Rocker Soles - The Right Way, and the Wrong Way - Part One

Part One - Background

The term "rocker soles" is often misused, in my view. There are many shoes on the market that call their sole design a rocker sole, that are both misleading, and potentially harmful to most people who either do not need a rocker sole, or who use a design that will actually cause them severe problems down the line. Remember Earth shoes and Root shoes? These two brands used what they termed a "negative heel" design, where the heel of the shoe was in fact lower than the ball of the shoe, or the forefoot. This actually made the wearer's knees hyper-extend. The companies used the spurious marketing claim that since this was the way we walk on the sand, it was somehow the "natural" and the "healthy" way to walk. Of course, they failed to mention two critical issues related to walking on the sand - one - after a while walking on sand would actually make your knees and back hurt, and two - how many hours of the day do we actually walk on a forgiving surface like sand? The results were numerous lawsuits, and the eventual demise of the negative heel concept. But don't just forget about this - we'll be coming back to it later.

A properly designed rocker sole, when applied correctly, that is, to the specific sort of problems that call for a rocker sole in the first place, is designed to do three things simultaneously. First, they prevent motion that is actually harmful to certain foot issues. Secondly, they provide the necessary motion for a more "normal" gait. And third, they protect certain foot issues from repetitive trauma, especially in patients with diabetic neuropathy. I will deal with each of these issues in depth over the next few posts.

For now, lets start with what a rocker sole design should be, and what it should NOT be.

If one Googles the term "rocker sole," they will find many medical articles either damning or praising them. Part of the problem is that, as with all forms of research, you can get what you want to find merely by how you design a study, and by how you ask the question itself. Rocker soles are no different in this regard. If the design used for the study is based on a specific patient population, but the rocker design used for the study is not a) consistently applied to all study participants, and b) not the appropriate design to address the actual pathomechanical issue at hand, then the results will have little value. Because few people have spent much time actually applying rocker soles to a wide array of pathomechanical issues and an equally broad array of foot types, not to mention using many different shoe styles to apply the rocker soles on in the first place, it comes as little surprise that the results are all over the map. But I am one of those few people who has actually done this kind of work with real patients who present with many different types of pathology. So what follows is based mostly on that experience, but with reference to the work others have done in the area of applied rocker sole therapy.

A rocker sole needs to do several things: they must permit the foot to proceed through the various phases of the gait cycle while simultaneously preventing painful or mechanically unsound motions; they must dramatically reduce the need for all joints above the foot to take on motion that is not in keeping with the healthy and natural motions commensurate with each of those joints; they must allow for a stable stance when the body is not in forward motion; and they must aid in promoting as smooth as possible over-all gait. This sometimes means the rocker sole must be rigid, and sometimes flexible, as far as the over-all impact on the foot is concerned. I will address each of these issues as we go forward here. (A little gait joke - sorry:-)

Some of the earliest work on the idea of rocker soles was done at the Carville, Louisiana site of the National Hansen's Disease Program. Hansen's disease is the official name for leprosy. One of the hallmarks of Hansen's disease is severe peripheral neuropathy,  as is also found in some diabetic patients. Peripheral neuropathy means the complete, or near-complete, loss of sensory nerves. Without sensory neural feedback, the body's tissues can break down very rapidly, and become ulcerated. In extreme cases, those ulcers can become gangrenous, and the result is, too often, amputation. It is the mechanical pressures and motions that in a "normal" foot would be accounted for cause this tissue breakdown. So the need in such patients is to significantly reduce both vertical pressure and horizontal "shear" in order to slow or completely stop the onset of ulcers that might lead to amputation. It was this need that led to the development of the rocker sole.

The need was to allow reasonably normal ambulation while severely reducing the vertical and horizontal forces that occurred during weight-bearing gait. No mean trick, it turns out. To stop motion, you have to stop the flexion and extension motions - that is - plantar (bottom of the foot) flexion, dorsi (top of the foot) flexion, but also, in- and eversion, ad-and abduction, and thus, lose supination and pronation, the motions provided to a significant degree by the actions of the subtalar joint. Now, all of these motions can be stopped simply through the use of a rigid sole - think steel plate, or plywood. Yes, that rigid. But what do you do, then, to permit somewhat normal ambulation? This can only be provided by applying those ancient principals passed down to us by the great Archimedes himself. You must provide a lever. Actually, you must provide several levers.

