Hallux Valgus excercises

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Would appreciate any views on Exercises for slowing down the process of Hallux Valgus....such as sppreading the toes such that the Halluces are abducted and holding them there or general exercises for strengthening the intrinsic foot musculature ie scrunching a tissue with the foot. Does any one actually recommend these to their patients who are concerned about the depelopment of their bunions? -Cheers

 

My view (which is not referenced before simon leaps down my throat ) is that they are a waste of time.

HAV develops because of a functional situation with the persons feet / walking. They use their feet for hours and hours. If you can find a way to persuade patients to do exercises or stretch for 5 minutes every day for a year please tell me how!! The boat fills quicker than you can bail it!

The research done on HV night splints (the reference escapes me for now) indicated that even adducting the 1st toe for some hours at night only suceeded in preventing the deformity from worsening and only if it was not beyond a certain point already! (10 degrees if memory serves).

As for scrunching a tissue between the toes, I somewhat doubt that that one works. Not seen anything approximating to evidence and the rational is more than a bit shaky as well! I suspect it's just something GP's use to get fretful patients out of their surgeries! Think of the forces going on in the foot during gait and the amount of muscle likley to be generated by 5 mins of non weight bearing exercise of the flexor group.

But thats just my view

Regards
Robert

 

I concur with this view. However, the Groiso study reported improvement in HA angle (if memory serves) while the ??? and Kilmartin study showed only stabilization of the angle.

 

While I agree it is hard to get compliance, strengthening the intrinsic muscles of the foot would help recruit other muscles and perhaps reduce some of the force the hallux receives for balance and toe off or better avoid other problems from developing elsewhere in the foot or above. To get patients to try them, give them a printed flyer of a few and reccomend they do them when they are forced to sit with little else to do ie driving the car, working at the computer even sitting in the bathroom. Test their toe strength at the start and at one month, you and they will be surprised at the difference.

 

1. Do you have any evidence to support this?

2. Could you expalin which muscles you mean when you talk about the intrinsic muscles

3. Could you explain what you mean by recruit other muscles?

4. Could you explain what you mean by reduce some of the force the hallux recieves for balance and toe off.

ta

RObert

 

1. I don't have specific documented literature to support this but you might find this article interesting in regards to training intrinsic muscles to reduce pronation.
http://www.aptei.com/articles/pdf/IntrinsicMuscles.pdf

2. I can't name the specific muscles. I have seen patients sent to have physical therapy who have metatarsalgia to learn how to strengthen the muscles in their feet i.e. in the transverse arch and it has helped them. Many people with plantar fascitis are instructed to perform these type of "scrunching" exercises along with stretching. Perhaps if the muscles had been stronger before they would have been less suceptible to developing the problem.

3. Recruiting the other muscles would be as in 1. and 2. For some, excess pressure from pronation has contributed to their hallux valgus. Perhaps practicing exercises from the article in #1 along other toe, transverse arch exercises would help especially for those who don't tolerate orthotics to solve their pronation problems.

4. I cannot recite to you the stages of the gait cycle in regards to the great toe. The role of the great toe is well documented as receiving the greatest force (weight) during ambulation and toe off. A hypermobile great toe allows the force to pass to the second met head which then can lead to metatarsalgia so then you are back to #2.


I agree with you Robert that "the forces going on in the foot during gait" are tremendous, that exercises are not a substitute for shoe modications, padding or orthotics, but I wouldn't disregard any benefit to be gained from something that costs nothing but alittle time, though 5 mins is probably not enough.

 

duh? The fundamental flaw with everything in that paper that the author seems to forget is that the intrinsic muscles in the foot do not actually fire until the heel is just leaving the ground. Strengthening is NOT going to make them fire any earlier. Any sort of neuromotor retraining is not going to make them fire any earlier. How can they stop a foot pronating?

 

Re: Hallux Valgus exercises

It looks like a literature review and project proposal. For a more complete look at the effect of abductor hallucis on medial longitudinal arch height, see:
Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M. 2003 Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 42(6):327-33.

