are applied to the posterior surface. Without the applied dorsiflexion the tendon collapses under the thumbs.

Figure 14.35 The anterior surface of the Achilles tendon can be accessed with lateral and medial displacement.

Figure 14.36 Unless inflammation is present, the fascia of the heel as well as the plantar fascia can be treated with a ‘scraping’ movement applied with the beveled pressure bar.

When heel spurs have been diagnosed (see notes earlier in this chapter), chronic tightness of the Achilles tendon and its contributing muscles should be addressed. Loss of integrity of the plantar vault and the resultant pronation of the foot, ‘splay foot’ and other conditions that place tension on the plantar fascia should also be assessed. The muscles of the posterior compartment of the leg, as well as the intrinsic muscles of the foot, should be addressed, as well as proprioceptive retraining incorporated for the muscles of the feet (see Box 14.2).

MET assessment and treatment of tight gastrocnemius and soleus (Fig. 14.37)

Assessment of tight gastrocnemius

• The patient is supine with feet extending over the edge of the table.

• For right leg examination the practitioner’s right hand grasps the Achilles tendon just above the heel, avoiding pressure on the tendon.

• The heel lies in the palm of the hand, fingers curving round it.

• The left hand is placed so that the fingers rest on the dorsum of the foot (these are not active and do not apply any pulling stretch), with the thumb on the sole, lying along the medial margin.

• This position is important as it is a mistake to place the thumb too near the center of the sole of the foot.

• Stretch is introduced by pulling on the heel with the right hand, taking out the slack of the muscle, while at the same time the left hand maintains cephalad pressure via the thumb (along its entire length).

  Page 547 

• A range of movement should be achieved that takes the sole of the foot to a 90° angle to the leg without any force being applied.

• If this is not possible, i.e. force is required to achieve the 90°angle between the sole of the foot and the leg, there is shortness in either gastrocnemius and/or soleus. Further screening is required to identify precisely which (see soleus test below).

• It is possible to use the right hand, which has removed slack from the muscles via traction, to palpate the tissues with which it is in contact for a sense of bind, as the foot is dorsiflexed.

• The leg should remain resting on the table all the while and the left hand holding/palpating the muscular insertion and the heel should be so oriented that it is a virtual extension of the leg, avoiding any upward (toward the ceiling) pull, when stretch is introduced.

Figure 14.37 A: Gastrocnemius assessment position. B: Soleus assessment position

(adapted from Chaitow 2001).

Assessment of tight soleus

The method described above assesses both gastrocnemius and soleus.

MET Treatment of shortened gastrocnemius and soleus (see Fig. 14.37)

An alternative treatment position for gastrocnemius, which can also be used for assessment, involves the practitioner using the forearm to stabilize the sole of the foot as the heel is cradled in the palm of the hand. (Fig. 14.38) Flexion of the knee (rolled towel under the knee) would allow this position to be used for assessing and/or treating soleus.

Muscles of the deep layer of the posterior leg

Between the superficial and deep muscles of the calf lies the deep transverse fascia of the leg. It extends from the medial margin of the tibia to the posterior border of the fibula. It is thick and dense proximally and is continuous with fascia covering popliteus and receives an expansion from the tendon of semimembranosus. It is thin at intermediate levels and thick again at the distal end, where it is continuous with the flexor and superior fibular retinacula (Gray’s anatomy 2005).

The deep flexors of the calf include flexor hallucis longus, which courses along the posterior shaft of the fibula, flexor digitorum longus, which lies on the posterior shaft of the tibia and tibialis posterior, which lies between the two bones, directly superficial to the interosseous membrane (Fig. 14.39).

Figure 14.39 Muscles of the deep layer of the posterior compartment of the right leg

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Popliteus, which only acts on the knee joint, lies across the posterior aspect of that joint capsule and wraps around to the lateral surface of the lateral femoral condyle. A portion of the popliteus can be treated at its attachment on the upper 3–4 inches of the posteromedial shaft of the tibia when the flexor digitorum longus is addressed.

The deep layer is separated from the superficial layer by the deep transverse fascia and an interposing substantial neurovascular complex, which serves the leg and foot, and from the anterior compartment by the interosseous membrane. A portion of the toe flexors can be reached on the posterior shafts of the bones but little of the tibialis posterior is available to palpation due to its central location (being housed between the two bones) as well as the overlying neurovascular structures that forbid intrusion into its belly.