If you break down the human weight-bearing portion of the gait cycle, you see there are three primary moments required - heel strike (when the heel hits the ground,) full foot loading (when all of the foot is on the ground, and toe-off, or the propulsive phase of gait. But it makes better sense to break each of those three moments down a little further. There is heel strike, followed by an adduction moment, when the subtalar joint is working to internally rotate the leg on the ground. This is followed by full foot loading, and then by the subtalar joint reversing direction to allow the leg to externally rotate through a supination moment. This sets up the foot to enter the propulsive phase of gate. This is then followed by heel-off, when the knee above begins to flex in preparation for the limb to leave the ground and enter the swing phase while the opposite limb begins its weight-bearing phase of gait. There is then a momentary portion of the gait cycle where a part of both feet are on the ground - the toes of the limb now entering the propulsive phase, and the heel of the opposite limb as it begins it's weight-bearing portion of the gait cycle. There - you just got your first class in biomechanics!

And this is why its helpful to understand this with respect to rocker soles. The design of the rocker sole must permit heel strike, full foot loading, and toe-off in a smooth and efficient manner. The pronational and supinational moments are provided by a specific element in the proper design of the rocker sole that we will get to later. For now, let's stay on the first three elements. If you look at a typical shoe, the posterior edge of the heel represents a right angle to the ground. That is, from where the back edge of the heel strikes the ground to when the heel is fully on the ground is the result of a single point of contact. This causes the foot to have a very abrupt heel strike and what can be described as a "slap" into full foot loading. This is where the greatest vertical force occurs for the foot with the use of a traditional heel design. So, we need to rethink that part of the design first. We need to both soften the heel strike, and slow the foots advance into full foot loading. And here comes good old Archimedes, right on time. We want a ramp, essentially. Most athletic footwear today has figured this out, by "rolling up" the heel of the shoe at some varying angle to the rest of the sole of the shoe. And since the foot is at an angle to the ground as it descends in preparation for heel strike, the effect of this rear rocker angle is to allow heel strike to begin a slight amount before it normally would, and arrive at full foot loading slightly later than it usually would. This lowers the vertical shock at heel strike, and reduces the horizontal, or shear forces, that occur in the later portion of the heel strike phase of gait. Essentially, it reduces, and in some instances, eliminates "slap."

Now, there are many so-called rocker soles out there that have a very minor rear rocker angle, which do not act to reduce this "slap" into full foot loading. But there are also some that use such an extreme angle that it forces the mid-foot to "climb a hill" to arrive at full foot loading. Essentially, they represent a negative-heeled shoe by virtue of this design choice. Remember the knee? Remember hyper-extension? Of course you do! And these extreme rocker angles do in fact drive the knee to hyper extension, and in people who have tight ligaments, that hyper-extension can be very damaging. In people with more normal or loose ligament tone, there is still potential for damage, but it might take a longer period to manifest. And some of these extreme rear rocker angle designs seem as though they are competing with each other for being the most extreme. As I said before, just because the marketing folks can spin a good rationale for any type of design does not mean it works, or is right for any particular person. There must be logical biomechanical reasoning behind the design.


OK, that's all for Part One. Next, I will go further into the design issues, and provide some diagrams to aid in understanding the rationale for these designs. Stay tuned! 

So, In Another Vein...

Well, the good news is, it's not venous insufficiency. The doppler is god on these things, I suppose. So while I now know I am not facing an imminent blood clot to the brain (well, as much as any of us knows these things, I suppose), the bad news is, I still ain't got a clue as to what is causing this pain. This, of course, means many more doctors, much more seepage from my meager bank account. Don't you love how the rich and the Repubs always scream about "socialist wealth transfer" when they engage in "capitalist wealth transfer" all the time, as though one is better than the other? They shouldn't have to "feel the pain" but the rest of us suckers should smile and bow and say, "thankya, Massa."

