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Great article! I’ve been using short foot a lot in the clinic for the common lower extremity injuries that a lot of ya’ll have mentioned and it has been really effective. Since starting residency training, I have gotten a lot better at looking at the big picture with all of my patients (at some point). I’ve found a lot of people with SIJ issues/low back pain and hip pain to have deficits all the way down the chain and these can really be beneficial for them as well. Especially for people on their feet a lot- I feel like it helps to address “the cause” of some of their pain by treating the movement dysfunction. You’ve got to think that the foot is the interface between the body and the ground and if we aren’t moving well there, we probably are compensating somewhere else. I find it surprising how many people are weak here but it makes since considering the sedentary nature of a lot of jobs.
I found what they said about barefoot running to be interesting as well. My instinct is to avoid that type of activity in someone with a weak foot until they can “stabilize” and have them run shod only. However, it might be worth trying TM jogging for athletes barefoot in a controlled environment to improve their strength/control. It’s an interesting thought- will definitely try it.
As far as cueing, I’ve found it helpful to have patients try to “pull the ball of the foot towards the heel” without it coming off the floor. Also, a colleague of Myra’s cues patients to pretend there is a marble under their arch. I have had success with both. And when someone is really struggling, it helps to do the uninvolved or less involved side first. They can usually at least grasp the idea and then have more success on the involved side.
Great article to discuss and steal the term “foot core”. I thought their results after 4 weeks was pretty vague- I had to remember that they did not mention a functional change (i.e. SEBT, hop to stabilization, figure 8 hop test time) after strengthening of the “foot core” but saw a “framework” in which foot core may assist with this (granted I did not read all of the other articles). As far as categorizing who may need these exercises, I would say patient’s with plantar fasciitis, CAI, achilles tendinopathy/itis, post surgical ankle/foot/knee- really any patient who is allowing for prolonged or too quick of a deformation of the medial longitudinal arch and has goals for prolonged walking, hiking, running, etc. The short foot exercise is tedious to cue, however, plays an active role in further advancement of NMR or ther ex especially when we are working on dynamic stability/balance whether young or old.
Thanks for the clarification on toe yoga exercises Eric. Interesting.
I’m currently utilizing intrinsic strengthening with short foot exercises for a patient I’m seeing with bilateral plantar fasciitis. He presents with increased midfoot hypermobility which appears to overload his plantar fascia. Therefore the goal is to increase the intrinsic strength of the muscles in his foot for improved support of the midfoot and achieve a more effective lever at push-off.
•The table describing the functional quality and descriptions of the intrinsic foot muscles was really helpful.
•Kyle- I’m with Michelle, I’ve never heard of toe yoga exercises either. Please explain, haha.
•Michelle- I don’t think it’s probably necessary to cover intrinsic strengthening with every foot/ankle patient. Just as you wouldn’t perform stabilization/TA exercises on every low back patient. I think it would be important to classify the patient as far as their dysfunction and treat from there. Just me thinking- certainly room to discuss further ideas with this.
•I also thought the point they made about the significant improvement in single limb postural stability between barefoot and a thin sock was interesting. I certainly could imagine a difference between barefoot compared to shod however not simply between barefoot and a thin sock. So that was interesting information to read. I guess I will have more patients walk around barefoot rather than in socks. So Michelle, I’m with you on educating patients to walk around barefoot at home- that is if they don’t have diminished sensation.
•Since working at our clinic, I’ve probably spent more time with this patient population on performing short foot exercises than I may have in the past due to my own ignorance. Just like TA’s, I find it a very difficult exercise to cue patients on. For one, I can barely do it myself, so demonstration doesn’t really help much in that respect. Also, it is a great building block to progress the patient with in exercise- short foot with star excursion balance, short foot with bilateral squats, single leg squats, ect.
Great article on the role of foot intrinsic muscles. I think explaining foot intrinsics to patients as the “core of the foot” will help patients to have a better understanding of the role of the foot intrinsic muscles as it relates to foot dysfunction. Would you address foot intrinsic strengthening with every pt. that presents with a foot/ankle dysfunction?
The article provided supporting evidence for the short foot exercise as an effective strengthening exercise for improving intrinsic foot muscle strength. I’ve prescribed this exercise as well as the towel scrunch exercise to patients for foot intrinsic strengthening; however, after reading this article, the evidence suggests that the short foot exercise is more effective.
The article also mentioned barefoot/minimalist walking and running as a means for strengthening foot intrinsic muscles. If a patient presents to the clinic with foot/ankle dysfunction and one of the primary goals initially is to strengthen the foot intrinsic muscles, should we recommend the patient walk around (in their home) barefoot? Thoughts?
Kyle–what is the toe yoga exercise?
I am on board with all of the above thoughts. I may not let this article guide treatment solely, but would look at the cluster of research available and at my patient’s goals. I believe both theories and protocols for retraining are valid, but are more valid based on the patient’s demographic, previous functional level, and future goals. In regard to lumbar stabilization, I am biased toward more functional re-training and functional movement patterns as I believe standing and transitional movements (i.e. sit to stand, supine to sitting, stooping/bending) are more inclined to provoke a patient’s pain than in a purely supine position.
I agree with everyone, I think this article was very interesting and should definitely lead to some further research, but as far as guiding my treatment with patients, I am not sure how useful it is. Like Michelle mentioned, they gave very little detail on the treatment protocols they used. However, they did find improvements in pain and function so I may be inclined to seek out some other articles with more specific treatment protocols similar to the two they mentioned here and use those to guide my treatment more.
