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Keep Moving Pod Transcripts

Episode 7: Foot Health-- The Biggest Blind Spot In Medicine

Today we are going to be talking about foot health. It's something I have a deep passion for and have been doing for about seven plus years in my clinical practice. So my belief is that foot health is the largest blind spot in all of medicine, certainly the biggest blind spot within orthopedic and sports medicine. We're going to go through the different factors and concepts that are both common today in foot health care, but also then the corrective measure that I employ with my patients. And hopefully, you know, help you begin to see how far off sort of conventional mainstream care is today. So the goal with foot health and the answer in general terms to have a healthy foot, healthy foot that can move, healthy foot that can feel, healthy foot that's not in pain. Is alignment and strength. This is just like every other part of the body, right? The overall direction we want to be. headed in when we're talking about how do we create health in the foot comes down to two basic components that are closely related and they are alignment and strength. What we do now in sort of conventional mainstream care not just podiatry so one thing kind of just at the start is I'm not I'm not a I'm gonna try really not to sort of bash any particular individual doctors this is not a problem of just the podiatry profession although it is a huge problem within that profession but it's also MDs orthopedic sports medicine people it's It's chiropractors, it's physical therapists, it's people like myself. It's, it's really across a very wide spectrum. So it's not specific to a certain profession or a, or a specific, um, type of practitioner, um, but what is done now sort of in the mainstream with how we treat the feet, both in terms of sort of quote unquote preventive, quote unquote, common sense care, but also in terms of treating disease and treating pain is we deform and progressively weaken the feet. We don't do this to any other part of the body, right? But this, the, the mainstream care is constrict, deform, prop up and progressively weaken. Okay. So what we're going to do is start with what I, uh, consider arguments from first principles, right? So what this means is regardless of what we see out in the real world or in studies, which we'll go over, uh, starting with first principle arguments, meaning if we just sort of, if we're an alien coming to earth and we look at, you know, the human foot and we go, okay, like, what do we think's going on here? The kind of arguments that lay the groundwork for, uh, logical and intuitive, um, approaches. So the number one idea is form and function. This is a common concept in physiology and biology. You see it a lot in evolutionary, evolutionary biology. Form and function is this idea that the shape or form of a body part in this case. Tells us something important about the function of that body part Feet and I'm and obviously I'm talking about the human foot the human foot is Designed to support itself Feet are designed to support themselves If we start by looking at baby feet We have in both my offices we have prints of baby feet One of my son and at North's foot an ankle. We have dr. Ray's daughters Their their baby feet prints up in the office to show people the shape of a human foot before it gets in shoes is widest out at the tips of the toes and Sort of wedge or triangle shaped back to the heel That is the form of the human foot And if we look at cultures where people don't wear shoes or don't wear constrictive shoes, the foot stays like that. Widest of the tips of the toes, sort of triangle or wedge -shaped back to the heel. So that is the form of the foot. Now with form and function, we go, okay, the form of the foot is a triangle, roughly speaking, right? It's a tripod. Tripods, we all understand, are inherently stable. That's why stools can be a tripod and you can sit on them. You don't need, you don't need to sit like on a, so the contrast would be like sitting on a log where there's no empty space beneath where you're sitting. It's just a column. Whereas a tripod has empty space underneath it, which is with just three struts. The empty space does not cause weakness, right? The strength comes from the counteracting collection of forces that the three struts are creating of the tripod. Tripods are inherently stable. We also, in terms of form, have arches. We have three arches in our foot, one that goes along from the heel to the big toe, one that goes from the heel to the little toe, and one that goes from the little toe to the big toe. Now, this is a little bit easier to see visually, but that tripod formation is also a tripod of arches. So we understand that tripods are stable. We understand that arches are very stable. That's why we build bridges with arch architecture. And we actually have in the foot a tripod arch form. And so what this tells us about fungal, again form and function as a first principles argument is that the function of the foot is designed to support itself right the foot is made to be stable inherently intrinsically right so that's number one we just look at how a human foot is shaped and it tells us something about what it is supposed to do next first principles argument is when we look at what we do to the arch of the foot in mainstream medicine primarily with the use of orthotics and arch supports again we don't need to know anything about the studies about our supports just yet if we just look at the logic of propping up an arch from underneath with stuff this is a method that we would not apply and that we do not apply to any other arch anywhere in the universe, right? Arches are strong because of their shape. They're meant by design to have empty space underneath them. That's the whole point of an arch. Propping an arch up from underneath sounds intuitive when you're told, oh, your arch needs support. But then you think about it for a second, you go, what other arch needs this type of support? And the answer is none. There is no other arch that we support in the same way that we try to support the arches of the feet. Propping stuff up from underneath defeats the whole purpose of an arch. And we know that arches are strong from an engineering and physics perspective, okay? And we can see this through engineering. We can see in natural archways. We can see that the apparent logic used to justify arch supports now for decades and generations is flawed on its face. It doesn't make any sense, okay? And I think the key is people will say, oh, well, the foot arch is different. The foot arch is not quite an arch or something like that. And it's just, it's simply not true. Again, we go back, form and function. It's a tripod arch. Nothing about the stability of a tripod, the stability of three arches oriented in a tripod would suggest that it needs to be propped up from underneath, okay? So we don't do this to any other arch in the universe. We also don't do what we do to the foot to any other part of the body, all right? So third argument here under the first principles category, number one, form and function. Number two, we don't prop up any other arch anywhere with stuff from underneath except for in the foot. Number three is we don't do what we do to the foot to any other part of the body, all right? So not only is the sort of support in constriction model of the foot, illogical in terms of sort of physics and arch engineering. It's also illogical in