Wow, did I just get all political and sarcastic, or what? Sorry for the slip, its just every once in a while I can't help but connect the dots, ya dig?

So, in other news, anybody out there still reading this blog? Always helps to have some input, right? So, your turn. What do you want from this blog, are you already getting it, or at least some of it? Tired of my complaints? Hoping for nude pictures (of feet)? Let me know - I aims ta please!!

Claudication and More Than You Really Wanted to Know About Your Calf/s

So, new article for your edification:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686819/

This one is in:

J Child Orthop. 2009 June; 3(3): 171–178. Published online 2009 May 6. doi:  10.1007/s11832-009-0179-4

PMCID: PMC2686819

Copyright © EPOS 2009

Leg muscle atrophy in idiopathic congenital clubfoot: is it primitive or acquired?

Ernesto Ippolito, F. De Maio, F. Mancini, D. Bellini, and A. Orefice

Department of Orthopaedic Surgery, University of Rome “Tor Vergata”, Viale Oxford, 81, 00133 Rome, Italy

Ernesto Ippolito, Email: ippolito@med.uniroma2.it, Email: e.ippolito@mclink.it.

Corresponding author.

Received February 25, 2009; Accepted April 18, 2009.

In which:

Conclusions

Our study shows that leg muscular atrophy is a primitive pathological component of CCF which is already present in the early stages of fetal CCF development and in newborns before starting treatment. Muscular atrophy increases with the patient’s age, suggesting a mechanism of muscle growth impairment as a possible pathogenic factor of CCF.

Those skinny calves? They may pre-date the actual club foot/feet, and there is at least some speculation they may lead eventually to a clearer understanding of causation of talipes.

Now, the real question re: intermittant claudication is, is there a connection? To that end, I am runnning for this week's special a simple poll"

Do you ever experience the following symptoms:

"Intermittent claudication is the medical term for pain, numbness, achiness, burning, heaviness or cramping in the legs that occurs during activities such as walking or climbing stairs. You may feel these symptoms in any of your lower limb muscles, including those in the feet, calves, thighs, or buttocks. Intermittent claudication may be localized or diffuse, affecting one or both legs."

In my case, I have had these symptoms several times a year since childhood. As the classic cases do not usually manifest until age 50 or later, and usually in conjunction with other risk factors for peripheral artery disease, this at least suggests the symptoms in my case are a part of the lower-leg atrophy. My symptoms usually disappear within 24 hours, whereas classic symptoms can remain for weeks or months before other blood vessels "take up the slack" for the apparently narrowed artery causing the problem.

Now, I wish to be quite clear here. I cannot say with any certainty there is a direct correlation between the atrophy and the claudication. But. Given that I have had these symptoms since childhood, and that I have a substantial amount of atrophy, it seems unlikely there is not at least some correlation. As I am scheduled for an examination on this specific issue shortly, I will have something more to add in the next few weeks.

Stay tuned.

Claude's on Vacation

Well, as they say, if its not one thing.... Now, because I've been favoring the right foot due to the reaction to the prolo, my left leg, especially ankle and calf, have been visited by the poltergeist of intermittent claudication. Basically, narrowing of the peripheral blood vessels that intermittently cause blockages of the peripheral arteries. The effect is one where the affected limb feels heavy, and painful like an almost-cramp that does not subside. It can (and believe me, it does) cause difficulty walking, sitting, sleeping, dancing (ha!) and just about anything you want to do in life.

Now, I have actually had this condition since I was a little kid, and as the years have gone by, and I've learned more about this condition, it became clear to me that my particular form of this condition is not like the classic forms as described in the literature. The vast majority of intermittent claudication occurs in a) males over 50, and show the following symptoms:

• cyanosis
• atrophic changes like loss of hair, shiny skin
• decreased temperature
• decreased pulse
• redness when limb is returned to a "dependent" position

Now, I do get number 2, but none of the rest. I now believe (though, in keeping with the spirit of truth in advertising, etc., I cannot prove factually,) that my form, as it has been with me since quite young, is associated with my post-club feet. This makes sense, actually, when you consider the following:

1. I spent many years in casts, tight braces, and a lifetime in high-top, lace up shoes, for their additional support.
2. Like nearly every post-clubber I've met, spoken with, or encountered here, one of the accompanying symptoms is muscle atrophy, especially of the calf muscles. This may in fact provide the narrowing of the distal arterial supply that causes these symptoms without the presence of any acute blockages.

