Treating Injuries:

Are Rest, Ice, Compression, and Elevation Appropriate?

“Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.”

 – Gabe Mirkin, MD, March 2014

Dr. Mirkin first used the term Rest, Ice, Compression and Elevation (RICE) in 1978.  In the years that followed RICE became recognized as the standard of care for acute injuries (especially for the ankle).  RICE was actually later modified to Range of motion, Ice, Compression, and Elevation to reflect the need for movement after an injury.  Today, the original developer of the RICE protocol, Dr. Mirkin, now believes that both ice and rest may actually delay healing.  Inflammation is the body’s natural response to injury and brings in important healing factors.  By applying ice and compression early, we may inhibit swelling but this also inhibits the body bringing in important cells to begin the healing process.  Attempting to inhibit swelling early on may actually delay healing.  Additionally, Dr. Mirkin has found that “Anything that reduces your immune response will also delay muscle healing, such as cortisone-type drugs, pain-relieving medicines like NSAIDS, immune-suppressants, and applying cold packs or ice.” 

So what is the answer?

Reducing an athlete’s symptoms requires load management.  Isometric (holding against resistance while not moving) contractions have been shown to be analgesic and pain reducing.  It is important to factor in stage of tendinopathy and treat it as part of a well-rounded rehabilitation program involving kinetic chain exercises, education in proper landing technique, and management of load and return to sports.   Additionally, children heal faster and require little external help except management of pain and loading for short periods of time.

Recommendation

Avoid ice, NSAIDs, or other corticosteroids early on.  A short bout of 3-5 minutes of ice may be appropriate for pain management to allow the athlete to movement and begin load management as soon as possible.

Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy. 2014.  60: 122–129.

Contact us at www.naturalperformancerehab.com for any questions

15 Health Benefits of "Barefoot" Running Shoes, According to Science

Wanted to share this article on barefoot living and using minimal shoes from another great experimenter.  This is one of those life lessons I keep learning over and over again.  Be flexible, adaptable, open, willing to try new things and experience new paradigms.  Ultimately we have to be our own experimenters, despite whatever the latest study might suggest is correct, the answer is what works best for us.

15 Health Benefits of Barefoot Running Shoes, According to Science (+8 Tips for Beginners)

Common Causes of Knee Pain when Running

A common myth we have all heard floating around at one time or another is that running will "ruin your knees."  This is even stated by some well-meaning medical practitioners despite the lack of scientific evidence.  In fact, studies suggest that if anything, runners are less likely to develop debilitating hip or knee osteoarthritis when compared to a more sedentary population (ref 1 & 2).

That said, many runners do suffer with knee pain at some point in their running careers.  This month I hope to direct your attention to a few common causes of knee pain and broadly discuss their remedies.  Let me preface the rest of this article by saying for most knee pain caused by activity, the official diagnosis isn’t particularly helpful.  It’s the medical version of Juliet’s monologue on the balcony, “what’s in a name?” she says!  Whether you have tendonitis, tendonosis, a partial tear of something, iliotibial band syndrome, or you ate too much cake last night…the key in recovering is finding the dysfunction.

Problem #1 - Hip and/or ankle stiffness

The ball and socket joint of our hips provide our lower extremities with a great deal of motion and adaptability.  Likewise, our feet and ankles are paramount in adapting to our running surface.  If either of these areas lack proper range of motion, it's not uncommon for this imbalance to manifest itself as knee pain.  Because the hips and/or foot/ankle complex is not moving correctly, the knee will take excess stress.  Your practitioner should always check your hip, ankle, and foot for restrictions if you present to them with knee pain.  Once you understand the problem, the remedy is quite intuitive, improve range of motion and practice basic exercises to ensure the muscles of the hip, ankle, and foot are working properly.

Problem #2 - A lack of pelvic and core control

This problem is a bit more insidious and often more difficult to self-test.  Essentially, many of us have muscle imbalances involving our spines and pelvis.  Some of these imbalances may occur because we sit too much or we over-train one movement or activity.  Most adults do not move in novel ways unless they are actively engaged in a movement practice or have a job that requires many different types of activities (i.e. When was the last time you did a cart-wheel?).

Ultimately, the muscles throughout our trunk (core) must coordinate with the muscles in our hips to provide a stable pelvis when running.  If we are not coordinating things correctly we may find that we have chronic back, hip, knee, or even ankle/foot pain.  The coordination process is quite complicated but thankfully the remedy is usually much more simple.  In the same way that one learns to throw a baseball or play the violin, we can break down the basic movements of the spine and pelvis, testing each one until we find a lack of integrity.