Indications for treatment

Special notes

The flexor muscles of the toes stabilize the foot and ankle during walking, while they contribute to plantarflexion of the foot and the resultant forward transfer of weight onto the forefoot. Additionally, flexor hallucis longus (FHL) plantarflexes the great toe (and sometimes others), while flexor digitorum longus (FDL) flexes the four lesser toes. Both of these muscles act as supinators of the foot and FDL also supports the medial arch.

FHL courses down the posterior surface of the tibia, then through a series of grooves on the surface of the talus and the inferior surface of the sustentaculum tali of the calcaneus. These grooves are then converted by fibrous bands into a canal, which is lined by a synovial sheath. FHL crosses FDL (being connected at that point by a fibrous slip) and then crosses the lateral part of flexor hallucis brevis (FHB) to reach the head of the first metatarsal between the sesamoid bones of FHB. It then continues through an osseo-aponeurotic tunnel to attach to the plantar aspect of the base of the distal phalanx.

FHL may also offer connections to the second, third and sometimes fourth digit.

FDL has a similar course down the lower half of the fibula and crosses the posterior ankle and tibialis posterior. It passes behind the medial malleolus and shares a groove with tibialis posterior, being divided from tibialis posterior by a fibrous septum that separates each tendon in its own synovial-lined compartment. FDL courses obliquely forward and laterally as it enters the sole of the foot. The quadratus plantae and the lumbricals radiate into the tendon complex of FDL.

Though gastrocnemius and soleus are considerably stronger plantarflexors, FHL and FDL certainly make a contribution to this movement. Both muscles flex the phalanges of the toes, acting primarily on these when the foot is off the ground. Gray’s anatomy (2005) notes:

Trigger points in FHL refer pain and tenderness to the plantar surface of the first metatarsal and great toe, while FDL refers to the plantar surface of the middle of the forefoot and sometimes into the lesser toes. FDL may also radiate pain into the calf and medial ankle, while the FHL referred pain is confined to the foot (Fig. 14.40). Over-activity of these toe flexor muscles contributes to the development of hammer toes, claw toes and other deforming foot conditions as they attempt to stabilize the foot (Travell & Simons 1992) (see Box 14.11).

Figure 14.40 Trigger point target zones for flexor digitorum longus and flexor hallucis longus

(adapted with permission from Travell & Simons 1992).

Indications for treatment

Special notes

Tibialis posterior is the most deeply placed muscle of the posterior compartment (see Box 14.10 regarding compartment syndromes). It lies on the posterior surface of the interosseous membrane, which separates it from the anterior compartment. Distally, the tendon of flexor digitorum longus lies just superficial to it and they share a groove behind the medial malleolus, although they have separate synovial sheaths. In the foot, it lies inferior to the plantar calcaneonavicular ligament, where it contains a sesamoid fibrocartilage. The tendon then divides to attach to all tarsal bones except the talus (to which no muscles attach) and the bases of the middle three metatarsals.

Although the tibialis posterior may assist in plantar-flexion, its primary role is as the principal supinator of the foot and it assists in elevating the longitudinal arch of the foot, although it is quiescent in standing (Gray’s anatomy 2005). Gray’s anatomy notes:

It is phasically active in walking, during which it probably acts with the intrinsic foot musculature and the lateral calf muscles to control the degree of pronation of the foot and the distribution of weight through the metatarsal heads. It is said that when the body is supported on one leg, the inverter action of tibialis posterior, exerted from below, helps to maintain balance by resisting any tendency to sway laterally. However, any act of balancing demands the cooperation of many muscles, including groups acting on the hip joints and vertebral column.

Trigger points in tibialis posterior produce pain from the calf through the plantar surface of the foot, with a particularly strong referral into the Achilles tendon (Fig. 14.41). This muscle’s trigger points are particularly difficult to treat with massage techniques, or injections, due to the overlying muscles and interposed neurovascular structures. The authors have found spray and stretch techniques, as described by Travell & Simons (1992), or ice stripping with stretch to be effective treatments. If, in addition to correction of associated muscular and skeletal conditions, such methods are coupled with PRT and MET procedures in a home-care program, reduction in pain from these trigger points is likely.

Figure 14.41 Trigger point target zones for tibialis posterior

(adapted with permission from Travell & Simons 1992).