Of course, finding a clinician/specialist who is willing to entertain that notion for serious consideration may be harder than learning to skateboard on one's head. But now, the pain is the worst I've yet experienced with this condition, and not getting any good night's sleep is slowly wearing me down.

So, it's off to see the wizard time again. Yippee.


Stay tuned.

Slow But Steady Never Gets You Anywhere These Days

OK, some improvement. This recovery from a prolo session is taking a very long time, and I've begun to think there may be something else going on, possibly systemic, so I've scheduled a look-see with my GP. (Hey, that rhymes!!) I am quite guilty of denial sometimes, especially when I've been dealing with pain and it's associated fun times for an extended period. I just get tired of the whole mishegas. But eventually, I get down to business. It just seems the older I get (and believe me, I'm gettin' old,) I have less enthusiasm for chasing down yet another set of symptoms. Spirit is the journey, body is the bus is all well and good, but I gots myself one busted down bus, ya dig?

I recently had someone castigate me for daring to complain about my pains. They used that old tried-and-not-so-true insult of comparing my widdle-piddle owey with someone "much worse off." I really hate that crap, ya know? I live with my pain everyday, not with someone else's. And I have more compassion for other people's pain that this particular twit has (why is it always people who have no (obvious) physical pain that try to diminish or knock down people who do?) I can assure you of that. And this is something I have had many occasions to wonder about over the course of my life: why do people insult, bully, or dismiss people who have physical pain, whether resulting from congenital or accidental causes? I strongly suspect it is because they are afraid.

Yep, that's what I said. Bullies are actually afraid they might catch what the person with pain and handicap has, so by diminishing and bullying, they can ward off the evil spirits. I know this is a bit simplistic, but seriously - why else would any reasonable human being tell another that the pain they experience is not worth complaining about? Or have the audacity to try and compare one person's pain or handicap level with another's? It HURTS, you fool! That's why!!! Its really no wonder that palliative care for pain is centered on the dying, that people with chronic pain have to practically prove they are melting from radioactive death beams before a doctor will prescribe adequate meds, or get them into a pain management program, and even that insurance companies think that after a month of treatment, hey! Your pain is gone now! According to actuarial tables compiled by accountants who've never had anything worse than a paper cut, you know that's how that little number goes.

You know about that woman whose face and hands were torn off by a pet??? chimpanzee? It seems like unless you are that bad off, where people can look and say, "Oh, yeah, give her anything she wants," (not to diminish HER suffering, but to merely point out how bad off someone has to be before the bully's are silenced,) your pain is a nuisance to them, so shut the hell up, already!

But clubbies who (let me be clear here) are NOT among the lucky one's whose surgeries and treatment was actually successful (to preempt an objection I've had before,) have to deal with not merely the daily physical pain, but often the daily prospect that this is exactly what tomorrow, and tomorrow, and the next day, and the next day is going to look like. We deal with the realization that unless we do something drastic to end the pain, (amputation, anyone?) we get to live in various states of pain all of our lives.

So to that bully recently encountered, to all the bullies of the past, and to all the (inevitable) bully's of the future, let me say this: Live with it. Because we have to live with our pain. You, bozo, you go live with your fears. And shut the hell up!

This Is Not The Time To Quit

Yes, just keep telling myself that, I said to myself. What's a little pain? Look at what Thor had to endure. No----wait---- maybe I'm thinking about his silly voice. Hmm. Oh, well, I did once have a Thor some, but I digress (when don't I?) What? Who, me? Oh. OK, I've just been told to get this post back on track or go home for the day (which doesn't sound like such a bad choice, actually.) But, whatever.

