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From The Ground Up - Part I
April 22, 2017 SHOES - PART I (Elevated Heel) This post is the first from a series entitled From The Ground Up. The series will explore the human body and will provide information that everyone should know about their own body: basic anatomy, common injuries and most effective exercises to keep you strong, mobile and awesome.
You will have a better understanding of the human body than the vast majority of other people and you will learn how to apply your newfound knowledge. You will become a superior being with nothing to stop you from world domination and you will have the wisdom to politely correct people when they refer to the "rotator cup". Arrgh!
This topic will be divided into 4 parts due to sheer volume of information. It will also be the only non-body part that will be explored: SHOES. The perfect example of less is more.
Are you ready to stretch your brain? Zapatos, Chaussures, Schuhe, Topanky, Skoene - AKA:
SHOES "Natural gait is biomechanically impossible for any shoe-wearing person." - Dr. WIlliam A. Rossi in a 1999 article in Podiatry Management
Imagine it's a beautiful Summer day and you are standing in a lush field of green grass. The sun is warming your face and you feel the earth under your...wait, you have on your big, clunky shoes and you feel nothing because 25mm of foam separates you from happiness. Now take those things off and chuck them. Dig your previously confined toesies into the earth. Feels nice, doesn't it?
Shoes are bad for you. They are a necessary evil in most of today's concrete world but barefoot is best. Shoes should serve one purpose: to protect our feet from dangerous items on the ground (rusty nails, broken glass, angry vipers, etc.) A flat, thin layer of protection and some twine is all you need.
However, shoe companies have hijacked this simple design by adding a bunch of foam to the sole, narrowing the toe box and adding unnecessary "support". This pure, simple thing has been bastardized until you have a SUS: Sport Utility Shoe. Traction! Stability Control! Smooth ride! Whaaat? Next will be bluetooth connectivity and an automatic rear lift gate.
Here's a headscratcher - in populations that live barefoot, foot problems do not exist. How are they not tragically crippled by their foam and arch support deficiency? Lemme 'splain.
The typical shoe of a first world country has 4 major flaws that I have creatively dubbed "The Four Flaws".
Tapered Toe Box
Upturned Toe (Toe Spring)
Arch Support / Rigid Sole
Hey there, nice foam... Let's get into it.
A heel does not have to be a stiletto for it to cause significant issues. Any shoe where the heel is higher than the toe...has a heel! Therefore, it will pitch you forward and your body must compensate. Yes, even your favorite sneakers. If you don't believe me, take your sneakers and measure the height of the foam at the heel and then at the toe. What is the difference? Most sneakers have an elevation change between 8-13mm. Here is a great illustration, courtesy of William de Rossi's article "Why Shoes Make Normal Gait Impossible" -
If you were to wear heels and not compensate, you'd fall flat on your face.
Here's the takeaway: The single most common and significant negative impact that a heel has on your body is postural compensation. Here is what happens every time you wear a shoe with a heel - remember, this applies to sneakers, men's dress shoes, etc.
Achilles tendon and calf muscle shorten and become chronically tight, increasing the risk for injury and knee pain
Increased pressure on the balls of your feet, potentially creating hammer toes, bunions, neuromas and plantar fasciosis
Excessive low back extension (hyperlordosis)
Loss of normal hip and low back mobility, creating tightness, instability and increased chance for injury/pain
Chest, shoulders and head get pushed forward of normal center of gravity, equaling tight shoulders/upper back and possible headaches and neck pain
This is the short list of heel-related issues. Your new mantra should be: Heel higher than toe? It's a NO GO! Why do shoes have heels? Women's shoes have heels to create height and shapelier legs. Men's dress shoes have heels because we ll used to be cowboys and needed them for stirrups and for when we'd jump off the horse and land on our heel - we needed more padding. I'm not joking. Giddyap, cowboy.
The Takeaway - Problem: You're wearing heels! An elevated heel prevents normal standing, walking and exercise posture. Action: Buy new shoes with no heel - "zero drop" shoes. I like Lems, Altra and Vivobarefoot. There are others, just look for the drop height when searching. Difficulty: Easy. No effort required other than a little time to find the right shoe.
As always, I hope you will reach out to me with questions, constructive feedback or topics that you'd like to see explored.
