The Short Foot Exercise

Here it is, in all its glory...Our version of the short foot exercise. Love it or hate it, say it “doesn’t translate”, we find it a useful training tool for both the patient/client as well as the clinician. It awakens and creates awareness of the sometimes dormant muscles in the user and offers a window to monitor progression for them, as well as the observer.

Remember that the foot intrinsics are supposed to be active from midstance through terminal stance/pre swing. Having the person “walk with their toes up” to avoid overusing the long flexors is a cue that works well for us. This can be a useful adjunct to your other exercises on the road to better foot intrinsic function.


Dr Ivo Waerlop, one of The Gait Guys

Sulowska I, Mika A, Oleksy Ł, Stolarczyk A. The Influence of Plantar Short Foot Muscle Exercises on the Lower Extremity Muscle Strength and Power in Proximal Segments of the Kinematic Chain in Long-Distance Runners Biomed Res Int. 2019 Jan 2;2019:6947273. doi: 10.1155/2019/6947273. eCollection 2019

Okamura K, Kanai S, Hasegawa M, Otsuka A, Oki S. Effect of electromyographic biofeedback on learning the short foot exercise. J Back Musculoskelet Rehabil. 2019 Jan 4. doi: 10.3233/BMR-181155. [Epub ahead of print]

McKeon PO, Hertel J, Bramble D, et al. the foot core system: a new paradigm for understanding intrinsic foot muscle function Br J Sports Med March 2014 doi:10.1136/bjsports-2013- 092690

Dugan S, Bhat K: Biomechanics and Analysis of Running Gait Phys Med Rehabil Clin N Am 16 (2005) 603–621

Bahram J: Evaluation and Retraining of the Intrinsic Foot Muscles for Pain Syndromes Related to Abnormal Control of Pronation http://www.aptei.ca/wp-content/uploads/Intrinsic-Muscles-of-the-Foot-Retraining-Jan-29-05.pdf


#shortfootexercise #footexercises #footrehab #thegaitguys #gaitanalysis #gaitrehab #toesupwalking



https://vimeo.com/342800960

How is your foot is connected to your butt....?

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If you have been following us for any length of time, you have heard us talk about how the lower kinetic chain is connected, how ankle rocker effects hip extension and how important hallux (great toe) extension is. 

What can we conclude from this study?

toe spreading exercises are important for reducing navicular drop (and thus mid foot pronation, at least statically)
In addition to increased abductor hallucis recruitment in ascending and descending stairs, when hip external rotation exercises were added along with toe spreading exercises folks had more recruitment of the vastus medialis (a closed chain external rotator of the leg and thigh)
 
Keep in mind:

the exercises given were all non weight bearing and open chain for the external rotators. Imagine what might have happened if they were both closed chain AND weight bearing!
They concentrated on the effects of toe spreading (AKA  lift/spread/reach) on the abductor hallucis. It also has far reaching effects on the dorsal interossei, long and short extensors of the toes. 

Abstract: The purpose of the present study was to examine the effects of toe-spread (TS) exercises and hip external rotator strengthening exercises for pronated feet on lower extremity muscle activities during stair-walking. [Subjects and Methods] The participants were 20 healthy adults with no present or previous pain, no past history of surgery on the foot or the ankle, and no foot deformities. Ten subjects performed hip external rotator strengthening exercises and TS exercises and the remaining ten subjects performed only TS exercises five times per week for four weeks. [Results] Less change in navicular drop height occurred in the group that performed hip external rotator exercises than in the group that performed only TS exercises. The group that performed only TS exercises showed increased abductor hallucis muscle activity during both stair-climbing and -descending, and the group that performed hip external rotator exercises showed increased muscle activities of the vastus medialis and abductor hallucis during stair-climbing and increased muscle activity of only the abductor hallucis during stair-descending after exercise. [Conclusion] Stair-walking can be more effectively performed if the hip external rotator muscle is strengthened when TS exercises are performed for the pronated foot.