The doggies are a bit better, improving veeeeerrrrryyyyyy sllllooooowwwwwwllllllyyyy. And I'm doing the whole nine yards - soaks, analgesics, creams, massage, Acme safes from a great height. I've even forced myself to watch golf on TV - not quite as numbing as watching paint dry, but close. Really close. And really trying to keep the pain meds at an extreme minimum - don't like they way they make me suddenly enjoy watching Oprah reruns (shudder).

On other fronts, I recently made the acquaintance of a new clubbie - three months old, now. Dos piedes clubbo (bilateral, if you must know!) Cute (redundant when speaking of babies, unless you are George Castanza, I suppose.) The Mommy was freaked when she first got the news (is it just me, or do sonograms make you long for the Dark Ages when you had to wait for the actual arrival? It is? Oh.) But I reassured her to not worry, her kid would grow up to be the president of something anyway, which given how badly we treat presidents these days may not be much reassurance. I also told her to buy shares in some guy named Maddoff way back when, but thankfully, she didn't listen.

I was glad to see she'd chosen a Ponsetti approach - I just love those things at Christmas time, don't you? And the kid really looks good in a pot, besides. Seriously, he's cute. Really! I did want to grab him and run for the border, but then I remembered that word that should strike terror in the hearts of all do-gooders - diapers. So, sorry to say, the kid will just have to make do with what he's got - loving parents, well-trained Doc Martins, and a martini when he turns twenty.

On me. Yep - I put it in writing.

What a Heel! Part Deaux

Well, in my efforts to get this heel spur issue resolved, I went in for another prolotherapy session. Painfuuuulllll! (say it in a very high, squeaky voice, then pass out, for full effect.) But the fun was just beginning. It turns out that inducing inflammation (which is part of the prolo process, by the way), can on occasion have a cascade effect - inflammation squared, you might say. So imagine my delight upon waking up Sunday (the session was Saturday morning) to discover my foot was swollen about like that really bad boil you had last spring. You know the one - you just knew if it didn't subside soon, it was going to go volcanic all on its ownsome, because the skin simply had no more room to stretch? Yeah - call it Pop-a-palooza. So there I was, completely unable to even flex my ankle without screeching pain, like a 16 penny nail being driven into my heel with a pile driver. Every motion. Every single bloody motion. Oh, joy.

So, crutches, cold packs, hot soaks (both of which produced their own special pains,) elevate, massage (oh, no you can't!!!) drugs (what kind of weak soup do they make these things from?) When I take a med for pain, by gummy, I want to feel NOTTHING!!!! What's a guy gotta do to get some relief around this dump???!!@!

So, the doctor, (nice guy, by the way, sends me jokes by email,) says, take aspirin, elevate that sucker, cold and hot soaks, and (you will just LOVE this one ) time. Time, he says!! That's easy for him to say! He doesn't have to try and walk on pitchforks, does he?

Two days off work. Back today, but with a rigid cast shoe (I'm telling everyone else it was a skiing accident, but for some reason, they just laugh at me - must know me too well. Note to self - Have to change that.) Crutches, too. Makin' my arm pits ache. Giving me a 10-scale back ache. Giving me grief. Yeah, I know, it will settle down, and be better in the long term. Well, I have my own term for that weak-assed explanation:

Phooey.

Limpy Gimp - At Least I'm Not a Governator

Let's face it - muscles will get you further than a limp in this world. They will make you more money, get you more attention, even (apparently) get you more sex. So, workout, Dude! But there is apparently a downside - these days, nearly everyone will think you cheated. Steroids, philandering, pay-for-play, whatever spin you want to give it, its still cheating. At least I came by my limp honestly (not like I had any choice, mind you.)

But, I hear you say, those of us who are not rich and famous cannot possibly know the troubles they've seen, oh, the hard-pressed rich folk! Yeeeaaah -no. I don't think so. There are many examples of wealthy and powerful people who don't resort to cheating, but the press finds no value in such boring fare. They only salivate to the freaks and crazies - makes better money for them, you see. But gimps? Sure, they gave Roosevelt a pass, maybe because of that cigar, who knows. And Stephen Hawking (my hero, I'll admit,) well, he only gets press because he's too freakin' smart, and that high, squeaky machine voice doesn't hurt his screen presence, either. (Besides, he may be our only hope against the black hole headed this way. Oh, sorry, you missed that story? Well, too late for that now. Have a nice day, won't you?)