NOTE: The second installment of the SHOES post will come shortly and we'll look at the dreaded narrow toe box. --------------------------------------------------------------------------------------------------------------------------------------------
May 5, 2017
SHOES - PART 2 (Toe Box) Welcome to the second post about shoes in the From The Ground Up series. We're going to discuss a shoe's toe box . First, do you know what should be the widest part of a healthy foot? The toes. What part of a typical shoe is the narrowest? The toe box. See the problem?
Baby toes are the cutest! And the widest part of their feet...
And then we do this to them...
Or even this...
And then you get this... The foot adapts to the shape of the shoe.
See the problem? Here is an extreme example. How do you know if your shoe has a toe box wide enough to accommodate your toes? Take The Sole Test. Take the sole out of the shoe, put it on the ground and stand on it, barefoot. If your toes are overflowing over the edge of the sole, you know that when your toes are actually in the shoe, they're getting squeezed. At this point in the conversation er, monologue, you may be asking two things - "Why do shoe companies disfigure our feet?" and "What's the big deal with shoe companies disfiguring our feet?" If you're not asking those questions, you must be a shoe company executive and I urge you, it's not too late to change your ways!
First question - WHY are most shoes narrow in the toe box? The answer is Fashion. A possible second reason could be...um...let's see...still thinking...aerodynamics? Maybe? The truth is, my friend *in best Jack Nicholson voice* "You can't handle the truth!" Actually, I'm sure you can handle it and the truth is - there is NO GOOD REASON for the toe box of a shoe to be narrow. None. It makes no sense. My work here is done. *mic drop*
Second question - What's the big deal about a narrow toe box? Quick anatomy lesson, because I care about you (and your toes): Two primary functions of toes are balance and gripping. Guess what your toes cannot do very well if they're all squished on top of each other and shoved into a cramped little toe box? Both balance and gripping become compromised.
Balance: Your body relies on a wide, stable base for optimal biomechanical function. In other words, you wouldn't put bicycle tires on an SUV and that's what you're doing when your toes are not allowed to spread. Not that I'm calling you an SUV... With the toes being squished down to a narrow point, you lose surface area with which to push off every time you step and even when you're just standing. This forces your body to compensate and shifts more stress to other parts of the feet as well as to the knees, hips and lower back. Any time there is compensation and asymmetry, risk of injury increases.
For athletes, especially at the elite level, a narrow toe box will prohibit ideal performance and the athlete will not reach their full athletic potential. Imagine if track athletes or soccer players wore shoes that allowed full, healthy toe splay - they would generate more power and speed and be less prone to injury.
Usain Bolt's feet are pictured above...the bunions are probably courtesy of so many hours in restrictive track shoes. Imagine how fast he would be in proper shoes and no foot deformities!
Gripping: Take one hand and press your thumb to your pinkie. Now, rest your 3 middle fingers on top of the thumb and pinkie. Try to grab something. Nearly impossible. Now, spread your fingers out and ahhhhh, that feels better and you can use your hand and fingers as they were designed! The same concept applies to toes. Proper toe splay , or toe spacing, not only provides a solid base of support for your whole body but it also keeps proper foot bone (metatarsal) spacing and it keeps the foot and ankle muscles strong. When toes are allowed to spread out, they will grip the ground (built-in traction control!), thereby firing the muscles of your foot and ankle, allowing for minimal compensation and stress on the adjacent joints - the knee and hip.
This is a HUGE issue with most shoes in general - they prevent the foot muscles from firing and the muscles then become weak. Weak muscles and poor biomechanics mean injuries and a very popular "solution" to foot injuries is more supportive shoes and possibly orthotics. <<< This is how I feel when patients are told to buy ultra-supportive shoes and orthotics for their foot problems.
This is the part of the story where I lean a little closer and look you straight in the eye and say something like "Now listen up, because I'm only gonna say this once." Your feet are the healthiest when they are bare. As I said way back at the beginning of this series - shoes should serve one purpose: protection from dangerous items on the ground. Unfortunately, people have become dependent on shoes to do the job that their feet are able to do, if given the chance. An arch support in the shoe? Your foot has a built-in arch! An inch of foam on the heel? Your heel has a fat pad for cushion! The more "stuff" your shoe has on it, the more dependent your foot becomes on that stuff and the less it is able to function like an actual foot! But, I digress...here is The Takeaway for Toe Box.
