Ligament failure from wrist hyperextension weight bearing basic review

    

Ref: https://www.naasery.com/

            Have you taken weight on your palm with pain? Taking weight on the palm such as push up, handstand, or hand support is a common function in daily living and sports. To do this function requires wrist extension, that is motion from carpal bones. 

It is FOOSH injury which is nickname for an injury caused by fallen onto an outstretched band.

         

Different wrist hyperextension weight bearing direction make different ligament injury
(Ref: https://aulakinesica.com.ar/semioquirurgica/files/12389765.pdf)

           Carpal bones are 8 bone components in 2 rows of wrist joint which consists of trapezium, trapezoid, capitate, and hamate in distal carpal, and scaphoid, lunate, and triquetrum in proximal carpal. However, pisiform bone which is sesamoid bone on triquetrum and is easy to palpate because it locates out of carpal line superficially. 

The complex nature of carpal mechanics can be simplified by considering the distal carpal row (trapezium, trapezoid, capitate, and hamate) as securely attached to the medial 4 metacarpals through short, tight, intrinsic ligaments. The distal row moves with the hand as a single unit. The proximal carpal row (scaphoid, lunate, and triquetrum) can be considered a single free-body, intercalated between the hand (including the distal row) and the forearm, suspended by extrinsic radiocarpal and intrinsic intercarpal ligaments. 

Carpal bone anatomy
(Ref: https://www.lecturio.com/)

As the hand forearm unit moves the wrist, the position of the intercalary proximal row shifts at the radiocarpal joint (relative to the forearm) and at the midcarpal joint (relative to the hand), similar to a ball-and-socket joint. The carpal mechanism depends on the health and integrity of the intrinsic and extrinsic ligaments to guide bony relationships among the 7 critical carpals (pisiform excluded). 

Carpal alignment at rest is maintained with considerable stored potential energy and, by definition, a predisposition of the carpus to collapse into a more stable but less physiologic attitude. Ligamentous struts and guy wire mechanisms maintain the longitudinal axis of the scaphoid at about 47 relative to the longitudinal axis of the hand forearm unit. A neutral position of the lunate is maintained through its secure attachment to the proximal scaphoid pole by the scapholunate (SL) interosseous ligament. Separated from the palmar - flexing influence of the scaphoid, the lunate is predisposed to collapse into extension  

Wrist joint component: Radius, Ulnar, Carpals, Metatarsal, and Carpal ligaments
(Ref: https://www.ncbi.nlm.nih.gov/)

    Wrist extension pain is related to carpal instability that can develop to hyperextension. 

Carpal instability can occur after trauma, remotely after trauma, and sometimes without trauma. The 3 most important conditions are scapholunate instability, lunotriquetral instability, and perilunate instability complex. The carpus is considered unstable if it exhibits symptomatic malalignment, is not able to bear loads, and does not have normal kinematics during any portion of its arc of motion.  

There are 4 patterns of instability that have been described by various investigators and are widely accepted Carpal instability dissociative (CID) refers to instability within a row of carpal bones, such as scaphoid fractures or scapholunate dissociation in the proximal row. Carpal instability nondissociative (CIND) is instability between rows either at the radiocarpal joint (eg, radiocarpal fracture dislocations) or midcarpal joint (eg, midcarpal instability). Carpal instability combined/complex (CIC) is a combination of CID and CIND, such as Perilunate dislocations (PLDs). Carpal instability adaptive (CIA) refers to carpal malalignment in adaptation to extra carpal changes (eg, carpal collapse in malunited distal radius fractures). 

Scapholunate instability 

Scapholunate ligament
(Ref: http://rehabforbetterlife.com/)

Scapholunate instability is the most common form of carpal instability. Scapholunate ligament tears wrist instability commonly occurs in a spectrum of severity in hyperextension injuries. Contact sports such as football or rugby commonly place the athlete in a position of impact with hyperextension, ulnar deviation, and supination of the wrist that can lead to these injuries. This may be preceded by a fall. Pain is typically over the dorsum and dorsoradial aspect of the wrist, aggravated by loading the extended wrist or strenuous activity. Pain in a loaded, extended wrist with tenderness in the dorsal wrist at the interval between the third and fourth extensor compartments suggests possible scapholunate interosseous ligament injury. Lab investigations including x - ray and MRI are needed.