Being a crip does have it's upsides: I ain't never getting drafted, not even for the NBA. And the only famous person I have to model my own desire for fame on is Dudley Moore, and honestly? I cannot drink that much. My bladder would probably fail before I got fully loaded, so what's the point? Then there are all those other examples of fame and fortune who simply by fate were "Born This Way." No, not her, though I tend to think she's still in the closet about her gimp-dom. No, I'm talking about what's his name, and who-she. Right there on the tip of my tongue. Oh, well, more part-timerz, I guess. It will come to me when neither of us expect it.

Anyway, the point is, I'd rather emulate my shoemaker, who has spent his entire life using his time and talent to help other people live a little better life. Much as I'd like the money, I'd much rather, at the end of my life, be able to say I did good. You can't take the money with you, but you can leave a better legacy through honest effort than by basing your life on getting yours, and screw everyone else.

Uncle Gimpy's Story Time

Limping, as I've touched on before, is nature's way of accounting for pain, pathomechanics, and trauma, affecting the body in an asymmetrical manner. Again, the body has two primary goals in the face of any of these causes: to maintain as level a visual horizon line as possible, and to keep the inner ear balanced. All else is secondary to these two central requirements. This is mainly because it is easier to limp than to alter one's inner equilibrium or the alignment of the eyes with the horizon. Thus, the body works to compensate by other mechanisms: bending the knee, abducting the foot, lifting the heel on one side early in the gait cycle, externally rotating the leg. Each of these actions in turn produce effects further up the body: hip raise on one side, shoulder drop on the other; slow changes to the sacral level toward imbalance, that eventually results in scoliotic and lordotic changes; even going as far in some individuals as causing a primary head tilt. I have even met individuals whose multi-level compensation has led to an observable change in the levels of the eye orbits, this last being found only, in my experience, in individuals with pronounced ligamentous laxity.

The most interesting aspect of limping is how it varies from person to person. Some of us manage to compensate without limping, especially if the compensation has occurred throughout one's life. But when the trauma is new, the body has not had time yet to compensate, so it is left only with the option of limping, unless a lift, or the appropriate orthotic device is introduced, reducing or eliminating the need to compensate, and thereby stopping a limp from developing. This series of observations, over many years, has led me to an understanding of compensatory function and the secondary purpose of limping.

The primary purpose, in my view, is to offset changes to one's biomechanics in gait, that result first in pain, and soon after by challenging the inner ear and the visual horizon. Limping is thus initially an accommodation to a rude new reality. But as time goes on without any intervention, either mechanically or surgically, limping begins a chain of actions referred to as compensatory. That is, they permit the body to rearrange itself to account for the pathomechanical changes not otherwise addressed. So, an early heel-off limp might slowly be absorbed by the development of a change in the sacral-pelvic angle, which in turn may eventually lead to a shoulder drop on the opposite side. And each type of limp, combined with the ligamentous tonality in that particular person, will eventually reshape and realign the biomechanics presented originally into a new format, so to speak. Thus, we can see limps where the leg externally rotates (usually an effort to "shorten" a long limb - effectively reducing the length of the "lever arm" of the forefoot during the propulsive phase of gait); limps where the knee bends (long side) or hyperextends (short side, and usually accompanied by other levels of compensation); limps where the pelvic girdle rotates more than normal (where there may be some muscular weakness, often to the short side.) And of course, limps caused by acute trauma that dramatically or subtly alter the nerve, muscle, and tendo-ligamentous structures and functions.

The downside of non-intervention is obvious - the longer the limping is allowed to continue, the deeper and more problematic the resultant compensatory changes become. And time, along with severity of the pathomechanics, are factors in how to (eventually) intervene, and at what speed such intervention might reduce or eliminate the compensations. Someone who is twelve years of age when their trauma initiates the compensatory chain of events will allow for rapid response once intervention is initiated, whereas someone in their fifty's whose trauma has been interfering with their bodies for years may well take several years of graduated intervention before real counter-compensation can take shape.

