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Is the short foot exercise primarily an isometric exercise ?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, Feb 7, 2016.

  1. scotfoot

    scotfoot Active Member


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    The following was originally posted by me on a site called "Denver Fitness Journal"and I was hoping to get some further feedback from the Arena by posting it here .

    Post -
    Am I correct in believing that the short foot exercise is primarily an isometric exercise ? If so I can see why the exercise would help strengthening the intrinsic muscles of the foot as they are used during midstance but wonder if there would be any carry over of performance gain during late stance when the toes are in a more dorsiflexed position and the intrinsics in a more lengthened position .

    I recently read a paper (1) which reported that the plantar fascia is under the greatest strain during push-off . Perhaps that is why some suffers of plantar fasciitis report pain during this phase of gait . If the short foot exercise is primarily an isometric exercise then perhaps some additional strengthening of the plantar intrinsics to assist the fascia whilst the toes are in a dorsiflexed position might be a good idea .



    Gerry

    Gerrard Farrell
    Glasgow

    (1)Yaodong Gu ,Zhiyong Li ; Mechanical Information of Plantar Fascia During Normal Gait ;2012 International Conference on Medical Physics and Biomedical Engineering -
     
    Last edited: Feb 7, 2016
  2. Gerrard:

    The short foot exercise (SFE), as I understand it, involves raising of the medial longitudinal arch (MLA) of the foot while weightbearing, without using the digital flexors. Since this exercise involves joint motions, then it would be considered an isotonic exercise, not an isometric exercise.

    In addition, the motions done during the SFE are likely more due to the contractile activity of the posterior tibial and anterior tibial muscles, not due to the plantar intrinsic muscles, regardless of what is written over and over again on the internet. The plantar intrinsics simply don't have the strength to raise the MLA of the foot by themselves if the individual is standing on their feet and have their forefoot bearing more ground reaction force than the rearfoot.

    The plantar fascia is actually under the greatest tension force around the instant of heel lift during gait. The tension force within the plantar fascia was directly measured in a study over a decade ago in a dynamic cadaver gait simulator at the Penn State Biomechanics Lab by Erdemir et al (Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA: Dynamic loading of the plantar aponeurosis in walking. JBJS, 86A:546-552, 2004). See attached paper.

    As far as intrinsic muscle strengthening, this probably helps some people with plantar fasciitis and is something I use on some of my patients. The problem is trying to get people to consistently do these exercises. The plantar intrinsic muscles are active in late midstance and propulsion and help reduce the strain on the plantar fascia since they all share common MLA-supporting functions. However, foot orthoses and plantar arch strapping are, in my experience, much more effective cliniically at reducing the symptoms of plantar fasciitis than "foot strengthening programs".
     
  3. Damien Howell

    Damien Howell Welcome New Poster

    There is a growing body of evidence of the benefits of using isometric exercises for tendinopathy. There is research suggesting that isometric exercise of appropriate dosage has analgesic effects. I often question is the tissue source of plantar heel pain the plantar fascia or the tendinous insertion of the intrinsic plantar foot muscles. When I use ?short foot? exercise it is the initial exercise. Once the patient has mastered the coordination required standing with weight in both feet, progress to one foot. Once control is demonstrated one foot progress to bilateral heel raise while maintaining ?short foot position?. Once bilateral heel raise while maintaining short foot position progress to unilateral heel raise while maintaining short foot position.
     
  4. Damien:

    There is no doubt in my mind that most plantar heel pain is caused much more by the tension force within the plantar fascia than the tension force within the plantar intrinsic muscles. Thousands of podiatrists here in the States perform surgical lengthening of the medial half of the central component of the plantar aponeurosis which seems to quickly resolve the plantar heel pain symptoms in most patients. If the plantar heel pain was caused by the "tendinous insertion of the intrinsic plantar foot muscles", as you suggested, then the pain from partial plantar fasciotomy would increase the plantar heel pain, not decrease the plantar heel pain, as we so commonly see with partial plantar fasciotomy surgical procedures. I would agree that it is possible that the origin of the plantar intrinsic muscles on the plantar calcaneus may be the cause of the plantar heel spur, since the heel spur is deeper and more plantar than the origin of the plantar aponeurosis. This is commonly observed on the few occasions that we need to surgically excise the plantar calcaneal spur.

    Don't forget that many plantar heel pain symptoms are initiated and perpetuated by excessive and/or prolonged magnitudes of ground reaction force (GRF) acting on the plantar aspect of the medial calcaneal tubercle. No amount of "foot strengthening exercises" will reduce the magnitude or duration of GRF acting on the plantar calcaneus during weightbearing activities.