comparison to how we treat all other parts of the body. So when you have knee arthritis or or knee pain, meniscus, injury, whatever, the number one most evidence -based, most basic recommendation is to strengthen the muscles around your knee. This is, as far as we can tell, basically indisputably accurate as far as being beneficial. You have knee pain, number one thing, strengthen your knee, strengthen your quads, strengthen your hamstrings. If you have back pain, again back pain is a little more complicated but just in general, strengthening your core, you know, may not be everything but definitely doesn't hurt. Again, the key is the first reaction to dysfunction is strength because all things being equal, if you are just stronger, you can compensate better for any particular underlying issue. If you have a shoulder problem, the first thing you do is physical therapy to improve the strength of your rotator cuffs, of your surrounding and accessory shoulder muscles. The point is, every other part of the body, the first thing we do is try to strengthen it because that is what we should do. And yet in the feet, the first thing that is often done is constriction and weakening. It does not make any sense. Now next is, and this is the last one, the fourth, starting from first principles and looking at just the inconsistencies of the foot, is the unique role of fashion. Again, when we look at the unique way in which feet are treated, there is no other part of the body that is burdened with fashion ideas and fashion concepts in the way that the foot is. It is not unique in the sense that obviously there are fashion concepts that adorn all of our, like all over our body, whether we are wearing a specific type of shirt or obviously there is jewelry, there is body art, which is changing our body, but that is very much explicit. That is on purpose. We are changing our body, whether with a piercing or a tattoo or something, gauging your ears. You are changing physically the structure of your body. That is all very intentional. A shirt does not deform your shoulders. or it should most of them don't. Regular shirts don't deform your body. Regular pants don't deform your body. Most shoes deform your feet and these are all because of fashion concepts. So the the role of fashion is uniquely burdensome and uniquely deforming to the feet in today's world. There are other examples corsets being one in you know in I think it's I think it must be Victorian Europe right so corsets as a way to change the shape of a woman's body right those were physically deforming to the rib cage into the spine they were done explicitly for aesthetic reasons. Obviously you know not many people were in corsets today so in terms of modern Western culture shoes are uniquely burdensome as far as a fashion item on our body. and they deform the feet in a way that no other piece of fashion deforms our body. Imagine if we had pants and that the normal pants like the Levi's, all the sweat pants, all of the athletic pants, all of your dress pants had tight bands built into the pants that around your knees so that when you wore the pants normally your knees were pulled together and sort of touching in the middle right kind of pulling you into a knock need situation. And that's just how things were right we decided someone decided 500 years ago that that was what was aesthetically pleasing we want our knees to be knocked in together so we start making pants that pull our knees together and we get to today and everyone is just you know everyone just says well hey like that's just what pants that's just what pants are like we can't get around that like that's how pants are shaped uh what about all these knee deformities we keep treating people for right and doing surgeries on well that's hereditary um you know your mom had deformed knees and your dad had deformed knees and that's why you have deformed knees it's not because you all wore pants that knocked your knees in together um but of course if we were to look at other societies that didn't wear pants that knocked everyone knees together we wouldn't see these knee deformities the point is we take for granted what fashion sort of instills in us right pants aren't shaped like that right they aren't built like that and if they were right we would have really extreme physical problems with knee alignment and arthritis and all sorts of issues right but to not see that the pants are what would be causing the problem is crazy and again in shoes and their impact on the feet to not see that what we to not see how we deform the feet in shoes as a primary cause of foot issues is it is it is a form of blindness that is that is difficult to wrap your head around and we're gonna talk more about that later but we cannot ignore the role of fashion ok so from first principles before we get in physiology before we get into studies before we get into my clinical experience and all the other stuff that that really kind of grounds this in the real world just from first principles we have form and function The foot is shaped in a certain way that really tells us something about what it should do and how it's built. We don't do what we do to the foot arches to any other arch ever. We also don't do what we do to the feet to any other part of the body. And we also don't burden any other part of the body with fashion in the same way we do with feet, okay? So just those things right off the top, right? We're already onto something here, right? What we do to the feet is totally insane. And yet it continues. So I mentioned at the top, strength and alignment. Strength and alignment is what we're doing and what I'm doing with patients and obviously in broad strokes. That's basically the direction we're moving everyone in. So what does that look like clinically? What does strength and alignment look like clinically? Number one, it looks like this. It is wearing a foot shaped shoe that allows for normal foot movement, maintaining proper alignment and promoting strength. When we talk about alignment, the number one thing that we start with with everyone, whether or not you have problems in your toes or not, is we start with big toe alignment. Your big toe is a part of how your arch is supported. Your big toe is a part of your arch support. Having your big toe in the proper position, which is straight off the foot, not deviated in toward the little toes. Again, look at a baby's foot, straight off the foot so that the tip of your big toe is the widest point at the front of your foot. Widest point toward the midline on the front of your foot. That is big toe alignment. And what that does is it creates arch support along your medial longitudinal arch, which is your main arch. When people talk about arch of the foot, they're talking about arch of the foot. talking about your medial longitudinal arch right there are three of them but that's the main one as far as what people refer to it maintains that tripod position it acts like a kickstand and creates that wider tripod so that your arch doesn't flatten and fall in or collapse I don't like to use word collapse it's very dramatic there are obviously instances of collapsed arches but most people are told oh your arch is collapsing and it's mostly just that they're you know flattening out because their toes in a bad position so alignment and strength alignment starts with big toe alignment your big toe is disproportionately important for foot function right it is like your thumb on your hand right no one would argue that your thumb is