Flexor digitorum longus

Fibularis (peroneus) longus

Figure 14.44 The fibularis muscles. A) Note the course of the common fibular nerve near the fibular head; B) Fibularis brevis attaches to the styloid process of the 5th metatarsal; C) fibularis longus courses across the plantar surface to attach on the medial aspect of the foot.

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Fibularis (peroneus) brevis

NMT for lateral compartment of leg

Figure 14.46 Treatment of the lateral shaft of the fibula will address fibularis (peroneus) longus and brevis. Caution should be exercised to avoid compressing the fibular nerve near the head of the fibula.

Figure 14.47 Tendons of fibularis (peroneus) longus and brevis can be stroked with the tip of the beveled pressure bar. Caution should be exercised following ankle sprains to ensure that swelling and inflammation in this region have subsided before these techniques are used.

Note: The tendon of the fibularis longus crosses the foot to insert on the first metatarsal and medial cuneiform bone. This tendon should always be checked when there are formations of bunions on the first metatarsal or instability of the arches. This tendon is treated with the intrinsic muscles later in this chapter.

Tibialis anterior

Indications for treatment

Special notes

Tibialis anterior dorsiflexes the foot and supinates it when it is free to move. When gait, its activity begins just after toe-off as it lifts the foot, so that the foot and toes clear the ground during the swing phase. At heel strike, it prevents foot slap and then advances the tibia forward over the talus. Regarding its role in standing postures, Gray’s anatomy (2005) states:

The muscle is usually quiescent in a standing subject, since the weight of the body acts through a vertical line that passes anterior to the ankle joints. Acting from below, it helps to counteract any tendency to overbalance backwards by flexing the leg forwards at the ankle. It has a role in supporting the medial longitudinal arch of the foot; although electromyographic activity is minimal during standing, it is manifest during any movement which increases the arch, such as toe-off in walking and running.

Trigger points in tibialis anterior refer pain and tenderness from the mid-shin region to the distal end of the great toe, being strongest at the ankle and toe (Fig. 14.49). These trigger points may be activated by ankle injuries or overload, gross trauma or walking on sloped surfaces or rough terrain.

Figure 14.49 Trigger point referral pattern for tibialis anterior

(adapted with permission from Travell & Simons 1992).

Extensor hallucis longus

Extensor digitorum longus

Special notes

Extensor hallucis longus (EHL) lies between tibialis anterior and extensor digitorum longus, being covered for the most part by the two. It courses over the dorsal surfaces of the foot to attach to the great toe, which it dorsiflexes. The muscle sometimes produces a slip onto the second toe and sometimes it merges with extensor digitorum longus (Gray’s anatomy 2005). Between tibialis anterior and EHL lies the deep fibular nerve and the anterior tibial vessels.

Extensor digitorum longus (EDL) lies in the most lateral aspect of the anterior compartment. It courses over the dorsal foot to attach to the four lesser toes, which it dorsiflexes. The tendons to the second and fifth toes may be doubled and there may be accessory slips attached to metatarsals or to the great toe (Gray’s anatomy 2005).

Trigger points in the EHL refer across the dorsum of the foot and strongly into the first metatarsal and great toe, while the EDL refers across the dorsum of the foot (or ankle) and into the lesser toes (Fig. 14.50).

Figure 14.50 Trigger point referral pattern for extensor digitorum longus and extensor hallucis longus

(adapted with permission from Travell & Simons 1992).

Fibularis (peroneus) tertius

NMT for anterior compartment of leg

CAUTION: The following steps are contraindicated when anterior compartment syndrome is suspected (see Box 14.10). This condition requires immediate medical attention and application of massage to the affected area can increase the pressure within the compartment, with potentially serious repercussions.

Figure 14.51 A flat pressure bar can be substituted for the practitioner’s thumbs when the tibialis anterior is too thick to be treated effectively by the hands alone. In most cases, however, the thumbs are sufficient.

Figure 14.52 A double-thumb technique is used to simultaneously displace the tibialis anterior (TA) while compressing the extensor muscles against the shaft of the fibula.

PRT for tibialis anterior

Figure 14.53 The position of ease for the tibialis anterior tender point.

PRT for extensor digitorum longus

Dorsal foot muscles (Figs 14.58 A/B, 14.59)

Figure 14.59 Trigger point referral pattern of dorsal instrinsic foot muscles

(adapted from Travell & Simons 1992)

Figure 14.58 A: Muscles and tendons of the dorsal foot. B: With superficial muscles removed, the dorsal interossei are visible.