Forward wrist weight bearing (hyperextension, ulnar deviation, and supination)
Ref: https://www.amazon.com/)

 

Stage 1 of 6 which is initial treatment consists of splinting to allow healing in acute and subacute injuries with subsequent proprioception training of the flexor carpi radialis and extensor carpi radialis muscles. Surgery for recalcitrant pain includes arthroscopic interventions, such as de´ bridement alone or with thermal shrinkage and/or pinning, and has 80% to 90% success rates. Left untreated, it may progress to arthritis. 

Lunotriquetral instability 

Lunotriquetral ligament injury develop Lunotriquetral instability
(Ref: https://www.3pointproducts.com/blog/)

Lunotriquetral instability remains frequently underdiagnosed. It may occur in isolation as an acute traumatic tear or in association with degenerative causes, such as ulnocarpal abutment and central TFCC tears, and as part of the perilunate complex injury, to name a few conditions. Acute isolated injuries typically result from a backward fall with the hypothenar eminence striking the ground. Tenderness is localized to the lunotriquetral interval with the appearance of a volar sag, and the Reagan ballottement and Kleinman shear tests may be positive. Stage 1 of 3 which is acute partial injuries, above-elbow casting or splinting with a pad under the pisiform to boost the triquetrum into correct alignment is prescribed. Even in chronic situations, this should be the first line of treatment. Patients who remain symptomatic may benefit from arthroscopic de´ bridement with or without pinning of the lunotriquetral joint. 

Backward fall down
(Ref: https://www.jucm.com/)

Perilunate instability complex 

Perilunate instability complex is the most common wrist dislocation and presents a spectrum of ligamentous and/or bony disruptions to the carpal. The mechanism of injury is wrist axial loading and hyperextension, ulnar deviation, and intercarpal supination. Purely ligamentous injuries are termed lesser arc injuries and those with a fracture greater arc injuries. These terms are synonymous with PLD and perilunate fracture dislocation (PLFD), with the most common fracture a scaphoid fracture. Aside from the acutely painful and swollen wrist, clinical findings may be subtle and there should be suspicion with a high-energy injury mechanism. Acute median neuropathy may be present and was reported in 23% of cases in Herzberg and colleagues’ series. CT scans are indicated when fractures are suspected. This instability may need surgery recommendation from doctors. 

Perilunate instability or dislocation
(Ref: https://link.springer.com/chapter/10.1007/978-1-4471-6572-9_27)

Distal radioulnar joint (DRUJ) instability

    Distal radioulnar joint (DRUJ) instability can occur either from a variety of causes including traumatic and nontraumatic causes. Primary stability of the DRUJ is contributed by the congruity of its articular surfaces and the TFCC. The DRUJ is further reinforced by an osseocartilaginous lip on the volar aspect of the radius. The secondary stabilizers include the joint capsule, extensor carpi ulnaris, pronator quadratus, and interosseous membrane. DRUJ instability can be due to either alterations in the bony anatomy, resulting in altered sigmoid notch architecture or abnormal radioulnar relationship, and/or disruptions to the TFCC. 

TFCC injury develop instability
(Ref: https://pathologies.lexmedicus.com.au/)

DRUJ instability may accompany distal radius fractures due to TFCC disruption or basal ulnar styloid fractures. A fracture of the palmar lunate facet disrupts the buttress effect of the palmar lip and can cause instability. TFCC tears can be traumatic or degenerative. Synovitis in rheumatoid arthritis attrite the stabilizers of the DRUJ, causing instability. 

Patients may present with ulnar-sided wrist pain after a fall on an outstretched hand that is usually exacerbated with loading of the wrist in extension, at the extremes of pronation or supination, or after lifting weights. Patients may report clicking and hypermobility. There may be swelling over the ulnar side of the wrist with a dorsally subluxed ulna head projections of the wrist suspending 2.27 kg of weight and always should be compared with the opposite side. MRIs can delineate foveal and peripheral tears of the TFCC as well as assess the state of cartilage in the DRUJ. 

