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Intrinsic Foot Muscles for Pain Syndromes Related to Abnormal Control of Pronation Written By: Dr

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Intrinsic Foot Muscles for Pain Syndromes Related to Abnormal Control of Pronation Written By: Dr Evaluation and Retraining of the Intrinsic Foot Muscles for Pain Syndromes Related to Abnormal Control of Pronation Written by: Dr. Bahram Jam, PT Advanced Physical Therapy Education Institute (APTEI), Thornhill, ON, Canada July 21, 2004 Article published on www.aptei.com “Clinical Library” Abstract: Little clinical research exists on the contribution of the intrinsic foot muscles (IFM) to gait or on the specific clinical evaluation or retraining of these muscles. The purpose of this clinical paper is to review the potential functions of the IFM and their role in maintaining and dynamically controlling the medial longitudinal arch. Clinically applicable methods of evaluation and retraining of these muscles for the effective management of various foot and ankle pain syndromes are discussed. Key Words: intrinsic foot muscles, medial longitudinal arch, pronation, exercises Introduction: The medial longitudinal arch (MLA) has been forth layer includes the interossei (INT) muscles described as a critical structure of the foot that (Kura et al 1997). The IFM are diagrammatically contributes to shock absorption and the attenuation of represented in Figure 1. Of all the IFM, the abductor forces transmitted to the body during gait (Donatelli hallucis and the adductor hallucis have the greatest 1996). Many structures may contribute to varying physiological cross-sectional area (Kura et al 1997), degrees to support the MLA including the plantar which supports the hypothesis that these are the most fascia (Fuller 2000), ligaments such as the plantar dominant IFM. calcaneo-navicular ligament (Borton & Saxby 1997), extrinsic foot muscles such as the tibialis posterior Several clinically common overuse injuries and muscle (Soballe et al 1988) and the intrinsic foot syndromes have been linked to pes planus and muscles (IFM) (Fiolkowski et al 2003). Although excessive pronation, including plantar fasciitis, there are many papers describing the role of the Achilles tendonitis, hallux valgus, tibialis posterior plantar fascia, ligaments and the extrinsic muscles of and tibialis anterior overuse syndromes (Hintermann the foot in supporting the MLA, little clinical & Nigg 1998, Van Boerum & Sangeorzan 2003, research exists on the contribution of the IFM in the Kaufman et al 1999). It is the authors’ hypothesis that maintenance and the dynamic control of the MLA. the primary biomechanical cause of some foot and Moreover, there is little written on the topic of ankle syndromes is not ‘excessive pronation’, but specific clinical evaluation and retraining of the IFM. rather a ‘lack of pronation control’. The IFM may The purpose of this clinical paper is to review the have a functional role for stabilizing the foot during potential functions of this group of muscles and how single-limb balance (Travell & Simons 1992). They dysfunction of the IFM may potentially be a are also active during gait and function similar to contributing factor to various foot and ankle elastic springs by supporting the MLA and conditions. Clinically applicable methods of maintaining the concavity of the foot (Moore 1985). evaluation and retraining of the IFM will also be It is therefore suggested that effective neuromuscular reviewed. This is to provide clinicians with a control of the IFM is essential in order to stabilize the potentially effective management option for various tarsal and metatarsal bones and modulate the rate of pain syndromes related to abnormal control of pronation. This ‘fine tune’ control is not only pronation and reduced dynamic control of the MLA. required for static control of the MLA, but is likely essential for the dynamic control of the MLA from The IFM may be divided and grouped into four the heel-strike to the toe-off phase of the gait cycle. layers. The first layer consists of the abductor Considering the complex movements occurring at the hallucis (ABH), flexor digitorum brevis (FDB), and inter-tarsal, tarso-metatarsal and the metatarso- the abductor digiti minimi (ABDM). The second phalageal joints during the gait cycle, the IFM must layer includes the quadratus plantae (QP) and the be able to consistently activate the right amount and lumbricals (LUM). The third layer includes the at the exact right time during the stance phase of gait adductor hallucis transverse (ADHT), adductor in order to be able to attenuate the forces placed on hallucis oblique (ADHO), flexor hallucis brevis the articular and soft tissues throughout the lower (FHB) and flexor digiti minimi brevis (FDMB). The extremity. ADHT LUM ABH ADHO FDB ABDM QP INT FHB FDMB Figure 1. A diagrammatic representation of the intrinsic muscles of the foot Panjabi (1992) brought forward a revolutionary stabilizing muscles following trauma, pain and/or concept for spinal stability and proposed that the inflammation. The insufficiency and neural control spinal stabilizing system consists of three sub- inhibition of these muscles have been associated with