Ep.25 Breaking Conventions: Foot Strengthening with Matt Dilnot

Hold onto your seats because today, we're challenging conventional wisdom, breaking away from the norm and stepping into the thrilling world of foot strengthening with our revered guest, Matt Dilnot. We're turning the spotlight and stressing the urgency to break free from traditional methods. With Matt's expertise, we push boundaries and open up new dimensions in foot strengthening, taking you on a journey  of this fascinating field.

We delve into the role footwear plays in foot development and strength, highlighting the downsides of supportive shoes. We also explore the complex role of sensory perception and motor control in foot development. 

The strength of your feet is not just about physical prowess; it's also about healthy aging and maintaining balance. We make the crucial link between strong feet and toes and the prevention of common foot problems. Matt offers a wealth of practical advice and effective exercises to improve muscle strength and agility. We share innovative techniques such as the Vele manouver reflex, functional loads, and isometric contractions, all designed to enhance your foot's health and overall well-being. This episode is more than a conversation; it's a step towards a healthier you. Tune in, take notes, and take charge of your foot health today.

Podcast link https://feeds.buzzsprout.com/2195785.rss

@simplythebestpodiatry

@jasonagosta

jason@ ja-podiatry.com

@mattdilnott

m.dilnott@melbournefootclinic.com.au

ww.mytoepro.com.au

Melbournefootclinic.com.au

Goldmann, J. P., Sanno, M., Willwacher, S., Heinrich, K., & Brüggemann, G. P. (2013). The potential of toe flexor muscles to enhance performance. Journal of sports sciences, 31(4), 424–433. https://doi.org/10.1080/02640414.2012.736627

Mickle, K, et al., ISB Clinical Biomechanics Award 2009: Toe weakness and deformity increase the risk of falls in older people. Clinical Biomechanics. 2009. 24:787-791.

Mickle K, et al. Efficacy of a progressive resistance exercise program to increase toe flexor strength in older people. Clinical Biomechanics. December 2016;40:14-19.

The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome

Transcript

Speaker 1: 0:07

Hey there, everyone, welcome back to Simply the Best Paddye Tree and thank you for all your comments lately, because this show aims to pass on simple tips to enhance your best practice and we've had some great feedback, and particularly after episode number 22, and I don't have a famous sporting number for you tonight, but after episode 22 with Matt Diornaut, overwhelming feedback and what a session. And tonight I am joined for episode 25, which this is with Matt Diornaut. Thanks for coming back on Matt it was an absolute hit 22.

Speaker 2: 0:53

I just feel like it wasn't my best performance. Hopefully I get a bit better tonight so we can improve that even further.

Speaker 1: 0:59

So for those who haven't listened to professional development and lower limb strengthening with Matt Diornaut, go back and have a listen to it. And tonight we are going to discuss some strengthening of the foot which will coincide or link up nicely after listening to lower limb strengthening.

Speaker 2: 1:21

How are you, matt? I'm good, very good, very pumped about doing this one. Yeah, I like talking about foot strengthening. It's the next level, so I know we touched on some strengthening last time, but I think this is one of those gradually emerging fields. It's been around for a long time now, foot strengthening, but I think over the last 30 years.

Speaker 2: 1:42

The funny thing is I think we spoke last time about the Alfredson technique which has been around for a long time, I can't remember I think that was in the 90s, maybe it's early 2000s that came out and I think, as a practitioner, when you started to implement the Alfredson technique, obviously it helped some people but it didn't help everyone. And I think the stats I think we mentioned the stats last time I think it's about 60% of people at five years have still got pain after using the Alfredson technique. So it wasn't the magic bullet that we thought it was.

Speaker 1: 2:20

Or calf and Achilles strengthening, we should say.

Speaker 2: 2:23

Yeah, yeah, particularly if we're looking at mid-portion, even just mid-portion strengthening, which actually responds fairly well to strengthening. But I think we got sold at conferences that, hey, here's the Alfredson technique. If you do this really well, you will fix mid-band Achilles problems without an issue. And yet further studies were done and it didn't fix everyone and I think why do you think we embraced it so much, though?

Speaker 1: 2:52

because there was not much else around. I think it was Limited understanding.

Speaker 2: 2:57

I think it was the timing of it, because I think limited understanding was definitely part of it. I think our general attitude towards Achilles strengthening at that particular time was just rest, you've overloaded it, just rest. And people were just not getting better, obviously. But you go and see your local GP and they go oh, you've just been doing too much running. You just stop running and you'll be fine.

Speaker 2: 3:27

And I think it was quite a change in the way our thought processes at the time to say, hey, we can actually strengthen this tendon and rather, making it worse, it actually can make it better. We can actually stimulate those Tino sites to strengthen that tendon and wow, people are actually getting better with this sort of stuff. And I think that was a real revolution to the way we manage tendon problems. I think tendons have the least blood flow of all the soft tissue and they don't necessarily respond the way that we expect them to respond, so they can be a real battle. But perhaps one of the points I was going to get you with the Apprentice and Technique was that it wasn't the magic bullet. We went along to all those sports medicine conferences and we saw it being talked about in all the oh, I do it with a weighted backpack.