On slow motion analysis, a lack of pelvic or core control can manifest itself in a loss of alignment in the spine, pelvis, knees, and the ankle/foot.  It is usually most evident in the mid-stance phase, when all of the body weight is rested on a single leg.  It is at this point we usually see a break down of control.

If my pelvis dramatically loses alignment (drops in mid-stance), my entire lower extremity and spine will have to compensate.  Here we see a mostly level pelvis which allows the knee to stay aligned between the hip and foot.

On the other hand, a hip drop will cause compensation somewhere else in the body.  This gentleman is leaning his trunk to maintain balance and may also be increasing injury in the lower extremity.  Notice his left foot (behind him) is crossing towards the right leg which further identifies the hip drop.

Problem #3 - A lack of foot control

In our world of overly-cushioned shoes and high-priced orthotics, most runners today lack proper foot function.  It is a self-fulfilling prophecy to say that people need motion control shoes because they have never learned to control their own foot motion.  On slow-motion running gait analysis, the same pitfalls seen with poor pelvic control can be caused by a lack of foot control.  In fact, unless a practitioner tests both areas, they won't know which is causing the problem.  Often it is best to treat control and coordination issues globally because we know that everything has to work together to produce a healthy running gait.

Problem #4 - Over-striding or slow cadence

I have discussed this topic in the past but suffice to say over-striding or running with a slow cadence (<160 steps-per-minute) is highly associated with more impact force through the lower extremity.  Greater impact forces are associated with more lower extremity injuries to include knee pain.  Strength training and plyometric drills can help to improve force output, meaning, it is easier for us to run and maintain a healthier, more efficient cadence.  Poor force output resembles the ultra-shuffle while a high-force output can be seen in sprinters and excellent long-distance runners (Eliud Kipchoge anyone?).

Over-striding is equivalent to "braking" when running.  Ideally our feet will land closer to our center of mass.

Problem #5 – Doing too much too soon

We are all aware of this rule in exercise but I’m mentioning it anyway.  Because you could be doing everything else right but you’re doing more exercise than your body can adapt to within a given time frame.  Remember that exercise is a stress to the body and can depress our immune systems and cause injury when taken far beyond our current abilities.  The key to avoid this pitfall is to ask yourself before your workout, can I actually recover from this workout?  If you’re not getting enough sleep, mobility work, time spent relaxing, or good nutrition, you’re basically a ticking time-bomb for something breaking down.

Whether you visit me in the office or you already have a trusted practitioner, the path to healthy knees should include some sort of learning on your part.  I watch runners flock to quick fixes because they do not understand their problem.  But trust me, no human was born with a Hoka or orthotic deficiency.  If you're anything like the modern human, you probably need a little more balance in your life.  Finding out the true cause should be your aim.  Whatever you do, don't give up on running.

Ref 1: Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk. Med Sci Sports Exerc. 2013 Jul; 45(7): 1292–1297.

Ref 2: Long Distance Running and Knee Osteoarthritis A Prospective Study. Am J Prev Med. 2008 Aug; 35(2): 133–138.

Numbers, numbers, numbers!!!

I have struggled with the numbers game for some time but lately I realize that numbers (amount) do not mean nearly as much as purpose (quality). 

It sad when I see my friends, people I know, and so called experts post how many days they go to the gym,  focus on how many reps they do, and  focus on how many workouts they do.  It's even sadder when they equate the high number of things they do as the main reason for their success.  It is not the high number of things they do, but the quality of what they do.  If you work out hard 6 days a week, do you think that all the workouts are quality?   It's likely a few of those workouts are good but the others are "just get it down" work outs (I like to call them junk work out or for running junk miles).   The just get it done workouts can actually harm you by decreasing neuromuscular improvement or increasing your risk for injury.

If you work out hard all the time or at a high intensity, your body will eventually lose efficiency. 

You are completely taxing your system and not allowing for proper recovery.  Additionally, you should have a goal with each workout that does not include "just make it through it."  Good form, improvement in skill, improvement in strength, and/or endurance should be the goal (pick a primary and secondary goal for each workout).  Another goal should be to not get injured or feel "beat down."  You can have hard workouts that tax you but they should be to test your improvement not the norm.  

