resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Sleep, Less Sleep or No Sleep?
I had a dream I wasn't getting enough sleep. It was a very realistic dream, even though I was probably slightly awake and not really deep dreaming. Most likely I had been dozing, caught in that twilight of sleep and wakefulness.
Integrating Art with Clinical Practice for Patients with PTSD: The Artemis Project
Are you restricted by those one-on-one clinic dynamics? Why not join colleagues and clients in experimental group settings? Three of us volunteered to do just that in Austin on behalf of women veteranss from all branches of the service.
Animal Acupuncture: A Case Study in the Treatment of Traumatic Injury in the Equine
The rise of animal acupuncture in the U.S. began in the early 1970's as a result of the work by members of the National Acupuncture Association in Westwood, Calif.
Talking to Patients About Lumbar Facet Denervation (Medial Branch Neurotomy)
Lumbar facet denervation, more appropriately termed medial branch neurotomy (MBN), is a procedure that may be considered when patients suffer from recalcitrant non-radicular axial back and/or leg pain.
Optimism = Compassion = Trust
A randomized clinical trial recently published online in JAMA Oncology examined how patients viewed their doctor based upon how the practitioner presented bad news to the patient.
Marijuana, Apathy and Chinese Medicine, Part 1
This article was written in response to the unheeded acceptance of marijuana as a harmless substance that potentially does good when used for the medical relief of pain.
Applying the Thin Skull Principle
The "thin skull" principle, also known as the "you take your victim as you find them" principle, is a legal principle that can be summed up by the following statement.
How Much Do You Know About the Benefits of Birds Nest?
Edible bird's nest is the nest made by the Swiftlet bird of Southeast Asia that is usually prepared as a soup and prized in Chinese culture as a healthful delicacy.
Medicine is Clumsy, Don't You Be
All medical systems have clumsiness in them. If the technique isn't, the practitioner is. Everyone in every form of medicine is striving to improve. That is why we call it practice.
Low Back Pain in Professional Golf: A Common Muscular Relationship
Every sport creates its own unique demands on the body. Some sports require such a myriad of body positions that assessing pathology is often difficult and unpredictable.
5 Simple Steps to Create an Effective Marketing Calendar
In the educational experience of most healthcare practitioners, business and marketing are overlooked topics.
The Tide is Rising in the Acupuncture Profession
Former President Ronald Regan said, "When the tide rises all boats float." The tide is rising for the acupuncture profession. Many forces outside the profession are helping the tides to rise.
Turning a Blind Eye to History – and Reality
The American Medical Association is taking the Supreme Court's Feb. 25, 2015 decision exactly as it always does – by turning a blind eye to history, legal precedent and reality.
Functional Hip Impingement (Part 1)
Every time I sit down to write an article, I realize how much more there is to know about musculoskeletal pain. I also learn something new every time. (I want to give special thanks to Lucy Whyte Ferguson for assisting with this article.)
A View From the ER
The University of Western States has inked an innovative agreement with local nonprofit health system Legacy Health whereby UWS sports-medicine fellows can experience observational clinical rotations in emergency-room settings within the Legacy system.
The Challenges of Integrating Eastern and Western Medicine
My Masters thesis was titled, "The Challenges of Integrating Eastern and Western Medicine," which highlighted several reasons why it is hard for these two worlds to mix.
The Acupuncturist's Problem
I want share with you some observations and insights into what seems to be the most common problem my colleagues in the acupuncture profession struggles with. If you also struggle with this problem, I hope you get a valuable "aha" moment from reading this.
A House Divided?
The American Chiropractic Association's House of Delegates voted on 30 resolutions at its annual business meeting in Washington D.C., but two in particular took immediate center stage due to their controversial nature.
PCOM Granted Regional Accreditation
Pacific College of Oriental Medicine (PCOM) recently announce it has received regional accreditation from the Western Association of Schools and Colleges (WASC). This achievement reflects five years of hard work on the part of faculty, staff, and students.
Term Limits: What's in a Word?