disproportionately important compared to your other four fingers for hand function right the opposable thumb provides a level of dexterity that no that the four other fingers in a single, any single finger can't match. Your big toe is similar to your thumb. It is disproportionately important for the form and function of your foot to be in the right position. Now, by aligning the bones and aligning the toe specifically, what you're also doing is you're moving the muscles that attached all of those bones. And this gets us into muscular support, right? So by moving the big toe and maintaining proper alignment of the big toe, you are increasing what I call structural support, right? Support just by nature of alignment, right? This is like a tripod. Now there's muscles connected to all these bones. So as you align the toe, you're also aligning the muscles. And this provides better muscular support. There's an idea in muscle physiology. And my major in undergrad was exercise and support science. And this is very, very basic stuff, right? This is muscle physiology 101, which is that there's something called the length to tension relationship. And that says that a muscle produces its maximum force output when it is basically in the middle of its length distribution. So when the muscle is very, very shortened, it's not as strong. When the muscle is very, very lengthened, it's not as strong. When it's in the middle of that length, that is when it's its strongest, when it can produce the most force. So by realigning the bones, by realigning the toes, we're putting the muscles in a better starting position. to produce more force. So conventional shoes today and the mainstream foot care would have you deform your foot in a way that over stretches your muscles and thereby decreases the possible force that they could produce. Not to mention the fact that they're also progressively weakening them, right? So there's this that creates weakness, but also a bad position, an overstretched position that creates less force production and less and less strength. So hallux alignment or big toe alignment is important, not just for that tripod position, but also to put your muscles in the best possible length to tension relationship so that when they are used, they can produce an adequate amount of strength. Having your big toe on alignment also increases blood flow and circulation to the front of the foot, which can be very important for healing any type of injury. It can be important for neuropathy, it can be important for Morton's neuromas. Aligning the big toe also promotes joint health of that big toe joint especially. So one of the main downstream effects we see with bunions, for example, is arthritis. Again, going back to the pants that cause knock knees, right? If we had pants that pulled our knees in together just automatically, we would have much worse arthritis and we already have a lot of arthritis in knees. So promotes joint health just through alignment. Hallux alignment and big toe alignment also promotes glute activation and knee alignment because if your big toe is in the right position, it prevents overpronation, which means flattening of the arch. So it prevents flattening of the arch, which prevents your knee from falling toward your midline, which prevents your hip from internally rotating and stretching and elongating your glutes. So big toe alignment and activation of your arch actually helps to align your knee and activate your glutes because your glute activation and your arch activation in your foot are very, very tightly connected and they're along the same tensegrity network so that when one is strong, the other is when one is working well, the other can work well too. Now, we use correct toes, toe spreaders to achieve big toe alignment. We're going to get into shoes here in a second, but wearing wide shoes is a must. But for most people who have been wearing narrow shoes for a long time, just switching We're going to get into shoes here in a second. into wider shoes, generally is not enough because what you do is you maintain the deformity of your toes that have occurred from the narrow shoes. So we need something to actively push back your toes into a better alignment, right? As opposed to just removing the cause, which we need to do, we need to remove the cause and get active realignment by wearing a toe sputter that pushes the big toe out into its best alignment and natural shape. These are like braces for your toes. A lot of people will sort of grow out of them. Some people, if whatever their issue is progressed to a certain amount of severity, you'll need active toe alignment and correct toes indefinitely. But in either case, they're like braces where we're holding and actively realigning your toes. holding them in place, holding them in a better alignment for structural and muscular strength and then using your foot so that your muscles and tissue remodel and grow stronger around the proper alignment and so this is another key where especially with a lot of physical therapists we'll do a bunch of foot strength exercises in the PT office barefoot and then say okay great good job you know we're gonna get this plantar fasciitis healed do a bunch of foot strengthening stuff barefoot and then go inside of a shoe that deforms constricts and props up the foot and really is counter to everything you just did strengthening wise so we want that alignment to maintain itself while we are active because when we're active is when the remodeling and the actual changes in your body happen so you can't just wear toe spreaders at night that's passive you're not weight -bearing you're not getting muscle remodeling you need active big toe realignment and then be on your feet for progressively increasing amounts of time to the point where you are have your toes spread and using your foot for days and weeks and years on end because most people come to me after decades of wearing shoes that scrunched their toes together so we need a lot of time often to to reverse these things permanently the great thing is that almost everyone has short -term relief right within a month or two people almost always feel better and then there's this longer project of getting these these big big changes over a longer period of time because they've taken a long time to develop last thing about big toe alignment is that the conventional mainstream treatment for foot problems either promotes misalignment as normal Again, the sort of well, that's just how shoes are shaped, right? that kind of line or So it either promotes the misalignment as normal like oh, yeah, there's nothing wrong with your foot being You know your toes being scrunched together That's what feeder. That's what feet look like, you know Or it completely ignores The role of big toe alignment all together All right people there's a serious conversation in foot medicine is we have no idea why bunions occur the hereditary, right? Your mom had them you had them. It's genetic not it completely ignoring the fact that You know you and your mom both wore shoes that are shaped like bunions right completely ignoring the fact of environmental influence The we have no idea why bunions occur is one of the biggest examples of just head in the sand thinking I can think of in all of medicine. Look down at your feet. Are your shoes shaped like a bunion? Yes or no. That's a very good starting point to begin this sort of journey. Because if they are, your foot can't support itself because the form has been distorted. It won't function