Getting back to the initial thread of HAV and exercise, the idea of reducing or halting hallux valgus deformity via night splints or exercise is nice. Unfortunately the exercises described are not specific to abductor hallucis which has its origin at the medial tubercle of the calcaneus and insertion at the plantar medial aspect of the proximal phalanx of the hallux and the most medial aspect of the tibial sesamoid (via the plantar plate/ joint capsule complex). At this point it may be worth remembering that abductor hallucis' insertion is said to move plantarly as part of the deformity and perpetuate it (hallux valgus) once the tibial sesamoid is sufficiently laterally deviated. Any muscle inserting medially on the hallux ought to help reduce deformity (as long as there's no fixed bony deformation). Aside from abductor hallucis, the only other potential for increasing abduction (medially away from the midline of the joint) moments is the medial head of flexor hallucis brevis. I like to think I have good control over my body (depending on how much I've had to drink ) but I can not isolate either of these muscles (or heads of muscles) to abduct my toe (apologies for the poor sample size, but I can vouch that I have no significant DJD, etc...).

Recent work by Temple University (21st ISB congress podium sessions 2/7/2007) has piloted daily functional electrical stimulation of abductor hallucis (although I don't doubt that some electric stimulation of other local intrinsics occurred) and yielded promising results - a 1 degree reduction in hallux valgus angle after 3 months (10 subjects, and I realise the inter and intra repeatability issues surrounding hallux valgus angle measurement on x-rays taken 3 months apart). A plus to the study is it's probably as specific as you are going to get for the effects of stimulating abductor hallucis.

In summary, I'd be surprised if general intrinsic muscle exercise will halt or improve hallux valgus as there's more chance you'd either do nothing or possibly make the deformity progress due to the lateral dominance of muscular insertion (especially with established deformity). Apologies for the clinical terms used throughout.

Might be better doing FES instead. Alternatively, you could medialise some of the soft tissue insertions when you’re doing your metatarsal osteotomy.

Have a good one,
Lee

 

Re: Hallux Valgus exercises

Look closely at that study. They got it wrong as well by igoring that this muscle does not activate until late in the stance phase as the heel is unweighting. Its too late for the muscle to affect the arch dynamically then. They only looked at people standing statically.

 

Re: Hallux Valgus exercises

Lee,

Is this a typo?? If not, this result is dismal and not "promising". Perhaps it is promising for the company that makes the stim unit, as it will require a life-long rental period.

Bottom line- The pathogenesis of HAV is not related to primary muscle dysfunction. Therefore the solution does not lie in trying to strengthen overworked muscles. Either accommodate the deformity or surgically correct it. Foot orthotics may decrease the progression in some individuals with flexible pes planovalgus. Anyone who believes they can straighten the toe nonoperatively is dreaming in technicolor.

Nick

 

Quote from Craig Payne.

Quite a big flaw IMO. Makes the results relevant for hairdressers, less so for anyone who walks.

That pesky 4th dimension complicates things does'nt it!

Regards
Robert

 

DaVinci - "They got it wrong as well by igoring that this muscle does not activate until late in the stance phase as the heel is unweighting. Its too late for the muscle to affect the arch dynamically then. They only looked at people standing statically."

I know. I have read the study. In fact, the majority of emg studies have been done on the static subject (or while performing some sort of task), so I fully agree with your point on dynamic action of the muscle. MAYBE statically increasing the strength of abductor hallucis MIGHT have a positive effect on dynamic function? I don't know, I'm not saying it will and again, I take your point on timing of firing during gait, although it'd be nice to see more stuidies on dynamic function of the intrinsics.



Nick (Scorpio622) - "Is this a typo?? If not, this result is dismal and not "promising". "

Behave Nick. 1 degree in 3 months on 10 patients is a better result than the research you or I have published. I did state that I recognised the inherant possible measurement error and stated the results were 'promising' (not fantastic - promising). I had no part in the study and I'm sure the authors are better placed to defend their results, however I was putting it forward as part of a suggestion that conservative treatment of hallux valgus may warrant further study. You'll notice my flippant remark at the end of my post about surgery - currently the only consistent method of reducing hallux valgus deformity.

"The pathogenesis of HAV is not related to primary muscle dysfunction."
Did anyone say it was? It is a complex deformity of bone, soft tissue and function.

