Gait & Posture 75 (2020) 40–45

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Gait & Posture

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Full length article

Effects of plantar intrinsic foot muscle strengthening exercise on static and T

dynamic foot kinematics: A pilot randomized controlled single-blind trial in
individuals with pes planus
⁎
Kazunori Okamuraa, , Kengo Fukudab,c, Sadaaki Okia, Takeya Onoa, Satoshi Tanakaa,
Shusaku Kanaia
a
Department of Physical Therapy, Faculty of Health and Welfare, Prefectural University of Hiroshima, 1-1 Gakuen-cho, Mihara-shi, Hiroshima 723-0053, Japan
b
Graduate School of Comprehensive Scientific Research, Prefectural University of Hiroshima, 1-1 Gakuen-cho, Mihara-shi, Hiroshima 723-0053, Japan
c
Department of Rehabilitation, Innoshima Ishikai Hospital, 1962 Innoshima nakanosyo-cho, Onomichi-shi, Hiroshima 722-2211, Japan

A R T I C LE I N FO A B S T R A C T

Keywords: Background: No reliable evidence has confirmed whether plantar intrinsic foot muscle strengthening exercises
Pes planus improve static and dynamic foot kinematics in individuals with pes planus.
Plantar intrinsic foot muscles Research question: Does the short-foot exercise affect static foot alignment and foot kinematics during gait in
Strengthening exercise individuals with pes planus?
Foot kinematics
Methods: This was a randomized controlled single-blind trial involving 20 participants with pes planus who were
Randomized controlled trial
randomly allocated to a short-foot exercise group (exercise) or a control group (controls). Exercise patients
performed a progressive short-foot exercise three times per week for 8 weeks; controls received no intervention.
Before and after the 8-week intervention, foot kinematics during gait, including dynamic navicular drop—the
difference between navicular height at heel strike and the minimum value—and the time at which navicular
height reached its minimum value were assessed, using three-dimensional motion analysis. We assessed static
foot alignment by foot posture index and navicular drop test, and the thickness of the intrinsic and extrinsic foot
muscles using ultrasound. All measurements were performed by one investigator (KO) blinded to the partici-
pants' allocation.
Results: After the 8-week intervention in the exercise group, foot posture index scores with regard to calcaneal
inversion/eversion improved significantly (p < 0.05). Moreover, the time required for navicular height to reach
the minimum value decreased significantly (p < 0.01).
Significance: For individuals with pes planus, the short-foot exercise effectively corrected static foot alignment
and temporal parameters of foot kinematics during gait. This temporal change, which shortens the time for
navicular height to reach its minimum value, indicates an improved windlass mechanism. Therefore, short-foot
exercise might effectively prevent or treat injuries related to the pes planus alignment.

1. Introduction
Pes planus alignment, in which the medial longitudinal arch (MLA)
height is decreased, has been described as a significant etiological
factor for several lower extremity overuse injuries such as plantar fas-
ciitis [1,2] and medial tibial stress syndrome [3,4]. Although various
ligaments such as the plantar fascia and the spring ligament are prin-
cipal components in preventing a decrease in MLA height [5,6], the
MLA is also supported by muscles [7–11]. Several recent studies have
focused on the capacity of the plantar intrinsic foot muscles (PIFMs) to
support the MLA [9,8–11]. The extrinsic foot muscles, such as the
posterior tibialis, are strong MLA supporters; however, in individuals
with pes planus, the PIFMs are atrophied compared with those in in-
dividuals with a normal arch [12]. Moreover, smaller cross-sectional
areas of the PIFMs, such as the abductor hallucis and flexor hallucis
brevis, are correlated with more severe pes planus alignment [13].
Therefore, PIFM hypofunction may be a cause of pes planus alignment
and related injuries.
Based on these findings, PIFM strengthening exercises have been
prescribed in rehabilitation and sports medicine to prevent and/or treat