Basal ulnar styloid fracture is in red box.
(Ref: https://www.reddit.com/r/)

TFCC injuries can occur with injuries to the extensor carpi ulnaris and fractures of the radius and/or ulna bone, and these must be addressed concurrently. Nonoperative treatment of acute TFCC injury involves casting or splinting the patient in the position of stability for a period of 6 weeks. In patients with persistent DRUJ instability after fracture reduction or after a trial of nonsurgical treatment, TFCC repair is warranted. This can be done as an open procedure for arthroscopic assisted or arthroscopic capsular repairs. An open repair can be done via an approach between the fifth and sixth extensor compartments. An inverted L-shaped capsulotomy is made, preserving the dorsal radioulnar ligament. The TFCC is then anchored via bone tunnels or suture anchors.

Triangular Fibrocartilage Complex (TFCC)
(Ref: https://www.orthobullets.com/)

Scaphoid fracture 

Scaphoid fracture type
(Ref: https://www.rch.org.au/)

Scaphoid fractures are the most commonly injured carpal bone with a high incidence in college football players and an increasing incidence in female athletes. This hyperextension wrist injury tends to occur in a pronated, radially deviated hand. Presentation can range from disabling wrist pain to mild swelling and decreased range of motion. It is not uncommon to find a scaphoid nonunion with a remote history of a wrist sprain. Located at the radial side of the carpus, athletes will complain of radial-sided wrist pain with exquisite tenderness in the anatomical snuff box, axial loading of the thumb, or pincer grasp. Radiographic and MRI assessment of the wrist should be involved in diagnosis. 

Anatomical snuff box is represented by red triangle
(Ref: https://teachmeanatomy.info/)

Treatment decisions depend upon fracture location and displacement, with strong surgical consideration being given to scaphoid fractures which are displaced and/or proximal. Whether treatment affects the athlete’s continued participation in his or her sports within the context of the status of the season may also play a role in determining whether or not to operate. Due to retrograde blood supply, distal pole scaphoid fractures can effectively be treated nonsurgical.

There are basic wrist hyperextension injury reviews that raise during wrist extension weight bearing activities. The signs and symptoms are demonstrated on the radial side, the most. Mechanics of injury history, physical assessments, and radiography are combined in diagnosis confirmation. In case of mild damage, it needs to be immobilized by a brace. In case of more instability, it needs to be operative. However, all cases need physiotherapy to improve the quality of movement. 

    

Push up bar
(Ref: https://theworkoutdigest.com/)

                Push up bar or fist weight bearing on thick cushion may compensate pain mechanical.

Ref: https://blog.joinfightcamp.com/

Reference:

http://ortho2.md.chula.ac.th/phocadownload/data-sheet/injuries-wrist-AdisornMD.pdf 

https://josr-online.biomedcentral.com/articles/10.1186/s13018-016-0432-8 

https://aulakinesica.com.ar/semioquirurgica/files/12389765.pdf 

https://www.researchgate.net/publication/319937516_Treatment_of_scapholunate_ligament_injury_Current_concepts 

https://journals.sagepub.com/doi/pdf/10.1177/23259671221088610 

Low back health assessment by manual technique and Isokinetic dynamometer technique

             

Ref: https://www.southeasttexasspine.com/blog/

            Low back pain (LBP) is one of the most common musculoskeletal problems in many ages both of male and female. Presently, we have seen LBP in younger populations such as university students. Digital lifestyle is always mentioned as the cause of LBP.  

LBP refers to pain, muscle tension or stiffness below the costal border and over the lower gluteal fold, with or without sciatica. It can be classified according to its duration in acute low back pain (ALBP), less than six weeks, or chronic low back pain (CLBP) when the pain persists for more than three months. By the way, It can be divided into 2 groups by cause of pain including non-specific LBP (NSLBP) and anatomical LBP.