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Trigger points in these muscles target the area immediately surrounding (and including) their bellies and may be associated with trigger points in the corresponding long toe extensors. Trigger points should be sought in these muscles when structural deviations exist that might be influenced by chronic toe extension, such as hammer toes or claw toes.

NMT for dorsal intrinsic muscles of the foot

The patient is supine with the knee supported by a cushion while the practitioner stands or is seated at the level of the foot on the side to be treated.

Extensor digitorum brevis and extensor hallucis brevis are palpated anteromedial to the lateral malleolus, just anterior to the palpable indentation of the sinus tarsi. Their location is more evident if resisted extension of the great toe (for EHB) or the lesser toes (for EDB) is applied with one hand while the other palpates this region (Fig. 14.60).

Figure 14.60 Palpation of extensor hallucis brevis and extensor digitorum brevis at the base of the sinus tarsi. Practitioner resistance against dorsiflexion of the lesser toes will assist in locating the muscles.

Once the muscle bellies are located, short gliding strokes, transverse gliding or static compression against the underlying boney surface can be used to treat these muscles. Additionally, the beveled pressure bar can be used to assess each tendon with short, scraping strokes or the thumb can be used in a gliding assessment.

The dorsal interossei are discussed with the plantar muscles since they are innervated by the plantar nerve. However, they may be best accessed here with the dorsal muscles. The beveled tip of the pressure bar can be wedged between the metatarsal bones, from the dorsal surface, to examine and treat these small muscles, which lie deeply placed between the bony surfaces (Fig. 14.61). While the finger tip can be substituted, the authors find that the beveled tip of the pressure bar is a better fit and can be angled more effectively than the finger tip.

Figure 14.61 The beveled tip of the pressure bar can be wedged between the metatarsals to examine the dorsal interossei.

Plantar foot muscles

The plantar aponeurosis (plantar fascia) is orientated mainly longitudinally but it also has some transverse components (Fig. 14.62). It is considerably denser, stronger and thicker centrally, where it overlies the long and short digital flexors. Running from the calcaneus to the metatarsal heads, it divides into five bands, each attaching to a single toe. It broadens and thins distally and is united by transverse fibers.

Figure 14.62 Plantar aponeurosis (fascia) of the right foot

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

It should be borne in mind that applications of manual massage techniques to the plantar surfaces of the foot will be applied through this plantar fascia. The integrity of this fascia is important to the arch system of the foot and overenthusiastic applications to ‘loosen’ it could be detrimental. As noted in Box 14.6, the plantar aponeurosis is tensionally loaded and in this way helps retain the plantar vault. When abused by structural stress (which might include prolonged standing or loss of the integrity of the arch through overload or repetitious strain), this tissue may develop inflammation, which is commonly termed plantar fascitis (Cailliet 1997).

The plantar muscles, which lie deep to the plantar fascia, can be grouped in two ways. First, they can be discussed according to where they longitudinally lie on the foot. This has merit since, for the most part, those that serve the great toe lie in the medial column of the foot, those that serve the fifth digit lie in a lateral column and those that lie in between these two groups serve the middle digits (except adductor hallucis, which lies transversely across the forefoot). In clinical application it allows all muscles associated with a particular toe or group of toes, to be assessed at once. Alternatively, after the removal of the plantar fascia, they can be considered in four layers. This is particularly useful in anatomy studies, as cadaver dissection is often performed in this manner. It is also useful in the application of manual techniques, since superficial layers need to be addressed before underlying tissues are palpated. In the following discussion of anatomy details, the second style is employed, although the first can be easily substituted in clinical application once the reader is familiar with the anatomy.

Travell & Simons (1992) note that trigger points in the plantar intrinsic muscles are activated or aggravated by, the wearing of tight, poorly designed or ill-fitting shoes, ankle and foot injuries, structural inadequacies of the foot, articular dysfunction or loss of structural integrity of the joints of the foot, walking on sandy or sloped surfaces, conditions that allow the feet to get chilled and systemic conditions (especially those that affect the feet, such as gout).

First layer

The superficial layer of plantar muscles includes abductor hallucis on the medial side of the foot, abductor digiti minimi on the lateral side, while flexor digitorum brevis lies between them (Fig. 14.63).