Regarding APAs, my thought at this time is that the research doesn’t yet point one way or another (they aren’t always finding delayed APAs for example). While I think it definitely plays a role in some way, I don’t know that I’d hang my hat on fixing this for everyone. My thought of what would fix a delayed APA would be training TA to pre-activate prior to functional movements like Steph mentioned. I do tend to train TA in anyone with back pain since the research is there that this muscle shuts off, however according to this article, this treatment isn’t actually affecting APAs. I don’t think we will ever do harm by training this so I plan to continue until there is more research on it (and it helps with pain and function anyway). I will say that I have had the most success with this type of treatment with patients who report pain with transitions (sit to stand, rolling, etc.) and I may spend much more time and put much more emphasis on pre-activating TA with these people than with someone else.
The results of the study state that the APA’s in patients with LBP did not change, however the patients got better. It’s tough because we know that patients are more likely to have improved outcomes when they are appropriately matched to a treatment. However, the patients in the study got better regardless of treatment, and regardless of the goal of treatment, which was to improve their APA impairment. So the question is, why did the patients get better? So I feel like if I had a patient meeting the inclusion criteria, I could really use either protocol in the study (STB or MSI) to improve their disability and function. However, if I wanted to be specific in addressing improvement in APA impairments, then I would have to seek out additional sources of treatment that have demonstrated more success. I’ve certainly thought about APA’s with patients and commonly think with my reasoning that impairments in APA’s are a contributor to movement dysfunction and pain. I’ve used TA activation techniques as an early treatment approach on several occasions. Maybe APA’s are too highly focused in on and we’re missing the bigger picture?! Maybe APA impairments are not the end all be all for reoccurring LBP. I have no idea, haha.
Mike- I need your brain! I’m anxious to hear your thoughts.
The article did not provide much detail on the protocols so I’d be interested to learn the specifics and whether or not the STB group performed training in functional positions.
I certainly think that APA is something that should be addressed when treating patients. I like to instruct patients in pre-activating core muscles with functional activities and incorporate perturbation and balance training to teach the system how to react to unanticipated stimuli.
• I wish the authors utilized a table outlining the details for the 3 objectives for each protocol. I’m curious to know what the functional activity modifications were specifically for the MSI protocol.
• I agree with the argument of the exclusion criteria; however, I also have a lot of patients who would fit into this study as well. I’ve seen a large population of young patients with a gradual onset of low back pain that’s chronic in nature. It would be interesting to see like Cameron suggested, having a subgroup of patients that have had spinal surgery or disc herniations and matching them to each tx group to see the results comparatively.
• I would also be interested in seeing results of each treatment approach after 8 weeks or even 12 weeks of treatment. Especially since the STB treatment protocol they referenced was an 8 week program. When thinking about CNS adaptations, I would think a longer program would be indicated.
• I think an important take-away from the article is that both STB and MSI tx protocols significantly reduce pain and increase function which is maintained up to 12 months. So at least we know there’s evidence to support what we’re doing helps. However, maybe the recurrence of LBP is not simply due to APA impairment but rather to non-compliance with continuation of independent management that further contributes to the delay of APA’s. Therefore I think more of the lack of response is due to the treatment duration rather than the paradigm of treatment.
I agree with everyone that the exclusion criteria eliminates a large percentage of low back pain patients that we treat in the clinic. It’s possible that those individuals that met the exclusion criteria may exhibit even more impaired APAs than those meeting the inclusion criteria given the nature of the dysfunction. It would be interesting to see a study that examined APAs in specific diagnoses of low back pain (i.e. disc herniation, stenosis, hypermobility) to see if a specific dysfunction inhibits APAs more than others. I also wonder if an individual’s prior level of function would affect APAs. For example, would the APA of an athlete that has done prior core work and demonstrates good NM control differ from a sedentary individual.
Interesting article! I do agree with you Cameron- it does seem like their exclusion criteria included a lot of what I would think would contribute to chronic LBP (BMI, magnification of sx, etc.). I thought it was also interesting that they did not find a delay in APAs and there is so much conflicting evidence about this, yet it is still the goal of their treatment to change this. I think their findings may lead researchers in a little different direction- maybe we need to be seeking out the proper treatment protocol to teach patients how to modulate movement strategies based on the task at hand. They did allude to this when they said “Treatment programs might benefit from additional practice and variation in task context to improve modulation of postural control and transfer of learning beyond treated exercises.” Until the research exists on what exactly this treatment would look like, it seems like it would definitely be beneficial to continue to train TA/mult but in functional positions (specifically where they have movement impairments/pain) and use all the concepts of motor learning (for example train sit to stand with TA from a million different chairs/surfaces/heights, progress from blocked to random training, increase variability in the task, add load/distraction, reduce feedback, etc) to try to encourage subtle changes of movement strategy based on the specific task.
I thought this article was very interesting in that it compared two “schools” of thought and found neither more effective. But what I do question is their exclusion criteria. I understand their reasoning for exclusion criteria but that excluded nearly 90% of all individuals that reported LBP. That’s a pretty big cohort of individuals that will walk into our clinic. Did anyone else find this interesting? Maybe the residual 90% of individuals would have responded to one of the two groups of treatment?