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Journal of Back and Musculoskeletal Rehabilitation -1 (2022) 1–13 1

DOI 10.3233/BMR-210374
IOS Press

Review Article

The effects of short foot exercises to treat flat

foot deformity: A systematic review
Shigeyuki Haraa , Masashi Kitanob,c and Shintarou Kudob,c,d,∗
a
Department of Rehabilitation, Kindai University Nara Hospital, Nara, Japan
b
Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka, Japan
c
Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
d
AR-Ex Medical Research Center, Tokyo, Japan

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Received 13 December 2021

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Accepted 23 May 2022
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Abstract.
BACKGROUND: Studies on the effects of performing short foot exercises (SFEs) on the medial longitudinal arch (MLA) have
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been inconclusive.
OBJECTIVE: This study aimed to conduct a systematic review of the effects of SFEs.
METHODS: ‘SFE’ and ‘intrinsic foot muscle’ were keywords used to search for randomized controlled trials. One researcher
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screened relevant articles based on their titles and abstracts, and two independent researchers closely read the texts, accepting nine
studies for inclusion. Outcomes, intervention duration, frequency, and the number of interventions were investigated.
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RESULTS: Of 299 potential studies identified, the titles and abstracts of 211 studies were reviewed, and 192 were excluded.
The full texts of 21 studies were obtained and evaluated according to inclusion and exclusion criteria. Nine studies met the
inclusion criteria. Six studies concerning the MLA were identified, with four reporting MLA improvement. There was no
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consensus concerning the number and frequency of SFEs performed, and the mechanism of MLA improvement was unclear. MLA
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improvement was observed in participants who undertook > 5 weeks of interventions.

CONCLUSIONS: The results suggest that performing SFEs for > 5 weeks is effective in improving the MLA. Randomized
controlled trials with details concerning the number and frequency of treatments are required.
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Keywords: Flat feet, intrinsic foot muscles, medio-lateral arch, short foot exercise
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1 1. Introduction ing factors have been associated with flat feet: occu- 7

pation [2], obesity [3], and age [4]. Recently, injuries 8

2 1.1. Flat foot deformity to foot ligaments [5] and a decreased muscle cross- 9

sectional area of the intrinsic foot muscles (IFMs) [6] 10

3 Flat foot deformity is a chronic foot condition that in- have also been reported in flat feet, suggesting that foot 11

4 cludes flattening of the medial longitudinal arch (MLA), function is impaired. Studies comparing flat feet with 12

5 hindfoot valgus, and midfoot abduction [1], with a re- normal alignment have reported that flat feet involve a 13

6 ported prevalence of 2–23% in adults [2]. The follow- higher incidence of plantar tendinitis [7]. Furthermore, 14

flat feet have been cited as an important etiology of 15

several lower extremity overuse injuries, including low 16

∗ Corresponding
author: Shintarou Kudo, Morinomiya University back pain [8] and shin splints [9,10]. Therefore, treating 17
of Medical Science, 1-26-16 Nankoukita,Suminoe-ku, Osaka-shi,
Osaka 559-8611, Japan. Tel.: +81 6 6616 6911; Fax: +81 6 6616 a flat foot deformity may potentially prevent overuse 18

6912; E-mail: kudo@morinomiya-u.ac.jp. injuries. 19

ISSN 1053-8127/$35.00
c 2022 – IOS Press. All rights reserved.
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2 S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

20 1.2. Treatment for flat foot deformity ing the number and frequency of SFEs undertaken, the 69

duration of the intervention, and the types of outcomes, 70

21 Flat feet have previously been classified as flexible along with the effects of SFEs. 71
22 or rigid [11]. For rigid flat feet, surgical treatment to
23 correct the bony structure is common [12]. For flexible
24 flat feet, clinically asymptomatic cases do not require 2. Methods 72
25 intervention [13]. For symptomatic cases, conservative
26 therapy such as nonsteroidal anti-inflammatory drugs,
This systematic review was conducted according to 73
27 weight loss, functional foot orthoses, physical ther-
the Preferred Reporting Items for Systematic Reviews 74
28 apy, and exercise therapy remain treatments of choice
and Meta-Analysis (PRISMA) statement and was reg- 75
29 to relieve pain and prevent progression of the defor-
30 mity [14,15]. Exercise therapy for flat feet includes istered in the PROSPERO database under the identifi- 76