Speaker 2: 4:19

Oh, I do it with this particular thing and whatever this improves the results, et cetera. But it didn't answer all of the questions and I think, as practitioners, quite often when you get to that point you think, oh right, that's it, that's as far as we can go. Where?

Speaker 1: 4:34

do we go from?

Speaker 2: 4:34

here. If we go back to that last podcast we did, you see that there are people out there who do find another way. They do look at the way in which those well, maybe it's actually the way we're doing that exercise, Maybe it's the way the fibers are actually growing within the actual tendon. If we load those fibers differently, if we do some different work to the medial gastroc muscle, perhaps we can actually change the loading of the tendon and people find a different way.

Speaker 1: 5:07

Yeah, okay.

Speaker 2: 5:09

And I think that's the interesting thing with a lot of this foot strengthening is that we have a bit of a gist of I think foot strengthening might be good, but how many do we do, how long do we do it for it's all a mystery. And I think, as practitioners and I think we might again, we might have said this last time is that as practitioners, you want to have something concrete, you want to be able to give something to someone and give it in a very precise, masterful sort of way, and the patient responds, and podiatrists have not been very good at executing that.

Speaker 1: 5:42

Well, you make me think back. I was never taught any strengthening.

Speaker 2: 5:46

No, I never, was I Like you, taught me.

Speaker 1: 5:50

Well, I'm not sure about that, because I learned some from the physiotherapist I was working with in a multidisciplinary clinic. But that was about it, and then it was go off and read a lot and work on some things yourself.

Speaker 2: 6:03

But I was never really taught that much, but it became, I think, just difficult because you got to a dead end. You go and pick up the books and you go and read the stuff and you think, ok, I don't really feel like I'm that much better off, yeah, having all this sort of stuff. And yet you get those people who gradually come along and they find a new way. They break through that, that ceiling or that whatever you like to call it, and which is so exciting. Now, there's not hundreds of people who are doing that, there's a very few number of people. And if you look at some of the reading that I've done, you do find that you've got these select articles that you go back to over and over again and go, oh, that's really clever, they did something quite different here and they helped us to understand something.

Speaker 1: 6:44

It's interesting, isn't it? Because, looking at the foot strengthening literature, there's not much out there and a lot of us done really poorly. Yeah, it's quite inconclusive as to the results of it. Just talking about results, Can we just go back and before we move on, you're talking about strengthening of calf and Achilles and the Alphysen technique. You mentioned that the outcome 60% of people after five years, was it?

Speaker 2: 7:13

Yeah, I think it's the rough guide. Yeah, I think there's a couple of papers that ultimately show that that was the case, that 60% of people at five years still had some level, still struggling, still had pain.

Speaker 1: 7:24

Okay, still, yeah, okay. So if we move on to strengthening of the foot, which follows on from what you've been talking about, it's really interesting because, if we think about muscle strength and muscle volume, there's been some work in assessing those aspects of the foot done but, as I said earlier, fairly inconclusive.

Speaker 2: 7:47

The one that I wanted to talk about to start off the bat was this paper that was published 95. So this is back in our day, jason, so back when they did real research 95, because that's your day, well, after my day.

Speaker 2: 8:04

Well, there's a paper that was published in Foot and Ankle International and 95, Linda Ferris was the person. She did a few papers at the time with this group in Sacramento and this paper was really interesting because what they did was they took a essentially a freshly amputated leg it was so it was off people that basically died in the last week or so, which is that awful. But essentially they clamped it into this apparatus with the forefoot on a, as they called it the time of petrobarograph, In other words, a force plate, and essentially what they did was they attached actuators to the tendons entering into the foot, the main tendons, so the Achilles tendon, the flexi-halosus, longest tendon, and on the flexi-dutrombus, longest tendon as well. So they placed actuators on these tendons and basically applied enough force that it replicated toe-off.

Speaker 2: 9:09

So the foot was in A and this is a slightly tricky talking on podcast but the foot's in a slightly planar-flake position, replicating the forces that you're trying to replicate, the forces that the foot undergoes as you're about to push off the ground. So let's just assume that we have no tendons attached other than the Achilles tendon and we just pull down as hard as we can with our Achilles tendon to push the forefoot down into this pressure plate. And what they did was they looked at the force that was going through the second metatarsal, so they put an actual strain gauge in the second metatarsal and they looked at how much force was going through the strain gauge and they're obviously looking at also the force in the actual forefoot.

Speaker 2: 10:01

And what they found when they were not activating flexi-halosus longest and flexi-dutrombus longest is that essentially, when you start to get to those really high pressures that you would get through walking, just pulling down the Achilles tendon without the other tendon functioning, the force that was going through the metatarsal was enough to basically break it. Okay. Then they did the same activity with the actuators pushing down on flexi-halosus longest and flexi-dutrombus longest to essentially push the toes down onto the force plate at the same time, and they also measured the force through the second metatarsal at the same time. And essentially what the answer was was that when you activate flexi-dutrombus longest and flexi-halosus longest at the same time, it actually spreads the load across the toes, takes the pressure away from the metatarsals, protects it and actually is very effective in dispersing those loads towards the toes.