Goo YM, Kim DY, Kim TH. The effects of hip external rotator exercises and toe-spread exercises on lower extremity muscle activities during stair-walking in subjects with pronated foot. J Phys Ther Sci. 2016 Mar;28(3):816-9. doi: 10.1589/jpts.28.816. Epub 2016 Mar 31. 
link to  FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842445/

The QP....What's the deal?

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Possibly heard of, rarely implicated and not often treated, this is one muscle you should consider taking a look at.

The quadratus plantae is generally considered to arise from two heads of differing and variable  fiber type composition, with the lateral head having slightly more Type 1 endurance fibers (1) The two heads are separated from each other by the long plantar ligament, though it can arise from from one (somewhat more common)  to 3 heads (very rare).  The attachments can be variable, The medial head is larger and more muscular, attached to the medial calcaneus, lateral aspect of the long plantar ligament and often from the plantar calcaneocuboid ligament (2);  the lateral head is smaller and more tendinous, attaching to the lateral border of the inferior surface of the calcaneus and the long plantar ligament.  The two portions join and end in a flattened band which inserts into the lateral, upper and under surfaces of the muscles, tendons or aponeurosis of predominantly the flexor digitorum longus and usually of the second and third, and sometimes fourth toes (2,3). 

Its action can be equally as variable. In addition to augmenting the pull of the long flexor tendons along the long axis of the foot and so that the 3rd and 4th toes do not curl under the foot, the tendinous slips of the FHL may distribute the load of the great toe to the second toe to the third or fourth toe in the forefoot, especially during toe-off (3).

look at the 4th and 5th digits trying to "crawl under the foot"

look at the 4th and 5th digits trying to "crawl under the foot"

The main attachment of the QP to the tendinous slips of the FHL may provide more efficient control of the long flexor tendons in comparison with that of the QP to the tendon of the FDL (3). EMG studies suggest it resists extension of the toes during the stance phase of locomotion, which serves to increase the stability of the foot. Additional EMG studies suggest it actually acts as a primary toe flexor in voluntary movements, being preferentially recruited over flexor digitorum longus and from comparative anatomical considerations it also seems likely that quadratus plantae may be an intrinsic evertor of the foot (4).

This muscle is a major player in gait and rehabilitation of this muscle should not be overlooked. I could only find one study looking at exercise activation of the QP (5) . It was examined along with the abductor hallucis, flexor digitorum brevis, abductor digiti minimi, flexor digiti minimi, adductor hallucis oblique, flexor hallucis brevis, interossei and lumbricals during rehabilitative the short-foot exercise, toes spread out, first-toe extension, second- to fifth-toes extension.

So, what else can you do?

  • you could ignore the muscle and hope it gets better. (in all likelihood it will worsen)
  • you could give them long flexor, toe scrunching towel-curling, marble-grasping exercises, like you see all over the internet…and give the flexor digitorum longus even more of a mechanical advantage, and make the problem worse
  • you could give them exercises to increase the function of the long extensors, which would increase the mechanical advantage of the quadratus plantae. like the shuffle walk; lift, spread and reach and tripod standing exercises
  • look north of the foot to see what might be causing the problem (loss of ankle rocker, insufficient gluteal activity, loss of internal rotation of the hip, etc) 

Check out the QP on your next foot pain patient, or whenever you see the toes trying to crawl under the foot. You may be surprised at your results. 

 

1. Schroeder KL, Rosser BW, Kim SY. Fiber type composition of the human quadratus plantae muscle: a comparison of the lateral and medial heads. J Foot Ankle Res. 2014 Dec 13;7(1):54. doi: 10.1186/s13047-014-0054-5. eCollection 2014.

2. Pretterklieber B1. Morphological characteristics and variations of the human quadratus plantae muscle. Ann Anat. 2017 Nov 21;216:9-22. doi: 10.1016/j.aanat.2017.10.006. [Epub ahead of print]

3. Hur MS, Kim JH, Woo JS, Choi BY, Kim HJ, Lee KS. An anatomic study of the quadratus plantae in relation to tendinous slips of the flexor hallucis longus for gait analysis. Clin Anat. 2011 Sep;24(6):768-73. doi: 10.1002/ca.21170.