31 extrinsic muscle and IFM strengthening to maintain cation number CRDCRD42020183467. 77

32 the MLA [16,17]. The effects of toe flexion exercises,

33 such as the toe curl exercise (TCE), have also been re- 2.1. Search method 78

34 ported [18]. However, the TCE involves the use of both

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35 IFMs and extrinsic foot muscles, and recent studies A combination of the following keywords and their 79

36 have focused on the IFMs alone [19–21]. It has been variation were used: (short foot exercise OR (short or 80

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37 reported that patients with flat feet have higher inci- foot or exercise) OR SFE) AND (intrinsic muscle OR 81

dence rates of IFM atrophy compared with patients with (intrinsic or muscle) OR IFM) to search for randomized

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38 82

39 a normal MLA [7] and there is a correlation between controlled trials (RCTs) up to October 2021. We used
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40 cross-sectional areas of atrophied IFMs, such as the PubMed, Physiotherapy Evidence Database (PEDro), 84

41 abductor hallucis longus and flexor digitorum brevis and the Cochrane Library (including Cochrane Central 85

muscles, and the severity of flat feet [22]. Short foot Register of Controlled Trials, CENTRAL) as search
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42 86

43 exercises (SFEs) have been used as exercise therapy for databases. Two reviewers independently conducted the 87

44 IFMs. search. 88
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45 1.3. Short foot exercises

2.2. Inclusion and exclusion criteria 89
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46 SFEs shorten the length of the foot through con-

47 tracting the plantar muscles of the foot to pull the first The target studies were selected in terms of the ab- 90
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48 metatarsal towards the heel and heighten the MLA with- stracts of related articles identified during the database 91

out flexing the toes [23]. In flatfoot deformity, SFEs search. The retrieved studies were screened to deter- 92
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49

50 are used to strengthen the IFMs, which maintain the mine their relevance. Inclusion criteria comprised: (i) 93

51 MLA [24,25]. Okamura reported that this exercise de- RCTs, (ii) studies that included at least one group using 94
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52 creased foot posture index (FPI) values [26]. In chronic an SFE as an intervention, and (iii) articles published in 95

53 ankle instability, an eight-week SFE intervention was English. Exclusion criteria comprised: (i) animal exper- 96
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54 shown to increase Cumberland Ankle Instability Tool iments, and (ii) abstracts, letters, reviews, systematic 97

55 (CAIT) values [27]. reviews, meta-analyses, or case reports. 98

56 Prior studies have reported that some patients cannot

57 perform SFEs satisfactorily, even after two weeks of 2.3. Quality assessment 99
58 practice [28], and that this is one of the most difficult
59 exercise therapies to implement. In addition, studies on The selected studies were independently and criti- 100
60 the effect of SFEs on MLA improvement in patients cally reviewed and evaluated by two reviewers using 101
61 with flat feet have reported differing outcomes [29] and the Cochrane risk of bias tool for randomised trials 102
62 this area remains contentious. Furthermore, the number (RoB 2.0), to assess the methodological quality of the 103
63 and frequency of SFEs performed, the duration of the included studies for risk of bias across five domains: 104
64 intervention, and the types of outcomes evaluated have (i) the randomization process, (ii) deviations from in- 105
65 not been fully investigated.
tended interventions, (iii) missing outcome data, (iv) 106

66 1.4. Study purpose measurement of the outcomes, and (v) selection of the 107

reported results. Studies with a low risk of bias in all 108

67 The purpose of this study was to conduct a system- five domains were considered to have a low risk of 109

68 atic review of studies that provided full details concern- overall bias, studies with some concerns in at least one 110
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S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review 3

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Fig. 1. Flowchart for the selection of included trials.