We are complex creatures, physically (I am unqualified to speak to our other complexities, except to admit to their existence.) And the fact our bodies are capable of changing structurally in response to trauma, whether abrupt, or of a congenital nature, is for me an amazing challenge, and will continue to be something I study, because there is nothing I like better than solving mysteries. And believe me, humans are nothing if not full of mysteries.

Home on the Range of Motion-Redux, or, Tilt-a-whirl is My Middle Name

I've spoken about the concept of range of motion before, mostly to highlight how us clubbies don't have much to play with. The thing about feet is, they are (usually) a rather remarkable adaptation by the organism known as Prince, er, humans. They are extraordinarily adaptive to changing conditions, both on the ground, and, like most amphibious critters, in the water, as well. But that adaptability is highly dependent on an adequate range of motion. When that range is restricted, well, lest just say it leads to a life of mischief. No?

OK, how's this? When you can't adjust to changes in ground contour sufficiently, your body has two choices - compensate, or fall down. Most of us, with the possible exception of skateboarders, would opt for number one - compensate. But compensation, while not that problematic in the short term, can be very problematic over time. For example, you walk down the same sidewalk every day, when going to work, with your right side pointing toward the street, and when returning in the evening, with your left facing the street. Now, nearly all sidewalks have some degree of "cant," that is, they tilt toward the street, for the obvious purpose - to shed water more effectively. But this means walking on that sidewalk off-centers your body, with one side acting longer than the other.

Now, a truly adaptive foot can accommodate this imbalance with little strain, but feet with poor, or limited range of motion are forced to use joints other than those of the feet to achieve any degree of compensatory function, meaning the ankle, knee, hip, back, and shoulder/cervical spine complexes. Depending on the duration of this forced compensation, meaning both number of such encounters, and the amount of time each such encounter takes, the compensation can create both acute (short term), and chronic (long-term) changes to the entire body. And this can be further complicated by the quality of the ligamentous tonality. That is, people with a loose ligament tonality will generally compensate to a higher degree than people with tighter tonality. But looser tonality usually permits more levels of compensation to occur at a quicker rate than will happen with tighter tonality, while having a lower likelihood of pathological impact, and tighter tonality's compensations have a higher likelihood of producing a greater pathological impact. Not the best tradeoff, but there it is.

In some respects, this may explain why some clubbies have fewer long-term issues, especially if they have a loose ligamentous tone. It might also explain why some clubbies get other gait and postural issues as they age - tight ligamentous tonality will more likely cause up-chain pathomechanics (above the feet.) If you are wondering about your own ligamentous tone, there is a simple test to at least ball-park it for you: Take your right (or left) thumb with the opposite hand, and bend the thumb down toward your forearm.  If you can get it close to, or even touch the thumb to the forearm, you have a loose tone, whereas if you can't get it much past 90 degrees, you run tight. (The phrase, "double-jointed" usually refers to someone with very loose tone.)

In my experience, I've found that people with tight tone need to be evaluated for any possible discrepancy in the functional and/or anatomical length of their legs relative to each other. Because they cannot usually compensate as readily, they will benefit the most from both orthotic and lift therapy, to help offset the trauma of poor compensation. And as for post-club feet specifically, even where there is loose tonality, there may be little benefit over tight tone. Especially where there have been many surgeries, as the more surgeries, the higher degree of scar tissue potential that further tightens the structures of the foot. This is usually a good candidate foot for rocker sole therapy.

Now, obviously, these are generalizations, but in my experience, they show themselves in these manners more often than not. I simply point out that, having a better understanding of your own ligamentous tone can help explain your won particular development over time. And while it wasn't me that originally said, "hey, its all downhill from here," it probably applies. Most clubbies I know find they have a harder time walking off paved surfaces, or on canted paved surfaces, and especially, on sand. Meaning Cabo is probably better appreciated from the cabana bar.