Figure 14.63 Superficial plantar muscles of the right foot,

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Abductor hallucis (AbH) attaches proximally to the flexor retinaculum, medial process of the calcaneal tuberosity the plantar aponeurosis and the intermuscular septum, which separate it from flexor digitorum brevis. Its distal tendon attaches to the medial side of the base (or medial side or plantar surface) of the proximal phalanx of the great toe. Sometimes fibers attach to the medial sesamoid bone of the great toe (Gray’s anatomy 2005). It abducts and/or weakly flexes the proximal phalanx of the great toe (Platzer 2004) and is a ‘particularly efficient tightener’ of the arch (Kapandji 1987). AbH crosses the entrance of the plantar vessels and nerves, which serve the sole of the foot, and it may entrap these nerves against the medial tarsal bones (Travell & Simons 1992). Trigger points in AbH refer to the medial aspect of the heel and foot and the taut bands associated with trigger points in this muscle may be responsible for tarsal tunnel syndrome (Travell & Simons 1992).

Flexor digitorum brevis (FDB) attaches to the medial process of the calcaneal tuberosity, from the central part of the plantar aponeurosis and from the intramuscular septa. It courses distally through the longitudinal center of the foot, dividing distally into four tendons, which insert into the four lesser toes, accompanied through their tendon sheaths by the tendons of flexor digitorum longus. At the base of each proximal phalanx, the corresponding FDB tendon divides, forming a tunnel through which the tendon of FDL passes, to attach to the distal phalanx, while FDB attaches to both sides of the shaft of the middle phalanx. Because it is ‘perforated’ by FDL, the brevis is sometimes called perforatus (Platzer 2004). Gray’s anatomy (2005) notes: ‘The way in which the tendons of flexor digitorum brevis divide and attach to the phalanges is identical to that of the tendons of flexor digitorum superficialis in the hand’. It also states that variations of FDB include second, supernumerary slips, that a tendon may be absent or it may be that a small muscular slip from the FDL, or from quadratus plantae, may be substituted. FDB flexes the middle phalanges on the proximal ones. Trigger points in FDB refer to the plantar surface of the foot, primarily to the region of the heads of the four lesser metatarsals. They may be associated with trigger points found in FDL (Travell & Simons 1992).

  Page 568 

Abductor digiti minimi (quinti) (ADM) attaches to both processes of the calcaneal tuberosity and to the bone between them, to the plantar aponeurosis and to the intermuscular septum. It attaches to the lateral side of the base of the proximal phalanx of the fifth toe. Gray’s anatomy (2005) notes:

Some of the fibres arising from the lateral calcaneal process usually reach the tip of the tuberosity of the fifth metatarsal and may form a separate muscle, abductor ossis metatarsi digiti quinti. An accessory slip from the base of the fifth metatarsal is not infrequent.

ADM abducts the fifth toe and also flexes it. Kapandji (1987) mentions that it also ‘assists in the maintenance of the lateral arch’. Trigger points in ADM primarily target the plantar surface of the fifth metatarsal head and the adjacent tissues.

Second layer

The second layer of plantar intrinsic muscles consists of quadratus plantae and the four lumbrical muscles (Fig. 14.64). The flexor digitorum longus tendons accompany this layer and are intimately associated with these muscles.

Figure 14.64 Second layer of plantar muscles of the right foot

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Quadratus plantae (QP) is also known as flexor digitorum accessorius or the plantar head of FDL. It attaches to the calcaneus by two heads, proximately separated by the long plantar ligament. The medial head attaches to the medial concave surface of the calcaneus, below the groove for the tendon of FHL, while the lateral attaches distal to the lateral process of the tuberosity and to the long plantar ligament. The larger medial head is more fleshy, while the flat lateral head is tendinous. They both join the lateral border of the tendon of FDL, either to the common tendon or into the divided tendons, varying as to the number it supplies. The muscle is sometimes absent altogether (Gray’s anatomy 2005). QP assists in flexion of the four lesser toes by compensating for the obliquity of the FDL tendon by centering the line of pull on the tendon. It also serves as a stabilizer for the lumbricals, which attach to the distal side of the same tendon unit. The trigger point target zone for QP is strongly into the plantar surface of the heel.

The lumbrical muscles are four small muscles that arise from the FDL tendons as far back as their angles of separation. Each lumbrical attaches to the sides of two adjacent tendons, except for the first, which arises only from the medial border of the tendon of the second toe. They attach distally on the medial sides of the dorsal digital expansions, on their associated proximal phalanx; one or more may be missing. They serve as an accessory to the tendons of FDL by assisting flexion of the metatarsophalangeal joints of the lesser toes, as well as extension of the interphalangeal joints. Travell & Simons (1992) note that their trigger point patterns are likely to be similar to the interossei, although the patterns have not been confirmed.