Speaker 1: 11:03

Right, okay, so there's almost like a protective mechanism there to stop the bending or the loading of the metatarsals, correct, exactly, which really is providing stability of the forefoot Stability.

Speaker 2: 11:16

Exactly, and I think I tend to look at it really as distribution of pressure over a larger surface area, yeah, so those toes come down and the pressure that's distributed over that larger surface area is much greater. So therefore you don't have those forces going through the forefoot.

Speaker 1: 11:29

Okay, so what we're saying is, if you don't have the strength of the long flexors, you are going to have less distribution of pressure and more force across the forefoot.

Speaker 2: 11:43

Yes.

Speaker 1: 11:44

If we just, if we're just really strong in our calves and not our yeah best really strong in our gastroxylase and not our long flexors or intrinsic, perhaps we're putting much more load on the metatarsals.

Speaker 2: 11:58

Absolutely Exactly so I think this paper was obviously interesting for a start. It's a pretty interesting paper the way they actually do Very interesting.

Speaker 2: 12:07

But it was the first one that really captured the fact that having strong toes helps to reduce pressure on the forefoot area. So that's the thing that I think was actually was particularly interesting. I think when we start from that, we can then basically start to look at what happens as we get older and when we start to get problems with those muscle function. Sure, I don't know whether we are interested in going down that path or talking about the aging process at this point.

Speaker 1: 12:38

Absolutely. Hey, I'm always interested in that 56 onwards Absolutely. Let's go back a bit before we start with that. So why worry about foot strength then? Is it pressure? Is it bony? Yeah, health it's ankle stability, so many things.

Speaker 2: 12:58

I think there is a lot of talk about, obviously, muscles and arch support. There's a lot of research in that area, just supporting the arch. I always refer to, often have referred to some interesting studies that were done, particularly one particular paper that was published a long time ago, but I've continued to refer to it and you may recall, of this stuff, robbins was doing a lot of this stuff, jeffrey Robbins, I think back in the year. Yeah, robbins and Gow, yeah, that's right. Yeah, so there's a Congolese population that they studied and they essentially looked at populations wearing no shoes, wearing sandals, versus those who are put straight into Western footwear.

Speaker 2: 13:40

And this is an interesting paper because when we start to study the effect of exercising the foot, we can't just grab a multicultural population like Australia because the foot architecture is so different across so many different groups.

Speaker 2: 14:00

And so if you were to take a group of primary school kids in Australia that were from different, multi cultural backgrounds and gave them, you know, different types of shoes, you would find that diversity of genetics would create so many other factors that it'd be really, really hard to study.

Speaker 2: 14:17

And this is part of the problem when we start to look at the effects of footwear and on foot development. You have to have a population that's homogenous in its genetic pool. You have to take a group of people that basically are very, very similar in their genetic makeup, and this particular paper which I referred to years ago was the fact that those who were basically wearing no shoes whatsoever were shown to actually have higher arch feet than those who are wearing the most supportive footwear at the other end of it. So we've had a few papers like that over the years, essentially saying that you know, wearing stiffer, firmer footwear tends to. You know and this goes against some of the stuff that Luke Kelly's been doing up at Queensland, but let's go into that later on but essentially, if you're not using the muscles in your arches and so forth, then you end up with potentially a different shape footwear Sure and so weakness.

Speaker 2: 15:11

Yeah, weakness, I think so. I think we'll categorise it as weakness so, and I think there are. Yeah, it's tricky not to go off in different tangents here, but when we're walking over rough ground, it stimulates the continuing susceptibility to the foot, and those cutaneous receptors in our foot are very much aligned with the function of the muscles in our feet and the way they activate.

Speaker 1: 15:36

Okay, so this is sensory perception and, turning on our muscular control, correct exactly. That's right, that's one thing the shoes take away Absolutely.

Speaker 2: 15:44

And there's delayed.

Speaker 1: 15:45

Muscle on set of muscle contraction.

Speaker 2: 15:47

Exactly, that's right. So when the cutaneous receptors, say underneath the forefoot, are fired, then it tends to cause the toes to flex downwards. It's a reflex contraction, and so if you have rocks and stones underneath your forefoot area, you'll naturally start to trigger off your toes to try and reduce that pressure on the forefoot. And so it starts that feedback loop from a very young age which then creates that motor control patterns that we have and subsequently we end up firing groups of muscles in a certain way which helps to distribute loads more evenly across the forefoot. If you don't have that stimulation, then you don't end up developing those same motor control patterns, and so we'll be cautious, perhaps to say that it's just purely about strength. You have the world's strongest feet, but if you don't have the motor control pattern to go with it, then you won't be using those muscles at a particular time. So part of the issue that we have is that you can go and strengthen a foot as much as you like, just as you can do with other parts of the body, and we've done these fantastic studies exactly with around the hips and the knees.

