If I Only Knew Then What I Know Now
The airport is an excellent place to be... if observing behavior is your thing and you've got someplace you need to fly to. I couldn't help but notice all the turned out feet with fancy sneakers. Sneakers, and shoes, that are just binding everyone's toes together.
Swished toes are my jam. Not toe jam, it's the thing I'm really good at fixing. I love technical details and I love problem solving, toes and feet make up a complex dynamic system. And that stimulates my ADHD brain into hyper focus.
I deal with tootsies every day in practice. When someone says they need better hip mobility and core strength, I say they need to work on their tootsies. It's actually true for the majority of the musculoskeletal problems I see.
Understanding what foot function means for preventing back pain and injuries, even the need for joint replacements, is a new perspective. I find it mind blowing that we didn't realize this sooner, especially considering the impact it has over traditional hip focused rehab.
Feeling Strong + Tearing My Labrum
I began exercising more seriously and running when I was in college. I did several sprint and Olympic triathlons, then my first half ironman triathlon during chiropractic school. Shortly after my second half ironman, when I was feeling my strongest, I tore the labrum in my right hip while running. I had no indications that anything was wrong, it was a total shock.
A beautiful sunny and not too hot day, perfect for running. I had done a full body weight lifting routine in the gym that morning and I felt so good that I decided to go for an easy run. At this point I was practicing Chiropractic and already had a lot of training in functional movement. I told myself I'll enjoy the run and as soon as I feel fatigued I'll walk the rest of the way. That's what I would have told a patient.
After 6 miles I was feeling strong but thought it best to walk the mile back home for a proper cool down. It was my right leg that initiated the transition to walking, when my heel hit the ground I felt a sudden severe sharp pan in the front of my hip that made me double over. Then my hip flexors went into spasm. In one instance I went from feeling stronger than ever to limping back home, in a lot of pain.
How could that happen?
Hind sight is always 20/20 and it's clear to me now how the layers of dysfunction built up over years and in one moment changed everything.
My Sneakers + My Chiropractor
Asics were my go to sneakers. I knew my heel was more narrow than my forefoot, and I needed some support in my arch. They just felt good on my feet.
I actually dealt with chronic SI and IT Band pain from the time I started running, prior to chiropractic school. I needed to be adjusted almost weekly by my chiropractor at the time in order to keep running without pain.
This was acceptable to him and I definitely didn't know better then. It sure got annoying though to have to constantly be going to get adjusted so I could exercise without pain.
My brother also started running and we signed up for a local 5K for some family comradery, ah hem competition. But the day before the race I developed a sharp pain at the ball of my right foot. Even the bend of that joint during walking was really painful. So I pulled out of the race. You're welcome Kevin!
It resolved with rest after a few days and never happened again. I was definitely puzzled why it happened, I was wearing my orthotics. Now I know it was just another layer of dysfunction forming before my hip injury.
Fast forward to chiropractic school, I continued running and signed up for my first sprint triathlon. I continued getting chiropractic adjustments on campus for my chronic SI and IT Band pain because the 10th trimester students work in the student clinic, the chiropractic version of residency.
One fateful day I was assigned a student doctor who had taken some outside training in an advanced myofascial treatment called Active Release Technique (ART). This was a major course correction moment for my career, and recovery.
This student doctor adjusted me but also did ART myofascial release of my Iliopsoas muscles, which made a HUGE difference in decreasing the amount of adjusting I needed in order to run without pain. Why wasn't every chiropractor doing this?
Needless to say I saved all my absences and money, shared travel and hotel costs with other students, and started getting certified in ART before I graduated from chiropractic school.
I even contributed on the ART treatment team at Ironman Lake Placid before I graduated, a great way to gain experience as a soon to be Doctor of Chiropractic. This is where I began developing the skill of understanding the body functioning through a kinetic chain.
I was focused on hip flexors and triathlons as I made my way through chiropractic school. Now it was my turn to work in the school clinic.
