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Pilates and Hallux Valgus (Bunion)

Masami Miyauchi October 2017

Studio Rituel, Paris, France

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Abstract

Hallux valgus is a progressive foot deformity in which the metatarsophalangeal (MTP)

joint of the large toe is laterally deviated resulting in an abduction of the first metatarsal

while the phalanges adduct. This changes the anatomy and the biomechanics of the

foot, often leading to a development of a bony prominence and soft tissue on the

medial side which is called a bunion. Progression of this deformity can cause foot pain

which can extend further up the chain to the leg, hip and back and simultaneously lead

to malalignment of the posture. The BASI pilates has the appropriate exercises to

address this painful condition and the BASI Block System allows to approach the

whole kinetic chain in order to realign the body (including foot posture) affected by the

hallux valgus to relieve pain and prevent further development.

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Table of Contents

Abstract……………………………………………………………………….. …….. 2

Anatomical Description…………………………………………………...………… 4-6

Case Study Introduction……….……………………………………………….…... 6

Conditioning program………………………………………………………..….….. 7-10

Conclusion…………………………………………………………………………... 10-11

Bibliography……………………………………………………………………….... 12

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Anatomical Description The foot is an intricate part of our body which bears weight and allows for

locomotion. The Hallux or first toe is formed by three bones instead of four. It is formed by the first metatarsal (articulates with two 2 sesamoid bones), the first proximal phalanx and the first distal phalanx. The other toes have an extra bone called the intermediate phalanx.

The first toe has three synovial joints. The first, the tarsometatarsal joint is

situated between the medial cuneiform and the first metatarsal bone where little movement is possible. The second joint, the metatarsophalangeal joint is found between the first metatarsal and first proximal phalanx. The joint allows flexion and extension of the first toe and minor abduction and adduction. It is also reinforced by collateral and plantar ligaments. The last joint, the interphalangeal joins the two phalanges of the first toe. This joint is also reinforced by ligaments but only allows flexion and extension.

The two sesamoid bones mentioned earlier articulate with the first metatarsal bone. They protect the tendons of the muscles that are attached to them, but their main function is to allow the tendons to exert greater forces on the body.

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What is Hallux Valgus (Bunion)? Hallux valgus is a progressive foot deformity in which the

metatarsophalangeal (MTP) joint of the large toe is laterally deviated resulting in an abduction of the first metatarsal while the phalanges adduct. This changes the anatomy and the biomechanics of the foot, often leading to a development of a bony prominence and soft tissue on the medial side which is called a bunion. Progression of this deformity can cause foot pain which can extend further up the chain to the leg, hip and back and simultaneously lead to malalignment of the posture.

Hallux valgus angle 𝝰: between the axis of the first metatarsal and the first proximal phalanx

• Less than 15° is considered normal. • Angles of 20° and greater are considered

abnormal. • An angle of 45-50° is considered severe.

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Hallux Valgus and its effect on body alignment Hallux valgus starts from dysfunction of three intrinsic foot muscles

(abductor and adductor hallucis and flexor hallucis brevis) which function to abduct and adduct and flex the first toe. The flexor hallucis brevis also helps stabilise the medial longitudinal arch. As these muscles loses its function, eversion of the heel (inward rolling of the calcaneus) occurs then the medial arch collapses leading foot to pronate. Collapsed foot arch (overpronation) causes tibia and femur to internally rotate leading the knees inward followed by the femur, hips and pelvis to internally rotate and slight anterior tilt of the pelvis.

Case Study My client is a 33-year-old moderately active female who has minor degree of

hallux valgus (HV) in both feet. She was initially diagnosed over 15 years ago when she experienced pain and discomfort in the metatarsophalangeal joints. She was advised to stretch her calf muscles regularly and to change to wider and flatter footwear in order to relieve pain. She was also told that the only solution to correct the deformity was through surgery which would leave her foot in a supporting device for several months. As she was a young active athlete at the time, surgery was not considered but she changed her footwear as advised and the pain was eliminated.

Now at 33 years old, she has stopped playing regular sports and most of her work consists of sitting at a desk. So, she has kept as active as she could with regular yoga practice and has recently introduced pilates to her routine. Although occasionally she still experiences pain at the metatarsophalangeal joint which tends to occur when she lacks exercise or has been on her feet for too long. Therefore, she has continued to avoid wearing narrow or high-heeled shoes to prevent progression of the HV and foot pain.