An anatomical source of pain (e.g, Epidural abscess, compression fracture, spondyloarthropathy, malignancy or cauda equina syndrome) is known by clear causes from pathological or trauma. 90% of LBP cannot identify specific causes, so it is denominated non-specific LBP (NSLBP). However, multiple factors have been associated with the occurrence of NSLBP, among them the alteration of the neuromuscular response of the trunk, the deconditioning (or decrease in the function) of the lumbar musculature, the reduction in the muscular mass of the trunk, and the reduction in the muscular strength of the trunk.

Spine and disc degenerative
(Ref: https://www.sandiegospinefoundation.org/)

577 million people suffered from LBP in 2017. It is among the three leading causes of years lived with disability.

The LBP is closely related to instability in the lumbar spine segment from both mechanical and degenerative. The spine needs to be mechanically stable at all times to avoid injuries that can eventually lead to pain. Maintaining this stability is the role of the active neuromuscular system, and thus the trunk strength plays an important role in different aspects related to health and sport.

Stability of the lumbar and pelvic complex is defined as the ability to keep balance and firmness in their structures while performing body movements, and the improvement of segmental stability and trunk neuromuscular control can provide a solid foundation not only for the segment, but also for the whole body, as it prepares the body to deal with external disturbances, such as traction, torsion, and shear, which can cause injuries to the segment or other body parts.

Soft tissue force vector to balance and stabilize spine
(Ref: https://chiro.org/Low_Back_Pain/Stability_From_Biomechanical.shtm)

Trunk strength has been related to injury prevention, which is why it plays an important role in the functional evaluation of people or athletes. Muscular strength refers to the “maximal force (measured in newtons or pounds) that can be generated by a specific muscle or muscle group“. 

Stability needs not only trunk strength but also trunk endurance. Endurance or fatigue of the trunk is important because it has been widely reported that patients with low back pain develop a deconditioning syndrome that particularly influences the strength and function of the back muscles, with such patients being much weaker than healthy controls. Lack of endurance has also been highlighted as a key factor for predicting low back pain, and this suggests that the assessment of fatigue warrants further investigation. 

The progression of low back degenerative develops pathology and instability
(Ref: https://content.iospress.com/articles/journal-of-back-and-musculoskeletal-rehabilitation/bmr210097)

Muscle endurance refers to “the ability of a muscle group to perform repeated contractions over a period of time sufficient to cause muscular fatigue, or to maintain a specific percentage of maximum voluntary contraction for a prolonged period of time”. Muscle fatigue is a complex and multifaceted process involving physiological, biomechanical, and psychological elements. It is an important phenomenon, as there are numerous proven relations with work related musculoskeletal injuries.

The ways for assessing lumbar and pelvic stability range from simple palpation of local muscles and isometric endurance tests to use of equipment such as electromyography, ultrasound imaging device, and isokinetic dynamometer. 

Prospective studies have shown trunk assessments that specifically isometric and isokinetic of trunk flexors and lumbar extensors muscles. By practicality in the clinic, core endurance was assessed by using the Mcgill Core Endurance Tests including.

(1) The anterior core endurance was assessed by using the flexor endurance test. The test was initiated with the participant’s hands crossed at the shoulder; the knee and hip joints at 90˚ flexion; the feet stabilized by the research assistant physiotherapist. The participant’s body was flexed until the lower end of the scapula rose from the bed and the duration of maintaining this position was recorded by using a stopwatch. 

The anterior core endurance test
(Ref: https://www.e-jer.org/journal/view.php?number=2013600519)

(2) The extensor endurance test was used to test the erector spinae and multifidus. During this test, the participant’s body was hanging down from the table as the ASIS aligned with the table edge, the hands were crossed at the shoulders and the feet were in the supported position. The test was initiated when horizontality was achieved and the duration to maintain this position was recorded by using a stopwatch. 

The extensor endurance test
(Ref: https://www.researchgate.net/figure/Summary-of-correlations-between-core-stability-functional-movement-screen-and_tbl1_41548703)

(3) The lateral bridge test was performed to test lateral core muscles. This test was performed in a side-lying position with the legs extended with one foot in front of the other foot and the body in a straight line by lifting on the front arm of the lying side. The duration to maintain this position was recorded by using a stopwatch. This test was assessed for the dominant side first and then for the nondominant side.  