Injury occurs from both mental and physical fatigue. 

Injury occurs when you one or more areas are overloaded to the point that they body cannot continue to adapt enough.  So, if you are sore all the time or working to maximum do you think you fatigue mentally and physically?  Do you think you will become stiff and not able to control the movements properly leading to excessive overload?  So, why not try to stay mentally focused and physically able?  Maybe, program in some warm-up and recovery (do not rely on your coach or instructor to do this for you)?

Instead of focusing on hitting the gym, trails, pavement, etc. 5-6 days week, maybe focus on 3 good workout and 2-3 days of mobility and skill building.  

Instead of thinking always about the number of sets and reps, think about good quality reps and sets.  This all applies to running as well.  Instead of always focused on miles or time, focus and quality running that improves your abilities.  Running 100 miles a week without a purpose or goal besides getting the miles is only going to get you 100 miles with some improvements.  It will most likely get you hurt and frustrated as well.   Better every day should be your focus not more every day (more ≠ better, better = better). 

If you are interested in quality of movement and exercise, Natural Performance Rehab offers group classes or individual sessions to help you understand and improve your quality and become better every day. 

Bulletproof Feet

Now that I have bestowed my opinion on the webernets regarding what makes a healthy shoe, it's time to talk about the feet again.  But first a disclaimer...

The purpose of this post is NOT to make you a barefoot runner but rather to help you have feet that are strong and functional and a stride so soft and smooth that you could run barefoot on pavement without pain if you wanted.

This is important because weak, deformed feet that do not function as nature intended can and do set us up for injury, pain, disability, and expensive treatments such as injections and surgery.  Before I continue my rant, please enjoy this short news story on barefoot running from 2005 which features "Barefoot" Ken Bob and Dr. Irene Davis, director of the Spaulding Institute.

Science has shed light over the past several decades that our obsession with shoe technology (aka bad shoes, see post on healthy shoes) has led to the following problems...

- toe deformities (bunions, hammer toes, etc) and narrowing of your base of support
- de-differentiation in the brain, decreased awareness and muscle control (aka maladaptive neuroplasticity)
- decreased bone density, weakened cartilage, tendons, and ligaments
- compensations from the ankle, knee, hip and spine
- decreased feedback leads to transient impact peaks when running or performing higher-impact activities (higher impact peaks are associated with injury)
- I feel like I'm writing about a terminal medical diagnosis right now

Death by shoes.

Fortunately this problem is all by our own doing and it can be reversed with intelligence and patience.  Many of the shoes we've been told we need to wear actually act like a cast on the foot, offering completely unnecessary support and cushioning.  We know that when we remove a cast we have one of two options.  Option #1, we continue to rely on the cast for support and hope for the best or, option #2, we diligently strengthen and retrain that body part.

Keep in mind that while strength, flexibility, and all the other training principles are important, how strength or flexibility will be applied to each individual is different.  While many roads may lead to Rome, you still need a plan to get to Rome.

I believe that a healthy mindset of the body includes strengthening and improving its functions regardless of age.  This path involves learning new things about yourself, breaking through old barriers, improving your health in a sustainable way, and maybe even becoming even better-looking than you already are.  After all, improving your health and knowledge should improve your confidence and everyone knows confidence is sexy.  At the very least your goal should be to avoid the fate of many aging Americans...the walker, bed pan, and catheter.

The gentleman on the right, Ray Moon, is 83-years old in this picture.

Here is the problem with all this ideological speak.  If we have weakened our feet or been told we needed support and just went with that, transitioning to less shoe or no shoe is not going to happen overnight without sustained effort.  Transitioning a feeble body part to normal function is a very slow process in the beginning.  The equivalent of what most people do is attempt a 500# deadlift when they haven't picked up more than a jug of milk in 10 years.  Be sure to start where you're at, not where you want to be.

The only thing that can protect you from injury is your plan and listening to your body.  First, you'll want to develop a simple and smart plan to improve mobility and strength in your feet and ankles.  This will be a plan where you gradually and progressively add load and difficulty and you'll listen to your body to ensure you get enough recovery between bouts of exercise.  How long it takes to get where you want to be depends on where you are starting and where you want to go.

It's too bad you don't see exercise charts for feet and ankles at the gym.
For some reason our society treats our feet like they are not part of the body
when the reality is they are the base of everything we do in weight-bearing (which is most human activity).