The Takeaway - Problem: Your shoes have a narrow toe box that squishes your toes together and creates poor biomechanics and increased injury risk. Action: Find shoes with a wide toe box! Similar to the previous post, I really like Lems, Altra and Vivobarefoot but there are others out there, so go searching and remember to give shoes the sole test I mentioned above to see if the shoe is restrictive. Difficulty: Easy. Find the right shoe and embrace the space that your toes will have!
NOTE: The next post will cover both Toe Spring and Arch Support/Rigid Sole and I will also go over the most common foot conditions that can be caused by shoes with any or all of the characteristics that we are discussing.
As always, I trust that you will reach out to me with questions, constructive feedback or any topics that you would like to see covered. DrThistle@DrThistle.com
-------------------------------------------------------------------------------------------------------------------------------------------- May 18, 2017
SHOES - Part 3 (Toe Spring, Arch Support / Rigid Sole) When you stand on the ground barefoot, do your toes touch the ground? I sure hope so. So, why are most shoes designed with an upturned toe (toe spring)? Toe spring can be defined as a design feature that "creates a subtle rocker effect that allows your foot to roll into the next step." Have you ever had trouble rolling into your next step? Didn't think so. Here's what I'm talking about:
See the upturned toe? It puts your toes in an unnatural position of extension.
Here is a great illustration of how the last two bones of the foot (metatarsals) are forced into extension (curved upward) in a shoe with toe spring.
The top is a healthy foot. The bottom is what toe spring does.
Similar to the Tapered Toe Box problem, there is no consensus or straightforward reason from shoe manufacturer's why this is done. As I mentioned above, maybe it's to help you "roll into your next step" which is not just mind-numbingly dumb but also harmful to your feet! And THIS, my dear friends, is why I am so passionate about shoe design - because it is not harmless. Most shoes in developed countries are creating significant injury to your feet and therefore, to the rest of your body and it is all unnecessary. But, fashion and the absurd desire to fix what is not broken has created a whole industry of foot conditions that don't exist in cultures that go barefoot or in simple sandals!
*clears throat* Thank you for allowing me to vent. Back to Toe Spring! Check out the photo below and this is how you check your own shoes for toe spring.
Photo courtesy of pivotalmotionpodiatry.com.au
Since most shoes have both an elevated heel AND toe spring, you get a shoe that is essentially "U" shaped - elevated at both ends. A healthy foot isshaped like a gentle arching bridge, sloping slightly downward at each end, with the 3 natural arches of the foot providing support. This dissonance between your foot's ideal shape and the shape of a shoe will often give rise to problematic foot conditions/injuries, such as Plantar Fasciosis, Hammer Toes, Bunions and Morton's Neuroma. Let's explore the wonderful world of the Arch Support/Rigid Sole. Go get yourself another Hot Pocket and a glass of iced tea, this is gonna be fun.
Arch Support / Rigid Sole Arches of the foot, as defined by Wikipedia: The arches of the foot, formed by the tarsal and metatarsal bones, strengthened by ligaments and tendons, allow the foot to support the weight of the body in the erect posture with the least weight. They are categorized as longitudinal and transverse arches.
Even this illustration has bunions from a narrow toe box!
Illustration courtesy of teachmeanatomy.info
So, reading the definition above and looking at the illustration, it should now be clear that we have THREE natural arches of the foot. Do we REALLY need a fourth arch, as provided in nearly every shoe worn in a developed country? The shoes we buy have artificial arch supports in them because our natural arches have been weakened and made useless by the very shoes that have the artificial arch supports in them. AAAAARRRRRRRGGGGGHHHH! And this is the point in the blog where I go lie down on the couch and ask one of my sons to bring a warm washcloth and a large glass of Daddy's special happy juice.
Here is a study of 2,300 children with the conclusion of: "...shoe-wearing in early childhood is detrimental to the development of a normal longitudinal arch." Children should be barefoot as much as possible and I will go further and say ADULTS should be barefoot as much as possible. Preferably, on a white sand beach with your own large glass of happy juice.
An arch support in a shoe is actually a brilliant design because it creates a need for itself. The artificial arch acts as a brace for the foot and the natural arches of the foot don't have a need to work as hard, thereby weakening them. And, what do you need if you have weak arches? An arch support! And so it goes, on and on and on...