The lateral bridge test
(Ref: https://www.e-jer.org/journal/view.php?number=2013600519)

Isokinetic dynamometry is a machine which provides resistance to control speed motion. 

In the term “Isokinetic” was referred to angular velocity consistency. For example, the machine was set for low angular velocity, if you push high power and speed, the machine will generate high resistance to you to control your motion at the setting. 

"The most 2 popular isokinetic dynamometry brands which I have seen are Biodex and Humac norm".

Isokinetic dynamometry is a well-accepted tool for assessing strength of the upper and lower extremities as well as trunk muscles, and isokinetic strength testing is a useful approach to assess trunk extension and flexion in healthy individuals as well as in patients with low back pain. 

Brand Biodex
(Ref: https://ssrc.ac.ir/)

Isokinetic assessment relates to LBP that determines the muscle torque of flexor and extensor groups, analyzing the agonist/antagonist balance for better treatment planning and injury prevention in reducing an athlete’s risk of injury, providing criteria for discharging the patient. isokinetic measurements can be used to identify strength deficits in individuals with and without pathologies. Moreover, it is used to define deficits in specific pathologies, as well as to evaluate effectiveness of training and therapy. 

This measurement is based on the principle of testing strength capacity under constant rotational or linear motion velocities and is considered the ‘gold standard’ for assessing strength capacity. Current dynamometers are capable of measuring isometric, concentric and eccentric contraction modes for clinical, performance and scientific applications. 

Brand Humac Norm
(Ref: https://www.humac.com.au/)

The assessment of fatigue and endurance in the trunk is important because it has been widely reported that patients with low back pain develop a deconditioning syndrome that particularly influences the strength and function of the back muscles, with such patients being much weaker than healthy controls. Lack of endurance has also been highlighted as a key factor for predicting low back pain, and this suggests that the assessment of fatigue warrants further investigation. 

  In the field of sports, it is thought that increases in the ability to exert the maximum trunk muscle force (trunk muscle strength), as well as the ability to exert trunk muscle force repeatedly or continuously over a long period of time (trunk muscle endurance), can improve athletic performance and help prevent and treat back disorders in individuals with trunk muscle weakness.  These positions may produce dissimilar levels of peak torque, work, and power of isokinetic concentric trunk extension and flexion at 60°/s and 120°/s in the sitting and standing positions. 

The 60°/s represents strength assessment, whereas the 120°/s is used for endurance or fatigue assessment. The range of motion in assessment varies that is possible to be -10˚ of hyperextension to 80˚ flexion. 

Isokinetic dynamometry assessment has limitations. Although it is commonly used in clinical practice for testing of the extremities, only a few findings regarding the reproducibility of trunk strength testing exist. Unfortunately, it is not universally accessible and is rarely used clinically owing to its high cost, requirement for considerable user expertise, and protracted testing time.

“The product price is greater than a million THB”.

Moreover, there is a lack of normative data of trunk flexors and extensors muscle strength in the literature. Particularly, there is a lack of normative data from asymptomatic adolescent and adult athletes, unlike the arms and legs. In this way, the comparison of the trunk strength of an individual always will need to be compared with population normative data or parameters of normality.

Isokinetic dynamometry evaluation result sheet
(Ref: https://www.pbscentre.com/en/biodex-dijagnostika/)

The functional applicability of isokinetic measurement still remains questionable. Some scientists agree that isokinetic movements are “unnatural” and the motion involved is not related to that which occurs during sporting performance”. In addition, it has to be emphasized that what is being measured is not internal muscle tension but the torque/force output of complex muscle systems especially when assessing the spine.

It is nice to have a trunk isokinetic dynamometry assessment if you can afford the bill and can access the machine. If not, you can have a manual assessment as above. As far as I know, one health service place where this machine is located is the Bangkok Academy of Sports And Exercise Medicine in Bangkok hospital. 