⁎
Corresponding author.
E-mail addresses: k-okamura@pu-hiroshima.ac.jp (K. Okamura), 511kengofukuda@gmail.com (K. Fukuda), oki@pu-hiroshima.ac.jp (S. Oki),
ono@pu-hiroshima.ac.jp (T. Ono), s-tanaka@pu-hiroshima.ac.jp (S. Tanaka), kanai@pu-hiroshima.ac.jp (S. Kanai).

https://doi.org/10.1016/j.gaitpost.2019.09.030
Received 13 June 2019; Received in revised form 2 September 2019; Accepted 27 September 2019
0966-6362/ © 2019 Elsevier B.V. All rights reserved.
K. Okamura, et al.
lower extremity injuries related to pes planus alignment. The short-foot
exercise is one of the best-known exercises to strengthen the PIFMs.
Because a previous study [14] reported that the electromyographic
(EMG) activity of the abductor hallucis was significantly higher during
the short-foot exercise compared with the traditional toe-curl exercise,
the short-foot exercise is considered a useful PIFM strengthening ex-
ercise. However, there is limited evidence to support the effects of the
short-foot exercise, and previous studies have reported conflicting re-
sults. One previous study that used a pre- versus post-test design
without a control group reported that a 4-week short-foot exercise
program improved static foot alignment as assessed by the navicular
drop test and arch height index, and that these effects were maintained
for 4 weeks after exercise intervention [15]. The effectiveness of short-
foot exercise was also confirmed in a parallel group, non-blinded trial in
which long-distance runners who completed 6 weeks of short-foot ex-
ercise achieved significant improvement in foot alignment as evaluated
using the foot posture index (FPI-6) [16]. In contrast, another study
reported no change in MLA height during standing after 4 weeks of
short-foot exercise intervention [17]. In addition to conflicting results,
these previous studies also had limitations. First, these studies were not
blinded, and second, participants did not have pes planus alignment.
Furthermore, these studies evaluated foot alignment only in the static
condition, although injuries related to pes planus alignment are at-
tributed to overload during dynamic activities such as gait and running.
Therefore, no reliable evidence supports using the short-foot exercise to
improve static and dynamic foot kinematics in individuals with pes
planus.
The purpose of this study was to determine the effects of performing
the short-foot exercise on static foot alignment and foot kinematics
during gait in individuals with pes planus using a randomized con-
trolled single-blind trial, to improve on previous studies. We hypothe-
sized that the short-foot exercise can effectively improve both static and
dynamic foot kinematics in individuals with pes planus.
2. Methods
2.1. Trial design
This single-blind, randomized controlled trial was performed at the
Prefectural University of Hiroshima. Participants were equally allocated
to one of two groups: a short-foot exercise group (exercise group) re-
ceiving an 8-week unilateral short-foot exercise intervention, and a
control group (controls) who received no intervention, but were eval-
uated before and after the 8-week intervention period in the same
manner as the exercise group.
2.2. Participants
Participants were recruited from our university students, and data
were collected in the university setting. Exclusion criteria were: FPI-6
score < 6 points, where a score ≥6 was used to identify individuals
with pes planus alignment [18]; any sign of lower-limb pain; neurolo-
gical disease; previous personal experience with the short-foot exercise;
preexisting conditions such as seizures and demand pacemakers, which
were contraindications for electrical stimulation devices to facilitate
learning the short-form exercise.
This study was approved by the Ethics Committee of the Prefectural
University of Hiroshima, and written informed consent was obtained
from all participants. The study conformed to the guidelines of the
Declaration of Helsinki.
2.3. Interventions
First, subjects allocated to the exercise group were required to at-
tend a 20-minute initial training session. Participants received verbal
instruction and a demonstration of the correct technique to perform the
41
Gait & Posture 75 (2020) 40–45
short-foot exercise. Participants were asked to shorten their foot in the
anteroposterior direction and actively attempt to bring the head of the
