Most of us, in our second-50 years, remember a time (not necessarily fondly) when winking at someone was considered harmless and cute. It’s still often cute depending on the context, but just as likely could get one in trouble or simply seem creepy. Discretion is advised, and little gray cells should be activated before the cranial nerves involved in eye-winking are engaged. Translation: think before you act. Luckily, I totally digress because the ‘wink test’ has nothing to do whatsoever with our face and eyes, and instead (surprise) has all to do with our feet and toes.
Toes & Health Activities
As we age, toe weakness is frequently ignored, especially compared to other conditions that crop up. Not considered vitally important (except perhaps by athletes who understand the nuanced gain), our toes actually do play a part in aging. From pain, to balance, to quality of movement and more, our toes are instrumental and we might suffer if they’re overlooked.
You may have noticed in PizzazzEE-25 (a full body workout at no charge and found at www.PizzazzEE.com ), the toes are part of the process. Weakness in those little piggies can lead to heel pain, arch issues, heel spurs, plantar fasciitis and has even been liked to risk of morbidity from falls (mostly in the elderly). If you are still involved in a sport requiring running or jumping (like pickelball, tennis, volleyball or basketball), toe strength can provide an advantageous toehold to better performance.
How Toe Muscles Work
Muscles and tendons in our toes tend not to be familiar to us. We know our biceps, triceps, hamstrings, quadriceps, but few could name a muscle in the toes. Likely, many of us have never heard their names.
Two of the important muscles of the toes are the flexor digitorum brevis (abbreviated as FDB) and the flexor digitorum longus. (If you guess the latter is abbreviated as FDL, then yell “bingo” for me.) When the FDB is strong it pulls the terminal “phalange” (a toe bone) against the ground. This increases our foot contact and the ability to generate force. Additionally, it adds enhanced proprioception (spatial perception) both for static stance and movement.
When the FDB (brevis) is weak, the FDL (longus) can compensate and cause conflicting motions (driving the tips downward, instead of the distal end phalanges and joints). Thus, there is less beneficial contact with the ground. Subtle? Maybe, but it makes a difference.
Real Life Implications of FDB Weakness for All Ages
Admittedly, the greatest advantage of “brevis” strength is in athletic performance. This may matter to you. However, if you aren’t athletic in any way, the difference between a strong and weak FDB may go unobserved. Yet, the actual results can still be noticeable, even if they seem unrelated.
Heel Pain
A 2015 study (Musculoskeletal and activity-related factors associated with plantar heel pain – PubMed (nih.gov) demonstrated that a weak FDB is a common finding in heel pain.
Heel Spurs and Plantar Fasciitis
Other research demonstrated that heel spurs start to form with strain and pulling by the muscles on the heel attachment point of the FDB (not from the back part of the foot which was long believed to be the case). See note in reference section regarding the FDB muscle origin and insertion.
Arch Support
Whether looking for new shoes, standing for a long time or improving active play-time, we notice our arch. The FDB supports the arch and plays a role in the way force is transferred from the rear to fore foot as we move. A strong FDB means greater natural arch support.
Highlights for Seniors and the FDB
It’s no secret that for seniors, falls (often related to postural balance) have a strong correlation to morbidities. Additionally, our posture is connected to lower limb injuries in all populations (young and old). Luckily, the FDB can help.
Perhaps due to its ability to boost our proprioception in space (remember, there is more contact with ground), a strong FDB has been shown to reduce falls as we age. Strengthening exercises can help.
While the broad little FDB muscle generally receives little attention, its capability to contribute to posture control is statistically significant. A 2021 Study (Quantifying the contributions of a flexor digitorum brevis muscle on postural stability) demonstrated that by itself, the muscle could create changes in static posture, seen by changes in the center of pressure.
Perhaps even more impressive are the results from a 2020 review of nine (9) studies (conducted with healthy participants between 60 and 90 years old, 73% women). The study, “The evidence for improving balance by strengthening the toe flexor muscles: A systematic review,” noted that each of the 9 studies presented directly-proportional evidence correlating toe-flexor strength and postural balance. It highlighted that because postural balance is correlated to both falls and injuries to the ankle, that strengthening toe flexor muscles improves balance, and is important to healthy aging.
The Wink Test
If you have a doctor prepared to do a more complete test (probably most likely a chiropractor, osteopath or even PT), a dynamometer is the best tool. It can quantify strength of your muscles. Although the toe muscles are rarely in the mix of those tests, it may be that they aren’t being identified as a root-cause of other problems. Dynamometer readings provide specific numeric details of function ability.
Yet, there is another quick and easy scan as well. Even better, you can do it yourself at home.
Dr. Thomas Michaud (author of Foot Orthoses And Other Forms Of Conservative Foot Care – 2018 and Human Locomotion: The Conservative Management of Gait Related Disorders – 2011) calls this easy scan, the “wink test.” (In my mind, the name does demand some imagination.) You may want someone else to double check results as you perform the test, but generally you can see it yourself.