Reference: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967351/

https://www.scielo.br/j/fm/a/BgHgg3ywrynZkkMcQftPBDm/?format=pdf&lang=en

https://bjsm.bmj.com/content/bjsports/39/10/731.full.pdf

https://zaguan.unizar.es/record/71215/files/texto_completo.pdf

https://www.e-jer.org/upload/jer-14-3-413.pdf

https://sciendo.com/pdf/10.2478/hukin-2019-0035

https://core.ac.uk/download/pdf/82354186.pdf

https://pdfs.semanticscholar.org/fd1e/8eb99caab68a5f20321b1e2f0f07c2a81f7f.pdf

https://www.escueladefrutos.es/wp-content/uploads/2012/11/trunk-stability-trunk-strength-and-sport-performance-level-in-judo-2016.pdf

https://gexinonline.com/uploads/articles/article-jrpr-121.pdf

12 basic Flat feet rehabilitation and therapeutic exercises

 

Ref: https://health.clevelandclinic.org/

The foot ankle complex includes bone, muscle and ligament which support the medial 

longitudinal arch which gives shape, strength and stability to the joint. Flat feet are determined by the collapse or over - flattening of the medial longitudinal arch of the foot. Most previous studies have concluded the indications of flatfoot to be related to the collapse of the medial longitudinal arch caused by abnormal bone structure in the foot or the relaxation of muscle ligaments. 

  Joint ligament relaxation was also a critical factor in the occurrence of flatfoot in children, adolescents or adults. The occurrence of flat feet was shown to be affected by internal factors (age, sex, nutritional status, genetics, race, and development differences) and other external factors (shoe shape, environmental conditions, and physical activities). 

Flat feet's shoes shape
(Ref: https://sgbonedoctor.com/)

I think of creep's phenomenal deformity biomechanics. It is visco - elastic properties of foot soft tissue, especially ligament that creates a deformation in the soft tissues (muscles, tendon, and ligaments). It is the non-recoverable strain energy that results in the permanent deformation or resting length change of the feet tissues. 

Flat feet was divided into two types: congenital and acquired. A rigid flat feet or congenital flat feet is characterized by a stiff, collapsed arch in both weight-bearing and non-weight-bearing positions. The acquired flat feet was mainly affected by external factors, such as physical activity level, shoe-wearing habits, and living area. 

Flexible flat feet when full weight and heel off
(Ref: https://orthoinfo.aaos.org/)

The flexible flat feet or acquired flat feet is characterized by a normal - appearing arch when the foot is not bearing weight but by a flattened arch when weight - bearing. Flexible flat feet are the most common type of flat foot. 

Most of my patients have flexible flat feet that have different complaints. I have seen 2 most common flat feet characters while standing in the clinic, including small arch and full flat. All flat feet were evaluated carefully by me to get specific mechanics of impairment that consists of internal and external factors. This information will be designed to be customized therapeutic exercise and accessory support for each single case.

Mild flat feet or flat feet first degree (the second from the left)
(Ref: https://www.runningshoesguru.com/)

Basic 12 therapeutic strengthening exercises to treat flat feet.

 

Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week.

Exercise #1: Achilles tendon stretching: You can follow stretching on previous topic that is https://yimphysionearme.blogspot.com/2022/07/physiotherapy-with-9-options-to-stretch.html The stretching leading to 30 sec hold and was repeated 5 times each session. I would like to recommend to who have pain, should follow stretching exercise #1. Whereas, patients who do not have pain, should follow exercise #3 or exercise #8, or exercise #9.

Exercise #2: Toe extension exercises: You are in a sitting or standing position and lift the big toe away from the floor with hold 5 seconds in each rep. You can apply some resistance by a very light elastic band if you want. You can be in a long sitting and tight the band away from your toes.

Exercise #3: Toe flexion exercise: You are in a sitting or standing position and bend the big toe away from the shin with hold 5 seconds in each rep. You can apply some resistance by a very light elastic band if you want. You can be in a long sitting and hold the band away by your hands.