It was the French historian and philosopher Voltaire who once declared the Holy Roman Empire was neither holy nor Roman nor an empire.
April, 2013, Vol. 13, Issue 04
Reclaiming Functional Feet: The Janda Short Foot Exercise
By Nicole Nelson
The plantar intrinsic foot muscles might be the most underestimated players in the quest for optimizing posture and ideal function. These muscles are instrumental in controlling the dissipation of ground forces and stabilizing the foot during impact.Likewise, afferent inputs from the sole of the foot are believed to affect postural awareness and gait. It stands to reason that improving the function of the intrinsic foot muscles may be one of the best ways to promote ideal stabilization and motor control throughout the entire body. The following is a review of the basics of the intrinsic foot muscles (IFM), the implications of imbalance in the IFM and a discussion of Janda's short foot exercise.
Anatomy and Function
The plantar IFM are arranged in four layers, all of which are innervated by the plantar branches of the tibial nerve. The first layer consists of the abductor hallucis (often celebrated as the captain of the IFM), flexor digitorum brevis and the abductor digiti minimi. The second layer includes the quadratus plantae and the lumbricals; the third layer includes the adductor hallucis transverse, adductor hallucis oblique, flexor hallucis brevis and flexor digiti minimi brevis. The fourth layer includes the interossei muscles. The plantar IFM differ from their more extrinsic foot counterparts in that they strictly span the foot and do not cross the ankle. Their primary function is to provide dynamic support of the medial longitudinal arch (MLA) of the foot and to control forces that act to excessively spread the arch while walking, running or jumping.
The MLA consists of the calcaneus, talus, navicular, cuboid, three cuneiforms and the first three metatarsals. Many conceptualize these bones as fixed; however, there should be a fair amount of rotation, flexion and extension occurring between these structures during impact and push off phases of gait, as this mobility is necessary for additional shock absorption and force generation. While many foot structures contribute to the static and dynamic control of the MLA, the intrinsic foot muscles may be the most important. A study by Fiolkowski et al 2003, discovered a significant navicular drop (the keystone of the MLA) after administering a nerve block in order to de-activate the intrinsic muscles in study participants. Another study by Headlee et al 2008, induced fatigue to the IFM and also discovered a significant navicular drop. Both of these studies indicate the essential role of the IFM in supporting the MLA and suggests that IFM weakness can contribute to an unstable, poorly functioning foot.
IFM Imbalance Implications
Although difficult to isolate the IFM during testing, weakness in these muscles have been associated with many foot and ankle problems including plantar fasciitis, lesser toe deformities and bunions. Weakness of the intrinsic foot muscles is considered a risk factor for plantar ulcerations in individuals suffering from diabetes. This is likely due to the altered foot rollover during gait and ineffective plantar load distribution. Imbalance in these muscles is not simply a local issue, as faulty foot mechanics are known to cause compensations up the kinetic chain leading to knee, hip, low back and cervical issues.
How about just going for a barefoot run to train the IFM? I'm often asked if minimalist footwear or going sans shoes is a good way to correct poorly functioning feet. As Gray Cook would probably say,"don't add strength to dysfunction." The problem I have with our clients ditching their clunky running shoes is that their feet are not prepared for the demands of their body weight meeting the ground without a nice cushioned buffer. It is my opinion that some feet just don't have the potential to go completely naked; those that do will need to improve the function of the intrinsic foot muscles and progressively strengthen the musculature before they begin wearing the minimalist footwear or going barefoot for extended periods of time. In other words, running barefoot or wearing minimalist shoes are the end game, not the place to start. Janda believed that the proprioceptors on the sole of the foot need to be stimulated and a balance of activity among the intrinsic and extrinsic muscles of the foot needs to be established in order for lasting positive change can occur. So our "restore the foot project" should begin with a combination of appropriate soft tissue work and sensory motor retraining and maybe somewhere down the road, our clients can let their feet run naked. As always, consider the entire body when doing your evaluation and assessments.