    Rather. a therapeutic combination of proper shoes, reduced activities, stretching, foot orthoses, foot strapping, night splints, cortisone injections,and foot strengthening exercises has produced the best results in my treatment of thousands of patients with plantar heel pain over the past 30+ years. I'm all for foot strengthening exercises, but when used in isolation, contrary to what the barefoot/minimalist running zealots have claimed for the past five years on the internet, they are a very blunt tool in the treatment of plantar heel pain.
     
  5. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    on the SFA, I wrote this somewhere else:
    Here is a video on it:


    and attached is a screenshot of a tabulation of the research done on it:
     

    Attached Files:

    Last edited by a moderator: Sep 22, 2016
  6. scotfoot

    scotfoot Active Member

    Thank you for your replies .

    Kevin
    Many thanks for the paper on the plantar aponeurosis which was one I was keen to have a look at . I think I know were you are coming from re your comments on the motions carried out during the SFE being due to the actions of tib ant /tib post but feel that the toe flexors must also have a significant involvement .

    Damien
    Do you have any evidence to show that that heel raises in the SF position are a progression from the SFE in single leg stance ?

    Also it should be relatively easy to determine whether heel pain is generally caused by the"tendinous insertion of the intrinsic plantar foot muscles" rather than the plantar fascia although possibly more difficult on a case by case basis depending on the symptoms .

    Craig
    Thanks for the info

    I still see the short foot exercise as primarily an isometric exercise and feel that superior intrinsic foot muscle exercises exist .

    Gerry
    Gerrard Farrell
     
  7. Damien Howell

    Damien Howell Welcome New Poster

    There is a need to identify a valid, reliable, functional responsive measure of the strength of the intrinsic plantar flexor muscles of the foot. Short of that there is a need to incorporate objective outcome measures when conducting controlled clinical trials for management of heel pain. A majority of the clinical trials conducted on heel pain use standardized self-reported outcome measures, and do not include functional performance measures. This is particularly true when it comes to looking at effectiveness of stretching exercises for heel pain. A majority of the studies do not report change scores for range of motion of 1st MTP joint in response to intervention.

    I am not aware of evidence (research studies) showing the effectiveness of progressing short foot exercise to single leg heel raise is effective. Clinical trial is needed comparing groups with standard care with out short foot exercise and with standard care with short foot exercise using objective functional outcome measures (changes in strength and range of motion measures) in additional to the standard of self-reported disability sores.

    Clinically, I do not find it easy to distinguish tissue source of plantar heel pain. Diagnostic imaging (MRI) can, and musculoskeletal sonogram has the potential to distinguish tendinous insertion pathology versus plantar fascial insertion. I think if we begin to stratify tissue source of heel pain we can better design a plan of care.

    Damien
     
    Last edited: Feb 14, 2016
  8. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Gait Guys weigh in:
    Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

     
  9. terigreen

    terigreen Active Member

    What about a heel wedge, to raise the posterior medial heel. This would off load medial band of the plantar fascia. Been using heel lifts for awhile and yes they do work well for chronic plantar fasciitis. A 8 degree heel wedge placed in the shoe under the insole seems a simple treatment option.
    Atlas Biomechanics
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Differences in the angle of the medial longitudinal arch and muscle activity of the abductor hallucis and tibialis anterior during sitting short-foot exercises between subjects with pes planus and subjects with neutral foot.
    Lee JH et al
    J Back Musculoskelet Rehabil. 2016 Mar 18
     
  11. scotfoot

    scotfoot Active Member

    Hi Damien
    From a physiotherapists point of view do you see any merit in the ideas contained in the posts below . That is , might early lesser toe deformity be reversed in the manner described ?

    Gerry

    Post 1
    Correcting footwear induced toe deformities

    Might it be possible to correct mild , footwear induced , toe deformities , such as hammer or claw toes , using the type of device shown in the advertisement I have linked to below ?(1)
    Note ;this is a question and the views expressed in the text below should not be viewed as any sort of recommendation on the part of the author .

    Link
    ..the digit exerciser - Bigger Faster Stronger

    www.biggerfasterstronger.com/uploads2/88_Jan_DigitExercise.pdf

    The Brigham associated digit exerciser seen in the link is described in the accompanying text as providing "progressive resistance exercise for the toe flexor muscles causing articulation at metatarsophalangeal joints " .

    In my opinion , as the toe flexors apply force against the movable platform of the digit exerciser , the toes move around the MTPJ's but are at the same time encouraged into a straighter alignment with regard to the inter phalangeal joints .
    .That is to say that the toes have a tendency to DORSIFLEX at the inter phalangeal joints as the toes PLANTARFLEX around the MTFJs .Thus ,using the device to exercise feet exhibiting mild toe deformity may ,under the guidance of a suitably qualified individual , eventually encourage the toes to function in more natural ,pre deformity alignment, as well as strengthening the muscles involved in the movement .