Exercise #4: Toe abduction exercises: You are in a sitting or standing position and shall be instructed to stabilize the ball of the foot on the ground while lifting and spreading out the toes, with hold 5 seconds in each rep. Or you can be long sitting if you want.

Exercise #5: Ankle Dorsiflexion: You are in a sitting position or standing position and bend the foot away from the floor with hold 5 seconds in each rep. You can apply some resistance by a light elastic band if you want. 

Exercise #6: Ankle Inversion with plantar flexion: You are in the long sitting position on a mat with back supported and bend the foot away from the floor with hold 5 seconds in each rep. You can apply some resistance by a light elastic band if you want. Or you can be long sitting if you want.

Exercise #7: Foot abduction:  Sit on a chair with feet touching the floor. One end of the exercise band is fixed around the feet, and the other end of the band is held by the other foot to maintain resistance. Bending needs to hold 5 seconds in each rep. You can do active bending if the exercise band is too heavy for you. Or you can be long sitting if you want.

Exercise #8: Short foot exercises: Place the foot flat on the ground, and draw the metatarsals inwards creating an arch with progression which holds 5 seconds in each rep.

Exercise #9: Heel raises with ball: You are in a standing position near a wall or stable furniture, with ball placed between the malleolus of left and right side, then raise the heel up - down slowly. 

Exercise #10: Heel raises waking: You are in a standing position performing heel raises. Then walk forward with the heel raise (without shoes).

Exercise #11: Towel curls: You are in a sitting or standing position and bend your toes to pick and slide towels into you. 

Exercise #12: Objects curls: You are in a sitting or standing position and bend your toes to pick objects and put them in the box.

Although foot exercise may be able to improve foot arch posture permanently, stronger soft tissue may increase pain or injury threshold. I have always encouraged foot exercise in patients with flat feet. Not only therapeutic exercise, but also control risk factors may be an essential component to help to treat flat feet. 

The distinct limitation of this study design is that no separate the external and internal factors affecting flatfoot, which is likely to be a significant confounder, as more external and internal factors progressions increase the risk of flatfoot development.

Factors such as age, gender, foot length, familial history, practicing the usage of footwear early in infanthood, body mass index (BMI), comorbid illness, associated with pain, fatigue in women, and urban residence were reported to be associated with flat feet. Flat feet are also seen secondary to ligamentous laxity, neuromuscular disorders, hereditary conditions (osteogenesis imperfecta, Down syndrome, and Marfan syndrome), collagen disorders (Ehlers‑Danlos syndrome). Biomechanical causes (ankle equinus, valgus deformities, accessory navicular bone) are potential to develop flexible flat feet may relate to secondary injuries like ankle sprains, plantar fasciitis also deformities include hallux valgus . It is often difficult to identify the exact reason for flat feet in every individual because of the existence of various factors associated with developing it. 

One of Marfan syndrome clinical
(Ref: https://www.istockphoto.com/th)

Adolescents who are not fully developed should avoid taking part in overloaded labor (such as burden-bearing) and sports (such as weight lifting). They could engage in high leg lifting, jumping activities (such as rope skipping, long jump, high jump, vertical take-off, etc.), and climbing activities (such as climbing ladders, using balance beams, rope climbing, pole climbing, etc.) to fully exercise the muscles and ligaments of the arch of the foot.

According to one theory, failure of muscles supporting the arch leads to flat foot; according to the second theory, weakness of passive ligamentous support around the arch leads to flat foot; and according to the third theory, failure of both muscles and ligaments leads to flat foot. Many studies demonstrate weakness of intrinsic foot muscles and extrinsic foot muscles that the posterior tibialis tendon is the main dynamic stabilizer of the arch with lesser contributions from the peroneus longus, flexor digitorum longus, and flexor hallucis longus. 

Long tendon from posterior shin muscles
(Ref: https://www.howtorelief.com/)

Tightness or any changes in Achilles tendon is associated with dysfunction of tarsal alignment that leads to dorsolateral displacement of the navicular bone causing chronic stress on posterior tibialis tendon eventually, leading to microtrauma and degeneration in the later stages.