As much as I like simple assessments, the old "wet foot test" probably doesn't reveal all that much in terms of what we need to do to help our clients reclaim functional feet. Although many would say the SFE is well suited to the flat foot (pes planus), those with high arches (pes cavus) and neutral arches can collapse just as much as the structurally flat foot during dynamic foot movements. Along these same lines, all arch sizes are subject to issues such as plantar fasciitis, achilles tendonopathy, tibialis anterior and posterior overuse syndromes, stress fractures, etc. This has led many researchers and clinicians to suggest that these commonly seen overuse pathologies may be a result of the client lacking the ability to control the arch upon landing and pushing off rather than just having a puny arch. So, if our goal is to improve the ability of these muscles to dynamically control the MLA, we need to see the client's feet in action. I use two dynamic assessments, which are not meant to take the place of a thorough exam by a foot specialist, but it will give you an idea of if the IFM are adequately controlling the MLA.
Walking test. Without the client's knowledge, observe the way they walk toward you (you will get a more accurate impression of their foot control if they don't know you are critically assessing them). A few things you want to look out for:
Single leg test. Have the client stand facing a wall, with the feet and knees shoulder width apart, with the knees slightly flexed. The client should place their finger tips on the wall for a bit of balance help. Instruct the client to gently supinate the feet by lifting their toes (this will wind the plantar fascia and create an arch), then slowly drop the toes but try to maintain the arch that was created. If they can't do this on their own, you can help by placing your hands on their foot and actively shortening their foot for them. While holding the MLA, have the client lift one foot and stand on one leg for 30 sec. Note the steadiness of the client and watch for any reduction in the MLA. Keep a look out for excessive toe grabbing; this is considered faulty patterning and demonstrates a dominance of the more extrinsic muscles of the foot and ankle. Have them perform the same test on the other foot.
If you observed any the faulty patterns mentioned above, the SFE is likely a good corrective exercise for them.
Towel Grab vs. Short Foot Exercise
I admit, I used to love the towel grabbing exercise for my weak footed clients; as it turns out, it may not have been the best IFM strategy. Recent research pitted the towel grab exercise against the SFE with the researchers concluding that the SFE is more effective at recruiting the IFM. Despite these results, don't ditch your towels, just save them for the clients with weak, unstable ankles.
I find the best time to work the SFE into a session is after bodywork. Specifically after I've done some big toe mobilization and myofascial work on the feet. When your clients first attempt the SFE, they will likely have no sense of how to turn on these intrinsic muscles, this will be seen by the client grabbing the ground with the toes. This lack of motor control will require your assistance to model what the foot should do. With your client seated, place one of your hands on the back of the client's heel, while the other hand should cup the forefoot. Gently squeeze the 1st and 5th metatarsals together while creating a supportive pressure to the back of the heel. Your intention is to condense their foot, which should create a neutral arch for them. Ask your client to feel what is happening to their foot and to try and appreciate the energy it would take to hold this foot posture.
With your hands on the client's foot, have them actively hold the arch, assist them with some tactile support when you note a failure of proper foot activation. Cue the client to narrow the forefoot and pull the front of the foot toward the heel. They should be able to create an arch while the toes and heels remain flat on the floor and the toes are not excessively grabbing the floor. Once the client has developed a feel of what the short foot feels like, keep them seated but wean them from your help by taking your hands away and have them hold the short foot for 10 seconds followed by a short rest, then repeat 4-5 times. The next progression is to perform the SFE while standing, once again challenging them to hold the short foot for 10 sec and then resting and repeating 4-5 times.
As these muscles get stronger and more adept at firing, have them hold the short foot for longer intervals. Eventually have the client integrate their new and improved "short foot" to more functional activities such as performing a squat-single leg standing while touching a wall for support (single leg standing without the wall) performing a lunge, etc.
The SFE may be one of the best ways to re-establish control of the intrinsic foot muscles. These muscles are known to have a positive influence on posture and gait, yet are often times "out to lunch" regardless of foot type. Soft tissue work in addition to improving motor control of the foot will go a long way to restoring muscular balance, optimizing posture and preventing injury.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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