Preforming the Wink Test
This takes just a few seconds, but be sure to understand WHERE you are looking to catch the glimpse of the wink (no, it’s not fleeting). The wink should appear at the joint located at the very tip of your 4 little toes – an area known as the distal interphalangeal joint, which is just another way of saying the farthest away joint in between the last two little bones of each toe. (Did you know there were different bones in your toes?) Either way, it should be easy to find. Don’t expect too much at the ‘little piggy toe,’ but the others should have a clear line (or dimple) running horizontally along the end of the toe. (See the figure.)
Directions:
1. Stand Straight
2. Push toes as hard as possible into the floor
3. Lean SLIGHTLY forward
4. Look for the “wink”
If you see the wink, it indicates strength of the FDB. If you do NOT see the wink, it designates a weakness of the FDB. That weakness may mean that the FDL (longus) is compensating and leading to problems mentioned above. Strengthening toes may be a good prescription.
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Options for Strengthening Toes
Tip. My tip to you is that while these are easy movements, don’t over do it. You can strain and then later feel discomfort as you walk. Toes may go unnoticed, but that quickly changes if there is annoyance, pain or disruption to mobilization. Take it slow —– but steady (meaning, don’t blow it off). A few times a day for any of the quick options is better than 15 minutes all at once.
Second tip? These are good exercises for all of us.
- PizzazzEE-25 – put it in your weekly routine. It helps ALL muscles and joints.
—– - Toe Curls
— Sit straight in a chair (even while watching TV or on the phone)
— Put feet flat on the floor
— Place a towel on the floor
— With one foot at a time, grip the towel with the toes and lift toward you
— Repeat 5 times and change to other foot
—– - Marble Pick-up. (Since few “play marbles” nowadays, you may try finding relics of these ‘antiques’ in the floral décor department.)
— Gather 15 or 20 marbles
— Prepare 2 bowls or trays and place all marbles in one
— Sit straight in chair
— With toes of 1 foot, grasp 1 marble at a time and place it in opposite container
— When all marbles are moved, switch to other foot and repeat
—– - Arch Dome
— Sit straight in chair or on sofa, feet flat on floor
— Press right toes down into floor – keeping heel on the floor and toes straight
— Feel the arch of your foot ‘dome’ (other bones, other than heel and toes may lift off floor)
— Relax foot – repeat 10 times
— Switch and do on Left foot
[Start out with one set only, but can work up to 3 sets/foot.]
FINAL THOUGHT
I love solutions that fit into our daily life with no extra time commitment. While the wink test may give you an idea of how strong or weak your toe flexors are, nothing stops you from preforming these exercises to augment ability you currently demonstrate. You can improve your balance, gait and functioning. Any assistance in avoiding morbidity seems like a great motivator to me. Pick one exercise you like for down times (like TV time) and add it to your routine.
These exercises are sure to keep you on your toes.
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References
Note: Big toe and smaller ones are controlled differently. The concentration of our topic, the FDB (sometimes called short toe flexor) has an origin (calcaneus) and insertion (last 4 toes) different from that of the big-toe muscle, FHB (flexor hallucis brevis aka short Great toe flexors). Further, Flexor digitorum longus (FDL) has an origin at the tibia while the big toe’s flexor hallucis longus has an origin at the fibula.
Sullivan J, Burns J, Adams R, Pappas E, Crosbie J. Musculoskeletal and activity-related factors associated with plantar heel pain. Foot Ankle Int. 2015 Jan;36(1):37-45. doi: 10.1177/1071100714551021. Epub 2014 Sep 18. PMID: 25237175. Retrieved Aug. 5, 2021 Musculoskeletal and activity-related factors associated with plantar heel pain – PubMed (nih.gov)
Nicolelin. Quantifying the contributions of a flexor digitorum brevis muscle on postural stability | China MFG Guide (world.edu) Retrieved electronically August 12, 2021
Shayan Quinlan, Alycia Fong Yan, Peter Sinclair, Adrienne Hunt. The evidence for improving balance by strengthening the toe flexor muscles: A systematic review. Gait and Posture, Volume 81, September 2020, Pages 56-66. Retrieved August 11, 2021
Karen J. Mickle, Bridget J. Munro, Stephen R. Lord, Hylton B. Menz, Julie R. Steele, ISB Clinical Biomechanics Award 2009: Toe weakness and deformity increase the risk of falls in older people, Clinical Biomechanics, Volume 24, Issue 10, 2009, Pages 787-791. ISSN 0268-0033. https://doi.org/10.1016/j.clinbiomech.2009.08.011 (https://www.sciencedirect.com/science/article/pii/S0268003309002010)
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Picture credit: Wink photo by Unknown Author is licensed under CC BY
Figure drawing: Michael Sawicky