While I can't tell you exactly what you should do as an individual through a blog post, I am going to outline several important steps that I took to regain foot and ankle health.  Ready, set, GO!



STEP ONE:  Wake up your feet and get your brain interpreting the information better.

Spending time barefoot in your house or outside can be very helpful if you aren't diabetic or otherwise have neuropathy or are concerned about minor cuts.  Walk over a variety of terrain and things that are a little uncomfortable in a safe manner.  #darwinism  Successfully transitioning to less shoe requires that you can feel your feet but for whatever reason there are people who do not interpret body signals very well (this occurs in the brain).  Without good awareness the likelihood of injury is extremely high.

There are two major benefits to moving barefoot.  One benefit is the natural strengthening and mobility that occurs with having less shoe and using your feet more naturally.  Your muscles and tendons get stronger making them more resistant to injury, perhaps your foot widens and your toes begin to straighten, and you even improve the bone density in your feet.  The second benefit involves everything else about your movement that changes for the better.  Without a shoe you learn how to protect yourself.  You learn to land softer and step lightly, all of the behaviors which protect your joints and work your muscles properly.  This is a complete paradigm shift from what modern marketing tells you to do, which is buy their product to protect you.  Unfortunately many people take that route in life and end up using a walker.

If you're like most Americans and you cannot spread your toes apart, I would consider investing in a pair of Correct Toes.  Wear them as directed by the website and the insert in the product packaging.  Like going barefoot, you can get sore feet and overdo it early on.  Avoid this pain!

It has taken a few years but my toes have widened to a healthier stance with more space between the big toe and second toe (as it should be).  I still use Correct Toes at night and sometimes during the day to help improve and maintain my GAINZ!

STEP TWO: Get out of bad shoes.

How you do that is entirely up to you, there is no single perfect way to transition for everyone.  You can start simple by wearing a flat shoe with a wide toe-box and only the amount of cushioning you need.  Sandals work great too, which is why I wear them nearly all of the time.  Regardless of your choice, your shoe should feel comfortable and not compress your toes in any way.  Tired or sore feet are okay but pain is not.  If you have pain, whatever you just did was too much for your current foot fitness level.  Spend more time on step one and three and re-visit footwear changes later.

Whatever you do, don't take your foot out of a cast and blast out sled pushes, distance running, plyometrics, or whatever fun thing you like to do.  Go slow.  Start with short walks barefoot or in minimal shoes.  Do the basic exercises outlined in step three.  If ready to run, run at a slow pace and for a very short distance.  By going slow in your program you will actually be speeding up your transition.  Nothing slows athletic progress down quite like a new injury.  I would know because I am the Queen of hurting myself in the name of science and discovery.

Be the test dummy.  "For the things we have to learn before we can do them, we learn by doing them." - Aristotle

STEP THREE: Incorporate basic mobility and strengthening exercises into your routine.

This will be the equivalent of doing the seated-granny exercises in your house with 5# weights.  Yes it's sad and kind of funny but it's completely your fault that you let your feet get so weak.  Stop complaining.  This will be fun.

Start by working soft tissue mobility if you need it.

Ankle dorsiflexion mobility is important for everything you do in weight-bearing.  Running and squatting can be a disaster without good ankle mobility.

Foot control and strengthening exercises.  These are just a few ideas I captured on video.  If you appreciate these you may also like this cool video by GMB with additional ways to strengthening the foot and ankle.  I have tested the GMB movements in my own routine and find them valuable.  I also like the book, "Barefoot Running" by Michael Sandler and Jessica Lee as a step-by-step guide to helping you achieve strong feet/ankles as well as proper running technique.

As you feel more comfortable with barefoot walking and basic exercises, you can progress to other movement drills and plyometric movements.  Working on plyometrics will help improve your natural springs over time.

STEP FOUR: If running in minimal shoes or barefoot, improve your technique!

One of the worst things you could do would be to take away protection that your body is used to but never improve your technique (aka impact moderating behavior).  Dr. Mark Cucuzzella, a fellow sandal, minimalist shoe, and barefoot runner, did an excellent podcast with Trail Runner Nation on this exact topic.  This is important.  People who transition shoes but never improve their movement almost always hurt themselves.  It's not a surprise why this happens.  If you're banging your head against a wall then taping a pillow to your forehead will help but it is best to learn to stop banging your head against the wall in the first place.


