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Working with Hammertoes: the Lower Leg
By Til Luchau
Small things can have very big effects. Toes are an excellent case in point: when they are painful or don’t bend properly, as in a hammertoe condition (Image 1), they make standing unbearable, throw off your stride, affect your balance, and cause other troublesome compensations throughout your body.
In our last article (May/June 2012, “Working with Hammer Toes: the Foot,” page 112), I described the mechanisms of hammertoe contracture, specifically the tendency for both the extensors and flexors of the toes to be simultaneously contracted (Image 2). I also talked about ways to work with the short toe flexors and extensors, as well as with the ligaments and tissues of the toes themselves. When shortened, these are the main structures within the foot itself that contribute to hammertoe conditions; however, the foot structures are just part of the picture.

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Hammertoes involve simultaneous shortening of the toe flexors and extensors (Images 1 and 2). The extensor (red) and flexor (green) digitorum longus (red, in anterior tibia) originate in the lower leg (Image 3). Also pictured are the flexor digitorum brevis and minimus (red, in foot), discussed in the previous article. Image 1 courtesy Healthwise; Image 2 courtesy Advanced-Trainings. com; Image 3 courtesy Primal Pictures. All used by permission.

FLEXOR DIGITORUM LONGUS TECHNIQUE While working with the shorter structures within the foot is an essential part of addressing hammertoe patterns, the long toe flexors and extensors (Image 3) exert even more contractile force than their shorter brevis cousins. Originating in the lower leg, the long flexors and extensors cross the ankle and attach to the most distal bones of the toes, powerfully assisting in balance, jumping, stride push-off, toe pointing, etc. As with their shorter brevis cousins within the foot, when both the long flexors and extensors are shortened, they buckle the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints (the joints of the toe itself), as well as the metatarsal phalangeal (MTP) joint at the base of the toe. Even though they affect the toe joints, the main part of the long toe flexors and extensors are in the lower leg. We’ll release them there by utilizing the Golgi tendon organ reflex. When stimulated with a combination of pressure and active movement, the Golgi tendon organs (which are often concentrated near a muscle’s attachments to the periosteum) signal the motor units’ alpha motor neurons (via synapses in the spinal cord) to lower that muscle’s firing rate. With a minimum of effort on the part of the practitioner, working a muscle’s attachments and stimulating this Golgi response results in a reduction in local tone, and finer global movement coordination.1

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The proximal attachments of the flexor digitorum longus can be accessed on the medial side of the lower leg, midway between ankle and knee, on the posterior aspect of the tibia (Images 4, 5, and 6). To stimulate a Golgi response here, wrap your hands around the shin and feel into the structures just behind the tibia with your fingers. This is a sensitive area, so proceed slowly. By asking your client to flex (curl) the toes, you’ll be able to locate the precise attachments of the flexor digitorum longus on the posterior side of the tibia. Rather than sliding or scrubbing, use firm but gentle static pressure here, as your client continues to actively curl and uncurl the toes. Asking your client to “gather up the sheet with your toes” is an effective cue. Feel for a release and softening of the tissues under your touch, as well as a shift in the initiation of your client’s movement. Once the Golgi response has engaged, movements will initiate more gradually and smoothly, and with finer control; in other words, with less of an initial jerk or all-or-nothing contraction. Repeat this slow, steady release in several places along the mid-section of the tibia where the flexor attaches, right up next to the bone, wherever you feel muscle contraction with toe flexion. Then, finish your work here with longer or gliding strokes to ease out of this sensitive area. Working the long flexors in this way will address toe curling (flexion); we’ll complement this with work on the long extensor to address the upward bending (extension) of the MTP joints.

EXTENSOR DIGITORUM LONGUS TECHNIQUE The extensor digitorum longus attaches to the medial surface of the fibula, all along the proximal threefourths of that bone’s length. It also attaches to the intermuscular septa and the interosseous membrane of the leg, which span the fibula and the tibia. To work the long toe extensor attachments, use the same aroundthe-shin grip that you used for the flexor digitorum longus techniques, but this time, your thumbs will do the work (Images 7, 8, and 9 page 116). Find the front of the fibula by sinking just anterior to the long, ropy peroneals on the lateral side of the leg. Care for your thumbs by avoiding hyperextension—maintain a slight flexion in each of your thumbs’ joints. The extensor attachments can be tricky to find—the tissue here is dense, compact, and undifferentiated on many people. Sometimes, using a broader, more superficial technique to prepare the front of the leg first can help make the extensor attachments more accessible. One possibility is the Tibialis Anterior Technique, described in “Working With Ankle Mobility, Part 2,” (May/June 2011, page 113).

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Flexor Digitorum Longus Technique (Images 4, 5, and 6). The long toe flexors lie on the posterior side of the tibia. This is a sensitive area and easily bruised, so use gentle pressure and active toe flexion (curling), rather than sliding or moving your fingers. Images 4 and 5 courtesy Advanced-Trainings.com. Image 6 courtesy Primal Pictures. All used by permission.