"Therefore the solution does not lie in trying to strengthen overworked muscles."
Perhaps it might help? I don't know, but the 10 people in the pilot study I mentioned are the only results I know of. Ultimately, it's unlikely to cause significant harm, so it might be worth a try.

"Either accommodate the deformity or surgically correct it."
Yes, entirely agreeable.

"Foot orthotics may decrease the progression in some individuals with flexible pes planovalgus."
Shaky ground.

"Anyone who believes they can straighten the toe nonoperatively is dreaming in technicolor."
Any dream will do.

Again, I'm not suggesting that it's the best thing since sliced bread, but if it has a possibility of helping it's worth a look at surely?

 

A couple of points:

Phasic activity of the plantar intrinsics has been shown to be altered in pes planus. So point made re: time of activity during gait cycle is probably incorrect in dysfunctional situation such is seen in hallux valgus. See Basmajian. As I recall he actually looked at phasic activity in hallux valgus- me getting old and memory getting blown.

Experimented with muscle stimulation early on in my PhD studies- it hurt. may ave improved with better stimulator technology- but at the time it hurt me too much to try and apply it to a research study.

1 degree does not exceed the limits of the error so ignore any claims of improvement- this is rubbish and none science.

Finally, crap research is still crap research even if it is better than the research you have done. Don't accept the crap just because it's all that you have to go on, go out there and do it better.

P.S. for fans of surgery- read the Cochrane review- pretty big post op dissatisfaction rate- as I recall from memory about 1/3

 

I do not think that any exercises or anything one can stick inside his or her shoe will be effective. I am a fan of surgery (the right surgery).

Nat

 

"1 degree does not exceed the limits of the error so ignore any claims of improvement- this is rubbish and none science."
I think I mentioned that in my original post. Yes I did. Hallux valgus angles are even less repeatable than intermetatarsal angles.

"Finally, crap research is still crap research even if it is better than the research you have done. Don't accept the crap just because it's all that you have to go on, go out there and do it better."
Alright, I will.

"P.S. for fans of surgery- read the Cochrane review- pretty big post op dissatisfaction rate- as I recall from memory about 1/3"
Yes. Can't remember the amount of dissatisfied, but there's also problems with assessing patient satisfaction and surgical outcomes (regardless of this, no one intervention is perfect).


Nat - "I do not think that any exercises or anything one can stick inside his or her shoe will be effective. I am a fan of surgery (the right surgery)."
Me too.

 

It's all that acid you dropped dancing in the garden at midnight trying to shift that VP. Don't worry simon, you can still spell better than me .

Thats a bit of a broad cut (sorry ) for me. I think some refinement is needed to discuss what somebodies favorite intervention is.

Firstly the thread actually started talking hallux valgus and everyone seems to be assuming hallux abductus or hallux abducto valgus. Different conditions which need different management

Secondly before we start talking exercises vs orthotics vs surgery we should talk about which element of the HAV, HA or HV needs addressing. If its the sticky out bit on the side of the foot then i'm with nat. Address the footwear first but if there is still no room, then surgery. If it's a painful articulation of a 1st mpj thats causing trouble i think you've GOT to at least TRY orthotics first before undertaking surgery with such a high complication rate (in our pod surgery dept it's 9% BTW. Lower than average but high enough to justify cautious selection of patients.)

As i have mentioned i do not feel there is either rational nor evidence to justify accepting intrinsic muscle exercises as a valid treatment. One degree does not float my boat at all, sorry.

Regards to all
Robert

 

Robert - 1 degree on 10 patients over 3 months. A pilot study.

Pilot study.

Pilot study.

PILOT STUDY.

Maybe worth investigating further, not really evidence that FES is the be all and end all.

 

I believe that the plantar intinsics have been shown to be active during late midstance while the heel is still on the ground. See this previous thread where I had a discussion with Craig Payne about this fact.
Plantar intrinsics fire during midstance.
The increased activity of the plantar intrinsics during late midstance allows them to contribute to stiffening the medial column (and lateral column) and helping limit or control pronation of the foot, which makes complete biomechanical sense to me. DaVinci, do you have any research that the plantar intrinsics are not active until heel off??