Speaker 2: 16:56

They do exercise programs to see what happens when they exercise the quads or the glutes or whatever it may be, and they've measured to see what changes it makes in gait characteristics. And for the vast majority of the studies it's shown that you can improve someone's strength by 50% and it makes no difference to the way they walk. And the reason because? Is because they still use the same program. They still use the same motor control program. So you have to somehow stimulate them to walk in a different way. So that's that gait retraining sort of stuff. And so I think it's quite interesting when I think it's a bit of an area to third people to be caught out is that you go and read an article and say, oh look, that article showed by doing this exercise increases my strength by 100% or whatever it is. But if you're not using that strength at the right time and the right place and the right way, then it's not going to make a substantial difference to what you're actually doing.

Speaker 1: 17:53

Okay, so is this? The first thing I think of when we're talking about this is shoes like free that came out that were really thin and flexible. I mean, this is the whole premise that they were made upon, and since then there's been many, many sort of minimalist shoes, enhancing sensory perception and making sure you can try and turn on your muscular control. That's right, so is there, would you say, that there's a place for that? Is this something that we really should be embracing?

Speaker 2: 18:26

I think it's something that requires further research. Still, I think I've always said this all along that everyone wants a simple answer. They want a black and white answer. Should I be barefoot shoes only, or should I be going barefoot?

Speaker 1: 18:38

together.

Speaker 2: 18:40

And the answer is not that clear.

Speaker 1: 18:43

No, most of us aren't going to adapt back. It's been too long for us to get back to barefoot.

Speaker 2: 18:49

Exactly, and I think that's one of the biggest issues. You know the fact that you have this window of opportunity, probably in the first five or six years, to develop these neural control patterns, and once you get out of that, it's quite hard to implement new neural control patterns. So this is the challenge and, of course, the manufacturing, and I think there is some value to doing that strengthening, allowing more room for things to spread and so forth.

Speaker 1: 19:13

Yeah.

Speaker 2: 19:14

But it's not the panacea that people perhaps try and sell it as.

Speaker 1: 19:18

Yeah, I mean, people ask all the time you know, should I be just wearing minimal shoes for half an hour a couple of times a week, and I don't think there's much of a problem with that? No, I agree. Yeah walking, doing easy runs or walking in it just a little bit. I think it's okay. But what is interesting is it seems to be the people who are a little younger, maybe in their 20s and 30s, who cope with that Yep, Whereas you try and do that with stiffness. It's much, much harder.

Speaker 2: 19:47

Yeah, absolutely, yep. Once you get to our age, it gets harder and harder.

Speaker 1: 19:53

Of course, You're the Billy Idol of Tadatri. I've just worked out Ageless, okay, so other things we can talk about, other things we can talk about foot strength.

Speaker 2: 20:06

So other things, of course. Ankle injuries is another one. So there's been some good papers basically showing that even just toe strength can reduce your risk of ankle sprains. Plantar fasciitis has been quite a bit of research on that. Plantar fasciitis One of the big areas of plantar fasciitis is about this concept of low distribution.

Speaker 2: 20:29

With plantar fasciitis, the plantar fascia has a very high number of incredible density of nerve fibers in it and there is some evidence to suggest that the plantar fascia is in fact a very significant proprioceptive tool. And so when the plantar fascia gets load through it, it actually triggers the afflicted digital embryo muscle to fire and so it distributes pressure away from the plantar fascia as you're walking and so that that proprioceptive feedback from the plantar fascia is just has its load distributed elsewhere to other tissues. And so if we do have the ability to have that strength around the plantar fascia, it potentially takes some of that load away from our plantar fascia. And so there has been some good research, good old Josh Burns up in New South Wales, who's an awesome researcher, who's done some interesting stuff with looking at dynamometers, strength testing and different types of plantar fascia, people with plantar fasciitis, and did show some correlations between perineal weakness with plantar fascial problems as well.

Speaker 1: 21:42

Yeah Well, there's been a bit done, hasn't there? About volume, muscular volume of the foot and plantar fascia.

Speaker 2: 21:48

Yeah, there has been.

Speaker 1: 21:49

I'm not sure the studies are too great, but there's some reports that if you've got more muscle bulk you're less likely to have plantar fascia pain.

Speaker 2: 21:59

Yeah, that was the study published in Runners, so they actually showed that runners who had muscle greater muscle bulk had reduced plantar fascial issues. Supposedly but again, probably fairly fairly weak studies, I would say yeah, yeah. Then there's the good old Halex phalgus. There's some papers around, funnily enough, on barefoot shoes showing that people wearing barefoot shoes were able to reduce the angle of Halex phalgus. Again, I think it comes down to that thing that once the horse is bolted and once the toes come too far across, you're not going to strengthen your way out of it. But I think it still draws the attention to the fact that pointy-toed shoes are associated with Halex phalgus and wearing restrictive footwear is associated, and having a shoe that allows your foot to spread is one of those things that probably helps reduce your risk of Halex phalgus.

Speaker 1: 22:54

So if we're stronger in our feet and, as you mentioned, toes, and the aim is to have a better distribution of pressure and also a better lever, we're talking about all the forefoot problems like loading sesamoids, metatarsal fractures limited metatarsal movement, nerve impingement, all of those. So this is big because if we know that we can get stronger and try and prevent some of these problems or assist them clinically, we are going to have to learn what to do Exactly.

