In my hands peroneal tendinopathy or tendonitis used to be a challenge. In the past I reckon I was close to a 100% failure rate in managing it. In the last 10 or so years I think I am now close to a 100% success in managing it. What changed? It was based on our research evidence. I talked about that in this blog post: Peroneal Tendonitis in Runners on my running research blog. It was pretty clear that almost everyone with peroneal tendinopathy had a lower than average supination resistance. That means the force needed to supinate the foot was low and as a consequence the peroneal tendons have to work harder, increasing the risk for tendinopathy. This also means that those with it need lateral wedging under the heel to decrease the loads in the tendon. That wedging actually leads to a substantial reduction in the forces that the tendon is subjected to, so hence the lateral wedging is a very and often is dramatically effective to manage peroneal tendonitis.

Yes, lateral wedges do try to pronate the foot more, but never had a problem with doing that. It did take a mindset change to get confident to start doing this 10 or more years ago, but I have not looked back. This is a perfect example of research informing and changing clinical practice.

This also means that a typically arch supporting medially wedged foot orthotic is going to increase the load on the peroneal tendon and is not going to be indicated. This also explains why I had almost a 100% failure on managing this in the past.

Also, of course, we do the usual load management approaches to this tendon once that reduction in load on the tendon with the wedge is done.

I am a big fan of teaching people how to measure the navicular drift and drop. However, the evidence is that for clinical use they are not that reliable, so that does limit the usefulness of these clinical tests in clinical practice.

Having said that, I still think we should be teaching how to do it, but in the context of the unreliability of them. The reason for this is that the concept behind navicular drift and drop does have implications for foot orthotic prescribing. What learning how to do the tests gives clinicians is an appreciation of the relative movements of the midfoot in the sagittal and transverse planes. Navicular drop measures the sagittal plane motion of the midfoot and navicular drift measures the transverse plane motion of the midfoot. Learning how to do the measurement of these two gives an appreciation of the relative motion of that midfoot in the sagittal and transverse plane. Once that appreciation and understanding is grasped, then there is probably no need to do the measurements on a routine basis in clinical practice. You can just observe it and note how much drop there is compared to how much drift there is. Are the about the same or is there more of one compared to the other?

My impression is that the amount of navicular drift should be about the same as navicular drop. If drop is greater, then that means that there is more movement in the sagittal place compared to the transverse plane. This means there is more arch collapse, when means that the foot orthotics need to have more support in the midfoot. If the drift is greater, then that means there is more movement in the transverse plane compared to the sagittal plane. This means that there is more movement of the midfoot medially rather than arch collapse. This means that foot orthotics need more medial and lateral support to control that midfoot transverse plane motion.

Functional hallux limitus is a theoretical construct. There is no doubt that the phenomenon that is functional hallux limitus exists, but that can often be as far any any agreement or consensus gets with this. There is no doubt that there are some feet when the foot is up in the air that there is a full range of motion available at the the first metatarsophalangeal joint yet when that foot is weightbearing during gait, that joint just does not want to move. That is the definition of what functional hallux limitus is.

I have written about this a lot, speculating that functional hallux limitus has many possible causes and that it may be better to conceptualize it as a nothing more that each person having a variable stiffness range of motion at the first metatarsophalangeal joint and that this may be related to the windlass mechanism. If this is the case then what we typically considered to be a functional hallux limitus is really the extreme of this variable stiffness and that functional hallux limitus probably exists as a continuum and not as an either/or entity.