correctly. And then you'll need a bunch of other stuff to make up for the main issue, which is that your toe is not in the right place. So that's toe alignment. It has a huge influence on everything, right? Even if you have an ankle problem, we're going to talk about toe realignment. If you have a plantar fascia problem, we're going to talk about toe realignment. If you have knee problems or hip problems, I might talk to you about toe alignment. So it's not about your toes per se. It's not about how your foot looks per se. It's about how the alignment and form of your foot directly affects the function of your whole lower limb. So that's big toe alignment. Now let's talk about muscle strength. Your foot's full of muscles, like every other part of your body. Muscles operate on the use it or lose it principle. If you do not use the feet of your muscles, if you do not use the muscles of your feet, they will get weaker. Again, we don't do what we do to the feet, to any other part of the body. We have to use our feet if we want them to be strong. If we never use our feet, they will never be strong and they will continue to get weaker and weaker. This is where people who are put in arch supports at a young age are continually being put in more and more dramatic and supportive arch supports. There's no end to it because is you prop up your foot with something, it weakens to a point where then the thing that you originally used doesn't do the job anymore and then you need more support to the, now it's support the weakened foot and then that gets weaker and then you need more support to support the further weakened foot. And it goes until either there's sort of a catastrophic, you know, issue with your foot and you either get a surgery to treat something that was totally preventable in the first place or you come and see me and we begin to work sort of unwinding a lot of these things. So muscle strength, right, depends on alignment, but strength itself is progressive use. The one of the concepts that I take my patients through is that with a lot of these changes, especially initially with foot health, one of the main things that's happening is that we're just doing a strength training program for your feet. Okay. That's not all of it, but that's a big portion of it. And thinking of it that way, I think helps people wrap their heads around like what it is and why it is we're doing all of this stuff that we're doing. Right. So why are we slowly increasing our correct toes use? Why are we slowly and carefully increasing how much we, uh, wear naturally shaped shoes? Why are we doing foot strengthening exercises? Because we are progressively strengthening all of the muscles in the feet because they have been chronically weakened in most people. Now, just like with any other strength training program, right? If you want to deadlift more, you cannot just put 400 pounds on the bar and go to the gym every day and just keep trying to pick up 400 pounds. Right. Um, now everyone understands that intuitively. It's kind of funny, right? When you kind of characterize it that way, that's not how strength training works, right? You have to start with where you are at and then very progressively, little by little, add more and more challenge so that your body can meet the challenge, adapt, become stronger, and then meet a slightly greater challenge and then so on and so forth as you get stronger and stronger. The main mistake that people make when doing this type of approach on their own, which says you can do it on your own, but the main mistake that people do is they do too much too fast. They go from wearing Hoka's or Nike's with custom orthotics and they say, Oh my gosh, like everything in this YouTube video, uh, from Dr. McClanahan, like makes so much sense. I'm going to start, I'm going to start just going barefoot and then they go barefoot and then they start running barefoot. And then it's way too big of a change all at once by and mechanically, which relates to this other issue or, or, or sort of phenomena that I see very, very commonly, which is people in general, both patients, which, you know, in some sense, we're all patients because we all have feet, but patients and doctors, I think doctors don't understand this either, but all people, we all tend to vastly underestimate the degree to which our feet are deconditioned. Right. Imagine if you never picked anything up with your left hand, you just never used it, right? It was always in a glove that kind of squished it, squished the fingers together and it, and it never was used to grip anything. And then you were surprised when you tried to use your left hand for something and it didn't work. Of course, we wouldn't be surprised. We've never used it. Why would we expect it to work? With the foot, we tend to, with the conventional approach, never ask our feet to do very much and then are surprised when there's dysfunction in pain and surprised when they don't work. We underestimate vastly the degree to which our feet are deconditioned. People's feet are generally speaking, coddled and, and, and never asked to do a challenge, um, and it results in a profound level of weakness and muscular dysfunction where people can't even move their toes, right? Because they've never moved their toes. So the progressive strength training component can really needs to start. And this is what I think I'm good at. And I think, you know, why it's worth seeing someone about this as opposed to, you know, if you're struggling and trying to do it on your own is really starting from where you are at, right? If, if, if you have really profound muscle dysfunction and weakness and deformity in your foot, everyone can get better, everyone can get better alignment and everyone can get better strength, right? But we have to start with where your foot's at. And just like, quote unquote, going barefoot is not a good idea for someone with that level of with a lot of, it's not a good idea for many people because their, their dysfunction is so profound and their weakness is so great. Related to muscle strength is arches. We already kind of went over the architecture of arches, but your muscles are really what are the contractile force that hold the arch together and hold the arch in its arch form. Again, use it or lose it. If you don't ever put force and stress through an arch, it will atrophy and weaken. So one of the big misconceptions that I hear constantly and that is just patently false is that people will say, oh I have flat feet. That's why I have pain. My doctor told me I have flat feet. That's why I'm in pain. What can you do about it? Oh well nothing you know just where arch supports for the rest of your life. And then the net literally the next patient I see will say, yeah I have high arches. And my doctor told me, yeah I have high arches. That's why I'm in pain. Okay well what they say was the solution. Well there is no solution just where arch supports for the rest of your life. Think about how illogical that is. A doctor is telling people, hey you have low arches, flat feet. That's why you have pain. Wear an arch support for the rest of your life. And then that same doctor is telling people, hey you have high arches. That's why you're in pain wearing arch support for the rest of your life. This doesn't make any sense It doesn't make an ounce of sense, right? Low arches do not cause pain high arches do not cause pain weak arches cause pain With my patience, I do not care how high your arches I do not care how low your arches I care how strong