At night and on the weekends I worked as a personal trainer in a New York Sports Club. That's were I was introduced to the concepts of Gray Cook and Functional Movement Systems. I continued my 'outside the box' education with their certifications, just when the term glute amnesia was getting popular. I was definitely riding that wave!
At the time, it was so clear why patients needed orthotics. Like every good chiropractic school we were introduced to a 'chiropractic specific' brand because they were the best (feel my sarcasm).
I was confident in a message that now feels outdated to me.
Luckily with all good science, we've learned a lot more since then. It was a good start to what we understand now, unfortunately the detail corrections don't seem to have caught on the same way.
Fast forward to 2009, post labrum tear. It took me two months to walk normally again, without pain. I guess a non stop ride across the country in a mini van for a week as a support crew for RAAM team didn't help, but it was a cool experience.
It took me another 2 years to get out of daily pain sitting and walking, forget about trying to run. I worked with many professionals trying to rehab my hip.
Surgery was not an option for me because I would have had to be out of work for months, and that was not realistic. A friend and amazing Rolfer worked deep through my iliacus (the Ilio part of the Iliopsoas) and my quadriceps.
Finally I wasn't in pain everyday and able to build stabilization and strength through my functional rehab exercises. I worked through the functional stages, assisting my activation pattern (the neurology to how you perform exercises) and building to unassisted then resisted. Now I could do everything I wanted, as long as I didn't run. Accepting that I wouldn't run again got easier over time, hey it really painful to start running again after a while.
In the midst of my labrum recovery I met a professional shoe fitter we'll call, The Shoe Man. Even though I was fitting custom orthotics it never occurred to me to measure patients feet to make sure they were actually wearing the right size shoes. Frankly I barely knew what a Brannock device was beyond seeing it at the shoe store my mom brought me to as a little kid.
I was just squishing peoples dysfunctional feet into a molds, casting their orthotics. Which only braced them in their dysfunction. Of course it decreased strain and pain, but we know now it also only braces the problem and perpetuates the layering of dysfunction. More on this in another post, but understand that at this point in time I was hard sold on the fact that orthotics were necessary for anyone with reoccurring lower body pain. And it didn't hurt that they made me a lot of extra money.
The shoe man grew up working in the shoe industry and his entire career was fitting shoes through the 1960s, 70s, and 80s when there were lots of changes. He has a unique perspective on the shoe industry because he witnessed the transitions in manufacturing and how shoes were sold. He often laments how quickly it become common for people to need a podiatrist and orthotics beginning in 1980's.
In 2014 I had a part time private practice in Providence, RI and maintained a part time contract with a major sports brand company to treat their employees onsite. Within a week of each other patients' from each location, who had no connection, went to see The Shoe Man without telling me until afterwards.
At their next visit I remember the surprise and significant shift I saw in their hip tightness. That's when they told me about the The Shoe Man. He changed their shoe fit, size and length, and took out their orthotics. The effect on their hip tightness in just one month was shocking.
He created results that I wasn't able to, with all my advanced training and understanding of movement. I had to know more and this started a more than 5 year journey that is worthy of a separate post.
So I travelling down this rabbit hole and realize that orthotics are not doing all we thought. Once I started actually measuring patients feet I realized that roughly 70% of the people coming to my office were wearing the wrong size shoes. This change in perspective helped a tremendous amount of people I was already working with and future patients. It was not a coincidence that this high percentage of people were coming to my office with various musculoskeletal pain problems and their shoes were too short in length and too wide for their mid foot and heel.
Most people did not have foot pain and not one person thought their shoes were uncomfortable. Even men wearing 2 sizes too short! It was a hard sell for many, but I knew what was now possible so I stuck to my conviction and my confidence grew. It's always fun to have someone try to put their old shoes on after 2 months of changing their shoe fit and have a giggle about how they can't even put the shoe on. And that shoe never felt uncomfortable to them because they were desensitize to it, it was what they were used to.
