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SECTION 6: ALIGNMENT

LOWER BODY

FEET AND ANKLES

The “big toe to hip relationship” task above provides some insight here. The concept is balance as always. Too much rotation outwards and too much rotation inwards (such as “pigeon toed”) is bad, and rather the aim is to generally have straight feet day-to-day, thus big toe aligned with your inner ankle – no more, or less, and regarding day-to-day, this is could be running, walking and standing. Straight feet therefore offers functional balance between all 3 arches of the foot (see picture).

PRONATION VS SUPINATION

Regarding posture and biomechanics, the medial longitudinal arch can vary between people. In general, there are 3 postures this part of the body can take:

  • Supination (+2 to +1): can progress into fallen arches and influence knee valgus. Lack of support from big toe, causing gravity to increase pressure down the inner tibia causing increased pressure down into the arch. Using your big toe (function and alignment) and things like towel scrunches help.

  • Pronation (-2 to -1): can progress into bow-legs/knee varus. Lack of use of the big toe causing increased pressures down the outer aspect of the foot, causing tension into the instep due to increased pressure on the toe/foot flexors. Using your big toe more with alignment reduces pressure on the outside of the foot and thus knee and hip.

  • Normal (0): functional use of the big toe, with balanced pressure absorption between outside and inside arches, influencing improved balance up the leg. 

There are specific exercises for those with supination or pronation to help create a normal medial longitudinal arch, which can be found in the next section (Section 7).

If you have normal arches, then bonus! If you have supinated or pronated arches, it can be cause or a symptom of other issues, such as hallux bunion (see below), hammertoe/s (see below), knee valgus/varus (see knees), medial/lateral femur rotation, medial/lateral lower leg rotation, and simply, not using the big toe efficiently. The list is endless, but ultimately, the position of the arch and its ability to function is paramount for overall body stability and equilibrium, with pronation and supination being highly associated with ankle sprains or ankle/foot ligament tears for example.

BUNIONS AND HAMMERTOES

THERE ARE PRODUCTS WHICH CAN HELP WITH SUCH DEVIATIONS. TO AVOID GETTING A PRODUCT LESS SUITABLE TO YOU AND OF POOR QUALITY, PLEASE SEE A QUALIFIED THERAPIST* WHO CAN HELP. (FOR EXAMPLES, PLEASE SEE 'RECOMMENDED LIST OF PROFESSIONALS'.)

*Qualification must be accredited by the relevant professional governing body, and include foot biomechanic training. Prime examples are Podiatrists and Chiropodists whom specialize on the feet, and Physiotherapists, Advanced Soft Tissue Therapists and Sport Therapists may also have relevant training. 

BUNIONS

Also known as hallux valgus, is where the big toe points outwards towards the 2nd toe which increases friction and eventually soreness and potentially swelling on the 1st metatarsophalangeal joint (where the foot meets the big toe). You can also get bunions related to the little toe (5th toe), again at the metatarsophalangeal joint, and these are generally called bunionettes.

You can be born with a bunion albeit very rare, and this is called Congenital Hallux Valgus. If it is acquired, and thus you are not born with it, there can be a plethora of causes. Such causes include wearing tight and/or narrow and/or pointed shoes, foot shape which is inherited, and medical conditions such as arthritis.

HAMMERTOES

Where the bones of the toe bend so that they cannot lie flat to the floor, and it can occur on the 2nd to 5th toes, it generally starts off mild and progressively gets worse without treatment. Such dysfunction tends to place increased dysfunctional pressure through the foot, producing further issues.

Alike bunions, they are rarely congenital meaning people are rarely born with them, and rather they are caused by a traumatic toe injury, wearing unsupportive footwear, increased pronation which can be hereditary due to foot shape or acquired through poor posture/biomechanics or injury, or medical conditions such as injury. Furthermore, poor posture/biomechanics can influence hammertoe through tightened ligaments and shortened muscles of the foot and lower leg.

KNEES

The knee is a hinge joint that joins the Tibia and Fibula of the lower leg to the femur of the upper leg, and because it translates various forces depending on its requirements, it has extensive connective tissue to help ensure its stability.

INSIGHT: The knee joint contains the largest sesamoid bone in the body, this is called the Patella, aka kneecap, and is situated within the Patella Tendon. When born, the patella is cartilage, not bone, with the cartilage changing into bone at the age of around 3 years and continues this process until around 10 years. It is positioned between the outside and inside grooves of the femur, with Patella dislocation occurring when the patella bone moves beyond these grooves.

LIGAMENTS: There are 4 predominant ligaments of the knee, these being:

  • Anterior Cruciate Ligament (ACL)

  • Posterior Cruciate Ligament (PCL)

  • Medial Collateral Ligament (MCL)

  • Lateral Collateral Ligament (LCL)

The ACL and PCL work together to maintain balance between pressures on the front and back of the leg, whilst the MCL and LCL work together to maintain balance in sideways movements.

INSIGHT:

ACL: Starting from the inside centre of the back of the femur, it runs down and forward to attach to the outside centre of the front of the tibia.

  • Resists backwards translation of the femur when moving on top of the tibia.

PCL: Starting from the inside centre of the front of the tibia, it runs up and backward to attach to the outside centre of the back of the femur.