your arch is people are shaped very differently There's a huge amount of Variety in the specific shape of the foot the height of the arch There's very very very rare extreme examples where the bony formation is is Sort of a an issue that can't just be Reminied with strength, but these are extraordinarily rare and people with completely normal feet have been led to believe that they're somehow like Catastrophically flat and deformed and there's nothing you can do about it So just never go barefoot and wear this arch support this this $800 custom arch support that you'll need to get done every You know two or three years forever Okay, it's completely incorrect low flat arches do not cause pain high Arches do not cause pain weak arches cause pain How do we Make a week. How do we make a weak arch stronger? We use it Right propping propping up a weak arch with something from underneath outside of the foot right propping up with something external Only promotes more weakness. Okay, this is what I just have to keep saying it over and over again because you have to break through the bad logic that we've all been trained in if You want something to be stronger you have to use it conventional shoes promote disuse because you're propping up and constricting the foot with something else something outside of the foot you need your foot to support itself in order for it to get stronger you need your foot in the proper alignment for it to work well enough to become stronger to support itself let's talk about shoes shoes are shaped like bunions this is the truth it's undeniable you don't need an evidence -based study to prove it just look down look down at your feet if you don't know what a bunion is take a look at a picture it's where the big toes deviated in toward the little toes basically where the foot becomes more pointed in the front why because shoes are pointed in the front this goes back to what we talked about with toe alignment Not everyone has bunions, not everyone with foot pain has a big toe misalignment. The point is that when your feet are inside of shoes that are shaped like bunions, nobody's foot can function normally because the, because from the very start, the form is distorted and the function will be distorted. There's a whole cascade of biomechanical effects that follow from big toe misalignment. You scrunch the toes together so that you ruin the tripod orientation of the foot. You distort the arches and then the foot falls inward over pronates and you say, ah, see, we must need arch support because the foot can't support itself. Right. But what you've done is deformed it and then proved that deforming it makes it not work. You have not proved that having arch supports is helpful. Right. So if you start from a bad place and then say, oh, well, this justifies the use of all these other bad ideas, right? You're just compounding your mistake, right? As opposed to saying, let's just start from a good place. Let's start with the toes aligned. Let's start with the foot in its, in its true form, right? The tripod arch orientation. And then you don't need something propping up your foot and then you don't need, you know, your heel elevated. So there's a whole cascade of biomechanical dysfunction that, again, tends to be compounded with more and more mistakes, more and more cushion, more and more constriction, more and more propping up, more and more elaborate arch supports, more and more disuse, more deformity, and more weakness in shoes, conventional shoes, right? So what I'm talking about is dress shoes. I'm talking about cowboy boots. I'm talking about really any formal shoe. I'm talking about most athletic shoes. I'm talking about Brooks. I'm talking about Nike. I'm talking about Adidas. Everything except for a few. that we'll talk about a small part of the market, feet are not pointed in the front okay but shoes are so there's a there's a fundamental mismatch there and that's the number one issue with shoes now shoes also have other features that shoes also have a raised heel where your heel is elevated above the level of your toes this is called a drop. Why this exists is purely a fashion phenomena high heels were in fashion shoes and they were brought into athletic shoes for no other reason other than that's what people were used to there is no foot health reason to have a raised heel there is no biomechanical advantage in fact there's many disadvantages to having a raised heel it's because that's what people were used to and if you're used to wearing high heels and you put yourself in a flat shoe you can get some Achilles irritation because high heels shorten your calf muscles Like physically shorten it so that you have a shorter Muscle and then when you go into a flat shoe it gets elongated and stretched and you can create some issues now That's again why we clinically would go slowly with people

But the heel itself has no justification other than that's just what people think shoes are shaped like Because it's put in a bad position with toes scrunched together and the heel elevated it becomes more unstable and then many people believe justifies the use of Propping it up with arch supports. Whereas as I've said if it's simply in the right position to start with you don't need the arch support now Why shoes are shaped like this is an interesting sort of history of anthropology and fashion Basically it is Narrow toed heeled shoes were popularized by aristocrats in Victorian Europe as a way primarily men as a way to Externally signal to people that they did not have to labor for a living. So they wore very impractical shoes Okay, so think about this Rich person in Europe You know like King King Louis Wanted to let people know that he didn't have to labor right that didn't have to work, you know because back then it's like if like working was You know was it was a sign that you were? You know that you were a peasant, right, you know, I don't know all the particular politically correct words, but like basically It was a sign of higher status if you didn't have to work So in order to signal that status you wore shoes that were completely impractical Right that had big heels on them right to make you taller And that were narrow in the front to create a certain aesthetic of like sort of slender, sleek, small feet. The whole reason those things were created was because they were impractical, right? Like, like, the whole reason shoes became healed with narrow toe boxes is explicitly because they were impractical, because they signaled that you didn't have to use your body for a living. Now those things then got integrated into, you know, what the public thought, you know, aesthetically pleasing shoes became, right, which became integrated into sort of dress shoes, informal shoes, you know, women's shoes, but men's dress shoes as well, right, we see it in cowboy boots, work boots. And then, you know, with the advent of athletic shoes, basically, you know, invented by Nike in Oregon, in Eugene, Oregon, and Bill Bowerman originally made a waffle iron shoe that was wide in front and flat because he was making shoes for his runners at U of O. And when they, this is hearsay, I don't know how true this is, but you can see the old shoe they made that's different. And basically what they were told was like, look, this is great, but you're never gonna be able to sell this shoe, right? If you like making a shoe for your college runners is one thing. But if you wanna make a business out of this, you have to make the shoe look like what people think shoes