Third layer

The third layer of plantar intrinsic muscles consists of flexor hallucis brevis, adductor hallucis and flexor digiti minimi brevis (Fig. 14.65).

Figure 14.65 Third layer of plantar muscles of the right foot

(Reproduced, with permission, from Gray’s anatomy for students, 2nd edn, 2010, Churchill Livingstone).

Flexor hallucis brevis (FHB) attaches to the medial part of the plantar surface of the cuboid, to the lateral cuneiform and to the tendon of tibialis posterior. The belly of the muscle divides and attaches to the medial and lateral sides of the base of the proximal phalanx of the great toe, with a sesamoid bone present in each tendon, near its attachment. The medial tendon blends with abductor hallucis and the lateral with adductor hallucis. An additional slip may extend to the proximal phalanx of the second toe (Travell & Simons 1992). FHB flexes the metatarsophalangeal joint of the great toe (a task that is critical in gait) and the medial and lateral heads abduct and adduct the proximal phalanx of the great toe, respectively (Travell & Simons 1992). Trigger points in FHB refer to both the plantar and dorsal surface of the head of the first metatarsal and sometimes include the entire great toe and the second toe (Travell & Simons 1992).

Adductor hallucis (AdH) arises by two heads. The oblique head attaches to the bases of the second through fourth metatarsal bones and from the fibrous sheath of the tendon of fibularis longus, and courses to the base of the proximal phalanx of the great toe, blending with the tendon of FHB and its lateral sesamoid bone. The transverse head attaches to the plantar metatarsophalangeal ligaments of the third through fifth toes and the deep transverse metatarsal ligaments, and blends with the tendons of the oblique head, which attach to the base of the proximal phalanx of the great toe. Gray’s anatomy (2005) notes: ‘Part of the muscle may be attached to the first metatarsal, constituting an opponens hallucis. A slip may also extend to the proximal phalanx of the second toe’. AdH adducts the great toe (toward the mid-line of the foot), assists in flexion of the proximal phalanx of the great toe and aids in maintaining transverse stability of the forefoot (Travell & Simons 1992) and in stabilizing the great toe (Kapandji 1987).

Flexor digiti minimi (quinti) brevis (FDMB) attaches to the base of the fifth metatarsal and the sheath of fibularis longus and courses to the base of the proximal phalanx of the fifth toe, usually blending with abductor digiti minimi. ‘Occasionally some of its deeper fibres extend to the lateral part of the distal half of the fifth metatarsal bone, constituting what may be described as a distinct muscle, opponens digiti minimi’ (Gray’s anatomy 2005).

FDMB flexes the proximal phalanx of the fifth toe at the metatarsophalangeal joint. Its trigger point referral pattern has not been established but Travell & Simons (1992) suggest it would be similar to ADM.

Fourth layer

The fourth layer of plantar muscles consists of the plantar and dorsal interossei (Fig. 14.66). Gray’s anatomy (2005) notes:

They resemble their counterparts in the hand, but they are arranged relative to an axis through the second digit and not the third digit, as occurs in the hand, as the second is the least mobile of the metatarsal bones.

Figure 14.66 Fourth layer of plantar muscles of the right foot. Plantar interossei are visible.

(Reproduced, with permission, from Gray’s anatomy for students, 2^nd edn, 2010, Churchill Livingstone).

The four dorsal interossei (DI) are situated between the metatarsal bones. They each arise by two bipennate heads, from the sides of adjacent metatarsal bones and course distally to attach to the bases of the proximal phalanges and debate exists as to their possible attachment to the dorsal digital expansions (Travell & Simons 1992). The first inserts into the medial side of the second toe, while the other three pass to the lateral sides of the first three lesser toes. The DI abduct the second through fourth toes away from the mid-line of the foot (second toe) and assist in plantarflexion of the proximal phalanx or hold it in dorsiflexion when dysfunctional (see Box 14.11, Movements of the toes). The interossei act to stabilize the foot in rough (varying) terrain and stabilize the toes during gait. See PI below for trigger point details.