Speaker 2: 23:27

Right, and I think again, we don't want to make it too complicated. It's just a matter of the fact that we're giving some support to the fact that we should be doing some sort of strengthening for people to assist them with their recovery process, and we have been ignoring this forever and relying too much on footwear and orthotics to be the answers to things. And I think people are scared. They're not given nice recipes to follow and subsequently, if you haven't been given a nice recipe to follow, you just feel like you're in the, you're wandering around in the dark and you don't know what to do.

Speaker 1: 24:03

We just don't know. That's the thing and there hasn't been an emphasis of probably most of our training. So as we get older you mentioned this in last time you were on air with me about losing muscle mass as we get older and I know that you also mentioned that if you lose foot or toe or strength of your toes, that is significant for older people.

Speaker 2: 24:31

Absolutely yeah. So if we look at some of the work and this is probably the next one of the most significant authors in this area is Karen Mikkel, australian author. She was at Victoria University in Footscray. I think she did some work with Hilton Menz in this area. She did some fabulous work looking at thaw's risk and toe strength and for some people this might be old news but it's still relevant.

Speaker 2: 25:02

So when you are older, adults in general have around about 35% toe strength declines and this is associated significantly probably more significantly than virtually any other measure of the risk of falling. So having a weak foot is a representation of your probably your lower limb health. Now you may be familiar with hand grip strength and if listeners haven't heard about hand grip strength before, you're just getting a dynamometer and squeezing it in your hands and measuring your grip strength and this is one of those things that predicts your risk of heart disease. It predicts your risk of early death. So your hand grip strength is a representation of your general body physiology and body function and to some degree I would say that the same thing happens with the foot, that when we start to lose that foot strength, there's a representation of what's going on internally inside your body. So I think sometimes much of the reduced foot strength is correlated with falls. It's not just because you've got weak feet that you are going to fall over.

Speaker 2: 26:23

It's a representation of your entire body function, if you like. But, at the same time, it is an area that obviously is, but itris, that we're working, that we can actually measure the strength of feet and we can actually get a sense of the health of that foot.

Speaker 1: 26:42

And this is also with the elderly. As far as falls, absolutely, absolutely. We're talking about, I'm thinking, stability.

Speaker 2: 26:50

Yeah, exactly, yeah. So there's a few things that go on as we get older. So, basically, elderly people that fall have basically 20% less foot strength than those who don't fall, and this is particularly around the big toe. So when you increase your big toe plant affliction strength by 1% of your body weight, your risk of falling decreases by 7%. So just to put that into perspective so 1% of your body weight, so if we've got an 80 kilogram person or 70 kilogram person, 1%, 0.7 kilos Thank you, thank you, it's too late Almost a kilo. So basically, if you can increase the strength under your big toe by 1 kilo, then you're reducing the risk of falling by 7% in theory. So that's basically some of the numbers that we can look at.

Speaker 1: 27:48

So this is, if I'm thinking clinically, about how I can measure that and how, like how would I know whether someone's weak or not on some sort of scale? Yeah, this is the sort of stuff we need to know, isn't it?

Speaker 2: 28:06

So there are various tools around you and I hate to be mercenary, but you can buy a toe strength dynamometer Tope Pro to make a dynamometer you can use to quickly measure it. You could, in theory, just use a business card. The old technique of getting a business card, putting it under your big toe and trying to pull it out while someone's pushing down on the business card is not a terrible way, to be honest, of actually measuring toe strength.

Speaker 1: 28:33

Is that the toe or the first MTP?

Speaker 2: 28:36

Under the big toe. So you're not putting under the MTP Jates, under the big toe, and they're pushing down on that card while you're trying to pull it out. And if you're really struggling to get it out, then basically they've got pretty good foot strength.

Speaker 2: 28:50

Seated or standing Seated, and preferably with the tibia at around about negative five degrees, so it's angling backwards, so they can't lean on top of it and push down on the big toe, but they are actually. So you put your hand on their foot and you hold their foot down, keep the heel on the ground and you actually get them to. You slide the card underneath their big toe so they're seated, the tibia is going backwards around about negative five degrees, the heel is on the ground, your hands on top of their foot, holding in position. You slide the card underneath their big toe and you ask them to contract as hard as they can and you try and pull that card out.

Speaker 1: 29:33

I love this. It's a simple thing, isn't it?

Speaker 2: 29:35

That is, yeah, been around for a long time, developed in leprosy clinics in the US back in the 1950s, which is also where the monofilament came from as well. But, yeah, so the but. If you want to measure it, you can buy a dynamometer, and Topro have actually got a dynamometer. And the beauty of that is that if you are going to implement strengthening, you can clearly measure how much improvement someone's getting with their, with their foot strength, and so that can give some nice feedback to the patient as they, as they're getting better.

Speaker 1: 30:10

Okay, what about maintaining muscle strength? Obviously, we can do some strengthening, which we'll get into a minute. But what about our activities and things we can do ourselves to maintain muscle strength or bulk as we get older? Because that, as we, as you mentioned, as we get older we lose our mass?