SOLUTION: Yes, I have one and it's fabulous -
Go barefoot more and wear shoes without arch supports (and a wide toe box). This will strengthen your feet naturally.
Strengthen your foot proactively
Practice standing on one leg, barefoot, with your eyes closed. You should be able to do this comfortably for at least 20 seconds. If that is too difficult, start with eyes open.
Get barefoot, sit in a chair and spread out a hand towel, long ways, in front of one of your feet with the edge of the towel just under your toes. Grabbing the edge of the towel with your toes, curl them under your foot, thereby scrunching up the towel. Do this until you've brought the entire towel under your foot (see video below).
This exercise is a fantastic way to strengthen the intrinsic muscles of your foot - those muscles that start and stop in the foot and do not cross the ankle joint. Takeaway: If your foot is strong and mobile, you have NO NEED for external support from a shoe, such as an arch support. I frequently hear the comment that someone needs to wear their orthotics or certain highly-supportive shoes or else their feet/knees/hips/low back hurt. This is because one, some or all of those areas are not functioning well. Wouldn't you rather work on getting your body healthier than be dependent on orthotics the rest of your life? If you want to be independent and free from the clutches of the shoe companies that are ruining your feet well then, I'm glad you're here *virtual fist bump* and now let's get to work.
Rigid Sole You don't want a rigid sole or a rigid soul. I can help you with the former. It's this easy - your foot is flexible (or should be) and your shoe should be, also. If your shoe does not allow your foot to bend, move and flex as it's supposed to, you WILL be creating extra stress not just on your foot but in your knees, hips and low back. Your sense of balance and joint position will be diminished as well because the specialized nerve endings in your feet aren't being stimulated properly when you walk. Proprioception is an awareness of the position of one's body and wearing clunky, stiff shoes takes that away. One segment of our population that I believe needs flexible shoes most of all are those 60+ years of age. And yet, these seem to be the folks most likely to NOT be barefoot and in clunky sneakers. Test your shoes to see if you can bend them in half with minimal effort or, better yet, roll them into a ball.
Can your shoe do this?
The Takeaway - Problem: Your shoes curve upward at the toe, have unnecessary arch support and are inflexible! Action: Find flat, flexible shoes. Or, just go barefoot. Try Lems Shoes and this website also has a recommended shoe list. Difficulty: Moderate. Find shoes that fit the above criteria, work on your balance and do the towel exercise. Soon, you'll have arches of steel!
Coming up: I am very excited to move on to the Foot + Ankle. I'll explore basic anatomy, common injuries and how to prevent them and why neglecting foot + ankle health will very likely cause issues elsewhere.
I trust that you will reach out with questions, comments and constructive feedback because you're an awesome person and you want to live an extraordinary life! Or you can just e-mail me with a joke. DrThistle@DrThistle.com
Move Happy, Dr. Thistle ----------------------------------------------------------------------------------------------------------------------------------------- May 28, 2017 Foot + Ankle Welcome to the wonderful world of the foot and ankle! I am going on the assumption that 99% of you are not interested in reading about the detailed and intricate anatomy of this region but rather, the most common injuries and how to rehab them, as well as just general exercises for balance and strength. If you are in the 1% that would find a discussion on the nuances of the dorsal cuneonavicular ligaments scintillating, send me an e-mail and...well, it may be accidentally filed under Spam.
Basic Anatomy I underlined "basic" because the foot and ankle are incredibly complex but here are the Top 2 Anatomical Facts that I hope you can learn today: 1. The ankle is made up of two joints: the true ankle joint and the subtalar joint
The true ankle joint is formed by the Tibia, Fibula and Talus. This joint is responsible for the up and down motion of the ankle.
The subtalar joint (below the talus) is the joint formed by the talus and calcaneous, which allows side-to-side motion.
2. The Achilles Tendon is where your two primary calf muscles turn into tough, dense tissue and insert into your Calcaneous (heel bone).
The two primary muscles of the calf, the Gastrocnemius and Soleus, join to form one tendon, the Achilles.
OK, phew, we got the dry stuff out of the way BUT now, if you ever want to impress a Personal Trainer, you can casually remark, "Wow, nice Gastrocs." OK, moving on then?