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111 domain were considered to have some concerns overall, Total score = [duration of intervention (weeks) × 130

112 and studies with a high risk of bias overall or a high risk frequency of intervention (times/week) × number of 131

of bias in at least one domain were considered to have repetitions (times) × number of sets].
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113 132

114 a high risk of bias. Studies with at least one domain The amount of load was also compared. 133

of some concern were considered to have a concern

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115

116 overall, whereas those with at least one domain of a 2.5. Statistical analysis 134
117 high risk of bias or studies with multiple domains of
118 some concern were considered to have a high risk of This meta-analysis was performed using Review 135
119 bias. Disagreements among the reviewers were resolved Manager Version 5.4 software. Statistical calculations 136
120 through discussion [30].
were performed for all included studies using detailed 137

121 2.4. Data extraction data for SFE alone, SFE combined with other exercise 138

therapies, and exercise therapies alone. An SFE group 139

122 A meta-analysis was conducted on dynamic balance, (SFE combined with exercise therapy) and an exercise 140

123 specifically the Y-balance test. One reviewer extracted therapy group (exercise therapy only) were compared 141

124 all the relevant data separately. The extracted and tab- using a random-effects model. Statistical reliability was 142

125 ulated data included the lead author, year of publica- calculated using 95% confidence intervals (CIs). Sta- 143

126 tion, the number of participants, total score (number of tistical heterogeneity was assessed using I 2 [31] and a 144

127 SFEs, frequency of intervention, duration of interven- random-effects model [32]. The significance level was 145

128 tion), type of muscle contraction, posture of execution, set at < 5%, and P -values < 0.05 were considered 146

129 duration of muscle contraction, and type of outcome. statistically significant. 147
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4 S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

Fig. 2. Risk of bias graph: a review of authors’ evaluations concerning each risk of bias item presented as percentages across all included studies.

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Fig. 3. Risk of bias summary: a review of the authors’ evaluations concerning each risk of bias item for each included study.
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148 3. Results are shown in Tables 1 and 2. Concerning the number of 161

times a single SFE intervention was conducted, the min- 162

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imum was five times and the maximum was 104 times. 163
149 3.1. Study selection
Interventions were provided 2–7 days per week, and 164
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the intervention period ranged from 4–14 weeks. The 165

150 A database search identified 291 potential studies, total score ranged from 120 to 6552. One study did not 166

151 and 211 abstracts remained after duplicate studies had provide details concerning the number of repetitions; 167

152 been removed. The abstracts were then reviewed, and therefore, the total score could not be calculated. 168

153 a preliminary evaluation was conducted to assess the

154 eligibility of 21 full-text articles. Nine studies met our 3.2.2. The MLA 169

155 inclusion criteria and 12 were excluded, as the inter- Navicular height, the navicular drop test (ND), and 170

156 ventions in those studies were deemed inappropriate the FPI were used to measure the MLA. Six reports 171

157 (Fig. 1). concerning the MLA were identified, of which four re- 172

ported an improvement in the MLA. Kim et al. con- 173

ducted a five-week SFE study among university stu- 174

dents with flat feet and reported a significant decrease 175

158 3.2. Study characteristics
in ND post-intervention [33]. Okamura et al. con- 176

ducted SFEs with electromyographic biofeedback in 177

159 3.2.1. SFE setting university students with flat feet and reported a signifi- 178

160 The basic characteristics of the nine selected studies cant post-intervention improvement in the FPI at eight 179

180
 Table 1
Characteristics of the selected studies
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Outcome
Author Year Patient Number of Group Introduction practice Intervention Outcome for conditions other
for MLA
patients than MLA
Jung et al. 2011 University 28 (1) FO + FOSF group were also (1) wear FO + SFE None – Cross-sectional area (CSA) of
students with M: NR SFE instructed in a short-foot (2) wear FO the abductor hallucis (AbdH)
flexible flat F: NR (2) FO exercise protocol. muscle
foot – Strength of the flexor hallucis
(FH)
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Fraser et al. 2017 Healthy adult 24 (1) interven- All participants were (1) SFE + Toe-spread-out None – Clinician-assessed motor per-
M: 12 tion verbally instructed, Hallux-extension Lesser-toe- formance
F: 12 (2) control provided demonstration, extension exercise. – Participant-perceived difficulty
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and guided through a (2) No intervention – USI motor activation mea-
single practice trial of the sures of the abductor hallucis
toe-spread-out, (AbdH), flexor digitorum bre-
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hallux-extension, and vis (FDB), quadratus plantae
lesser-toe-extension (QP), and flexor hallucis brevis
12/07/2022; 16:49

