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Frequently hip and sacroiliac joint pain can be the result of toes that don’t extend enough which causes a flat-footed walk, resulting in the pelvis tilting forward, and over-use of the hipflexors in walking, unlocking the SI joint.

I wrote a post a couple of years ago about how hip pain and SI joint pain can be the result of a pelvis that is tilted forward forcing a very effortful walk, and an unhappy wearing of the hip socket.

Through working with people in bare feet, I’ve recently noticed a common pattern in people with SI joint and hip pain – many have very poor flexibility and openness in the feet and toes, and I think it is at least possible if not quite likely that this lack of toe flexibility is forcing poor walking mechanics and a poor pelvic position, leading to SI joint and/or hip pain.

While kneeling on the floor, toe pads down, one should be able to easily put full weight through the toes by sitting on one’s heels. The toe fold should be about 90 degrees. One should be able to control the muscles of the toes, spreading them all apart.

Also the tops of our feet and ankles should be open enough to be able to tolerate kneeling and sitting back on one’s heels. Better yet, one should be able to grab the floor with the tops of the toes, pulling the toes forward until the ankles are flexed to about 90 degrees and then sit back on the heels with the toes turned under. Quite a painful experience for most of us!

In standing, when the feet are on the floor, all the pads of the toes should be in good contact with the floor. Because we tend to spend most of our life in shoes, many times shoes with very inflexible soles, it is not surprising that we lose foot and toe flexibility.

In walking, all the toes should be in contact with the ground at push-off, lightly pushing the body forward just before the swing phase of gait. This activates all the muscles in the back of the leg in sequence, starting with the toe flexors, then the calf muscles, followed by the hamstrings.

After the toe push, the leg swing should be quite passive with the leg feeling like it is hanging from the hip socket and swinging like a pendulum. If the toes are not in contact with the floor or there is a lack of flexibility in the toes making it impossible to use them to push, gait is changed completely.

With the toes are taken out of the equation, the walker is less able to push and is therefore more inclined to move the leg forward from the hip joint instead by using the hipflexors and the quads, making the swing phase of gait active and effortful.

Once this manner of walking becomes a habit, the hipflexors and quadriceps tighten and shorten which tilts the pelvis forward, changing the angle of force through the hip joint and making it impossible to dangle the leg from the socket during the swing phase.

So instead of a welcome period of decompression in the hip socket every time the foot is off the ground, the leg is compressed into the joint continually because the hipflexors are pulling the leg bone into the socket during the swing phase, and the leg bone is pushing up into the socket during the stance phase.

This constant pressure can cause the joint to wear, especially since the pelvis is tilted over the leg putting the force through a less ideal part of the joint.

Sacroiliac problems can also result from a lack of toe push because the when there is little to no activation of the hamstrings (back of the thigh), there is little to no tension put through the sacrotuberus ligament which is important to SI joint stability.

Combine this lack posterior stability with overly active hipflexors and quads from a pelvis that is overly tilted forward, and the SI joint is quite likely to unlock, causing pain and dysfunction.

Furthermore, an anteriorly rotated pelvis makes it nearly impossible to have a proper heel strike, causing the foot to land almost flat. One is supposed to hit the ground with the back of the heel, then roll over the foot and push off the toes keeping the back line engaged and the SI joint stable throughout the entire stance phase.

A flat-footed landing shortens the stride necessitating the hipflexors to move the leg creating a shuffling look to gait, and makes it harder to find the toes for push-off. The lack of toe off combined with the lack of heel strike both feed into each other and potentially making gait worse and worse over time as the pelvis is pulled further into anterior rotation (think of the pelvis as a bucket pouring water out the front).

In the past I’ve recommended hipflexor and quadricep stretches (and low back stretches for those stuck in lumbar extension) which is definitely very important, but if the toes and ankles are inflexible I’m not convinced the correct pelvis position can be maintained and proper gait restored.

So I would add calf stretches (particularly the straight-leg calf stretch or gastrocnemius) and the toe stretches described above. Toe spreaders are a great idea – the kind used to put toe polish on are perfect to start. Once they are no longer painful to wear and walk with, one can graduate to "intermediate" toe spreaders, and then finally to “advanced” toe spreaders, which will really help open the feet.

Also rolling the bottom of the foot on a tennis ball or racquet ball can stretch and loosen the plantar fascia. Strengthening glute medius posterior so the opposite hip joint can be held high enough to allow the leg to passively swing is very important as well.

Once the appropriate muscles are loose enough to make it possible to hold the pelvis in the correct position the hard work begins, as one must teach the brain a different way of walking.

Regularly concentrating on the landing on the back of the heel, then rolling over the foot and pushing off the toes, along with feeling the swing leg hang from the hip socket is what will do it.

When getting up from the floor from a kneeling position, one has two choices. One can do a “split squat” where the weight stays evenly split between the two feet. In this case, the back toes, both ankles, both knees and the forward hip should form a 90 degree angle, with the trunk being vertical. One pushes down evenly through the front foot and the back toes to move to a standing position. Flexible toes are needed to tolerate the weight going through them.

The usual method of getting up from the floor from a kneeling position is to transfer the weight to the forward foot, and step forward. The knee needs to come in front of the toe, and the ankle must be passive for this to happen. When there is not enough calf flexibility, the heel will have to come up a bit. This is fine as long as the ankle is soft, the muscles at the front of the lower leg are not activated, and the foot is puddled on the floor.

Frequently people bend at the hip to try to get the weight over the forward foot, rather than staying tall at the hip and bringing the knee and pelvis forward. Keeping the back knee and the front foot quite close together can allow the transition to weight bearing through the front foot to happen more easily. The back toes, as long as they are flexible enough, can help by pushing the body forward.

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