Most Common Conditions + Injuries This list is based on what I've most frequently seen in my 11 years of practice and just on statistical research. For each condition, I'll list the cause(s), the treatment and the prevention.
Bunions A bony bump that typically forms at the big toe joint when the big toe pushes against its neighbor.
Image courtesy of softstarshoes.com
Cause Most commonly, this is a result of constrictive footwear. If you are now thinking "Constrictive footwear? Of what could he be possibly speaking??" then, scroll yourself up a ways to the second post of the SHOES series from May 5th and enjoy the shoelicious facts and musings on why shoes are killing your feet.
Treatment * The least desirable treatment is surgery. Here is a good overview. * The next least desirable treatment is orthotics. Why? Because orthotics do not fix the problem. The problem is poor footwear and bad biomechanics. Orthotics are a crutch upon which your feet become dependent and the faulty biomechanics and constrictive footwear, which caused the problem in the first place, goes unaddressed. * The BEST solution is to move to a tropical locale and be barefoot forever. Not an option, you say? Fine. Then the next BEST option is to wear shoes with a wide toe box and toe spacers. I like these.
Prevention Life is good when the treatment and the prevention are the same thing! Wear shoes with a wide toe box and go barefoot when you can.
The next post will cover Plantar fasciosis and sprained ankles!
As always, thank you for reading and contact me with questions, feedback or pancake recipes. - Dr.T --------------------------------------------------------------------------------------------------------------------------------------------
August 3, 2017
Plantar Fasciosis Let's get one thing straight: the correct term is fasciOSIS, not ITIS. Plantar fasciosis is a more accurate name for this condition because it involves degeneration—microtears, cell death—of your plantar fascia, not inflammation. "ITIS" refers to primarily an inflammatory condition (bursitis, appendicitis, etc.) but that is not what is happening with your plantar fascia with this condition. What is plantar fascia, you ask? Gosh, thanks for the inquiry.
The plantar fascia of your foot is a broad, flat ligament that spans from your heel bone (calcaneus) to your toe bones (metatarsals). (What's the deal, this image has a bunion, too!??!)
This image is helpful because you can see the opposing forces of the Achilles tendon and the plantar fascia on the heel bone. Foam roll your calves, people!
Cause Lots of 'em. Most common causes are:
Improper footwear (Inconceivable! Any Princess Bride fans out there?)
Overuse (Too much, too fast...kind of like me with a plate of bacon)
To break it down, you damage the fascia and it can quickly become a chronic, stubborn and painful condition.
Symptoms Heel pain and arch pain are the most common symptoms. I will also hear that the first few steps in the morning are incredibly painful at the heel and then the pain lessens as the tissues warm up. This can be a dangerous cycle because people believe that all they need to do is warm up and then resume their normal activities. However, just because the pain decreases does not mean that the tissue is healed and the problem is gone. That brings us to...
Chiropractic care - A good chiropractor will be able to check for any biomechanical causes or contributors to the condition and fix them. Very often, there is a joint mobility problem in the ankle and/or knee that is preventing healing.
Decrease the offending activity! If you know what is irritating your poor, little fascia fibers, just stop it.
Get better footwear. Do I write this in every post? Yes, yes I do. Shoes that allow your toes to spread, don't elevate the heel and do not have toe spring will allow the fascia to heal quicker.
Therapy modalities such as massage therapy, low level laser, Graston and ultrasound can be helpful.
Self-care such as foam rolling your legs (don't forget the calves!) and self massage of your foot will speed up healing.
Don't overdo it! If you're starting a new activity or increasing the level (mileage) of your current activity, take it slowly and allow your body some time to adapt to the new stressors
Wear proper footwear. If you don't know what I mean by "proper footwear", you're totally not paying attention
Lose weight. Less weight means less stress on the body!
Have a good chiropractor check you out head to toe. Not in a creepy way, but speaking purely biomechanics, of course. Asymmetries, compensation and poor motor control patterns elsewhere in the body can manifest anywhere - even the foot!
Next up - sprained ankles!
Thank you for reading and e-mail with questions, comments or your favorite vacation spot!