look like, which is dress shoes. And so Nike explicitly started making their athletic shoes fashioned after dress shoes of the time because people thought that's what shoes were shaped like, right? They never made these decisions because of athletic performance. So then here we are today. We just think this is what shoes are shaped like. There's a complete disconnect between shoes and feet. And yet it's the thing we put on our feet every day. I don't talk about this very much, but since this is a long form podcast, I'm gonna just sprinkle this a little bit in here too, is women are burdened with this issue more than men. On average, women tend to feel more pressure to wear fashion shoes, right? To wear, especially in formal situations, high heels, very slender, narrow pointed shoes. The fashion component is disproportionately placed on women and disproportionately negatively affects women. This is like the, and I know cause I have so many female patients who when I talk to them about all of these things, they go, okay, like I get everything. you're saying, but like, what about my cute shoes? Like what about me looking good? Men say this too, but in this, I'm just making a point here about the disproportionate effect on women. The pointed bunion shaped shoe that I know that many women like that, like, like that is the patriarchy. Like, like that is the, the role of like Anglo men fashion concepts, like working its way through, implicitly through modern culture, right? So it's not a thing that women created for women. It disproportionately, uh, harms women creates more pain in their feet than there needs to be. Okay. So. it doesn't need to be it doesn't need to be that doesn't need to be seen as that but I think it's a powerful example of like wearing shoes that are shaped like feet is like a powerful could could be seen as like a powerful feminine stance again we don't you don't have to think about in that way but it's sort of an interesting angle because women's fashion footwear is more deforming than men's fashion footwear and so ladies don't get tricked like don't buy into it you can always wear cute shoes for specific reasons as we'll talk about you know we'll talk about now with shoes the idea with shoes is that it's like diet meaning you can be a healthy eater and still have junk food and dessert occasionally right that doesn't like ruin everything all the good habits that you've developed right so shoes are the same way basically meaning if you are a healthy shoe where if you're wearing shoes that are shaped like feet as a default most of the time when you're most active when fashion doesn't matter you're gonna be you're gonna have healthy feet all things considered and then you know your dress shoes your high heels are dessert they're your junk food and there's nothing wrong with doing that but you have to know what you're doing you have to do it on purpose right if you if you just don't know what you're doing to yourself you're putting yourself in a disempowering position right and this is men and women there's always sports specific and fashion specific reasons to wear unhealthy shoes or foot deforming shoes right I ski I'd cross -country ski I downhill ski there's no great ski boot there's no there's no foot -shaped ski boot right I just wear the boots I have a great time skiing and it's such a small amount of my time it doesn't ruin my foot health right this is this is the dessert theory the dessert analogy So it's not about hearing all of this and taking all this on and then throwing out all of your shoes although you will you know begin to shift your shoe collection there's still room for wearing your favorite pair of shoes when you want to look a certain way there's nothing like we want to feel good about ourselves you want to look good feel good right so fashion is important I'm not here saying that fashion should be completely disregarded I'm just saying you have to do you have to be fully informed and do things on purpose right so if you're not fully informed about the issues that your shoes are causing your feet you're setting yourself up for issues that you're not aware of if you are aware of these things you can at least wear a fashion shoe for a specific reason enjoy it and know that you are doing it with the understanding of the trade -off and the understanding that your default is going to be healthy and that the next day after that You know wedding or dinner or you know sort of fancy party you went to you're gonna wear your correct toes and do your do your Foot strengthening and stretching and you're gonna feel good So clinically speaking None of this we're starting from scratch, right? I mean obviously kids start from scratch and if you have kids or especially young kids Right the best thing is to just always put them in shoes that are shaped like feet Have them be barefoot a lot obviously when it's safe Have them be barefoot a lot and have them wear shoes that are shaped like feet And that's for kids. It really can be that simple Obviously that doesn't make you immune to every possible issue. You can still get injured You can still have issues right if you eat a perfect diet, you can still get sick but You don't need realignment with toe spreaders if you never get your toes crammed in the first place. So But most of my patients are adults Most of my patients have 10 20 plus years of wearing Narrow toe box foot deforming shoes. And so we're never we're almost never starting from scratch with people And not everyone can just quote -unquote go barefoot. That's bad advice. And I think a lot of times what I do Gets straw man into oh, he's just gonna tell you to go barefoot And that's not true. It's not what I do And if it was what I do it wouldn't work very well, right So a straw man meaning a bad representation of what I do This the steel man the strong representation of what I do is promote strength and alignment in the foot And that looks different for different people But just going barefoot doesn't work for most people doesn't work for a lot of people because it's too much too fast but even with that Every single person can improve Strength and alignment no matter how severe their issue is. Everyone can get better. It's just a matter of how much and how long it'll take So let's talk about arch supports. We've mentioned them and how they kind of have this long term downside basically the role of arch supports and the the use of them is a classic example of confusing short -term relief with long -term benefit I still use our supports with many patients within a wide toe box shoe that is zero drop right so the mean meaning the the heel and toe are at the same height a flat shoe flat shoe wide shoe but with an arch support can be helpful an arch support is like a sling if you have a shoulder injury a sling can be useful but the whole idea with a sling is that you use it for a period of time and then begin to work yourself out of it as you strengthen the shoulder so with an arch support we can use it for a length of time and then work yourself out of it to strengthen your foot the use of our supports in my practice is basically based on this idea of finding the Goldilocks zone of stress, right? We want to increase stress on your foot. If we wanted to get stronger, there's no other way. That's literally what strength training is. It is, it is putting stress through the body in a particular way to achieve a particular goal. Now, if you put in no stress, you get weak. If you're putting too much stress, you get injured. So the