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Client Assessment: Small bony prominences (bunion) in both feet can be seen but without any inflammation, low foot arch, anterior tilt of the pelvis and slight internal rotation of shoulders and head slightly forward. She also explained of experiencing lower back pain, tension in neck and shoulders, tight hamstrings as well as occasional pain in her bunions. A conditioning program is tailored for Amy to address the area of her HV and to also address the body as a whole in order to prevent further development of HV, bring relief to her painful condition and have more footwear options in the future. Our focus:

• Elevate her foot arch and improve ankle mobility to promote a more stable foot posture

• Strengthen leg muscles • Gain more flexibility in leg muscles such as the achilles tendon to counter the

stress on forefoot. • Stretch and strengthen hip extensors and hip flexors, improve hip mobility • Improve core strength to bring pelvis to a more neutral position • Strengthening upper back extensor muscles and shoulder stabilisers.

Conditioning Program The conditioning program below was tailored based the client’s symptoms and according to the BASI Block System. The exercise program is divided into 3 phases of 4 weeks each, total of 12 weeks. Exercises were conducted twice a week, starting and ending each session with a roll-down.

Block System PHASE 1 1-4 Weeks Reasons

Warm-up

Mat Pelvic Curl, Spine Twist Supine Chest Lift, Chest Lift with Rotation

Improving pelvic lumbar stabilisation. Cueing foot alignment during pelvic curl, chest lift. Pressing client’s forefoot down to remind engagement in her feet and elevate foot arch during those exercises.

Foot work

Reformer Parallel heals, Parallel toes, V Position toes, Open V heels, Open V toes, Calf raises, Prances, Prehensile, Single

The foot work series increases strength and mobility of ankles. Focusing on activating hip extensors as it was challenging for client. Calf raises and prances to improve ankle mobility and strength

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leg heel, Single leg toes Prehensile to stretch the plantar intrinsic muscles of foot and strengthening muscles to elevate the medial longitudinal arch.

Abdominals

Reformer Hundred prep, Hundred

Ankle plantar flexor strength. Strengthening abdominals to improve core strength and stability This will also decrease extra weight bearing on her bunion.

Hips Reformer Frog, Circles down and up, Openings

Improve hip mobility and strength, ankle plantar flexor strength

Spinal Articulation Reformer Bottom lift

This exercise activated her weak hip extensors whilst working on spinal articulation.

Stretch Reformer Standing lunge

Focusing on lengthening the hip flexors which have been shortened from anteriorly tilted pelvis. Her tight hamstrings can also be stretched.

Full Body Integration Reformer Elephant

Shoulder and trunk stability and hamstring stretch

Arm work

Reformer Arms supine series: Extension, adduction, up circles, down circles, triceps

Focus on building arm strength without extra tension on the lower extremities (especially lower back)

Full Body Integration - -

Leg work

Wunda chair Leg press standing

Strengthen hamstrings whilst challenging balance in standing leg. Focusing on foot alignment throughout.

Lateral Flexion/ Rotation

Wunda chair Side stretch

Co-contraction of abdominals and back extensors whilst maintaining pelvic stability and shoulder stability of the arm on the pedal. Lateral flexor stretch at the end to alleviate pain and pressure on lower back

Back Extension Wunda chair Swan on floor

Scapular stabilisation and back extensor strength. Emphasis on engaging abdominals in order to prevent excess load on lower back.

Block System PHASE 2 5-8 Weeks Remarks

Warm-up

Mat Pelvic Curl, Spine Twist Supine, Chest Lift, Chest Lift with Rotation

Improving pelvic lumbar stabilisation. Cueing foot alignment during pelvic curl, chest lift. Pressing client’s forefoot down to remind engagement in her feet and elevate foot arch during those exercises.

Foot work

Reformer Parallel heals, Parallel toes, V Position toes, Open V heels, Open V toes, Calf raises, Prances, Prehensile, Single leg heel, Single leg toes

Continued footwork on reformer paying close attention to foot alignment and increasing spring resistance for further strengthening.

Abdominals Wunda Chair Pike sitting

Strengthening abdominals as well as shoulder extensors

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Hips

Reformer Circles (down, up), Extended frog, Extended frog reverse

Focusing on hip adductors whilst keeping pelvic lumbar stability

Spinal Articulation Reformer Short spine

Hamstring stretch as well as spinal articulation

Stretch Reformer Kneeling lunge

Focusing on lengthening the hip flexors which have been shortened from anteriorly tilted pelvis. Her tight hamstrings can also be stretched.

Full Body Integration

Reformer Stomach massage series: Round back, flat back, reaching

Challenges trunk stability and ankle plantar strength.

