The Employment of Pilates to Improve Function And Reduce Injury Related to Congenital Pes Planus

Julie Lopez Santiago November 22, 2009

Costa Mesa

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Abstract

The purpose of this paper is to discuss the following concepts: How congenital Pes Planus or flat

feet cause compensatory rotation in the tibia and other mechanical stressors in the legs, leading

to pain and predisposing to injury. Also investigated is the possibility of developing an exercise

routine that will minimize the negative effects of this condition and/or need for invasive

procedures. Despite the significant incidence of this condition, the pathophysiology is still

debated. This paper will attempt to show a possible exercise plan and rehabilitation for treatment

for less-severe malformations whether it be for the congenital condition or for acquired Pes

Planus in adults.

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Table of Contents Abstract ………………………………………………………………………………… 2 Anatomical Description ……………………………………………………………….. 4-6 Case Study .…………………………………………………………………………….. 7 Conditioning Program .………………………………………………………………. 8-12 Conclusion ……………………………………………………………………………... 12 Bibliography …………………………………………………………………………… 13

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Anatomy of Pes Planus Condition The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of

over 120 muscles, ligaments and nerves. Our feet connect us to the ground. Their architecture is

the foundation for all of the body parts above. They serve the following functions:

- Support weight

- Act as shock absorbers

- Serve as levers to propel the leg forward

- Help to maintain balance by adjusting the body to uneven surfaces

Since the feet are very small compared to the rest of the body, the impact of each step exerts

tremendous force upon them. This force is about 50% greater than the person’s body weight.

The skeleton of the foot begins with the talus, or anklebone, that forms part of the ankle joint.

The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle

joint to form a very stable structure known as a mortise and tenon joint.

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The two bones that make up the back part of the foot are the talus and the calcaneus, or heel

bone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot

to bend up and down.

The subtalar joint allows the foot to rock from side to side. People with flatfeet usually have

more motion at the subtalar joint than people who do not have flatfeet. The increased flexibility

of the subtalar joint results in many compensatory actions of the foot and ankle in order to keep

proper foot alignment during standing and walking.

Just down the foot from the ankle is a set of five bones called tarsal bones. The tarsal bones work

together as a group. They are unique in the way they fit together. There are multiple joints

between the tarsal bones. The tarsal bones are connected to the five long bones of the foot called

the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at

the joints. Finally, there are the bones of the toes, the phalanges.

With a flatfoot deformity, bones, ligaments, and muscles are all affected. In the flexible flatfoot,

the bones are usually normal - but the supporting ligaments are lax or loose. The joints are

hypermobile. As the soft tissues and joints of the foot and ankle try to maintain a normal foot

position, increased stress is placed on them. This can lead to fatigue and loss of strength resulting

in a sagging of the arch. Other dysfunctions in the lower kinematic chain (i.e. knee, hip) are

commonly associated with excessive subtalar pronation.

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In the uncommon severe cases, calluses may appear where pressure occurs as the bones make

contact with the floor or hard surface. The loss of joint stability may alter the foot's ability to

absorb the load and conform to uneven ground or surfaces.

Excess pressure on the surrounding soft tissues (ligaments, capsules, tendons, muscles) can lead

to other problems such as misalignment of the patella (kneecap), hallux valgus (bunions), and

rotation of the knee and hip.

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Case Study

I have done the case study on myself, a moderately active 43-year old woman. The condition of

Pes Planus was not the source of injury or misalignment during childhood. The only injuries

suffered during that time were the occasional sprained ankle while participating in volleyball and

medial tibial stress syndrome (shin splints) as a participant in track.

In my 20s, I suffered from moderate to severe knee pain and chose to stop participating in

collegiate volleyball rather than undergo arthroscopic knee surgery to repair patellar tendonitis

and with physical therapy and time the pain subsided. Since that time I have been unable to jog

or run without experiencing pain and swelling in the knee joints. In addition I experience

occasional sharp knee pain while lifting weight with my legs or descending stairs.