first metatarsal toward the heel, without toe flexion. The forefoot and
heel were kept on the floor during the short-foot exercise [14,19].
Participants then practiced the short-foot exercise during the training
period on the foot achieving the highest score on the FPI-6. Three sets of
10 repetitions were performed; each repetition was held for 5 s. There
was a 45-second rest period between sets. This defined a daily session of
the short-foot exercise (approximately 5 min' duration). Following the
initial training session, participants performed the short-foot exercise
three times per week for 8 weeks. One investigator (KF) met with each
participant once per week to assess whether the participants performed
the short-foot exercise correctly, and to modify exercise progression.
The investigator also monitored and checked participants' daily exercise
record chart. Exercise difficulty was increased progressively by the in-
vestigator when the participant was able to perform the exercise cor-
rectly for the entire 5-minute exercise session without significant
muscle soreness the following day [15]. The short-foot exercise was
considered to be performed correctly when the participant elevated the
navicular tuberosity and maintained this position for 5 s without toe
flexion and/or lifting the foot off the floor. In this study, the short-foot
exercise began in a sitting position and progressed to double-, then
single-leg standing [15]. All short-foot exercise in this study was per-
formed using EMG biofeedback, where the muscle activity level of the
abductor hallucis during the short-foot exercise was conveyed to the
participant by a five-light indicator. Simultaneously, EMG-controlled
electrical stimulation was provided (Fig. 1). We used this biofeedback
method because our previous study [20] confirmed that the combina-
tion of EMG-controlled electrical stimulation with visual EMG bio-
feedback facilitated learning the short-foot exercise. EMG biofeedback
and EMG-controlled electrical stimulation were provided using a MURO
Solution instrument (Pacific Supply, Osaka, Japan). The details of the
settings on this instrument were described elsewhere [20].
2.4. Outcomes
The primary outcomes were foot kinematics during gait and static
foot alignment. The measurements of foot kinematics included de-
formation of the MLA assessed by dynamic navicular drop (DND),
which is the difference between navicular height at heel strike and the
minimum value during the stance phase (Fig. 2a), and the time at which
the navicular height reached its minimum value. Static foot alignment
was assessed by the FPI-6 and the navicular drop test. Secondary out-
comes were stance phase duration and maximum ground reaction force
(anterior, medial, and vertical directions) in the second half of the
stance phase of gait. We also measured the thickness of the abductor
Fig. 1. Short-foot exercise using the MURO Solution instrument.
During the short-foot exercise, the muscle activity level of the abductor hallucis
was conveyed to the subject by a five-light (red) indicator. EMG-controlled
electrical stimulation with an intensity proportional to the EMG activity de-
tected from the abductor hallucis was also provided. EMG, electromyographic.
K. Okamura, et al.
hallucis, flexor hallucis brevis, flexor digitorum brevis, flexor hallucis
longus, flexor digitorum longus, and peroneus longus on ultra-
sonography. In both groups, these measurements were performed be-
fore intervention, and again, after 8 weeks.
2.5. Data collection
All measurements were performed by one investigator (KO). To
measure gait-related parameters, we used a Vicon® system (Oxford
Metrics, Oxford, UK). The Vicon® system comprised 12 MX-T20S
cameras running at 100 Hz and six force plates running at 1000 Hz (two
Kistler plates (Kistler Instrument Corp., Amherst, NY) and four AMTI
plates (AMTI, Watertown, MA, USA). The Vicon Nexus® was used to
visualize and process three-dimensional motion. We attached reflective
markers (9.5 mm) to four anatomical points on one side of each parti-
cipant’s foot: the navicular tuberosity, the medial aspect of the first
metatarsal head, the lateral aspect of the fifth metatarsal head, and the
distal end of the calcaneus. The evaluated foot was the side achieving
the highest score on the FPI-6. In this study, navicular height during
gait was defined as the perpendicular distance of the navicular tu-