    Further to the above , my understanding is that the majority of toe problems /deformities are related to the use of ill fitting shoes and that prolonged use of , for example , tight shoes can lead to deformities that are difficult to correct . But let’s say we take our wearer of tight , pointy shoes and get them into a pair of shoes with a wide toe box .The cause of the problem has gone but the deformity remains . So how does a podiatrist fix the problem in a conservative fashion ?

    Some time ago I expressed the view that far from restoring correct muscle function the short foot exercise might actually re-tasked the toe extensors to act in concert with the toe flexors (intrinsic ) to produce a more pronounced medial arch but at the cost of producing less plantar pressure under the toes during gait . I would now further argue that if the structures of the foot can be educated to perform a previously alien task then surely they can be re-educated to perform "natural" tasks .

    In revision then ,when a person uses the Brigham Young University related "digit exerciser" the most distal parts of the toes push down on a platform which moves with the toes . This contact encourages the toes to both move around the MTFJ 's and to do so in more lengthened positions .The exercise stretches the toes out as they plantarflex . Perhaps progressive use of the device can correct deformity not so much by addressing strength deficits but by lengthening shortened tendons and re-establishing muscle synergies .

    .Gerrard Farrell

    Glasgow
    scotfoot, Apr 28, 2017
    ( The text above expresses one possible view point only .Always consult a physician before starting any new exercise regime)
    Last edited by Gerrard Farrell; 06-16-2017 at 08:17 AM.


    Post 2
    Re: Correcting footwear induced toe deformities

    Further to the previous post , it seems clear to me that tissue growth is promoted by progressive resistance training much more quickly than repetitive every day movements .Perhaps then ,if you want to realign the toes to pre deformity patterns then toe spacers etc could be used during exercise with devices like the "digit exerciser" to promote more rapid and more easily controlled tissue changes /realignment .

    Put more generally , if an individual wears a realignment device as they go about their daily business then perhaps the stimulus for realignment to the supported position will be insufficient for tissue changes to occur and give permanent change . Better results might be possible with a combination of realignment device and simultaneous growth promoting ,progressive resistance training .

    Always consult a physician before starting any new exercise regime. ​
     
  12. scotfoot

    scotfoot Active Member

    The question I have asked , above , is probably a difficult one to answer if no relevant studies have ever been carried out .

    It would be very useful if Dr Blauer's digit everciser were to be tested to see if it could be used to exercise the lesser toes in such a way as to reverse footwear induce lesser toe deformity . Dental impression putty , located on the resistance pedal , might be used to gradually adapt the toe/pedal interphase to best effect , and the study ,which might take the form of a simple ,pilot ,case study would be closely supervised by a suitably qualified individual .

    Any thoughts ?

    the digit exerciser - Bigger Faster Stronger

    www.biggerfasterstronger.com/uploads2/88_Jan_DigitExercise.pdfANNOUNCING! A NEW TOP PRIORITY. AUXILIARY EXERCISE. Editor's Note: During the past five years, Dr. Blauer. Bangerter has conducted research on his new in- novation: The Digit Exerciser. The following is a summary of that research completed at Brigham. Young University. I feel the Digit Exerciser which ...
     
  13. scotfoot

    scotfoot Active Member

    Try as I might I can't find a single study that looks at the effects of physiotherapy exercises on lesser toe defects such as hammer toe or claw toe . Plenty of material on restoring finger function but nothing on lesser toes . Not one study ever as far as I can see . Surely I am missing something ?
    Of course the problem might be that no effective physiotherapy interventions are perceived to exist and so no interventions have ever been tested .
    With regard to physio based foot exercise regimes some well regarded authorities within the foot and ankle community still recommend toe curls as a strengthening exercise for the toes regardless of the fact that this is principally an extrinsic exercises and ,in my opinion , is liable only to exacerbate existing muscle imbalances , if anything .

    The short foot exercise ,again in my opinion ,may actually be harmful in that it produces unnatural muscle co contractions but does little else with regard to intrinsic muscle strength .

    Dr Blauer's digit everciser ,although perhaps a little cumbersome ,is far more promising since it allows toe movement around the MTFJ whilst the toes remain extended at the interphalangeal joints and NOT curled .

    So it's worth repeating the sentence from my previous post -

    "It would be very useful if Dr Blauer's digit everciser were to be tested to see if it could be used to exercise the lesser toes in such a way as to reverse footwear induce lesser toe deformity . Dental impression putty , located on the resistance pedal , might be used to gradually adapt the toe/pedal interface to best effect , and the study ,which might take the form of a simple ,pilot ,case study would be closely supervised by a suitably qualified individual ."

    Surely the above is worth a try . If a university were to achieve success with one individual then a new therapeutic door might be opened .

    Gerry
     
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