Speaker 2: 30:32

Yeah, absolutely yeah. So just going back over that, last time we would have mentioned the fact that you know, by the time you get to the rough, rough areas around about the age of about 30 or 40, you start needing to lose 0.5% of your muscle fibers every year. Once you get to the age of 50, you're losing 1% of your muscle fibers every year, and by the time you get to 80, you've lost roughly 50% of your muscle fibers.

Speaker 1: 30:55

Okay.

Speaker 2: 30:57

So regard, and this is regardless of what you do.

Speaker 2: 31:00

Yeah, and there's a matter of how fit you've been what you've done before. You will lose your muscle fibers as you get older, and significant amounts of them, but at the same time, by the time you've got to 80, the ability to increase your muscle mass is still there. You can still triple your muscle mass at 80 by doing weight training and strength training. You can increase the number of fibers, but you can still hypertrophy the muscle fibers that you've got left, and so you can enable those muscle fibers to do more and maintain stability and strength around joints. There are still some challenges, though, because, when it comes to balance, balance is also neurological, and your neurological system also, unfortunately, freaks out as well. So and this particularly underneath the foot the foot is a particularly significant part of the whole balance equation, and so if we look at something like we'd be used to measuring at vibration perception and monofilament pressure perception in the foot, by the time you've got to 50, you've lost about 20, or you require 20% more pressure to stimulate those receptors.

Speaker 2: 32:22

While the time you get to 80, you need about 75% more pressure to simulate those same receptors. So, even though perhaps the density of those specialized receptors in your feet are actually still there, your ability to have those nice, quick responses to changes in body positioning has been lost over time, and so you need again greater strength to maintain your balance as a consequence.

Speaker 1: 32:53

Okay, so obvious question is how am I going to strengthen my feet? Yeah, so that's a scary. I don't want to lose 50% of my muscle bulk. That's scary.

Speaker 2: 33:06

Yeah, absolutely, I think it's a real worry.

Speaker 1: 33:08

Yeah, I think.

Speaker 2: 33:09

I think, on the real, the real basic ones is just is continuing to use the muscles in an agile way. So agility exercises agility, the ability to push off position. Your feet well changed position and so subsequently, your foot strength is going to be outrageously good in comparison to a lot of others.

Speaker 1: 33:33

If I skip or bound and all those things, all those sort of four foot weight bearing activities I can do barefooted, absolutely.

Speaker 2: 33:43

Or flexible shoe or Nike shoe if you want to do.

Speaker 1: 33:47

So that's going to be a benefit.

Speaker 2: 33:49

Absolutely exactly.

Speaker 1: 33:50

And more functional, obviously.

Speaker 2: 33:52

More functional as well. That's right so. So things like dancing going into different directions, backwards and forwards, side to side, so people continue to do ballroom dancing or whatever it may be going to the gym doing those sort of side to side Plimetric stuff. Yeah, plyometrics, that sort of stuff.

Speaker 1: 34:12

So what about walk? Is walking enough? Because I'm thinking that I've adapted to walking my whole life, so going for more, a little bit more distance with my walks. You know, let's assume someone's getting much older than they're not going to run and jump up and down so much. So if they increase their walking, is that really going to do much? Because we've actually adapted to that over many, many years?

Speaker 2: 34:38

Yeah, or do we need?

Speaker 1: 34:39

to load up even more.

Speaker 2: 34:40

I think you need to load up more.

Speaker 1: 34:42

Yeah.

Speaker 2: 34:43

I think you do, and I think, particularly, you've got to particularly target fibers that aren't being addressed by walking, which is typically your red fibers. Slow twitch fibers are going to be loaded more when you're walking. You know, if you look at someone like a marathon runner, it's something like marathon runners use like 20% of the muscle fibers. Yeah, they just get really efficient using the same small group of muscle fibers over and over and over again. So hence they actually don't need a lot of their other muscle fibers and they atrophy away and they end up with a really low bulk sort of run, which is great because it makes you more efficient. And I think the same thing when you look at older people are moving slowly. They're not getting that same stimulation of those other muscle fibers.

Speaker 2: 35:34

So I think you need to be doing exercises which are going to fatigue those red fibers and cause you to actually bring into play those other white fibers as well, which helps to maintain your muscle bulk. And so I think you do need to be engaging something that actually causes that fatigue of those smaller muscles and that requires you to, you know, do some sort of exercise barefooted or doing step strengthening, which is what you talked about last time doing that sort of stuff, because it's still going to require, when you stand the edge of a step and you raise yourself up and down on the edge of a step, you're still courting an isometric contraction of those short plantaflexes in the foot. So I still think it's a really valid exercise, just for strengthening the foot as well. So it's the one, it's the one-hit-one to sort of exercise in all its shape or form.

Speaker 2: 36:26

You can do calf strengthening with the foot turned in slightly or turned out slightly, or raising up onto the big toe or raising up on towards the little toe. Just changing the angle of movement, you can end up fatiguing different parts of the foot, and you don't. And you can do it in a reasonably safe way. You know you can hold onto rails whilst you're doing it. You can you know, and you can do it with shoes on or you can do it without shoes on, depending on your fitness and so forth. So I think there's some really simple stuff you can do out there, according to people's abilities.