Ten years ago, I underwent a bunionectomy combined with a procedure to repair the ligaments

and tendons around the big toe. The bunions had developed in my mid to late 20s but at that

point had reached a period in which severe foot pain was limiting my activities even when

wearing sensible shoes. The surgery was successful but I am still unable to wear shoes with a

heel for any length of time without discomfort in the foot. Additionally, I have severe callus

buildup due to excessive pressure under the second metatarsal head and on the outside of the big

toe. Ongoing maintenance on these callus points must be performed or the buildup is a cause of

additional foot pain.

Other problems which I have experienced and were likely caused by poor alignment is

Trochanteric bursitis in the hip joints and misalignment of the spine in the L3 and L4 vertebrae

both requiring chiropractic care and physical therapy to correct.

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Conditioning Program

Despite its delicate architecture, the human foot is strong, dynamic and adaptable. For good

balance and stability, the foot should contact the ground like a tripod, with the weight evenly

spread between the calcaneus (the heel) and the heads of the first and fifth metatarsals. When we

stand, the distribution of weight should be the following: the heel should receive the majority of

the body’s weight, the first metatarsal head should be secondary in its capacity, and the fifth

metatarsal head should support the least amount of the body’s weight. In order to avoid the

excess pronation, which ultimately causes the femur to roll in and pull on the pelvis anteriorly,

this conditioning program will focus on restoring that tripod balance.

For thousands of years our feet have functioned fine and maybe even better without elaborately

padded shoes such as today’s athletic shoes and orthodics. However, this type of treatment seems

to be the primary focus in podiatry today. More recent studies including a book by Christopher

McDougall, Born to Run (Knopf 2009) are concluding that being barefoot or wearing flatter and

more flexible shoes (i.e. those with less support) are more beneficial in developing proper foot

functioning. Our feet have many muscles that originate in the leg. Wearing running shoes may

lessen or diminish the “firing” of some of these muscles. When the foot is not in shoes, it

adapts—rapidly—to uneven surfaces, and in theory, forcing us to “use” all the muscles in our

foot. Further, running or other elaborately padded athletic shoes may actually decrease an

athlete’s awareness of their foot and the foot’s position, increasing the risk of injury.

The teachings of Joseph Pilates confirmed that the body was a well-functioning machine if it was

taught to be in alignment and developed sufficient supportive strength. That is the theory I am

following in developing this therapeutic conditioning program. It will include progressive

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stretching and strengthening exercises, including exercises that address impairments of the

pelvis, hip and knee which may be associated with excessive pronation, such as weak ankle

plantar flexors, week hip abduction and external rotation. Although the conditioning program

that follows includes a complete body workout, many of the exercises will include activities that

will challenge me to address the strength, flexibility, proprioception and endurance of the

muscles of my lower body in an attempt to restore proper functioning. Some highlights of the

workout that focus on the neuromuscular re-education for parts of my body that have long

functioned in a compensatory manner are as follows:

Footwork – I chose to do a majority of the footwork portion of the program on the Cadillac due

to my ability to watch my feet throughout the exercises. This would be to increase awareness of

any poor alignment issues in my feet and legs and focus on hip disassociation.

Two particular exercises to note are the Hip Opener and the Prehensile on the Reformer. These

two particularly focus on areas of interest. The Hip Opener I would use to address weak hip

abduction. The Prehensile exercise in wrapping the toes around the foot bar, places the forefoot

into a supportive transverse arch. Instead of rolling my legs inward to meet the bar evenly,

focusing on keeping the thighs in neutral alignment with the hip creates a pattern of strength

from the feet to the pelvis.

Abdominal – Focus on strengthening hip flexors and maintaining alignment in legs

Hip Work – Focus on building up mobility and support in the hip complex.

Spinal Articulation – Focus on watching alignment of feet and legs while stretching.

Stretches – Focus on lower body stretches to overcome compensatory tightness.

Full Body Integration 1 – Focus on ankle plantar flexor strength and knee extensors.

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Arm Work – Done on knees to help maintain lower body stability.

Full Body Integration 2 – Maintaining strong plantar strength in feet during exercise.