Arm work

Reformer Arms sitting series: Chest expansion, Biceps, Rhomboids, Hug-a-tree, Salute

Focus on shoulder extensors and trunk stabilisation

Full Body Integration - -

Leg work Reformer Hamstring curl

Strengthen hamstrings

Lateral Flexion/ Rotation

Cadillac Side lifts

Strengthening abdominal obliques as well as lateral flexor stretch

Back Extension Cadillac Prone 1 and 2

Back extensor strength, shoulder stability and stretch (in prone 2)

Block System PHASE 3 9-12 Weeks Remarks

Warm-up

Mat Roll up, Spine Twist supine, Double leg stretch, Single leg stretch, CrissCross

Ankle plantar flexor strengthening during the roll up. Strengthening abdominals and pelvic lumbar stability

Foot work

Cadillac Parallel heals, Parallel toes, V Position toes, Open V heels, Open V toes, Calf raises, Prances, Single leg heel, Single leg toes

More challenging for hip extensor strength than on the reformer and also allows them to stretch. A good view for client to see and become aware of her own foot alignment. Continued strengthening of foot stability, hip adductors.

Abdominals Cadillac Roll-up top loaded

Strengthening of abdominals as well as shoulder stretch

Hips

Cadillac Single leg supine series: Frog, Circles (down, up), Hip extension, Bicycle

Improve strength of hip extensor, adductor and pelvic lumbar stabilisation with the challenge of the single leg exercises.

Spinal Articulation Cadillac Tower prep, Tower

Deep lumbar flexion with hamstring stretch

Stretch Ladder barrel

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Gluteals, Hip flexors

Full Body Integration Cadillac Sitting forward

Spinal mobility, flexibility in hamstrings, strength in back and abdominal control

Arm work Wunda Chair Shrugs, Triceps press sit

Shoulder stretch as well as strengthening shoulder extensors

Full Body Integration - -

Leg work

Reformer Jumping series: Parallel position, V position, Single leg parallel, Leg changes

Dorsi and plantar flexion control and strength with awareness of correct foot alignment.

Lateral Flexion/ Rotation

Reformer Side over on box

Co-contraction of abdominals and back extensors while obliques control the movement. Side stretch at the end of the exercise for lower back pain relief.

Back Extension Reformer Pulling straps 1 and 2

Strengthening back and shoulder extensors

Conclusion

Unfortunately the true etiology of the hallux valgus is still unclear. For minor

degree of HV, often footwear alterations, orthotic insoles and even surgery are

recommended treatments but HV recurrence is one of the most common

complications in bunion surgery. During my research I found mentions of physical

therapy but the focus remained more on the foot and ankle instead of addressing the

body as a whole.

Although surgical procedures has not been undertaken to correct my client’s

HV she has been experiencing less foot pain after this 12 week program. Initial

challenges such as correcting foot alignment, engaging hip extensors and extension

and stabilisation of shoulders have gradually improved through consistent training

and improvement in her awareness in both foot and body posture. Other changes

were increase in her core strength, reduced lower back pain and shoulder and neck

tensions. After many sessions my client also mentioned of feeling a difference in her

body during the pelvic curl. She indicated that she was able to press into her forefoot

when lifting her pelvis as cued, whereas before she had difficulty engaging her feet.

This shows improvement in her foot strength and posture.

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She wishes to maintain her regular pilates practice in order to continue

strengthening her foot and ankle and improving her overall body alignment to prevent

her HV from progressing further and cause pain.

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Bibliography

Books:

Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body

Arts and Science International, 2013. Websites: Hallux Valgus, Physiopedia https://www.physio-pedia.com/Hallux_Valgus Dr. Fabio Levi, Flat Feet & Overpronation: The Impact on Your Health and Functioning, 15 Feb. 2015. http://fabiolevi.com/2015/flat-feet-overpronation-impact-health/ Matt Whitehead, How foot and leg posture influence each other and cause pain, Oregon exercise therapy, 17 Oct. 2017. http://www.oregonexercisetherapy.com/blog/how-foot-and-leg-posture-influence-each-other-and-cause-pain WARD M. GLASOE, PT, PhD, ATC, Treatment of Progressive First

Metatarsophalangeal Hallux Valgus Deformity: A Biomechanically Based

Muscle-Strengthening Approach, Journal of orthpaedic & sports physical therapy, July 2016. https://www.jospt.org/doi/pdf/10.2519/jospt.2016.6704

Orthoanswer, Bunions | Hallux Valgus, 11 Aug. 2012. http://www.orthoanswer.org/foot-ankle/bunions/index.html