berosity marker above the plantar plane of the foot bisecting the mar-
kers on the first metatarsal head, fifth metatarsal head, and the distal
end of the calcaneus (Fig. 2b and c), as defined previously [21,22]. A
previous study [23] reported that measuring DND and the time at
which the navicular height reached its minimum value using this
marker set had good between-day repeatability. Similarly, our pilot
study in which these measurements were obtained in nine individuals
on two different days by the same investigator (KO) revealed strong
between-day reliabilities; the intraclass correlation coefficient1,1 for
between-day reliability for DND was 0.88, and the intraclass coefficient
for between-day reliability for the time at which the navicular height
reached its minimum value was 0.80. To collect gait-related para-
meters, all participants were asked to walk on the 8-m walkway at their
preferred normal speed. Five gait trials were recorded and averaged.
The FPI-6 and navicular drop test were performed in accordance
with previous studies [18,24]. We evaluated muscle thickness using
ultrasound (Views i; Sakai Medical Co. Ltd., Tokyo, Japan) with a 6-
MHz linear array probe equipped with an electrical pressure gauge. The
measurement protocol followed that in previous studies [12,25]. We
used the average of three measurements for statistical analysis. To
improve the repeatability, the variation in pressure applied by the ul-
trasound probe to the skin did not to exceed 10 gf between measure-
ments before and after the intervention.
42
Gait & Posture 75 (2020) 40–45
Fig. 2. The definitions of DND and navicular
height.
(a) DND was defined as the difference between
navicular height at initial contact and the
minimum value during the stance phase of
gait.
(b), (c) Navicular height was defined as the
perpendicular distance between the NAV
marker and the plantar plane of the foot bi-
secting markers on the 1 MH, 5 MH, and DCA.
DND, dynamic navicular drop; 1 MH, medial
aspect of the 1 st metatarsal head; NAV, navi-
cular tuberosity; 5 MH, lateral aspect of the 5th
metatarsal head; DCA, distal end of the calca-
neus.
2.6. Sample size
A paired t-test power analysis of exercise influence determined that
at least 15 participants were required to obtain a power of 0.8 at a two-
sided level of 0.05 with and effect size (d) of 0.8. Analysis was per-
formed using the G Power 3.1 analysis program (Düsseldorf, Germany)
[26].
2.7. Randomization and blinding
The allocation of participants to the exercise and control groups was
performed randomly by one investigator (KF) using Excel™ (Microsoft
Corp., Redmond, WA, USA). The investigator (KO) performing the pre-
and postintervention measurements was blinded to the allocation.
Participants were aware of the allocated arm because they received
exercise intervention or no intervention.
2.8. Statistical analysis
Mixed-model repeated-measures analyses of variance testing was
used to assess statistical significance in the gait-related parameters,
navicular drop test, and muscle thickness measurements with the
within-subject factor being time (preintervention vs. postintervention)
and the between-subject factor being the group (control vs. exercise). If
there was a significant interaction (time × group), we performed post
hoc paired t-tests on the individual group data; post hoc independent
sample t-tests were performed on the individual time data. For the FPI-6
evaluation, we used Wilcoxon's signed rank test to assess differences in
the individual group data and the Mann–Whitney test to assess differ-
ences in the individual time data.
Differences were considered significant at p < 0.05. All statistical
tests were performed using SPSS 20.0 for Windows (IBM Inc., Armonk,
NY, USA).
3. Results
3.1. Participants
Participant flow through this study is presented in Fig. 3. We con-
tacted a total of 173 individuals to inform them about this study, and
excluded 153 individuals because they had an FPI-6 score < 6 points
(149) or did not provide informed consent (4). We then allocated the
remaining 20 participants equally to the exercise or control groups.
Participants' baseline characteristics for each group are shown in
Table 1. All participants in the exercise group completed an 8-week
short-foot exercise program. Participants performed 24.5 ± 1.4
K. Okamura, et al. Gait & Posture 75 (2020) 40–45