4. Sooriakumaran P, Sivananthan S. Why does man have a quadratus plantae? A review of its comparative anatomy. Croat Med J. 2005 Feb;46(1):30-5.

5. Gooding TM, Feger MA, Hart JM, Hertel J. ntrinsic Foot Muscle Activation During Specific Exercises: A T2 Time Magnetic Resonance Imaging Study. J Athl Train. 2016 Aug;51(8):644-650. Epub 2016 Oct 3.

Which foot exercises activate the intrinsics?

So, your goal is to strengthen the intrinsics. What exercise is best? Probably the most specific one, right? Well....maybe. These 4 exercises seem to all hit them.

This study looked at the muscle activation of the abductor hallucis, flexor digitorum brevis, abductor digiti minimi, quadratus plantae, flexor digiti minimi, adductor hallucis oblique, flexor hallucis brevis, and interossei and lumbricals with the short foot, toe spreading, big toe extension and lesser toes extension exercises with T2 weighted MRI post exercises (perhaps not the best way to look at it) and shows they all work to varying degrees.

"All muscles showed increased activation after all exercises. The mean percentage increase in activation ranged from 16.7% to 34.9% for the short-foot exercise, 17.3% to 35.2% for toes spread out, 13.1% to 18.1% for first-toe extension, and 8.9% to 22.5% for second- to fifth-toes extension."

Gooding TM, Feger MA, Hart JM, Hertel J. Intrinsic Foot Muscle Activation During Specific Exercises: A T2 Time Magnetic Resonance Imaging Study. Journal of Athletic Training. 2016;51(8):644-650. doi:10.4085/1062-6050-51.10.07.

link to full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094843/

The Power of Triangles

 

We talk about triangles a lot. Think about triangles. Hey Pythaogoras did! They are powerful distributors of force. Here we will talk about 3 of them.

There are 4 layers of muscles in the foot. The 1st triangle occurs in the 1st layer. Think of the abductor hallucis and the abductor digiti minimi. Proximally they both attach to the calcaneus and distally to the 1st and 5th proximal phalanges. Now think about the transverse metatarsal ligament that runs between the disal metatarsal heads. Wow, a triangle! this one is superficial.

Now think about the adductor hallicus. It has a transverse and oblique head. think about that transverse metatarsal ligament again. Wow, another triangle!

What about the flexor hallicus brevis and flexor digiti minimi? The former originates from the cuboid, lateral cunieform andd portion of the tib posterior tendon; the latter from the proximal 5th metatarsal. They both go forward and insert into the respective proximal phalynx (with the sesamoids intervening in the case of the FHB). and what connects these? The deep transverse metatarsal ligament of course! And this triangle surrounds the adductor triangle, with both occurring the 3rd layer of the 4 layers of foot muscles.

Triangles… and you thought geometry was boring!

Remaining triangular when we need to (because of our pointy heads)…

Yay for the lift, spread and reach exercise!   Toe spreads and squeezes are aimed at strengthening specific intrinsic foot muscles—the dorsal and plantar interrosei, according to Irene S. Davis, PhD, PT, director of the Spaulding National Running Center and a professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School in Boston. Doming or foot shortening exercises contract most of the muscles on the plantar side of the foot, and help to strengthen the abductor hallucis muscle   see our post here:  https://tmblr.co/ZrRYjx1iuSYMM   Goo YM, Heo HJ, An DH. EMG activity of the abductor hallucis muscle during foot arch exercises using different weight bearing postures. J Phys Ther Sci 2014;26(10):1635-1636.

Yay for the lift, spread and reach exercise!

Toe spreads and squeezes are aimed at strengthening specific intrinsic foot muscles—the dorsal and plantar interrosei, according to Irene S. Davis, PhD, PT, director of the Spaulding National Running Center and a professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School in Boston. Doming or foot shortening exercises contract most of the muscles on the plantar side of the foot, and help to strengthen the abductor hallucis muscle

see our post here: https://tmblr.co/ZrRYjx1iuSYMM

Goo YM, Heo HJ, An DH. EMG activity of the abductor hallucis muscle during foot arch exercises using different weight bearing postures. J Phys Ther Sci 2014;26(10):1635-1636.