Most of these patients needed a narrow shoe for the right volume around their mid foot and heel, not a standard medium width or wide width. The industry has long been self serving so when you try shoes on and your heel is slipping out you naturally go for a shorter, wider shoe. I'm not exaggerating when I say this is modern day foot binding. It's the basis of developing plantar fasciitis, Achille's tendonitis, IT Band syndrome, knee pain, piriformis syndrome, SI pain, excessive hip flexor tightness, glute weakness and more.
I too went from a 7.5 medium to an 8 narrow Asics. This was a great fit for my heel and mid foot, but it squeezed my forefoot. This still wasn't right but it was better than what I was doing so I was sold. I rode this wave for years, helping people in a way I wasn't able to before, by partially unbinding their feet. At least now their arches had the available length to stretch into and there was the right support along the sides of the mid foot and heel.
This too had it's limitations and I'm always looking for a better resolution. I wasn't making orthotics anymore and the more I learned about shoe making, shoe fit, and foot function I realized stretching and strengthening was the next important piece of the puzzle. Strengthening the foot directly needed a better solution than the standard rehab exercises didn't really work, people were told plantar fasciitis can take 6 weeks to 6 months to resolve if it goes away at all. Now I can get people walking without pain in a few minutes. So there was a whole lot I didn't know yet.
Joint Training + Wide Toe Boxes
I'm always in search of better solutions. I can't accept when things just don't work for some people when there is no explanation why. I love to learn and patients who have worked with me over many years know that first hand. While I think getting adjusted is important and healthy, I know it's not good for someone to need to be adjusted weekly or even monthly in order to stay out of pain. Sure there's exception, but for the majority of people I feel they haven't been given all the resources.
Supporting someone for real nervous system wellness and joint health means retraining the nervous system and joint capsules first, regaining lost motion and developing control over it. Then you would have less stuck, tight joints and need less intervention. There will be another post that covers this topic soon!
Back pain, plantar fasciitis, knee and hip replacements are an ever growing issue and high cost despite the advancement in orthotics and surgeries. I believe the body is amazing in i's capacity to heal and adapt. It's capable of compensating to keep you going until something 'breaks' and with the right resources it is capable of regaining lost motion and function in a way we really couldn't appreciate until now. The expectation that your body should ache and have joint pain with age is bullshit, we've just been doing things wrong.
Did I mention that hind sight is 20/20?
The truth is you shouldn't need orthotics or that your sit too much. Well that does have metabolic health issues but not so much the glute amnesia story. For most people, excluding those with actual congenital structural issues, orthotics only serve the purpose of removing strain because the foot is weak. Continuing to use them long term only makes the foot weaker.
We stopped bracing lower back pain many years ago because we realized the brace decreased the activation of the surrounding muscles and made the problems worst. Now they use programs of global back strengthening and lifting even through the chronic pain to build tolerance and prevent progression of the problem.
Strengthening the foot is the only way to re-establishing the dynamic function, heal injury and prevent injury. Except for the short foot exercise recommended by Czech physiologist and postural expert Vladimir Janda, MD, we need better exercises for the foot and ankle.
Weakness of several specific muscles in the foot, ankle, and lower leg are the cause of the majority of overuse soft tissue injuries and joint arthritis in the lower extremity and lower back. This is only exaggerated and worsened with increasing amounts of joint hypermobility or ligament laxity, more on that in a future post as well.
The two important muscles of the big toe, one that pulls it away from the other smaller toes, the Adductor Hallucis, and one that presses the big toe into the ground, the Flexor Hallucis Brevis, are the most overlooked.
These specific weaknesses with weakness of the Tibialis Posterior, it runs deep along back side of your tibia, your thicker lower leg bone, and wraps along the inside of the ankle attaching under the big toe at the arch. This results in the kinetic chain breakdown. You simply can not have proper dynamic function in the arch of the foot when these muscles are weak.
I've realized the tapered toe box shape to the vast majority of shoes today is a big cause or exaggerator of this problem! Here are a couple interesting articles on the history of shoe design.