  Page 570 

The three plantar interossei (PI) lie on the plantar surfaces of metatarsal bones of the last three toes, with each being connected to only one metatarsal. Each attaches individually to the base and medial side of its corresponding metatarsal and courses distally to the medial side of the base of the proximal phalanx of the same toe and into its dorsal digital expansion. The PI adduct the last three lesser toes toward the mid-line of the foot (second toe) and assist in plantarflexion of the proximal phalanx or hold it in dorsiflexion when dysfunctional. Trigger points in dorsal and plantar interossei target the region of the digit they serve: the dorsal and plantar surface of the associated toe and the plantar surface of its metatarsal. Travell & Simons (1992) add that ‘…TrPs in the first dorsal interosseous muscle may produce tingling in the great toe; the disturbance of sensation can include the dorsum of the foot and the lower shin’.

NMT for the plantar intrinsic muscles of the foot

For the NMT clinical application discussion below, first the medial column of the foot is addressed, followed by the lateral column and finally the middle section (the order is arbitrary). Variations in pressure and the angulation of the palpating digit will influence which tissue is being treated. Though some of these muscles are easily distinguishable one from the other, some are less identifiable by palpation and knowledge of anatomy and referral patterns for trigger points will offer assistance in determining which tissue is tender.

CAUTION: If there is evidence of foot fungus or plantar warts, the practitioner’s hands should be protected with gloves as these conditions can be contagious. If signs of infection are present (for instance, with an ingrown toe-nail), immediate medical attention is warranted prior to the application of manual techniques.

The plantar surface of the foot is most easily examined with the patient prone but he could also be supine or sidelying. In the illustrations offered here, the patient is supine so that the foot is in the same position as the anatomy illustrations presented in this chapter. Any position can be used, however, provided both the patient and the practitioner are comfortable.

The practitioner stands or is seated at the end of the treatment table in a comfortable manner. She can be seated on the table, as long as she can easily approach the foot without postural strain.

In the following palpation examination, assessment of the tissues can easily turn into treatment application when a tender tissue is located or reproduction of a referred pattern is noted. Sustained pressure, circular massage or short gliding strokes can be employed as needed to treat trigger points or taut bands of ischemia within these small foot muscles.

Figure 14.67 Palpation of abductor hallucis. Practitioner resistance to the patient’s attempts to abduct the great toe will help ensure correct placement.

Figure 14.68 Palpation of flexor hallucis brevis. Palpation of the fibers while the patient adducts the great toe against resistance will help ensure correct placement.

Figure 14.69 Palpation of lateral column muscles. Palpation of the fibers while the patient abducts the last toe against resistance will help ensure location of the abductor digiti minimi.

Figure 14.70 Pressure applied through the plantar fascia will penetrate to the flexor digitorum brevis and (deep to that) quadratus plantae.

Figure 14.71 The beveled pressure bar can be used to penetrate to the interossei as long as the overlying muscles are not too tender.

Goodheart’s positional release protocols

While PRT can be effectively utilized in treatment of pain and dysfunction of any part of the body (Chaitow 2007, D’Ambrogio & Roth 1997, Deig 2001), because of the complexity and size of the foot, with its multiple articulations and structures, the usefulness of PRT is particularly evident. The insightful observations of Goodheart, as described in Box 14.12, help to make PRT an invaluable clinical management tool for the foot.

Mulligan’s MWM and compression methods for the foot

The usefulness of simple translation/glide movements as the patient introduces active movement has been described elsewhere in this text (see Chapter 9 in this text and Volume 1, Chapter 10). Mulligan (1999) has created a model that is particularly helpful in dealing with small joints (although, as noted in Chapters 10 – 13, there are excellent MWM methods for larger joints as well). In addition, he has developed (based on earlier descriptions by Maitland 1981) what he terms compression protocols for some foot dysfunctions and these are described in Box 14.13.

In this chapter, we have explored the complexities of the foot – its anatomy, movements and responsibilities, and its interactions with the rest of the lower limb and upward through the body. Although it is easy to overlook the vast role that the foot plays in structural health, it becomes much more obvious when one considers locomotion without the foot, or with a foot whose function is seriously limited by injury or pathology.

Although it may take some effort to learn the anatomy and acquire the skills to address dysfunctions in foot mechanics and gait, the effort will undoubtedly reap benefits when regions far removed from the foot – in the knee, hip, and low back, or higher – are allowed to release compensation patterns that they have carried due to inadequate foot function. Likewise, addressing issues in other parts of the body will likely have an impact on the health and integrity of the feet.