Fig. 3. Flow chart based on the 2010 CONSORT flow diagram.

Table 1 3.1 revealed an effect size (d) of 1.0 and a power of 0.8 where the
Baseline characteristics of the participants in each group. correlation coefficient of 0.9 was used. Additionally, there was a sig-
Variables Groups p nificant interaction between time and group for maximum medial
ground reaction force (p = 0.033). The results of the post hoc paired t-
Control group Exercise group test revealed that maximum medial ground reaction force was sig-
(n = 10) (n = 10) nificantly decreased in the exercise group after the 8-week short-foot
Gender (female/male) 8/2 9/1
exercise program (mean difference = −0.7% body weight, p = 0.007).
Age (year) 20.2 ± 1.5 19.7 ± 0.9 0.40
Height (cm) 159.5 ± 8.8 158.6 ± 6.1 0.79 3.3. Static foot alignment
Weight (kg) 53.7 ± 7.7 49.7 ± 4.5 0.18
Body mass index (kg/m2) 21.1 ± 2.1 19.8 ± 1.4 0.13
Foot Posture Index-6 9.0 ± 2.1 9.7 ± 1.9 0.44 Table 2 shows a significant effect of time on the navicular drop test
(points) results (p = 0.001), and Table 3 shows the FPI-6 results. The total FPI-6
Navicular Drop test (mm) 10.9 ± 2.9 12.5 ± 3.3 0.25 scores were significantly improved in both groups (p = 0.024 in con-
trols; p = 0.014 in the exercise group). We also saw a significant im-
Values excluding gender are mean ± standard deviation.
provement (p = 0.046) in inversion/eversion of the calcaneus from foot
pronation towards neutral, in the exercise group.
sessions of the short-foot exercise (102.1% of predetermined sessions)
and took part in 6.2 ± 1.0 monitoring sessions (77.5% of pre-
3.4. Muscle thickness
determined sessions). All participants were able to progress through the
short-foot exercise program to single-leg standing after an average of
Table 2 shows that time, but not group, had a significant effect on
10.1 ± 6.5 sessions. Eight weeks after the baseline measurement, all
abductor hallucis (p = 0.035) and flexor digitorum longus thickness
participants in both groups completed their postintervention measure-
(p = 0.003).
ments. Recruitment and follow-up in this study were performed from
August to November 2018.
4. Discussion

3.2. Gait parameters 4.1. Gait parameters

The gait parameters measured pre- and postintervention in both
groups are shown in Table 2. We noted a significant interaction
(p = 0.010) between time and group for the time at which the navicular
height reached its minimum value, and post hoc comparisons were
performed. The results of the post hoc paired t-test revealed that in the
exercise group, the time for the navicular height to reach its minimum
value was significantly shortened after 8 weeks of the short-foot ex-
ercise program (mean difference = −4.4%, stance phase, p = 0.007),
but this was not seen in the controls. Post hoc estimation using G Power
The main finding of this study was that an 8-week short-foot ex-
ercise program shortened the time during which the navicular height
reached its minimum value. This indicated that the windlass me-
chanism was strengthened by performing the short-foot exercise.
Individuals with pes planus have an impaired windlass mechanism
defined as delayed or absent MLA elevation associated with passive
dorsiflexion of the toe [27]. Although the windlass mechanism is
formed mainly by the plantar aponeurosis [27,28], PIFMs also con-
tribute to this mechanism by increasing tension in the plantar

