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Hallux valgus and foot strengthening

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, Jul 2, 2022.

  1. scotfoot

    scotfoot Well-Known Member

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    Very encouraging to see this publication . The strengthening exercises being used are the ones that Mickle et al found to be effective for foot strengthening in older patients and include moving the toes around the MTPJ against progressive resistance.

    Footwear, foot orthoses and strengthening exercises for the non-surgical management of hallux valgus: protocol for a randomised pilot and feasibility trial



    Hallux valgus is a common and disabling condition. This randomised pilot and feasibility trial aims to determine the feasibility of conducting a fully-powered parallel group randomised trial to evaluate the effectiveness of a multifaceted non-surgical intervention for reducing pain associated with hallux valgus.

    Twenty-eight community-dwelling women with painful hallux valgus will be randomised to receive either a multifaceted, non-surgical intervention (footwear, foot orthoses, foot exercises, advice, and self-management) or advice and self-management alone. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks. The primary outcome is feasibility, which will be evaluated according to demand, acceptability, adherence, adverse events, and retention rate. Limited efficacy testing will be conducted on secondary outcome measures including foot pain (the Manchester-Oxford Foot Questionnaire), foot muscle strength (hand-held dynamometry), general health-related quality of life (the Short Form-12), use of cointerventions, and participants’ perception of overall treatment effect. Biomechanical testing will be conducted at baseline to evaluate the immediate effects of the footwear/orthotic intervention on pressure beneath the foot and on the medial aspect of the first metatarsophalangeal joint and hallux.

    This study will determine the feasibility of conducting a fully-powered randomised trial of footwear, foot orthoses, foot exercises, advice and self-management for relieving pain associated with hallux valgus and provide insights into potential mechanisms of effectiveness.
  2. scotfoot

    scotfoot Well-Known Member

    Mickle et al 2016 looked at the strengthening effects of progressive resistance exercises on toe flexor strength verses a home exercise program.

    The progressive resistance exercises worked, the home exercises did not. Presumably that is why La Trobe have chosen Mickles progressive resistance exercises for their trial into Hallux Valgus.

    Here is a run down of the home exercises that Mickle found did NOT work for older subjects.

    "The home-exercise group (Home group) received a booklet containing a series of eight general foot exercises that had little or no resistance and did not progress in ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT 8 amount of resistance. The warm-up consisted of ankle rotations, calf raises and toe raises, and the cool down consisted of rolling a golf ball underneath each foot for 2 minutes. They then performed a prescribed number of repetitions of toe squeezes, toe pulls, marble pickups and towel pulls as suggested by Frey 15 and the Short Foot exercise 11, three times per week. "

    Here is a YouTube video of the type of exercises that did work .

  3. scotfoot

    scotfoot Well-Known Member

    Calf raises ; do they usefully strengthen the intrinsic foot muscles?

    Well, calf raises were used by Mickle et al 2016, as a warmup exercise 3 times a week for the duration of the trial period and these, along with "toe squeezes, toe pulls, marble pickups and towel pulls" ,did not significantly strengthen the feet .

    A recurring misconception amongst those studying and advising on the foot is that the toe flexor component of intrinsic toe flexors is not significant in foot biomechanics .This is just plain wrong.

    If you want to strengthen these muscles, flex the toes .
  4. scotfoot

    scotfoot Well-Known Member

    Further to the above " doming" type exercises might well help with hallux valgus treatment since this exercise activates the adductor hallucis muscle which serves the pull the 1st MTPJ towards the 2nd MTPJ during toe flexion .
    It strikes me that "toes spread out" type exercises may tend to move these joints apart and may therefore be ultimately counterproductive.
  5. Dan T

    Dan T Active Member

    I find concordance to be low for a lot of single rep toe exercises, doming etc. I still give some out to neuropathic patients or the elderly who can't do more. Younger people, irrespective of initial complaint, I do like to give out angulated balance work in opposite directions depending on the deviation of their STJ axis. I like to progress these to slow heel raises with band distractions. It's fun, challenging and your toes get tanked by gripping the floor to maintain contact. If your balancing at 20-30 degrees of inversion with a posterior distraction everything is fired on to keep contact. This is the only time I can achieve mild DOMS in the intrinsics and toe flexors.
    If you watch how Jujitsu practitioners get their 'hooks in', or how Pavel tsatsouline moves a kettle bell whilst gripping the floor. Much more natural to design. Stuff like early HAV and adducted 5th toes I'll go thousands of reps on the band. I think better observations would be gained observing sedentary people going into sports. Nothing much more functional than the foot and I suspect too much emphasis on none weight bearing dynamic exercise.
    I quite like some of the stuff physio Liz Bayley does to rehab her dancers on the west end. She'll do intrinsic work but always moving towards progressive overload, balance and functional stuff
  6. scotfoot

    scotfoot Well-Known Member

    Good idea.