PRINCIPLES OF TRANSITIONING:

Inevitably we will all run into at least a few obstacles when making a huge change in how we use our feet.  Think about your own personal training and how difficult it can be to keep balance between exercise and rest.  Sometimes you overdo one area and learn the hard way.  In general your feet will usually tell you when you've done too much.  That said, having a smart transition plan can do wonders to keep you out of trouble.  Here are some principles that I have found helpful in my journey.

- Foot pain IS NOT part of the program.  If you have pain you did too much and need to recover more.  Remember that STRESS comes in many forms (i.e. if you remove support and/or cushion, if you have poor running technique or you lack normal joint range of motion this increases the stress).  Take frequent inventories of these stresses and understand if you change many elements at once it can easily overwhelm your tissue.  You might need to improve mobility and strength for a few months before ever considering running in minimal shoes or barefoot and that is OK.

- Start with less than you think...seriously.  The body can take 6-12 months to adapt to the stress of being barefoot or in minimalist / healthy shoes.  This is because tissues such as tendon, bone, fascia, etc take many months to remodel.  This is not a personal weakness on you, it's just science.

- Always start with barefoot or minimalist shoe walking before your try running.  I recommend at least a month of walking every other day, increasing your distance or time as tolerated (i.e. no pain but mild soreness is okay).  During this month you should also work on basic mobility and strength exercises to wake up your feet.

- Always carry shoes or sandals if barefoot in case you need them.

- If building into running, as Barefoot Ken Bob teaches, consider it an entirely new activity even if you run every day in shoes.  I personally recommend this basic program...jog 50-yards at a slow pace, take a day off, jog 100-yards at a slow pace, take a day off, continue adding 50-yards a day to your distance every other day (if and only if you do not have pain).

- Learning proper technique is king.  Even strong feet can be injured if you're always over-striding or otherwise landing with a high transient impact peak.


Life is truly meant to be lived and cherished each day.  One of my missions in life is to prevent unnecessary pain and suffering and educate people on how to fix themselves.  One of my beliefs about the world is that if you want to achieve something, find the person who did it and see what they did.  I listen to many surgeons, doctors, therapists, and podiatrists bash minimalist and barefoot running.  Funny thing is the ones that do have never done it.  Frankly, don't ask a fish how to fly or a wrestling coach to lead your basketball team to a national championship.

I'll leave you with some remaining resources I have enjoyed over the years.  These are people who walk the walk and I learned from them so I could fix my own problems.  Couldn't have turned out better.  Best of luck to you in this journey.

Christopher McDougall talks about running.
Barefoot Ted talks about running.
General articles by Stephen Robbins on issues with footwear.
Barefoot Ken Bob's website.
Barefoot Ted McDonald's blog.
Harvard Lab's Daniel Lieberman's webpage.
The Spaulding Center led by Dr. Irene Davis.
Dr. Mark Cucuzzella's Natural Running Center.

What is a Healthy Shoe?

Before I get into what I consider a healthy shoe, understand that I am basically a gangster in the medical world.  An alarmingly low percentage of medical professionals agree with me when it comes to shoe recommendations and spending time barefoot but I don't take that too personally.  My mission is to keep it real, to better understand the universal laws that govern life, and to find what works.  This is why I have come to love my barefoot time so much and I am a complete hard ass about good shoes when I need to where them.

After 45-years of shoe companies financing research in an attempt to prove that their shoes prevent injury and improve performance, they have yet to demonstrate any compelling data to support that claim.  Sigh.  This is certainly a topic for a much longer blog series which I would consider doing except that I get chest pains just thinking about it.  Xero shoes CEO, Steven Sashen, did a great job of unstupidifying this mess on the Boulderist Podcast, Episode 003.  Give it a listen and you'll be glad you did.  Steven is way funnier than I.

One last disclaimer before we get started.  Everything I'm saying in this article about healthy shoes meets two important criteria.  First, everything I am saying is supported by scientific evidence.  Second, I have lived the results of eschewing really crappy foot-weakening, Quasimodo-deforming footwear and have been able to rehabilitate back to healthy movement.  This is where I get all my gangster powers.

What is a healthy shoe?

Healthy shoes are shaped like your feet and offer adequate protection for the terrain.

Our toes are meant to be the widest part of the foot (look at a baby's foot for reference). Nearly all running and lifestyle shoes narrow our toe base and cause deformation of the toes in the name of fashion. It should seem like a common-sense rule of thumb that your feet should never deform their natural shape to fit inside a shoe.