exercises prior to baseline

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(FHB)
assessment.
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Iwona et al. 2020 Amateur 80 (1) SFE NR (1) SFE, Reverse Tandem Gait None – Functional Movement Screen
runners M: 57 (2) control exercise Vele’s Forward Lean (FMS) test
F: 23 Exercises with band loops – Myofascial flexibility
strengthening Stability disc
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exercises (2) No intervention
Kim et al. 2016 University 14 (1) SFE Before the intervention, (1) SFE ND Y-balance tests
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students with M: 10 (2) ASI the researcher (2) Walking wth ASI
flexible flat F: 4 demonstrated the short
foot foot exercises while giving
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verbal instructions.
ND
Kısacık et al. 2021 Patients with 30 (1) SFE NR (1) SFE – Visual Analogue Scale
FPI
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PFP M: 5 (2) control (2) Hip and knee strengthening – Kujala Patellofemoral Scale
F: 25 and stretching exercises – Rearfoot angle
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drop out: 5
Lynn et al. 2012 Healthy adult 24 (1) SFE The SFE and TCE groups (1) SFE ND – Range of the mediolateral
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M: 15 (2) TCE were instructed to return to (2) TCE (ML) movement of the center
S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

F: 15 (3) control the laboratory 1 week after
drop out: 6 initial testing to receive
training on exercises that
were to be performed
during the training phase
of the study.
(3) No intervention of pressure (COP) during par-
ticipants stood on 1 foot for 30
seconds,
– Y balance test
5
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Table 1, continued
Outcome
Author Year Patient Number of Group Introduction practice Intervention Outcome for conditions other
for MLA
patients than MLA
ND
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Okamura et 2020 University 20 (1) SFE Participants received (1) SFE + EMG + ES – Foot kinematics during gait,
FPI
al. students with M: 3 (2) control verbal instruction and a (2) No intervention including dynamic navicular
flexible flat F: 17 demonstration of the
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drop – the difference between
foot correct technique to navicular height at heel strike
perform the short-foot and the minimum value – and
exercise. the time at which navicular
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height reached its minimum
value
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– Thickness of the intrinsic and
extrinsic foot muscles using ul-
ed
trasound

ND
Manuel et al. 2020 University 85 (1) SFE NR (1) SFE None
FPI
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students with M: 42 (2) NBFE (2) NBFE
flexible flat F: 48
foot drop out: 5
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Navicular
Ramachandra 2019 Pregnant 86 (1) Study NR (1) Regulr antenatal exercise – Foot length
height
et al. women M: group + SFE, Heel raise Big toe – Foot width
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F: 86 (2) Control raises Toe raises Picking up
small object Toe curl Ankle in-
version and eversion exercises
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Ankle circling exercises Calf
muscle stretching
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(2) Regulr antenatal exercise
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SFE: short foot exercise, ASI: ancle support insole, NR: not reported, EMG: electromyogram, ES: electrical stimulation, PFP: patellofemoral pain, TCE: toe curl exercise, NBFE: non-biomechanical
function exercise, FO: foot orthosis.
S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review
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 Table 2
Total score of selected studies
Author Year Patient Number of Group Introduction Intervention Total Period Nsumber of Time of Number of Number
patients practice score [week] exercise intervention repetitions of sets
Galley Proof