Goldilocks zone is that right in the middle, not too much, not too little, right in the middle, just right, right in the middle means that you're stressing the foot in a way that's producing a beneficial increase in strength without, uh, an injury. So it's that Goldilocks zone of strength, promoting stress that we're after. And that's where our supports for people who with, with really profound weakness, what we will do is have them do foot rehab, foot strengthening, toe realignment, but then wear an art support in their shoes for some period of time, one month, two months, three months even, or continuing to wear indefinitely for high end activity while in the background slowly decreasing their use of it, you know, going to the grocery store without their art support in like, you know, low level activity cooking without an art support, like, and also while doing foot strengthening and toe realignment. So it's the external art support propping up your foot can be a useful tool in the graded exposure and a tool in making the change from bad constrictive supportive footwear to a naturally shaped shoe where your foot is supporting itself. It can make that change more incremental, right? Again, it's not all or nothing and doing too much too fast is the biggest mistake that people make. And, and some people, especially older folks, it may, our support may be useful for them longterm for high end activities. Like I have patients who, you know, they don't wear an art support. at all during the day, they wear their correct toes, they go through like really all their activities and their feet feel good, but they need to wear an arch support if they if they walk or hike for over five miles or three miles or whatever the number is and that's fine. Pain -free function is the goal. The goal is not to get you in a certain pair of shoes, a certain brand, right? Obviously you need certain criteria, but the goal is not just to get your foot to look a certain way even. The goal is pain -free function and so if you can promote foot strength and promote alignment but need an arch support to achieve the activity level that you want in certain areas, that's fine. What we want to do is not create dependence on an arch support and we want to if you do have dependency on an arch support to slowly unwind that dependency because it's the only way you'll get stronger and they're always they're always utilized in a shoe that is shaped like a foot, meaning wide toe box where your toes can be aligned, and a shoe that is flat, which is called zero drop. Let's talk about cushion. So I'm what I call cushion agnostic, meaning cushion is basically up to patient comfort. There's some pros and cons with it, but you can achieve all the biomechanics and all the strength promotion that we want with cushion under your feet. There's nothing about cushion that will inherently deter any of these goals from happening. Oftentimes it is the best first type of shoe for people because if you're used to a very cushioned supportive shoe, at least going to an alignment based cushioned shoe can be a good first step because again we don't want to do too much too fast. It can, cushion can provide forgiveness on harder surfaces and it can also just feel more familiar because going from very cushioned to just like walking on the ground can be quite jarring and it is quite jarring and a big change biomechanically. So none of what I've said so far requires that we all wear minimalist or barefoot shoes. It requires that we wear foot shaped shoes that promote alignment and strength, which can be cushioned. Again, the barefoot shoe for everyone all the time is a complete misnomer and straw man of what I do. We can achieve everything we want to with a shoe that has cushion. Okay, so if you haven't already, the cognitive dissonance is very real as we move through all these concepts. It's something where when we talk to patients, everything can make a lot of sense. Everything can be intuitive. It's like, yes, like alignment and strength. Everything you're saying makes sense. My shoe is shaped like a bunion. why like supporting your arch doesn't actually make any sense. I can't like people it's a great part of my job because I can literally see people's minds expanding and like getting their minds blown as I'm talking through all these foot things it's a very rewarding part of the job and yet even if that is all happening and it makes all the sense in the world the immediate question is like well how if everything you're saying is true how could this be possible like how could this be how could OHSU be this wrong how could the entire podiatry profession be this wrong how could Nike be this wrong and I don't have a great answer for you other than there are lots of dynamics that sort of correlate to this kind of thing the truth is every all those all those people are wrong and if you take the sentence arches needs support for example which we're told all the time, oh, your, your foot, your arch needs support. It makes sense out in first pass. You're like, oh yeah, yeah, you support it. Great. But then you, but then you say that sentence over and over and it's like, it doesn't make any sense. And so it's one of these logical fallacies that I think gets ingrained in people and then it goes unexamined, which happens in many other areas. It is a classic, the, the, the, the, the dissonance of like, if what are you saying is true, how could this be, right? How could all of medicine be wrong about it? How could we have this big of a blind spot? I think it's a very good example of collectively confusing short -term relief with long -term benefit, right? These are not the same thing. Again, to use a diet analogy, eating sugar can feel good in the short term, right? It gives you a dopamine rush. It's, uh, sensorily pleasurable, like, but we, but we are not tempted to confuse that short -term pleasure with a long -term health promotion yet with feet. We do everything we can to remove all stress from the feet, cushion it, support it, stiffen it, deform it, and then act surprised when the feet don't work. So confusing, and we do this with pharmaceutical therapy all the time. It's one of the biggest features of modern medicine and part of the reason why our healthcare system and culture is so screwed up, right? I would bet my life on this new weight loss, drug craze showing within the next few years. Oh my gosh, there's been, there's these long -term downsides that we just didn't see coming, quote unquote, didn't see coming. Right. So the short -term relief of losing weight quickly, right, is completely clouding our ability to see potential long -term detrimental issues. Right. So I'm talking about Wagovia, you know, Zempic, um, these, these drugs right now that are popular to lose weight. Um, it is such an obvious example to me of something that has a short -term relief. Right. The number on the scale goes down with very, very, very obvious long -term consequences, detrimental consequences, um, that people just ignore, right. That the FDA ignores, right. Because how can you do a safety study on something that people are going to be taking for years when that's only been studied for a year? Um. And then, you know, we could go on and on about that confusing short -term upside with long -term upside is a huge mistake. It's, it's ingrained in the human psyche. Um, but that's how we get to where we are with feet, right? We're in a cushion shoe feels nice, right? But then that niceness turns into weakness and we have long -term issues