    I'm not sure what you mean by "gripping the floor ". Strong toes remain straight during balance tasks ,they do not curl .

    The greatest gains in the toe flexor muscle strength have been achieved using isolated foot exercises . Nothing else currently in publication has come remotely close.

    Sure ,sports performed barefoot will produce stronger feet.

    Heel raises, even on sloped boards, do little if anything to strengthen the intrinsics .
    Last edited: May 13, 2023
  7. scotfoot

    scotfoot Well-Known Member

    The toe flexion found in foot doming also activates the adductors of the forefoot, pulling the met heads powerfully together .

    The abductor hallucis fires at the same time keeping the hallux from being pulled "off line" relative to the long axis of the foot. That is to say, the long axis of the hallux and the foot retain the same relationship in the transverse plan .

    You can see this in the linked to video
  8. Dan T

    Dan T Active Member

    By gripping I mean plantar flexing the toes at the MPJ into the floor for stability. I mean there is responsive tension in the toes, they aren't inanimate. You can stand on one leg and close your eyes and feel your toes firing on responsively. If you swing a heavy kettlebell without the toes joining in you'll slide backwards a few mls every rep. That's verifiably true if you tried that now.
    I can see the purpose of any exercise within a rehab period but the whole point should be to return one to activity. If your able to perform high repetition angulated and distracted balance work through functional ranges of motion I feel other exercises then become surplus to requirements.
    The same way the supraspinatus is essential to healthy shoulder function you wouldn't want to overemphasise the strength of this over the delts/lats for overall shoulder strength, stability and performance.
    Also, for eg. If your jumping rope barefoot then rolling for several rounds, your intrinsics are undoubtedly involved. Will they have measurable increases in strength? I don't think so necessary. They seem to me, to be needed for functionality over sheer strength. For example you can perform a plank for 10 minutes or 20. I doubt there would be a directly measurable strength output or size differential between the two but the muscle is certainly more functional with increased fatigue capacity.
    I'm not disagreeing with anything you've said btw, just shooting the shit after what you wrote got me thinking.
    What's the title/link of the paper by mickle et al?
    Also, As this seems to be an area of interest for you, let me ask you a question;
    I have a patient with instability of lateral column, manifesting as cuboid issues which respond to whip and general clunking etc from time to time with occasional pain and discomfort that moves around the lateral column. No issues with peroneals strength and insoles help but obviously want them out of these at some point.
    The only difference between the symptomatic side and the contralateral is the inability to plantarflex the 5th toe straight to the ground against band. When the bands on and they plantarflex they adduct the toe as well as plantarflex, to the extent they have to place a finger between 4th and 5th. This doesn't happen on the contralateral... they have good strength and control on asymptomatic side. They get great lateral column stability after working that 5th toe for a few days. I'm confident if we can return strength and function to this toe we can keep this stability long term. So my questions are; why do you think the lateral column instability seems so intrinsically linked to this presentation and can you think of any exercises/variations to get the abduction of the 5th toe to return
  9. scotfoot

    scotfoot Well-Known Member

    Shoes make our feet much weaker than they would otherwise be, even in active, sports oriented, young, adults.

    A recent study took a group of healthy individuals and got them to wear minimal shoes for everyday activities but not for sports activities like running.

    The trial period was 6 months after which the gain in toe flexor strength was ,on average, 56% .

    Mickle paper- https://vuir.vu.edu.au/34377/1/Clin Biomech accepted version.pdf

    Sorry, can't help with your problem .

    The scientific discussions on strengthening the foot seem to be going in a circle .

    A few years ago we had the idea that the foot would become just as strong as it needed to be just by being at the receiving end of ground reaction forces during sporting activities . Then we had the idea of isolated foot exercises to strengthen the foot and allow better overall performance.

    A couple of recent publications have brought us back to foot strengthening during global movements again . However, a few studies have shown promising strength gains with isolated foot strengthening exercises, gains that are greater than those of global movements like single leg calf raises .
  10. Dan T

    Dan T Active Member

    I imagine some people do great in minimal footwear. I would imagine on average these people are young(er), have a none 'problematic' foot type and have a normal BMI? I suppose the issue is that we were never supposed to spend most/all of our time on a 90 degree, horizontal plane. The modern world has very specific repetitive demands on the foot
  11. scotfoot

    scotfoot Well-Known Member

    Ok ,but I am not a particular advocate of minimalist shoes, I merely used the example of that paper to illustrate that aspects of modern shoes make our feet weak.