interven-
tons/day or
week
Jung et al. 2011 University 28 (1) FO + FOSF group were (1) wear FO + 1680 8 (1) 2/day × (1) NR (1) 5 (1) 3
students M: R SFE also instructed in SFE 7 days/week (2) none (2) none (2) none
with F: NR (2) FO a short-foot (2) wear FO (2) none
flexible exercise protocol.
flat foot
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Fraser et al. 2017 Healthy 24 (1) interven- All participants (1) SFE + 6552 4 (1) 3/day × (1) NR (1) 15 → (1) 3
adult M: 12 tion were verbally Toe-spread-out 7 days/week (2) none 8→3 (2) none
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F: 12 (2) control instructed, Hallux-extension (2) none (2) none
provided Lesser-toe-
demonstration, extension
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and guided exercise. (2) No
through a single intervention
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practice trial of
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the
toe-spread-out,
ed
hallux-extension,
and lesser-toe-
extension
exercises prior to
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baseline
assessment.
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Iwona et al. 2020 Amateur 80 (1) SFE NR (1) SFE, Reverse 1260 6 (1) 1/day × (1) 30 minutes (1) 30 (1) 1
runners M: 57 (2) control Tandem Gait 7 day/week (2) none (2) none (2) none
F: 23 exercise Vele’s (2) none
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Forward Lean
Exercises with
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band loops
strengthening
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Stability disc
exercises (2) No
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intervention
Kim et al. 2016 University 14 (1) SFE Before the (1) SFE Not rep- 5 (1) 1/day × (1) 30 minutes (1) NR (1) 1
S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

students M: 10 (2) ASI intervention, the (2) Walking wth etitions 3 days/week (2) 30 minutes (2) NR (2) 1
with F: 4 researcher ASI but time (2) 1/day ×
flexible demonstrated the 3 days/week
flat foot short foot
exercises while
giving verbal
instructions.
7
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 8
Galley Proof

Table 2, continued
Author Year Patient Number of Group Introduction Intervention Total Period Nsumber of Time of Number of Number
patients practice score [week] exercise intervention repetitions of sets
interven-
tons/day or
week
Kısacık et al. 2021 Patients 30 (1) SFE NR (1) SFE 120 6 (1) 1/day × (1) NR (1) 10 (1) 1
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with PFP M: 5 (2) control (2) Hip and knee 2 days/week (2) NR (2) 10 (2) 1
F: 25 strengthening and (2) 1/day ×
drop out: 5 stretching 2 days/week
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exercises
Lynn et al. 2012 Healthy 24 (1) SFE The SFE and (1) SFE 2800 4 (1) 1/day × 7 (1) NR (1) 100 (1) 1
adult M: 15 (2) TCE TCE groups were (2) TCE day/week (2) NR (2) 100 (2) 1
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F: 15 (3) control instructed to (3) No (2) 1/day × 7 (3) none (3) none (3) none
drop out: 6 return to the intervention days/week
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laboratory 1 week (3) none

ct
after initial
testing to receive
ed
training on
exercises that
were to be
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performed during
the training phase
of the study.
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Okamura et 2020 University 20 (1) SFE Participants (1) SFE + EMG 720 8 (1) 1/day × 3 (1) 5 sec/time (1) 10 (1) 3
al. students M: 3 (2) control received verbal + ES days/week (2) none (2) none (2) none
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with F: 17 instruction and a (2) No (2) none
flexible demonstration of intervention
flat foot the correct
er
technique to
perform the
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short-foot
exercise.
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Manuel et al. 2020 University 85 (1) SFE NR (1) SFE 140 4 (1) 1/day × 7 (1) 30 sec/time (1) 5 (1) 1
S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

students M: 42 (2) NBFE (2) NBFE day/week (2) 30 sec/time (2) 5 (2) 1
with F: 48 (2) 1/day ×
flexible drop out :5 7 days/week
flat foot
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 Galley Proof

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Table 2, continued
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Author Year Patient Number of Group Introduction Intervention Total Period Nsumber of Time of in- Number of Number
patients practice score [week] exercise tervention repetitions of sets
interven-
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tons/day or
week
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ct
Ramachandra 2019 Pregnant 86 (1) Study group NR (1) Regulr antenatal 4320 14 (1) 1/day × 4 (1) NR (1) 20 (each) (1) 3
et al. women M: 0 (2) Control exercise + SFE, Heel days/week (2) NR → 30 (2) NR
ed
F: 86 raise Big toe raises (2) none (2) none
Toe raises Picking up
small object Toe curl
Ankle inversion and
pr
eversion exercises An-
kle circling exercises
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Calf muscle stretching
(2) Regulr antenatal
exercise
fv
SFE: short foot exercise, ASI: ancle support insole, NR: not reported, EMG: electromyogram, ES: electrical stimulation, PFP: patellofemoral pain, TCE: toe curl exercise, NBFE: non-biomechanical
function exercise, FO: foot orthosis.
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S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review
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10 S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review