1. Why Aren't Shoes Shaped Like Feet? by Jacob Tober
2. The History of How Shoes Are Made by Mary Bellis
You've seen this pattern breakdown and just didn't realize it. It's most obvious in females due to a higher likelihood of joint hypermobility. It's also more obvious when someone is running because of the exaggeration from increased load bearing.
If you struggle in this area and you're always needing to stretch your hip flexors and you're always doing clamshell type exercises, but how much progress have your really made?
Two years ago I began my training with Functional Range Conditioning®
and Kinstretch®, it answered so many questions about what I had previously learned. It validated so many things I understood working with different people and completely supported the next evolution in the way I help people develop healthy joints.
It's a system focused on training the joint capsule first, re-establishing and training lost joint motion, without pain, and strengthening the system from the inside out. Used as a cross training system with your regular training, you work to gain as full motion to all the joints as they are designed and develop neurological control of that motion.
It's been a game changer for my patients and clients. Especially those with ligament laxity and joint hypermobility because the traditional exercise and rehab models do not work for them. Stabilization is such a problem they require significant exercise assistance for proper pattern activation.
In the FRC® and Kinstretch® training model the full available motion is almost an asset and the tissue is isometrically trained at end ranges. This using is the biggest weaknesses as an advantage to strengthening. These individuals can gain strength without concern of developing tendonitis and overuse issues like traditional training.
So is it time to take a look at your feet?
1. Assess your imprint on the inserts of your sneakers | Is the pad of the big toe pushed or squeezed to the toward the small toes relative to the ball of the foot? are the toe pad impressions cut off at all? Are they squished on top of each other?
2. Measure your HV Angle | Put your foot on top of a white piece of paper and take a picture over head. Use the photo edit to put a line through the middle of the big toe metatarsal bone (it should run through the mid point of the ball of the foot (1st MTP joint), blue line. Now put a second line through the middle of the big toe so it connects to the other line at the middle of the ball of the foot. Use the ruler feature to see the angle of each line and determine the difference between the two. That is your HV Angle. A normal HVA is <15°. Greater than that and you have significant weakness in the muscles I mentioned above.
The toe box of your shoes is likely tapered relative to proper alignment of your big toe. So your shoes are actually forcing this and preventing you, over your lifetime, from being able to engage those muscles of the big toe.
That is also the basis of why bunions forms, more on that in a future post.
If any of these are true for you then you need to transition to wide toe box sneakers and shoes so that your forefoot has the appropriate space for it's actual shape. If you don't then the foot exercises will help, but it's like drinking from a firehose to really get control because your shoes are forcing the weakness.
I recommend these as good transitional shoes. They have a good balance of support and cushioning while you begin to develop better strength in your feet so you can tolerate more barefoot styles shoes with wide toe boxes.
I came to appreciate that so much begins with proper function of the big toe and associated coupled movements through the ankle and knee, but I was in for a real surprise!
I needed a better resource for my patients so I developed the Foot + Ankle + Knee Playbook. It's a 6-week video guided daily progressive training for improving specific joint function in the foot, especially the big toe, ankle, and rotation of the lower leg at the knee.
I knew this was something that everyone could benefit from, I knew it was a solution my patients had been been asking for, a step by step guided recipe. What I didn't appreciate was that by developing the program I was going to be able to run again. Half way through the program development, on a random day walking my dog I needed to run with her a short distance. Until this point I would have definitely felt a twinge at least in the front of my right hip. I felt nothing then and haven't felt anything since.
While I'm not planning on doing any triathlons any time soon, the fact that I can now run with my kids and dog in the neighborhood without any hip pain during or after, from focused training of my big toe, foot, ankle, and knee shocked me. I had long accepted that I was not going to be able to run again because of my hip labral tear, based on all the previous knowledge I had.
This is extremely exciting, I realize that we beginning to redefine what we expect from rehab and injury prevention with these new systems. What movement would you like to gain better control over?
Here are a few resources for you to begin developing better strength in your big toe and arches.
Beginner Arch Strengthening:
Toe + Arch Strengthening with band and tennis ball assists:
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