I recently took part in a workshop where both manual and instrument assisted soft tissue therapy were heavily promoted as the gold standard in plantar sided foot pain presentations. While certainly such therapeutic interventions may act as positive adjuncts in the management of such cases, I often find myself using exercise interventions with relatively more rapid results. As always, patient management should always be context dependent but this is what I'm finding.
Interestingly, when therapists do consider exercise interventions, heel raises/lowers off stairs seem to be the "exercise of choice". Often such presentations are acute or "hot" and based on Craig Purdam's work on tendinopathies, such exercises may be too advanced for significant progress to be made.
Now before I introduce some alternative exercises, I'd like to address the "One Toe Syndrome". Patients with plantar sided foot pain, especially women for some reason, often present with this "syndrome". They may indeed have five toes, as most of us do, but if you look closely the toes actually function as one unit rather than five individual units.
Dewey Nielson wrote a nice post (Barefoot Training by Dewey Nielson) a while back that included how our feet should actually look like. Next time you're at the zoo, check out the monkeys' and the orangutans' feet. Others have written about the barefoot trend in recent times as well but often with relatively little suggestions. That said, Patrick Ward and Charlie Weingroff have made some suggestions themselves, so here's how they recommend integrating foot work in training.
Tissue extensibility dysfunctions seem to be common in such presentations as well so prior to exercise, I'll commonly get the patients to foam roll on their calves, feet and anything else that might need "freeing up". Maybe it does something, or maybe it just feels good.
Aside from the above, two specific interventions that I commonly prescribe are the Vele Forward Lean and the Reverse Tandem Gait. The Vele lean is Michael Jackson-like, or for those of you who ride the subway, similar to facing backwards as the subway enters the next station.
The Reverse Tandem Gait, on the other hand, is a simple eccentric exercise that integrates the intrinsic foot musculature with less load than other commonly prescribed exercises. The key is to ensure that the feet are actively engaged, with the heads of the first and fifth metatarsals firmly planted into the ground to create the tripod with the calcaneus.
Here are both exercises in a recent patient. Note that for those that suffer from the "One Toe Syndrome", I'll often use toe separators to bring the 2nd, 3rd, 4th and 5th toes back into action.
The one thing I want to make mention of, is what happens the other 23.5 hours of the day. To put it bluntly, high heels do your patients no favors. Neither do narrow toe boxes. Some will also argue that footwear is generally too supportive but personally, I (again) think it's context dependent. And apparently so does Alex Hutchinson. He wrote a nice post not too long ago on Why Normal nor Minimalist Running Shoes Will Disappear.
I do think we can transition toward less support so here are some suggestions for your active patients based on my own daily experience.
- Vibrams when performing kettlebell exercises...
- Vivos when deadlifting, squating and performing other lifts in the gym...
- New Balance Minimus when treating patients 12 hours a day.
Again, what I do on a daily basis may not apply specifically to yourself or those you work with, but it's what works for me personally.
If you would like more information on any of the above, check out Barefoot in Boston by Art Horne and Craig Liebenson's DVDs.