43
K. Okamura, et al. Gait & Posture 75 (2020) 40–45

Table 2 aponeurosis because several PIFMs attach to the plantar aponeurosis

The gait parameters, navicular drop test results, and muscle thicknesses for the [29].
two groups pre- and postintervention. In this study, we did not evaluate changes in muscle strength;
Variables Groups however, a previous study [30] reported that the strength of the flexor
halluces muscles increased significantly after a similar 8-week short-
Control group Exercise group foot exercise program. Therefore, in our exercise group, it was possible
(n=10) (n=10)
that increased PIFM strength improved the windlass mechanism.
Gait related parameter During gait, many forces stress the foot and can disrupt the MLA.
Stance phase duration pre 623.6 ± 36.8 610.1 ± 36.3 From midstance through the propulsive phase, the windlass mechanism
(ms) causes the foot to become a rigid lever arm and helps protect the MLA
post 618.8 ± 47.1 600.4 ± 34.5
from these stresses [28]. Therefore, the windlass mechanism is im-
Dynamic navicular drop pre 5.9 ± 2.6 6.2 ± 1.7
(mm)
portant to prevent foot injuries.
post 5.4 ± 2.5 6.2 ± 1.5 In this study, contrary to our expectations, DND did not change with
Time until minimum NH pre 74.7 ± 5.2 74.1 ± 5.4 the short-foot exercise intervention. It may be that the precision of the
(% ST) measurement was insufficient to detect DND changes because the
post†‡ 75.0 ± 5.5 69.7 ± 8.4**
shortened time required for the navicular height to reach the minimum
Ground reaction force (% BW)
Anterior direction pre 22.6 ± 4.4 24.0 ± 2.0 value suggested decreasing DND. Eichelberger et al. [23] reported that
post 23.8 ± 4.7 24.8 ± 2.5 measuring DND using a three-dimensional motion analysis system had
Medial direction pre 6.2 ± 0.9 6.0 ± 1.6 a relatively large minimum detectable change of 2.3 mm, which was
pos‡ 6.2 ± 1.3 5.3 ± 1.3**
38% of the mean DND. Therefore, more accurate measurement methods
Vertical direction pre 107.5 ± 6.2 109.1 ± 4.5
post 108.4 ± 6.5 108.3 ± 5.7
may be needed to detect DND improvement.
Our 8-week short-foot exercise program caused a slight decrease in
Static foot alignment
Navicular drop test (mm) pre 10.9 ± 2.9 12.5 ± 3.3
the maximum medial ground reaction force during gait. Our previous
post† 9.8 ± 2.7 10.6 ± 2.5 study [21] showed that electrically reinforcing the intrinsic foot mus-
cles facilitated efficient foot–ground force transmission. Similarly, the
Muscle thickness (mm)
Abductor halluces pre 12.2 ± 1.7 12.3 ± 2.4 weakened medial ground reaction force peak without a decrease in
post† 13.2 ± 2.1 13.4 ± 3.7 progression force might indicate facilitated efficient foot–ground force
Flexor hallucis brevis pre 14.3 ± 1.4 13.9 ± 1.6 transmission.
post 14.7 ± 1.1 14.0 ± 1.3
Flexor digitorum brevis pre 7.7 ± 1.7 7.3 ± 1.0
post 7.6 ± 1.6 7.1 ± 1.1
4.2. Static foot alignment
Flexor hallucis longus pre 22.8 ± 3.4 22.0 ± 3.5
post 23.2 ± 2.9 22.9 ± 3.2 Previous non-blinded studies [15,16] reported that a 4–6-week
Flexor digitorum longus pre 11.4 ± 2.8 13.3 ± 2.6 short-foot exercise intervention improved static foot alignment. In the
post† 11.8 ± 2.8 14.1 ± 2.3
current blinded study, the FPI-6 item related to the calcaneus improved
Peroneus longus pre 12.8 ± 1.9 11.7 ± 2.1
post 12.9 ± 1.8 12.0 ± 1.8 after our 8-week short-foot exercise intervention, similar to a previous
study [16]. Therefore, the short-foot exercise may effectively correct
Values are mean ± standard deviation. static foot alignment in individuals with pes planus. However, the
NH, navicular height; ST, stance phase; BW, body weight. clinical indicators of static foot alignment, such as the navicular drop
†, significant main effect (p < 0.05) for time (pre- vs postintervention); ‡, sig- test and the FPI-6, tend to be biased. The presence of bias was suggested
nificant interaction (p < 0.05) time × group; **, significant difference by the significant improvements in the navicular drop test and total FPI-
(p < 0.01) by post hoc paired t-test.
6 score after 8 weeks in both the exercise group and the control group.
As these assessments were performed manually or visually, the in-
Table 3
vestigator may have overestimated the effect in the second measure-
Foot Posture Index score for the two groups pre- and postintervention.
ment.
Variables Groups
4.3. Muscle thickness
Control group Exercise group
(n=10) (n=10)
In this study, we were unable to confirm an increase of PIFM
Foot Posture Index (points) thickness following the exercise intervention. A previous randomized
Total score pre 9.0 [7.5/10.5] 10.0 [7.8/11.3] controlled single-blind trial in participants with pes planus [30] re-
post 7.5 [5.0/10.5] * 8.5 [7.0/10.3] *
ported that the cross-sectional area of the abductor hallucis, but not
Talar head palpation pre 1.5 [1.0/2.0] 2.0 [1.0/2.0]
post 1.0 [1.0/2.0] 2.0 [1.0/2.0] muscle thickness, increased significantly after an 8-week short-foot
Supra and infra pre 1.0 [1.0/2.0] 1.5 [1.0/2.0] exercise program. In the current study, although we attempted to im-
lateral malleolar curvature post 1.0 [1.0/2.0] 1.0 [1.0/2.0] prove the repeatability of the measurement by keeping the applied
Inversion/eversion of pre 2.0 [1.0/2.0] 2.0 [1.0/2.0]
ultrasound probe pressure constant, measuring muscle thickness using
the calcaneus post 1.0 [1.0/2.0] 1.0 [1.0/2.0] *
Prominence in the region of pre 2.0 [1.0/2.0] 2.0 [1.0/2.0] this method may be inadequate to detect slight changes in smaller PIFM
the talonavicular joint post 1.5 [1.0/2.0] 1.5 [1.0/2.0] volumes.
Height and congruence of pre 1.0 [1.0/1.3] 1.0 [1.0/2.0]
the medial longitudinal post 1.0 [0.8/1.3] 1.0 [1.0/1.0] 4.4. Limitations
arch
Abduction/adduction of pre 2.0 [1.0/2.0] 2.0 [2.0/2.0]
the forefoot on the rear foot post 2.0 [1.0/2.0] 2.0 [2.0/2.0] This study has several limitations. The first limitation was the small
number of participants in this pilot trial (n = 20). The difference be-
Scores are presented as median [25th/75th interquartile]. tween the groups for the time at which the navicular height reached its
*, significant difference (p < 0.05) within a group by Wilcoxon's signed rank minimum value was significant, with a large effect size of 1.0. However,
test. the small sample size may have made it difficult to detect statistically
significant differences in the other parameters. The second limitation is