“Adequate protection” means that if you are traveling on harsh/rocky terrain, you'll want a thicker sole than if traveling on a smooth road, groomed trail, or grassy area. The rule of thumb here is to use the least amount of sole you need to get the job done, according to what your feet can handle.

Healthy shoes are void of cushioning or arch support technology.

Arch support was designed to fix a problem that wouldn't exist without bad shoes. As we narrow our toes and base of support, we effectively obliterate the function of our arches to load and spring back as they are designed to do. Although the sole of the shoe should be appropriate for the terrain, research demonstrates that cushioning actually causes people to land with more force when running or walking. Landing more forcefully places undue stress on your knees, hips, and spine during activity. Though cushioning might provide the feet with more comfort, it actually worsens movement quality and perpetuates bad habits.

But your joints will.

Healthy shoes are zero-drop and extremely flexible.

Wearing a heel in any shoe will cause postural modifications up the entire kinetic chain. A big, cushy heel also encourages harder landings and over-striding, which are associated with running injuries. The stiffness of most running shoes is one result of the faulty belief that we should run with a heel-to-toe gait pattern. Studies conducted in cultures lacking modern footwear demonstrate more natural running mechanics, which generally involves a midfoot to forefoot strike, a soft, quiet landing, and a springy return of energy. Children do not naturally run heel-to-toe before the introduction of heavily cushioned shoes. It's simply not natural or efficient. A cushioned heel in a running shoe is another answer to a problem we never had.

Why do I hype about flexibility? Our feet, much like our hands, are extremely mobile and flexible, providing us with a plethora of movement opportunities that actually help to protect our joints further up the body. Ski boots are a great illustration of the risk, because everything knows that once you cast the foot and ankle (by trapping them in boots), the knee is much more susceptible to a twisting injury. In the same way, making footwear stiff casts many joints of the foot and will place more stress on the ankle, knee, and hip over time.

An example of an extremely flexible road shoe.

A healthy shoe also doesn't claim to do the work for you.

I always find it silly when a shoe company claims that its shoes can do something for you.  By default, whatever a shoe does for you is something your body is no longer doing.  We turn then to our trusty use it or lose it principle for a quick reference in common sense.  Oh yeah, that's right, not using stuff is bad, I should probably let my body do some work unless I want it to deteriorate.  These marketing messages can bring about self-fulfilling and debilitating downward spiral—it is exactly that for many aging athletes.

In the 1990s, the standard of care for back injuries was often to use a back brace for additional support (oh yeah, and bedrest).  Eventually, research data showed that this treatment paradigm actually made people much worse and increased disability.  Providing unnecessary support to peoples' back and core muscles simply caused the wearers to grow weaker and less resilient over time.

It’s the same with shoes.  Following the warped shoe company logic, I might as well give everyone who has a sprained ankle crutches for life.  Instead, we know innately and science confirms that our bodies can adapt over time with the proper cycle of stress and rest.  Oddly, when it comes to footwear, we lose our minds and become fearful of utilizing the very training principles we use for every other athletic endeavor.

Can I interest you in a catheter and bed pan as well?

Since most people in our society wear shoes that do not fit these qualities, their bodies are not ready to do hard work without support/cushion/etc.  Their joints have become stiff, tendons weak, bone density decreased, and just as badly, many can no longer feel or understand the signals their feet are sending to their brain.  If you were to wear a mitten for a decade and never use your fingers independently your brain would eventually remap the hand (aka neuroplasticity, use it or lose it), and you would have lost your fine motor control of the hand (not to mention, it would be very stiff and tight).

When we finally free our feet from the coffins of bad shoes, we have to be careful about transitioning.  Our feet are vulnerable and our brains might not know what to do with all this new information.  In my next post I will offer some guidance and recommendations as well as resources for you to improve your foot health and prepare your body for a lifetime of better movement instead of needing that damn walker.

The Amazing Human Foot

"The human foot is a masterpiece of engineering and a work of art." - Leonardo Di Vinci

As a topic often misunderstood by medical professionals and laypeople alike, I'll be talking about feet (and healthy shoes) for the next several blog posts.  This can be a touchy subject in the running/athletic and medical communities primarily because people's livelihoods are involved in the myths surrounding footwear. I'm still going there anyway because if there is one thing that gets my blood boiling, it's bad information that ultimately leads to pain, disability, and unnecessary surgeries.