QUESTIONS A reader e-mailed with two questions regarding the last post: Q: If my feet do not hurt, do I still need to roll out my calves? A: Great question and YES, you should still roll out your calves, even without symptoms. Why? Because very often, pain is the last thing to come and the first thing to go. Rolling out your calves only when you have pain is like only putting on sunscreen after you've been burned. A daily regimen of rolling out hips and shoulders is a great way to keep the tissues of your body healthy and happy and a way to be proactive so that you never experience pain!
Q: Is there ever a situation where orthotics would be appropriate to use? A: Absolutely. I view orthotics as a last resort when there are certain unchangeable features of a foot that cannot be corrected with proper footwear and rehab. The problem is that many people view orthotics as a quick fix and either don't realize there are alternatives or don't want to put in the work to correct their feet properly. Many foot problems are caused by issues higher up, such as in the knees, hips, low back or even neck. Unfortunately, many podiatrists and primary care MD's don't have the time or training to properly assess the entire kinetic chain and so the ultimate cause of the foot issue goes undiagnosed.
Thank you so much for the questions - keep 'em coming!
Ankle Sprain Ah, yes. The good 'ol ankle sprain. They're kind of like that night in Tijuana where you stole a taxi, started a fight at a biker bar and woke up the next morning in a pet store. Everyone's done it but no one likes to talk about it. No? Just me? Moving on, then.
Ankle sprains are an injury to the ligaments of the ankle. Here's a knowledge nugget - a Sprain refers to a ligament and a Strain refers to a muscle tendon.
The most common type of ankle sprain is an inversion sprain where you "roll" the ankle and foot underneath the leg -
Image courtesy of shiftmovementscience.com
As you can see in the image, multiple ligaments are typically damaged and very often, muscle tendons of the foot and lower leg are strained. Therefore, a sprain injury is usually accompanied by a strain injury, as well.
The most important point of this whole post is that: a) If you do not rehab your ankle properly the first time that you sprain it, there is a very high likelihood that you will experience multiple sprains, decreasing the stability of your ankle and therefore your whole body, with every subsequent injury.
If you have already experienced multiple sprains, it's not too late! There's hope! Just kidding, there's no hope - just chop the foot off and work on your superpower of regeneration. Wait wait wait, try these exercises first and if they don't help, then you can start thinking about losing the foot.
Exercise #1: Single-leg Balance Just as it sounds, you do your best flamingo impersonation and stand on one leg, barefoot. You should be able to do this for at least 60 seconds, pretty comfortably. Practice with each leg, not just the injured side! If you're comfortable with 60 seconds, try closing your eyes. By taking away visual cues, you're taking away one of your brain's tools to maintain balance and it will force the ankle to work harder. If you want an even harder challenge, go fix the U.S. tax code. Or, balance on an unstable object like a thick, folded towel, a balance pad or a BOSU ball.
Wow, perfect form!
Image courtesy of National Geographic
Exercise #2: Resisted Inversion + Eversion This is a deceptively difficult exercise, especially if the injury is still relatively acute (within the last 6 weeks or so). You will be sitting on the ground and use a resistance band to...provide resistance. Be sure to perform both inversion and eversion, as shown below. Approximately 20 repetitions and 2-3 sets should do it. The band can be tied to something heavy like a table leg or my Aunt Peggy.
Peggy not pictured.
Image courtesy of ballroomguide.com
Exercise #3: BOSU Ball Lunges I'm assuming here that you have a decent working knowledge of proper lunge form. If not, look it up or e-mail me and we'll have a little chat. There are multiple ways to do this lunge but for ankle sprains specifically, I prefer the method shown below. You can either keep the front foot on the BOSU throughout the set or do the lunge, step off of the BOSU and then step back on for the next repetition.
Note that this model's posture is terrible!
You should go down until the back knee nearly touches the ground and push back up with the front foot. Dumbbells optional. If you do not have a BOSU handy, try a folded towel or a couch cushion.
There are many, many more great rehab exercises for the ankle but these are a great start and if you need more, drop me a note and I'm happy to help. An ankle sprain disrupts not just the physical structures of the ankle but the proprioception of the body, as well. That means that the brain loses track of exactly where the ankle and foot are in space, thereby reducing stability. Rehab exercises repair the physical damage but also help rebuild the brain's connection to the injured area, greatly decreasing the chance of a recurring injury.
As always, please reach out with questions. If you want to know more about Tijuana taxis or pet stores after hours, you'll have to wait for the memoir.