Speaker 1: 37:00

So one thing you're talking about is the functional sort of lengthening which I think you touched on last time spoke, and that's what you made me think of when I said the heel raise off the step. You still refer to that lengthening and then that heel raise. You need to do that in a lengthened position.

Speaker 2: 37:20

Yeah, look and I think this is the thing is, if we look at the ideal exercise for someone who's going to be strengthening any muscle, first of all, you want to strengthen the muscle in a functional lengthened position. Yeah, so what that basically means you can imagine your flexor digistrum longest, for example, when you're about to push off. What position is your flexor digistrum longest in? It's not in a planter flex position, it's in your heels raise, your toes are up in there, the dorsiflexed. So your flexor digistrum longest is in a lengthened position at this point.

Speaker 2: 37:59

Yes, absolutely. And so if you want to improve the strength in that you want to do an exercise in a functional position with the foot in a raised position. So and we know that when we let, when we strengthen any muscle, almost all muscles do better and strengthen better if they're in a lengthened position, not working in a shortened position. So a functional lengthen position is important. We preferably want to do some isometric contractions because they really help to improve tenor site activity and also talking about foot strength here and toe strength.

Speaker 2: 38:41

Yes, yes, so basically isometric contractions, functionally lengthened positions and preferably doing functional loads, which is preferably moving your body weight.

Speaker 1: 38:54

Yeah, okay.

Speaker 2: 38:55

So, when you look at previous activities that we've used which is why I think foot strengthening has not been particularly useful is that they will do something like they will crunch your toes up and pick up marbles, for example, or scrunch up and scrunch up a towel. When you're doing that, you're using the muscle in a position that never functions in whilst you're actually walking. It doesn't have any great benefit in that short and contracted position, exactly, yeah. So this is why, when we go and fight and sift through the literature, we have problems because they'll say, oh, the person got stronger doing this sort of activity, but it made no difference to the way they walked or function of the foot.

Speaker 2: 39:41

And so one of the papers again we're getting back to those key papers was and I'll refer a lot of people to this particular paper was a paper by Goldman.

Speaker 2: 39:52

Each is published in the Journal of Sports Science in 2013, I think, and what he basically did was he got a person to push down, or some participants to push down, into a force plate, one with their toes in a straightened position and one where their toes are actually pushed back about 25 degrees. So basically, we've got flexed digiturum longus and those other muscles in a dorsiflex position for the toes and they pushed down just firmly with a strong isometric contraction into this plate and they did this like for three seconds, had a three second rest and then did it again. They did it like five times and I think they did this four times a week or something. So it wasn't a huge exercise. The importance of this paper was significant because it was the first paper that showed improvement in functional movement. So at the end of this study, after six weeks, those who'd been activating their toes in a lengthened position had a 7% increase in horizontal jump distance.

Speaker 1: 41:02

Right, so there's a power output, absolutely so.

Speaker 2: 41:07

That was one of the most significant papers we've seen, because there's lots of papers that I tell you got stronger, didn't make any difference, didn't change anything, but the reason they didn't improve anything is because they were not doing it in a functional, lengthened position which replicated what they're going to be doing whilst they're actually moving.

Speaker 1: 41:28

So if I'm standing like in my room here now and I elevate my toes or extend my toes, rest it on a surface or a block of a certain height so my toes are extended and I lift myself up. That should be appropriate to, in that length and position, to accept my toe action.

Speaker 2: 41:52

So you need to be pushing down into that block, yes, okay, okay, so you could be firmly pushing down into that block or that pad or that rolled up towel or whatever. It might be pushing down very firmly as you're doing an activity. Now there is a particular activity and if your listeners are interested, they can go, and if they can try and Google something called the Valaymanuva, and the Valaymanuva is about V-E-L-E. This comes out of a paper that was published, I think, in Germany a long time ago, where they're trying to work out all the different aspects of what helps to keep people balanced upright.

Speaker 2: 42:25

And what I just may actually not know is that there is a reflex which is really important. A reflex is that when you stand up straight and lean forward around about five or six degrees forward, keeping your arms in line with your body, keeping your body basically straight, and you simply lean forward as you get to about five degrees, your toes reflexly contract to stop you from tipping over forward. And I must say I was never taught that reflex, but it's there as a writing reflex. As you're about to tip over and fall over, your toes instantly react once you get to about five degrees to stop you from tipping over. Now, if you actually put something underneath your toes like a rolled up towel and you stand up and lean forward five degrees, your toes will contract and push down to that towel, having to catch your body weight whilst it's in a lengthened position, and so it's then going to strengthen those muscles a lot more in that lengthened position. Okay, these are easy things to do, super simple, super simple, super simple.

Speaker 1: 43:27

Yeah, it's just sets of what five, six or seven, absolutely exactly.

Speaker 2: 43:31

Yeah, exactly. So just work your way up to you know, whatever you wanna work your way up to you should be able to do at least 20 reps, you know of those sort of stuff.