Intrinsic foot muscles are contained in the foot bone. To strengthen such as short foot and toe abduction exercises, help to prevent pronation related injuries and integrity of the medial longitudinal arch. This helps in reducing navicular drop scores and plantar arch index scores. They help to maintain not only longitudinal arch, but also transverse arch. 

Intrinsic foot muscles and tendon of extrinsic muscles anatomy
(Ref: https://quizlet.com/)

Although intrinsic muscle helps in maintaining arch, the tibialis posterior plays an essential role in maintaining the medial longitudinal arch during dynamic weight‑bearing and balance activities. For these reasons, strengthening of the tibialis posterior muscle is more preferred in individuals with flat feet than the intrinsic muscles. However, I will provide an exercise program for all of them if necessary. 

The function of the posterior tibialis tendon is essential to maintain the gait pattern without any abnormal deviations. During gait cycle, the posterior tibialis tendon function is critical during the push‑off phase. Posterior tibialis contracts to invert the foot and maintains the transverse tarsal joints in a closed pack position. Weakness of posterior tibialis tendon leads to failure of stability in the transverse tarsal joints during the push‑off phase. The unopposed peroneal muscles abduct the forefoot due to weakness of the posterior tibialis tendon. 

Muscle activities during walking that tibialis posterior works in stance phase
(Ref: https://www.researchgate.net/figure/Representation-of-muscle-activity-during-a-gait-cycle-The-grey-color-indicates-periods_fig5_297048967)

Long‑term goal of any flat foot rehabilitation program aims at strengthening the posterior tibialis muscle. Strengthening program begins with isometric and progresses to isotonic exercises. Concentric and eccentric types of exercises were routinely implemented in strengthening programs. 

Orthoses and taping were always suggested to diminish the demand of the posterior tibialis tendon during the stance phase of gait cycle. In the clinic, I have made rigid taping to stabilize and support the foot arch in patients with pain. To tape is a very good way to help these patients, but patients may feel annoyed and dirty from the adhesive. Moreover, it is not convenient for patients who are lazy to tape and unskilled to tape. 

Low - dye tape technique to stabilize foot arch
(Ref: https://clinmedjournals.org/) 

For this reason, I suggest they get insoles or stable shoes to support the foot arch. Running shoes are the easiest to suggest which is motion control running shoes. However, patients with mild flat feet may comply to select a stability running shoe which is lighter than motion control. 

Insoles for flat feet

For children, the correct choice of footwear is especially important because their growth and development are characterized by the evolutionary dynamics of the locomotor system and by the physical activity to which the lower body is subjected. However, this choice is often influenced by aesthetic, economic, or marketing issues, rather than by considerations of health. To raise awareness of the importance of these questions, and to enable parents and others to reach suitable decisions, research is needed to highlight the direct influence of the shoe on the movement of the foot and on its functionality. The design of children’s shoes should be based on the barefoot model, prioritizing impact absorption and load distribution, in the understanding that overly rigid and/or tight-fitting footwear can provoke injuries or deformities. 

Kids shoes

I do not involve people who do not have pain or poor quality of life from flat feet especially in the athlete population. Because some athletes are accustomed to sports specific skill with flat feet. Their performance may be dropped if their flat feet are changed that make worse than better. 

Reference:

https://www.ijhsr.org/IJHSR_Vol.12_Issue.1_Jan2022/IJHSR015.pdf 

https://www.semanticscholar.org/paper/Evaluation-and-Retraining-of-the-Intrinsic-Foot-for-Jam/5d8c4a3d6dfabf6060a16a57c5316d935647616f 

https://www.sjosm.org/article.asp?issn=1319-6308;year=2022;volume=22;issue=2;spage=74;epage=81;aulast=Ravichandran 

https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.74B4.1624509

https://www.drkinast.com/wp-content/uploads/2006-pinney-Current-concept-AFFD.pdf

https://www.mdpi.com › pdf 

https://www.researchgate.net/publication/330381128_Influence_of_Shoe_Characteristics_on_the_Development_of_Valgus_Foot_in_Children