181 weeks [26]. Ramachandra et al. conducted 14 weeks function and morphology, balance, foot morphology, 226

182 of SFEs in pregnant women and reported a signifi- and DND tests were used, showing the effect of SFEs 227

183 cant post-intervention increase in navicular height [34]. on IFM thickness and activity, and improvement in bal- 228

184 Kısacık et al. conducted a six-week SFE study of pa- ance. 229

185 tients with patellofemoral pain (PFP) and reported

186 a significant decrease in ND and FPI scores post- 4.2. Effects of the intervention on the MLA 230

187 intervention [35].

Recently, several systematic reviews have focused on 231

188 3.2.3. Other outcomes IFMs. Willems et al. examined the effects of a plantar 232

189 The outcomes for conditions other than the MLA IFM strengthening intervention on dynamic balance 233

190 were IFM function and morphology, balance, foot mor- control and foot function during gait in adults [38] and 234

191 phology, and the dynamic navicular drop (DND) test. Erin et al. reported the effects of an intervention on 235

192 In three studies, IFM function and morphology were functional mobility [39]; however, neither intervention 236

193 used as outcomes, and both IFM thickness and muscle method was limited to performing SFEs. In a systematic 237

194 activity were reported to have improved [23,26,36]. Of review, Cameron et al. focused on SFEs but limited 238

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195 two studies that used balance as an outcome, all patients their investigation to ND as the outcome [40]. Our study 239

196 showed an improvement in dynamic balance [33,38]. provided a review of studies reporting the effectiveness, 240

frequency, and duration of SFE interventions.

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241
197 One study used foot morphology as an outcome in preg-
Four of six included studies found improvement in 242
nant women and reported that foot length and width in-

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198
the MLA with SFEs. MLA improvement was observed 243
199 creased with advancing gestational weeks in the control
for interventions of > 5 weeks duration [26,33–35]; 244
200 group, but foot length and width did not change with
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however, no improvement was observed for interven- 245
201 advancing gestational weeks in the SFE group [34]. One
tions of < 5 weeks duration [41,42]. The total scores 246
study used the DND test as an outcome, and reported
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202
were 720 and 4320 for the studies in which the MLA 247
203 no change in DND test results [26]. Another study used
improved. In one study, the total score could not be 248
204 a visual analogue scale and the Kujala patellofemoral
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calculated because the number of repetitions was not 249

205 scale as outcomes in patients with PFP, and reported that
stated. The score for the study without improvement 250
206 values in both scales reduced post-intervention [35].
was 2800. This result suggests that the amount of SFE
ed

251
207 However, another study used functional movement load may not affect improvement of the MLA. Although 252
208 screen test results as a study outcome and reported that we could not reach a consensus concerning the number 253
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209 scores increased post-intervention [37]. or frequency of SFEs on MLA improvement, our find- 254

ings suggest that SFEs should continue for > 5 weeks.

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255
210 3.2.4. Risk of bias The plantar fascia is reported to be a major con- 256
211 Figures 2 and 3 show risk of bias ratings for each tributor to MLA retention [43–45]. The plantar fascia 257
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212 included study. All studies had an increased risk due overlaps the IFMs and attaches to the flexor digito- 258
213 to the impossibility of blinding the participants. The rum brevis. Therefore, IFM strengthening plays an im- 259
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214 risk of bias was also increased for studies that did not portant role in maintaining the foot’s medial longitu- 260
215 describe the randomization process, deviations from dinal arch [21,46]. Three studies described the use of 261
216 the intended intervention, missing outcomes, outcome IFM function and morphology as study outcomes and 262
217 measures, or selection of outcomes to report. reported improvements in both muscle thickness and 263

muscle activity. However, no study reported changes 264

to the structure of the IFM in relation to the height of 265

218 4. Discussion the MLA. Furthermore, one study reported no signifi- 266

cant change in IFM thickness but improvement in the 267

219 4.1. Summary MLA [26]. Additionally, one study showed an increase 268

in the muscle cross-sectional area of the abductor hallu- 269

220 A systematic review of the number and frequency of cis muscle, but no change to navicular height [47]. That 270

221 SFEs, the duration of the intervention, and the types study did not find an association between IFM hyper- 271

222 of outcomes, was undertaken to determine the effects trophy and the MLA. Therefore, the effect of SFEs on 272