systems, the passive, active and neural control. It has pain and dysfunction at the lumbar spine (Hides et al been proposed that if the passive system is impaired 1996), thoracic spine (Lee 2003) cervical spine (Jull for any reason (e.g. post macro or micro-trauma), et al 1999), shoulder (Magarey & Jones 2002), hip maximizing the contribution of the active and the (Sims et al 2002) and at the knee (Stevens et al neural control systems may enhance stability and 2003). It has also been demonstrated that if the reduce related pain (Panjabi 1992, Hodges 1999, stabilizing segmental muscles are inhibited following Richardson et al 1999). Although this clinical pain or trauma, their recovery is not automatic and concept was originally proposed for the spine, it may that specific motor control retraining may be be transferable to any joint in the body including the necessary for functional recovery of these muscles foot and ankle complex. (Hides et al 1996). Unfortunately, the compromised strength, tonic control and retraining of the IFM There have been a number of studies that have related to foot and ankle pain have not been described demonstrated a compromised neural control, reduced or established in any published papers to date. endurance and often the atrophy of specific tonic Myofascial Pain Related to the Intrinsic Foot Evaluating pes planus and pronation using the Muscles: Navicular Drop Test: It has also been proposed that insufficient strength Although pes planus and hyper-pronation have been and endurance of the IFM may lead to overloading linked to many overuse pain syndromes, objective these muscles following sudden increases in walking, measurement and identification of this condition can running and jumping activities which may result in be challenging. One relatively simple method that has the development of related myofascial trigger points been proposed is the navicular drop (ND) test (Brody (Travell & Simons 1992). Interestingly, many of the 1982). This test is considered to be a composite signs and symptoms of plantar fasciitis are also measure of excessive pronation (Menz 1998) since it characteristic of specific IFM myofascial pain has been theorized that the amount of subtalar joint syndromes, which means that in some cases, the IFM motion can be indirectly detected by measuring the may be the primary source of heel and foot pain amount of motion at the navicular bone (Picciano et (Travell & Simons 1992). It is possible that the al 1993). The ND test is performed by calculating the effectiveness of supportive shoes or orthotics may difference between the height of the navicular from sometimes be simply attributed to the fact that they the floor when the subtalar joint is positioned in help support the MLA, and therefore help partially neutral and the height of the navicular from the floor unload overused IFM, hence reducing the myofascial when in relaxed stance in a full weight bearing pain. The effectiveness of massage, local pressure position (Brody 1982). and passive stretching of the “plantar fascia” may be simply due to inhibition of the over-active IFM. Firstly, the navicular tubercle is marked with a felt tip pen. Since it is hypothesized that the IFM are more Then in the seated position, functionally active in individuals with pes planus the foot is passively placed (Grey et al 1968), it may help explain why these into subtalar joint neutral (Fig. Figure 2: Subtalar individuals are at greater risk of developing 2). A simpler option of joint neutral passive myofascial pain syndromes of the IFM. The risks of approximating and achieving positioning IFM overuse increases in individuals with pes planus subtalar joint neutral is by especially if they participate in activities that involve performing active extension of prolong walking, running and jumping in non- the toes without raising the supportive footwear. meta-tarsal heads off the floor (Fig. 3). The toes are then Management of patients with IFM myofascial pain slowly dropped back down includes, rest by reducing the load on the muscles by without “losing” the MLA. temporarily avoiding prolong walking, running and The height of the navicular jumping. They must also be educated on avoiding the tubercle from the floor is then Figure 3: Active use of tight fitting shoes especially at the forefoot. measured with a standard ruler extension of the toes This is to prevent restriction of toe movement; shoe (Fig. 4) and this number is constriction may overload the IFM and activate the referred to as the navicular associated trigger points (Travel & Simons 1992). height in neutral (NHN). Another effective management includes the prescription of supportive shoes or the temporary use The second measurement is of orthotics to help unload the over-loaded IFM. taken in relaxed and natural Some patients with myofascial pain from the standing. Once again, the superficial or the deep IFM may have tried orthotics, height of the navicular but have usually quickly removed them because of tubercle from the floor is intolerably greater pain from the increased pressure measured and this number is on the trigger points of the muscles (Travel & Simons referred to as the navicular 1992).
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