44
K. Okamura, et al.
the limited clinical generalizability. Although our participants had pes
planus alignment, they were asymptomatic. Therefore, we may not be
able to extrapolate our findings to a symptomatic population such as
those with pain. Moreover, although it would be better clinically for
individuals to perform the short-foot exercise on both sides, the short-
foot exercise was only performed on one side to reduce the time re-
quired for the exercise. Finally, this study was limited to evaluations
during gait. Because many injuries related to the pes planus alignment
are common in runners, future studies should be performed to examine
changes in foot kinematics during running in individuals with pes
planus.
5. Significance
In this study, the short-foot exercise effectively changed the tem-
poral parameters of foot kinematics during gait. This change, which
shortened the time for the navicular height to reach its minimum value,
indicated an improved windlass mechanism in participants with pes
planus. Therefore, the short-foot exercise should be included in pre-
vention or therapeutic programs for injuries related to the pes planus
alignment.
Author contributions
Kazunori Okamura: Conceptualization, Methodology, Validation,
Formal Analysis, Investigation, Resources, Data Curation, Writing –
Original Draft, Project Administration, and Funding Acquisition.
Kengo Fukuda: Conceptualization, Methodology, Validation,
Investigation, Writing – Review & Editing, Visualization, and Project
Administration.
Sadaaki Oki: Conceptualization, Methodology, Resources, Writing
– Review & Editing, Visualization, and Supervision.
Takeya Ono: Methodology, Validation, Resources and Writing –
Review & Editing, and Supervision.
Satoshi Tanaka: Methodology, Validation, Formal Analysis,
Resources and Writing – Review & Editing.
Shusaku Kanai: Conceptualization, Methodology, Resources, Data
Curation, Writing – Review & Editing, Supervision, Project
Administration, and Funding Acquisition.
Declaration of Competing Interest
None.
Acknowledgements
Funding: This work was supported by the JSPS KAKENHI [Grant
Number JP18H06441 and JP19K20043]. We thank Jane Charbonneau,
DVM, from Edanz Group (www.edanzediting.com/ac) for editing a
draft of this manuscript.
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