223 of SFEs Four studies showed MLA improvement com- the MLA require further investigation of morphologi- 273

224 pared with two studies that showed no improvement cal changes from an IFM perspective as well as from 274

225 in the MLA. For outcomes other than the MLA, IFM multiple other perspectives. 275
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S. Hara et al. / The effects of short foot exercises to treat flat foot deformity: A systematic review 11

276 4.3. Effects on balance women, patients with PFP, and college students Second, 322

it was not possible to determine whether the participants 323

277 Two studies showed an improvement in balance func- were able to learn how to correctly perform the SFEs. 324

278 tion [33,41]. Kim et al. used the Y-balance test as In previous studies, SFE requires an hour to two weeks 325

279 an outcome measure of balance [33]. Lynn et al. used of practice to master, and there are reports of failure to 326

280 a force plate and found a decrease in center of pres- master this exercise even after practice [29]. One in- 327

281 sure movements during the Y-balance test [44]. It has cluded study explained how to perform the SFE but did 328

282 been reported that patients with flat feet are more un- not mention the time taken to practice or an assessment 329

283 stable in a static standing position than those without of whether it had been performed correctly. Okamura 330

284 flat feet [48] and, in a study that evaluated dynamic et al. used electromyography as feedback, whereas no 331

285 stability during closed-eye standing using a force plate, feedback was provided in other studies [26]. 332

286 participants with flat feet were reported to have signifi-

287 cantly lower dynamic stability than those with normally 5. Conclusions 333
288 arched feet [49]. Lee et al. reported that eight weeks
289 of SFE intervention improved joint position, sense of The results of this study suggested that SFEs were 334

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290 the ankle joint, and dynamic balance in patients after effective in improving the MLA in participants with flat 335

291 ankle sprain [50]. In a systematic review of balance feet with an intervention period of > 5 weeks. The num- 336

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292 training, the most effective intervention period for im- ber and frequency of SFEs were not uniform across the 337

proving balance ability was 11–12 weeks, and many studies, and the mechanism of MLA improvement was

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293 338

294 reports indicate interventions of 5 weeks or longer [51]. not clear. The effect of the balancing function on MLA 339

improvement was also unclear. Future RCTs investigat-

295 From these reports, a period of more than 5 weeks is
fv 340

296 required for the prompting of the proprioceptive sensa- ing changes in the MLA in relation to IFM morphology 341

tion, which is consistent with the period required for the and proprioception are required.
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297 342

298 improvement of MLA by SFE. In other words, SFE may

299 have stimulated proprioceptive sensation in the foot,
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300 leading to an improvement in MLA. However, none of Acknowledgments 343

301 the RCTs selected in this study targeted proprioceptive The authors would like to thank Editage (www. 344
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302 sensation. We hypothesized that SFE had an influence editage.com) for English language editing. 345
303 with central nervous systems factors that affect muscle
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304 strength is the change in the firing rate of alpha motor

305 neurons (rate coding). When the CNS instructs a muscle Conflict of interest 346
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306 to contract, both alpha and gamma motor neurons are

307 activated. Gamma motor neurons to contract the intra- The authors have no conflicts of interest to declare. 347
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308 fusal fibers appropriately. Thus, IFM with SFE altered

309 the firing rate of gamma motor neurons, resulting in
Ethical approval 348
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310 altered proprioception.

No individual patient data was used for the meta- 349
311 4.4. Clinical significance of Neues analysis. Ethical approval was thus not required. 350

312 Five weeks of continuous SFE for flat feet may im-
313 prove morphology and proprioception in the IFMs and Funding 351

314 improve the MLA. In addition, SFEs have been shown

315 to be more effective than functional orthotic therapy in None to report. 352

316 improving the MLA [33].

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