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Once you’re in contact with the muscle attachments on the bone itself, focus on the fibula’s anteromedial aspect. As with the previous technique, use static pressure together with active toe movements to help locate and release the attachments. This time, use toe extension (lifting the toes). For the release phase, a cue could be “push the sheet out from under your foot by uncurling your toes,” in other words, the reverse of the movements used for the long flexors. As with the previous technique, feel for tissue release, together with a shift toward slower, smoother initiation of movement, as indicators of a Golgi response. Once you feel these things, move to different areas of the fibula, as well as into the space between the tibia and fibula to work the attachments on the interosseous membrane. The Tibialis Anterior Technique mentioned above, or similar broad technique, can also serve as a finishing move to smooth out the areas worked, especially if your focused pressure left edematous depressions in the front of the leg (not uncommon, but typically not cause for concern).

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Extensor Digitorum Longus Technique (Images 7, 8, and 9). The long toe extensors attach to the fibula and to the interosseous membrane of the leg in the space between the tibia and fibula. Use active toe extension in combination with static pressure on these structures’ distal attachments. Images 7 and 8 courtesy Advanced-Trainings.com. Image 9 courtesy Primal Pictures. Used by permission.

WHAT ABOUT BUNIONS? Hallux valgus (i.e., a bunion, Image 10) can often accompany hammertoes. Bunions are thought to sometimes cause hammertoes through the lateral crowding that the great toe exerts on the smaller toes. However, it also seems plausible that the same soft-tissue imbalances that contribute to hammertoe contracture could cause hallux valgus. While the smaller toes are stabilized by their neighbors and buckle easiest in the sagittal plane (flexion/extension), the great toe buckles easiest in the transverse plane (abduction/ adduction). Said another way, when their flexors and extensors are both short, the smaller toes buckle into a hammertoe position, and the big toe buckles into a bunion. Hallux valgus can also be related to factors such as external femur rotation, tight-fitting shoes, genetic contributors, and other influences. Whatever their cause, I’ve observed that working the flexor and extensor hallucis in ways similar to what I’ve described here can help relieve the soft-tissue contributions to bunion discomfort and rigidity. Hammertoes and bunions do not exist in isolation—their fixity and tissue shortness reflect patterns occurring elsewhere in the body. For instance, hammertoes are often present when the foot shows a high degree of overall connective tissue contracture, such as high fixed arches, or in extreme examples, talipes or pes cavus (Image 11). Hammertoe contraction is not limited to toe muscles—in my experience, hammertoes can be accompanied by tighter hamstrings, spinal erectors, and cervical muscles; exaggerated spinal curves; and other patterns of connective tissue shortness throughout the body. Similarly, restricted toe motion will have whole-body effects—changing

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knee and hip dynamics, impairing balance, increasing leg rotation and head-bob, shortening the stride, etc.

CAN JOINTS CHANGE? The curl of hammertoes can be more or less mobile, ranging from fairly flexible and springy, to quite fixed and rigid. Although hammertoes usually start as soft-tissue contractures, over time the stress of the bent position, lack of movement, and pressure from shoe contact can degrade the articular surfaces of the toe joints, causing articular rigidity and additional pain. The more rigid the toe joints are, the more likely it is that there are boney or articular changes. This isn’t reason to give up on working with them. In the previous article, I mentioned working with my granddad. By his 90s, when I started working with his hammertoes, his elderly joints were quite rigid and probably had a high degree of joint degeneration, but our work yielded very worthwhile results nonetheless. Bones and joints can change for the better; when normal tissue tone and movement is restored, joints can and do heal. Because hammertoes are sometimes the result of disease, neuropathology, and/or other issues, we obviously won’t be able to reverse every case of hammertoes; and there are clearly times when surgical interventions are probably the best remedy. But even in these cases, your skillful and thorough soft-tissue work will relieve pain, and help prevent further loss of movement and the resulting degeneration. Whatever the cause, if there are articular rigidities, it simply means you and your client need to be more modest in your expectations for a quick fix. Be patient and persistent, use your client’s active movements, and be sure to notice the small, incremental improvements as they occur. Note
1. Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation, Part I,” Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 14.

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Hallux valgus (i.e., a bunion) can accompany hammertoes. Ease bunion rigidity by working the flexor and extensor hallucis, both longus and brevis, in ways similar to those described for the toe flexors and extensors. Image courtesy Michael Nebel, used under CC BY-SA license.

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Hammertoes or bunions often accompany other conditions involving connective tissue contracture, such as talipes (also known as pes cavus or clubfoot), pictured here. Image courtesy Primal Pictures. Used by permission.

Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is also a Certified Advanced Rolfer and has taught for the Rolf Institute of Structural Integration for 22 years. Contact him via info@advanced-trainings. com and Advanced-Trainings.com’s Facebook page.

Watch Til Luchau’s technique videos and read his past Myofascial Techniques articles in Massage & Bodywork’s digital edition. The link is available at Massageandbodywork.com, at ABMP.com, and on Advanced-Trainings.com’s Facebook page.
ABMPtv.com “Extensor & Flexor Digitorum Brevis Technique”

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