    I am an advocate of foot strengthening since this can help improve athletic performance and alleviate some types of foot and knee pain .

    Recent papers on foot strengthening which compare global exercises with isolated foot exercises seem to have left out large swathes of isolated foot strengthening research but instead focused digital exercises like the "toe spread out" exercise which is little more than a mobility drill, in my view.

    If you want to strengthen the toe flexors, and the adductor hallucis and abductor hallucis are very much toe flexor muscles, then you flex the toes against progressive levels of resistance.

    Some years ago researchers at Brigham Young University produced an exercise device that allows exactly this and using it improved sprinting times in the tested individuals .

    Here is a link to Brigham Young's patent
  12. Dan T

    Dan T Active Member

    Got you. I'll add them to my reading list. I'm certainly open to it. I personally have foot and ankle work that I do biweekly and it has absolutely carried over to my lower body work.
    How would you progressively overload the toe flexors optimally in your opinion? And via what mechanism was it proposed it increased sprint speed?
  13. Dan T

    Dan T Active Member

    Saw the patent btw, I meant more is there a viable alternative for the average joe
  14. scotfoot

    scotfoot Well-Known Member

    Theraband flexion exercises work . Some very powerful people use elasticated resistance bands for building specific strength, including shot putters.

    The idea that you can strengthen the intrinsics by loading the foot and pay no attention to the ground reaction forces being generated under the toes is just plan wrong, IMO .

    If you load up one foot but then, in this loaded position, find that you can easily press down a lot harder with your toes, then the toes flexors went doing that much in the loaded position, obviously.
  15. scotfoot

    scotfoot Well-Known Member

    Below is a link to the Cybex digit exerciser from Brigham Young University . It was much studied at the time and improve toe flexor strength "greatly"( up to 66%) and in various studies gave improved acceleration and peak velocity in the 40m sprint and improved standing jump .

    Some isolated foot exercises are near useless and some are extremely effective. Recent papers seem to have compared global foot strengthening techniques only with the near useless isolated exercises.

    The Digit Exerciser

    Bigger Faster Stronger
    http://office.biggerfasterstronger.com › uploads2

    THE DIGIT EXERCISER ... Resistance Exercises (PRE) for toe flexor muscles, causing ... Brigham. Young University has bought 9; 4 went to P.E.-Sports, 4.
  16. Dan T

    Dan T Active Member

    Link doesn't work mate. I use a mini loop band and flex 1st and 5th a couple of times a week. I will do 2-4 but seems more like it's working FDL I enjoy doing it (main thing) and I do feel it carries over. Strength is never a weakness after all. I flex to the floor only as this is the only range of motion your toes require.
  17. scotfoot

    scotfoot Well-Known Member

    The link works for me but can be a bit ropy for some reason.

    I have a foot strengthening system coming out soon that makes foot strengthening pretty easy. It's called the Novabow System and is patented .

    I would put up a youtube video link but it will likely be considered advertising and disconnected if I do . If you put "Novabow System" into google it should come up.

    Presently, it's being used by an Olympic track and field athlete ,who seems to have benefited greatly from using it, and also by a professional sportsman with chronic foot/ankle problems ( to early to say if its helping ) .
  18. scotfoot

    scotfoot Well-Known Member

    Hi ,
    Re the above I now have some results to report .

    The " professional sportsman" I was referring to is actually a full time pro footballer and here, with permission, are his words after using the Novabow for only a short time. If you are involved in sports podiatry you will know that "counter-movement jump" really just means standing jump where you sink down a bit first by bending your knees etc. then jump upwards.

    "I have always struggled with foot and ankle pain as a result of the demands of the sport (and my size). I never used to condition these areas, I had always thought calf-raises and SL balance work would be enough. After suffering a stress-fracture in my navicular last season, Gerry gave me a Novabow device to try. The difference has amazed me. My feet feel so much stronger and more robust. The chronic pain in my ankles and calf muscles has now subsided. It’s difficult to say empirically whether my agility has changed, but I definitely feel more confident and explosive on the turn. I have noticed my cutting manoeuvres are pain free and am able to put more force through the ball of my foot and toes. Since using the device, I have achieved a record counter-movement jump score, as well as almost doubling my accelerations and decelerations in 90 minute games.
    The Novabow has really helped me.
    Regards ......."
  19. scotfoot

    scotfoot Well-Known Member

    Recent evidence suggests that the abductor hallucis is much more geared towards great toe plantar flexion than abduction . Also, the adductor muscles are very active during plantarflexion, drawing the met heads together . If an exercise can reduce the rate of bunion formation or relapse after surgery, toe flexion against increasing resistance is probably it.


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