  • Resists forward translation of the femur when moving on top of the tibia.

Therefore, ACL works when going from deceleration to acceleration, and when injured, can cause instability and pain when moving downstairs, where as the PCL works when going from acceleration to deceleration, and when injured, can cause instability and pain when moving upstairs.

VALGUS vs VARUS vs NEUTRAL

The position of the knee can give great insight into how the leg functions, and thus, can therefore somewhat explain knee injuries, knee pain, and furthermore, how to improve knee function and thus stability. Such positioning can be influenced by genetics, injury/ies, and general biomechanics and posture.

VALGUS

Aka Genu Valgus, it also known as ‘knock knees’, and enables an individual to stand with knees touching due to a medial rotation of the femur/s. Due to a weakened big toe – hip relationship, the knee falls down and in due to weakened hips allowing some inward rotation of the femur. This can lead to further dysfunction such as supinated or collapsed arches of the feet, tense IT Bands, and at worst, ACL injury. It can also influence Osteoarthritis.

There are 6 medial rotators of the hip:

  1. Tensor Fasciae Latae (outside of the hip and upper leg)

  2. Part of gluteus medius (outer half of the pelvis to hip)

  3. Part of gluteus minimus (outer portion of the pelvis close to the hip)

  4. Adductor Longus (inner thigh)

  5. Adductor Brevis (inner thigh)

  6. Adductor Magnus (inner thigh)

  7. Pectineus (top of the inner leg)

These muscles lengthen in eccentric contraction when you laterally rotate the hip/femur and shorten in a concentric contraction when you medially rotate the hip/femur. However, if the hip is medially rotated due to that leg being shorter, it can be somewhat weak despite the rotation (this is covered in more depth later in Hips and Pelvis).

NOTE

Due to engineering and physics, as the hip medially rotates, the pressure on the inside of the knee increases through compression, as the outside of the knee becomes strained and vulnerable. The two bones of the lower leg, the tibia being the larger of the two, are then having to compensate and absorb some of the tension pulls as the femur medially rotates, and this can commonly cause supination which can influence more lateral rotated feet although this is not always the case.

TRICK

Practice laterally rotating the femur into a straight leg position, noting foot position is also paramount.

VARUS

 

Aka Genu Varum, it is also known as ‘bowlegs’, and is where an individual is unable to stand with knees touching due to a laterally rotated femur. Due to a weakened big toe – hip relationship, the knee faces outwards due to tight hips and external rotation of the femur. This can lead to further dysfunction such as pronated feet or supinated feet, tight IT Bands, Sciatica, PCL tears and can influence Osteoarthritis.

The lateral rotators of the hip, thus, the muscles which rotate the hip and femur outwards are in the pelvis area, attaching the sacrum/sacral spine and the pelvis to the hip/top of the femur. So when you point your toes outwards, and your knee/s point outwards too, these muscles in your bum are shortening in a concentric contraction. There are 6 lateral hip rotators which are the antagonists to the medial hip rotators:

  1. superior gemellus

  2. inferior gemellus

  3. obturator externus

  4. obturator internus

  5. quadratus femoris

  6. piriformis

Daily examples of this lateral rotation include sitting cross legged, driving and rotating one leg out to rest on the door panel/middle section such as in an automatic or on cruise control, standing at 10 and 2 as in the armed forces, and standing/walking with toes pointing out is more common than you would think. Want to know which way your feet naturally point? Lie down on a flat surface face up, relax your legs and see which way your feet point.

NOTE

Due to engineering and physics, as the hip laterally rotates, the pressure on the outside of the knee increases through compression, as the inside of the knee becomes strained and vulnerable. The two bones of the lower leg, the tibia being the larger of the two, are then having to compensate and absorb some of the tension pulls as the femur laterally rotates, and this can commonly cause pronation which can influence either laterally or medially rotated feet. There is more information on this, especially the Piriformis later in Hips and Pelvis.

TRICK

Practice medially rotating the femur into a straight leg position, noting foot position is also paramount.

NEUTRAL

There is neither internal or external rotation of the femur as the big toe – hip relationship is healthy and strong, meaning the knee faces forward/straight allowing the connective tissue to translate various forces with efficiency, reducing likelihood of injury or pain.

FUN FACT

As the Gluteus Minimus and Medius muscles connect the pelvis to the Greater Trochanter (head of the femur – the hip), as does the Piriformis, they can impact each other greatly. Therefore, they act directly on each other, as the Piriformis shortens for example, the Gluteus Medius and Minimus MUST lengthen, and vice versa. Find balance between these 2 groups and you will find better pelvic balance which influences better knee balance.

MEDIAL AND LATERAL MENISCI

  • Menisci for plural, Meniscus for singular.

  • There are two within each knee joint.

  • They are crescent shaped pads of fibrocartilage attached to the flat surface of the superior tibia (tibial plateau) which reduce friction between tibia and femur, help weight distribution and act as shock absorbers.

  • There is one on the inner knee, and the other on the outer knee, the inner meniscus being the larger of the two. You can tear a meniscus by overloading the joint, placing excessive pressure which the meniscus is unable to absorb, and usually occurs when rotational pressures are involved.

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