And unfortunately the fact today is that advertising has inundated the population with myths and marketing regarding what needs to be worn on the foot to move properly, safely, sustainably, etc.  It's as though you need a special degree to understand how to use and take care of your own feet.  If we slow down for a moment to think about this issue we might realize how ridiculous this topic has become; how many of you need a PhD to use your hands properly?

What's my theory?  In general, bad shoes create nearly all of our foot problems (75% of Americans will encounter foot problems in their lifetime; most of us have foot deformities caused by bad shoes).  It is eerily similar to how processed junk food has helped create a health crisis in our country.  The medical machine awaits your foot problems with injections, surgery, more expensive shoes...oh yeah, and a cane or walker.  I hope to bring a few important concepts about feet to light in this article.

Did you know that your feet house a quarter of all the bones in your body and 250,000 sweat glands?  Each foot has 33 joints, 107 ligaments, and 19 muscles/tendons that support it.  Clearly as a point of anatomy, your feet are designed to be flexible and mold to the uneven terrain we find in nature.  By molding to the world, your feet send the brain important feedback that's used for balance and leg control.  Think of your feet and your ankles like the maestro for the rest of the body.  They lead the orchestra of muscle activation based on what they report (or what they don't report) to the brain.

When we are babies, in general, our toes line up perfectly with the metatarsals of our feet.  In other words, the widest part of our foot is at the end of our toes, not our metatarsal heads.  Nearly every foot I see today is deformed from its natural state due to a tapered toe box.  We can look at architecture and clearly see that the base of every arch must be stable for the arch to be strong.  By narrowing the toes we destabilize the base of our arch, meaning we lose the strength and proper functioning of the arch.  Most people who think they need arch support are actually lacking proper alignment of their toes due to years or decades of bad shoes.  You can look to a study published in the Journal of Bone and Joint Surgery in 1905 by Hoffman to see what healthy and unhealthy feet look like.  This is a must-read for anyone interested in foot health.  It's been over 100-yrs since this article was published and yet most of the public is not familiar with how our feet should look and function.

This narrowing of the toes and lack of arch stability ultimately leads to the need for pronation control.  Our arches are designed to store and release energy via pronation yet most shoe companies and salespeople will suggest that pronation is something the shoe technology needs to block or control.  The reality is that pronation is a normal motion of the foot and not being able to pronate can actually lead to stress fractures and other problems.  The flexibility of the arch allows us to pronate and store free energy in our arches.  Like a spring mechanism, we get free energy upon the release of this tension.  So controlled pronation is normal, it's great, it's supposed to be there.  You only need non-deformed toes and muscle control to allow the arch to work properly.  Throw in arch support and you block pronation, aka the storing and releasing of free energy (The Foot's Arch and The Energetics of Human Locomotion. Sci Rep. 2016; 6: 19403).

Or you can avoid surgery by not wearing stupid shoes.

While basic foot mechanics are quite fascinating, brain science is even more so.  Most people in our modern society stuff their feet into shoes from the time they wake up to the time they go to bed and never think twice about it.  But what would happen to your hands if you were to cast them nearly every waking hour?  Talk to any occupational therapist and they would tell you how quickly you would lose coordination, hand awareness, muscle strength, etc.  Try brushing your teeth with your non-dominant hand and if you're like me you feel quite clumsy.  This is not because my left hand is a poorly designed body part and I need to protect it, it's simply because I never use it for that task.  Our brains store maps of our body parts and the more we use an area the more detailed the map becomes.  Similarly, our maps become fuzzy with body parts we use less often and coordination becomes more difficult.  Fortunately our maps are malleable.

Let's consider a few other examples.  Did you know a woman from Arizona named Jessica Cox was born without arms and learned to fly a fixed-wing plane using only her feet?  Amputees may experience phantom limb pain for a period of time because their brain has not yet remapped itself as "not having the limb."  There are countless examples of brain mapping in action.  When we never take our feet out of shoes, we naturally lose foot control and coordination.  You can be the scientist here and hypothesize what sort of problems might arise from a lack of body awareness.

While the debate about footwear will likely rage on, the science actually demonstrates little true debate about the function of the human foot.  If bad shoes deform our feet, change our mechanics, cause weakness and compensations, and cause us to lose body awareness, then the answer must be healthier footwear as well as time spent out of shoes altogether.

My next post will dive a little deeper into what characteristics make up a healthy shoe. Stay tuned!