Additional Leg Work – Focus on articulating the foot and focusing on building strength in the

plantar flexors, knee extensors and hip extensors.

Lateral Flexion/Rotation – Maintaining proper alignment to maximize oblique work.

Back Extension – Engaging legs throughout and activating adductor muscles in legs.

Warm Up Mat Work – Roll up, Spine Twist Supine,

Double Leg Stretch, Single Leg Stretch, Criss Cross

Foot Work Cadillac – Parallel Heels & Toes, V Position Toes, Open V Heels & Toes, Calf Raises, Prances, Hip Opener Reformer – Prehensile

Abdominal Work Reformer – Hundred, Double Leg and Double Leg with Rotation

Hip Work Reformer – Extended Frog Series – Down Circles, Up Circles, Extended Frog, Extended Frog Reverse

Spinal Articulation Cadillac – Monkey Original, Tower Prep

Stretches Ladder Barrel – Gluteals, Hamstrings, Adductors, Hip Flexors

Full Body Integration 1 Reformer – Stomach Massage: Round Back, Flat Back, Extended

Arm Work Reformer – Arms Kneeling Series: Chest Expansion, Up & Down Circles, Triceps, Biceps

Full Body Integration 2 Reformer – Balance Control Front

Additional Leg Work Reformer – Jump Board Series

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Lateral Flexion/Rotation Wunda Chair – Side Pike

Back Extension Wunda Chair – Swan Basic, Back Extension Single Arm

In addition to the type of exercises noted in my conditioning program, I would recommend other

foot strengthening exercises to be done as well.

1) Doming the foot to improve the strength in the “tripod” contact points. Done either sitting

or standing.

2) Inch Worm is done by first doming the foot and then inching the heel point toward the

toe ball points, then moving the ball points away from the heel to relax the arch.

3) Toe Articulation exercises would include: Lifting toes up and separating them in the air;

Lifting the toes and lowering them one at a time; Keeping large toe down while lifting all

other toes also the reverse of this.

One final method of improving strength and alignment would be to include the Pilates Foot

Corrector exercises (see above) to my daily routine. This apparatus increases ankle stability,

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flexibility, alignment and propulsion. It also helps strengthen and stretch the muscles of the foot

and lower leg, as well as shore up the alignment of the ankle, knee, and hip when in parallel and

externally rotated positions. If a Foot Corrector is not available, many of the same exercises can

be done with a tennis ball or other flexible ball.

Conclusion

The feet are one of the most overlooked parts of the body when it comes to people's workouts,

yet they are the foundation of the body. Like the rest of the body, to keep our feet healthy, they

need to be stimulated and exercised. Often injuries to the knee, hip and spine can be attributed to

weakness or muscle imbalance in the foot not just congenital issues such as the flat feet. This

conditioning program would be of benefit to anyone that experiences foot pain due to overuse,

poor shoe support, weakness due to overly supportive shoes or who have experienced alignment

issues of the lower extremities. Many issues will need to be treated surgically or may require

more extensive treatment from an orthopedist or physical therapist. But everyone could benefit

from increased emphasis on the feet and improve their affect on the overall functioning of the

body.

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Bibliography

Christopher McDougall, Born to Run (New York, Knopf, May 2009)

R. Lorenzton, “Prevention and Management of Sports Injuries; Intrinsic Factors”, A. Dirix,

Howard G. Knuttgen, and Kurt Tittel, eds., The Olympic Book of Sports Medicine, (Wiley-

Blackwell (January 15, 1991), p. 376-384.

Rodney P. R. Dawber, Ivan Bristow, Warren Turner, Text atlas of podiatric dermatology

(London, Martin Dunitz Ltd, 2001)

Matthew Buchanan, MD, Gregory C Berlet, MD, FRCS(C), Abdi Raissi, MD, eMedicine

Orthopedic Surgery, February 27 2009.

Boerum DH, Sangeorzan, BJ. Biomechanics and pathophysiology of flat foot. Foot  Ankle  Clin    N  

Am. 2003(8):419-430.