 

LOL

Oooooh a pilot study. You should have said.

More study is always good but i don't consider that 1 degree improvement any different to 1 degree of getting worse especially with that small a sample size. But yes another study would be good.

Robert

 

Kevin - in the thread related to intrinsic muscles and arch height you've quoted 'Root, M.L., W.P. Orien and J.H. Weed: Normal and Abnormal Function of the Foot. Clinical Biomechanics Corporation, Los Angeles, CA, 1977, pp. 224-252'.

Unfortunately, I don't have a copy to hand (Chris Nester burnt mine, no wait, the dog ate it ) so can you let me know how they physically measured EMG during gait please? Or was it a reference from elsewhere and if so which one? Sorry about my poor book stock.

Lee

 

Robert - apologies for forgetting to mention it
Lee

 

Lee,

Most of the work in this field had Basmajians hand in it. They usually employed fine wire (needle) electrode EMG- this is not without it's problems. A fabulous read is:
Basmajian JV and De Luca CJ. Muscles Alive, (5th Edition): Williams and Wilkins

This text should be read by anyone interested in muscle function, i.e everyone.

see also the papers I referenced here:
http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=17398&postcount=19

Looking forward to reading your research.

 

Thanks Simon.
Looks like it's heading towards EMG (skin, no fine wire) of abductor hallucis during gait and having a more in depth look at 3D kinematics of the 1st MTPJ complex.
For future reference - apologies for the low sample size in the bone pin study - it was mainly about justifying my marker system, but if anyone wants to volunteer, I'd be more than happy to use fine wire and intracortical bone pins, especially if your southern.
Lee

 

The trouble with surface EMG and such small muscles that are anatomically so close to one another is differentiation, i.e it is difficult to be precise in which muscle is showing the activity. The trouble with needle electrode is it only measures the fibres in close proximity, so you may have activity elsewhere in the muscle without it registering on the EMG, i.e false negative. Even so, I'd pick needle every day of the week.

Have done some work on this in the dim and distant past when I was trying to work out the aetiology of hallux valgus for my PhD. If I can help, let me know Lee.

P.S. off top of my head Snijders (I thinks) did lots on kinematics in HV

Simon
Midlander

 

I tried to ignore this, but couldn't. Go on then Robert, explain yourself...

 

I hate it when you say that.

Simply that clinically not all "buniony" type feet present with a standard degree of Hallux abduction and Valgus rotation. Some hallucies are very valgus but not very abducted. Others are very abducted but not particularly rotated into valgus. I therefore do not like using Hallux valgus as a shorthand for any type of weirdness in the 1st mpj, i prefer to differentiate.

I suppose if you consider HAV to be a biplanar deformity (assuming it's not planterfexed as well) one could argue that a situation similar to planal dominance in the STJ exists. We assume a proportionate degree of deformity in transverse and frontal planes however some deformities may exist more in one plane than the other.

I tend to find that the different types of HAV / HV / HA respond to different treatment. An HAV with bags of A tends to involve a bigger bony protrusion and thus i tend to look to the surgery / footwear route. Don't matter how good the insoles are if there is no room for them in the shoes. HAV with more V than A i tend to find causes more problems with painful articulation but less of a lump therefor i tend to look to orthotics first.

Does that answer your question or am i missing something.

Regards
Robert

 

Curiously, I was watching a rather third-rate British late night TV show last night called "Emabarrasing Illnesses" or something like that.

The premise is that patients consult with medical practitioners about "embarrasing" conditions that they have, and the doctors explain it all to the viewers. Unsurprisingly, there a lot of breast, penises, and the like.

Last night, a young ?teenage female presents with a quite significant juvenile HAV. Clinically, she looked like she probably had a quite massive IM angle - at a guess.

The attractive female doc's advice: stand with her feet together and try to adduct the great toes towards each other. Repeat 20 times, morning and night. Then she threw up a bunch of pictures of severe forefoot derangements (looked like rheumatoid feet to me) and said that if the young lady stuck with her exercises then she will prevent her feet from looking that bad.

Too bad she already had severe deformity though...must be true though - it was on the telly.

LL