Speaker 2: 43:40

And it's easy. It's a safe exercise. Oldies can do it. They can do it near a wall like so, in case they fall over, they can just push, you know, put their hands out against the wall so you can just roll up a towel, put it on the floor and off you go. And they probably only need to do this three or four times a week for about five or 10 minutes and they'll get a significant improvement in their toe strength.

Speaker 1: 44:00

Okay, so thank you for that so clear. So the other thing to mention again is that me, with my feet flat on the floor and clawing my toes back towards me by pulling a towel or whatever it is, yeah, we just simply make a towel into a tube and put it underneath your toes, so it's cocking your toes up sort of stuff.

Speaker 2: 44:23

You're just getting flat on the floor, towel rolled up underneath your toes, so it's pushing them back up in the air. So imagine your toes floating in the air. And then all you do is you lean your body forward, keeping it straight, and take it at five degrees, and your toes will reflexly want to push down to stop you from tipping over, but they'll push down into the towel instead.

Speaker 1: 44:43

Anyway, I've got some exercise to do tonight. You can have a practice tonight. I realize I was gonna work so hard after this. Okay, I've got another question for you, matt. The age-old clawing of the toes and drawing the towel towards you, you said, is almost useless because it's not in a functional position, shorten position.

Speaker 1: 45:06

What if we do the so-called lumbaric cool strengthening, where I keep my foot flat and I am raising the arch of my foot, but keeping my toes flat and it almost like brings my foot from a splayed position to a raised?

Speaker 2: 45:25

arched position, but my toes are not flexed. Yeah, so he's talking about doming, is that correct? Yes, the doming of the foot, yeah.

Speaker 1: 45:34

It's a very common exercise for the dancers. Is there any worth in that, do you think?

Speaker 2: 45:39

I think it's a tough question, that one, because there has been probably, of all the exercises that's been studied, that's probably one of the most prescribed exercises. I think, again, one of the issues with that is that why wouldn't you do it with the toes extended to replicate that sort of that length and position of those tendons, because ultimately your toes, they're still gonna have some effect. But I don't think this is going to be as effective as doing it like we talked about.

Speaker 2: 46:07

With some extension yeah, but I think it's still gonna be useful. It's still gonna be useful exercise. I can't say that I prescribe it particularly a lot, because I tend to use the one that we talked about before. I use the valet maneuver all the time because it's simple and easy to do. I know it's effective and I combine that with doing the step. Strengthening, or calf strengthening is my standard two sort of exercises that I would do.

Speaker 1: 46:29

Sure, and just before we start, we were talking about hypermobility. There's a stretch reflex, isn't there? That comes into play here, and as far as activating your sensory neurons and you yeah, we were just touching on hypermobility and the influence of strengthening yeah.

Speaker 2: 46:50

so certainly one of the issues with hypermobility is the fact that it's that delayed activity of the muscle spindle. So in order for you to maintain stability around the joint, you need muscles to activate at the right time and ultimately, to put it in really simple terms, if you have hypermobility, then the time it takes to stimulate those muscle spindles to say, hey, you're moving slightly out of whack here. You need to actually activate that muscle. By the time you've got to that point, the moment's gone and the joint's almost gone too far out of whack and therefore the ability to control that joint has been lost, if you like, Is that?

Speaker 1: 47:35

sort of yeah.

Speaker 2: 47:37

So we need very. The muscle spindles have outrageously fast activation and one of the fastest muscle fibers in your entire body. It's like 150 meters per second for muscle spindles. But if that spindle is not being stimulated because you have faster takes than an ankle sprain, it's almost you've got like a hundredth of a second to react. If you don't react within that time, the angle of the joint or the angle of the ankle's gone too far and you've sprained your ankle. So I think with hypermobility one of the issues is that if we're not stimulating those muscle fibers quickly enough, subsequently we need to improve the strength of those tendons and those muscles to improve joint stability.

Speaker 1: 48:30

The activation is crucial, so you can turn on that rapid fire?

Speaker 2: 48:36

Absolutely exactly, and we spoke before about those cutaneous receptors in the foot. If you're losing those cutaneous receptors as a consequence of that, you're not gonna maintain the same stability on the joint and subsequently you'll end up falling over and breaking your hip.

Speaker 1: 48:52

All right, thank you once again. I really appreciate you coming on with me.

Speaker 2: 48:56

It's been good, my low expertise as usual.

Speaker 1: 48:59

Ha, ha, ha ha ha.

Speaker 2: 49:01

Well, it's a joy to share it with everyone.

Speaker 1: 49:04

And I realized that I'm losing my muscle mass and I'm getting slow, and it's because I haven't done enough strengthening. Ha ha, ha ha. That's why it's hard to run now. I'm sure you're faster than me, jason, ha ha, ha ha. All right, thank you, and we'll see you soon. Thank you, good on you, and that's Dylan. Art is a podiatrist at the Melbourne Foot Clinic in Montelbert here in Melbourne and also a clinical supervisor and educator at La Trobe University in the School of Podiatry. I'm Jason Agosta, and thanks for listening. Check the show notes for more details and links. We can also follow and support the show. Stay tuned, as we'll be presenting foot strength and strength training for you Foot strength and diabetic patients next week. Thanks for tuning in.