Foot pain is one of the more common lower extremity complaints seen in a chiropractic office. Since foot problems often have widespread lower extremity compensations; there is no profession better suited to address these issues.
To achieve excellent clinical outcomes, evidence-based chiropractors must understand of one of the most critical indicators of healthy foot function—the Windlass Mechanism.
Check out this 15-second video review of the WINDLASS TEST for plantar fasciitis. Then scroll down to watch Dr. Steele demonstrate how to apply this to your patient care.
The Windlass Mechanism
What is it?
During gait, the foot is required to transition from a flexible shock-absorber into a rigid propulsive lever. The windlass mechanism is central to the stabilization process. At heel strike, the plantar fascia is slack to allow the foot to accommodate uneven surfaces. As the heel lifts, the forefoot and big toe dorsiflex. This motion pulls the distal plantar fascia around the first MTP joint tightening the plantar fascia. The resultant shortening of the distance between the heel and forefoot raises the arch– creating a stiffer lever for propulsion.
Why does the Windlass Mechanism stop working?
One of the most common conditions affecting the Windlass mechanism is Hallux limitus (HL). HL is a painful, degenerative condition of the first metatarsophalangeal joint characterized by restricted range of motion at the great toe and progressive osteophyte formation. The restriction in ROM secondary to trauma, repetitive micro-trauma, or poor biomechanics threatens the articular cartilage and restricts the windlass mechanism from functioning smoothly (1).
Laird defined HL as dorsiflexion of greater than 50° when non-weightbearing, with less than 14° of dorsiflexion at weightbearing terminal stance (2) This loss of ROM has widespread implications for muscle activation, joint motion, and obvious gait alterations.
What happens when Windlass Mechanism doesn’t work?
Failure to approximate the heel and forefoot will diminish the ability to propel the body forward. Abnormal hallux dorsiflexion will impinge the first metatarsal and the proximal phalanx causing pain and inflammation (3,4). Alteration to foot and ankle kinematics may lead to OA changes in the first MTP joint, Achilles tendinitis, and plantar fasciitis (5,6) Hallux limitus can result from lack of use of the joint as well since patients adopt avoidance strategies to compensate for pain (7). Commonly, patients begin rolling the foot laterally since it hurts to push off. That repetitive stress mechanism can irritate the peroneal longus tendon, which is a plantar flexor of the first ray.
“What starts as a functional restriction of range of motion with no arthritis in the big toe joint progresses to the beginning of early arthritis with bone spurs limiting motion but the toe still able to function. Then progressive arthritis occurs with more and more limitation as the windlass mechanism fails to work and the great toe is completely locked up in hallux rigidus,”
–James G. Clough, DPM
How can we restore function?
Hallux limitus constitutes a sagittal plane blockade during gait. As a result, the body employs various compensation mechanisms that include walking on the lateral foot, increased pronation at the midtarsal and subtalar joints, abductory twist, early heel-off, and a lack of full hip and knee extension. These compensations do not come without a cost.
Foot symptoms related to functional hallux limitus include first MPJ dorsal exostosis, lesser metatarsal overload, neuroma exacerbation, pinch callus (aka tyloma) and hallux nail changes (8). HL related-symptoms can often migrate to the knee, hip, and back.
The following video provides an overview of assessing functional hallux limitus as well as how to treat the condition utilizing a simple reverse Morton’s extension.
Clinicians can use the reverse Morton’s extension alone or in combination with custom functional orthoses. Reverse Morton’s Extension orthotics, sometimes referred to as cut-out orthosis, significantly increase pronation of the 1st metatarsal head. The cut-out also reduces adduction movement of first metatarsal bone in the transverse plane. Use of this simple cutout method can improve your patient’s biomechanics and mitigate widespread compensation from a faulty Windlass mechanism.
Understanding the degenerative cascade of each joint will transform your evaluations, treatments, and patient education. In case you missed last weeks’ blog, click here to watch a 3-minute illustrated review of the degenerative cascade of a lumbar spine.
A thorough understanding of progressive mechanical dysfunction is the foundation for management and patient education regardless if you’re treating a foot, lumbar spine, or any other joint. ChiroUp subscribers employ an incredible tool that automates learning and patient education, but more importantly, allows them to work with like-minded, evidence-based peers to redefine our role in healthcare. Together we can become the undeniable best choice for patients and payors alike. Click here to try ChiroUp today.
- Lucas DE, Hunt KJ. Hallux rigidus: relevant anatomy and pathophysiology. Foot Ankle Clin 2015;20(3):381-389.
- Laird PO. Functional hallux limitus. Illinois Podiatrists 1972;9(4).
- Lichniak Hallux limitus in the athlete. Clin Podiatr Med Surg 1997;14(3):407-426.
- Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am 1998;80(6):898-908.
- Drago JJ, Oloff L, Jacobs AM. A comprehensive review of hallux limitus. J Foot Surg 1984;23(3):213-220.
- Piscoya JL, Fermor B, Kraus VB, et al. The influence of mechanical compression on the induction of osteoarthritis-related biomarkers in articular cartilage explants. Osteoarthr Cartilage 2005;13(12):1092-1099.
- Botek G, Anderson MA. Etiology, pathology, and staging of hallux rigidus. Clin Podiatr Med Surg 2011;28(2):229-243.
- Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc.1986; 76(11):648-52.
About the Author
Dr. Brandon Steele
Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.