Massage & Bodywork

May/June 2012

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6 to wear tighter shoes than men— studies claim that nine out of 10 women wear shoes that are too small).1 There are racial differences too, with hammertoes about three times more frequent in African-Americans under the age of 60 than in whites of the same age (though there is much less racial difference in people over 60).2 Nonsurgical care of hammertoes involves using more spacious shoes; padding points of contact; using special braces, spacers, or splints (Images 3 and 4); physical therapy; and exercises such as using just the toes to gather and ungather a towel on a hard floor. Whatever the root cause or factors involved in hammertoes, the result is that the soft tissues are too short to allow natural alignment of the toe bones. Surgeons address this by one or more of these methods (Image 5): 1. Lengthening the contracted connective tissue by cutting toe tendons, capsules, or ligaments. 2. Shortening bones to fit the contracted tissues by removing articular heads or other parts. 3. In advanced cases, performing arthrodesis (fusion) of the bent joints via wires or other means in combination with the two methods above. Although some consider hammertoe surgery easy to perform (it is often the first surgery new surgeons are allowed to do),3 complications do occur, most commonly pain and discomfort related to the loss of movement in the toe, especially when joints have been excised or fused. As manual therapists, there are many ways we can effectively release the shortened soft tissues involved in hammertoe and related conditions. Sometimes this is corrective, reversing the curling of the toes, and other times it is palliative, meaning that it helps relieve pain and other symptoms. It also is reasonable to imagine that soft-tissue lengthening could, at least in some cases, delay or prevent hammertoe surgery, and so avert the resulting loss of mobility that patients often experience after corrective surgery. Ida Rolf, the originator of Rolfing Extensors Flexors 7 structural integration, said, "In a balanced body, when flexors flex, extensors extend" (Image 6). Nowhere is this more obvious than in the toes. When toe flexors contract without reciprocal lengthening of the extensors, the toes are pulled short from both above and below. The toes can't collapse like a telescope, nor is it easy for them to bend sideways, as the great toe does in hallux valgus, or bunions; therefore, the middle toes shorten by buckling into a hammer, mallet, or claw shape (Image 7), depending on the shape of the joint involved, and on the structures that are responsible for the pulling. In normal movement, toe flexors and extensors take turns contracting and lengthening (Image 6). In hammertoes (Image 7), both flexors and extensors remain contracted simultaneously, buckling the toe. Over time, the ligaments and joint capsules shorten, further fixing the joint. Image 6 courtesy Primal Pictures; used by permission. Image 7 courtesy Advanced-Trainings.com. 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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