and that just gets ingrained. Um, so understand that I recognize there's cognitive dissonance happening. I don't have a great answer for you other than it is a thing. It simply is the case and we need to wake up to the fact that, um, we've been, everything we've been told about feet is, is wrong. Okay. We're going to go through some rebuttals and then summarize here. So I hear some very common retorts to my whole approach here. Um, and I'm gonna kind of go through them. I've been through some of them already, but like one thing that people will say in response to all of this as well, I tried barefoot shoes and I got hurt. Okay. Again, going barefoot is probably not the solution for many people that's going to work best. So that's just right off the bat, not a, not a rebuttal of this whole argument. And it just goes back to the too much too fast, right? You can't just watch a YouTube video and then say, great, I'm going to be a barefoot runner because you have no idea how deconditioned your feet are. You've never used them properly. So why would you think that they can be used or why would you think that they can work? You need to progressively strengthen them slowly. So doing too much too fast is the answer to that. Like yes, you got hurt, but it's not because going barefoot quote unquote is bad for you or that having your foot unconstricted is bad for you. It's that you were, it's that you did too much too fast and underestimated how deconditioned your feet were. Okay. The next retort or the next rebuttal is yeah, I hear what you're saying, but the ground is hard. Like the ground is hard. We live on modern concrete, you know, places and you know, you need support. And I would say, no, you don't. You need cushion. but you don't need support. Your foot is designed to support itself, right? We know this because of how it's shaped and the function inherent in that. And that goes back to what I was saying about cushion. I'm cushion agnostic. There's nothing wrong with using cushion. If you need it for comfort, you can achieve all of the strength and alignment that we are after with cushion. It's not about just going barefoot. How about people who say, well, there's no evidence for what you're saying. That's a very interesting point. How about this? There has never been a study showing long -term benefit of arch supports, and there's an entire industry based on it. There have been studies showing three to six month symptom relief with orthotics, with arch supports. And there has never been a study showing that people are better than placebo when you look at 12 plus months. Never been published. It has never happened because it doesn't happen. Okay, so the there's no evidence for that argument is a Distraction from the fact that there isn't any there isn't any evidence for the current Approach and there's also no first principles logic to it either. It's based on outdated Industrial Revolution age Thinking about the body is a broken machine and we and it and it doesn't know what to do. So we need to Dominate it and and and and externally force fixes upon it, right because it has no inherent wisdom Right, which is which is a complete Ignoring of Basic sort of biological and physiological concepts And you know the other evidence the evidence for what I'm saying, right again is based a lot on those first principles Arguments like there's lots of studies showing that increased foot strength decreases planar fascia injury. For example There's lots of studies showing that spreading your toes increases circulation You don't need a study to tell you that your shoe is shaped like a bunion Right, you don't need a study to tell you that your that your shoes are deforming your feet There is zero question that they are And there's no evidence to support the remedy mainstream for it anyway Here's my favorite one What about people who say well athletes wear them? How could how could Nikes be bad for you LeBron James? Wears Nikes like this doesn't make any sense The number one thing with that claim is that peak athletic performance and long -term health are not the same thing And they're not even really that closely related to each other So whatever you do to get peak performance, whether it's in basketball or any other sport Is not a template for how to live a long and healthy and pain -free life. Athletes tend to, and as an athlete, a former former former athlete, I know this, like I played football and prioritized short -term performance gains in football over what I now know to be like long -term health. And I have mild but like consequences of pushing my body when I was 20 years old, 22 years old, that if I was longevity focused when I was 20, I wouldn't have been doing the things I was doing, right? But I wasn't, and not saying that people should. Athletics are great. There's a different incentive paradigm for athletes. So saying that, oh, well, athletes were Nikes, therefore they must be good for me is a complete misunderstanding of how things work. The other thing that I like to point out is that, yes, athletes sell and endorse Nikes. athletes sell and endorse Sprite in Coca -Cola and Doritos but we don't confuse athletes endorsement of junk food with health like do we think LeBron James is as good as basketball because of all the Sprite he drinks I actually don't think he drinks any Sprite right he just endorses it because they pay him good for him but it but we don't we aren't tempted to confuse his endorsement of junk food with his athletic prowess but we are we are confused about his endorsement of junk shoes with his athletic prowess so I would just say Nike is the same as Coca -Cola their commercial success does in no way indicate a health benefit to the customers they serve I'm not saying that Nike is as bad for you as Coca -Cola products are right Coca -Cola will ruin your health if you drink soda it's like smoking cigarettes like you really really like there's there is no silver lining of drinking soda it is an unabated awful thing for you right that that we just everyone needs to stop and that we all basically pay for in the form of health care premiums and that the government subsidizes by making high fructose corn syrup cheap but that's a whole nother podcast um the point is I'm not saying Nike is as bad for your health as Coca -Cola is but I am saying that their level of commercial success in no way indicates that they're good for you now the last thing that we'll go over is there are differences between activities so people are like well yeah but I can't run with what you're saying and that comes basically back down to matching context right a lot of people can wear barefoot minimalist shoes during work chores activities of daily living You do yoga, barefoot, right? Weightlifting is a great place to go minimal or barefoot. But you go for long walks and your feet hurt and you go for runs and your feet hurt, wear some cushion. Even potentially wear very targeted, low level arch supports. If that is what gets you to that activity level you want, right, but matching the context with the footwear is an important part of that. So you don't need arch support when you lift weights, right? If you're lifting weights and wearing big supportive shoes, you are robbing your feet continually of an opportunity to get stronger. At a low risk too, because strength training is low impact, activities of daily living, cooking, low impact. It's low stress. Why do you need arch supports to do that? Get strong enough feet so you can stand in your kitchen.

So in summary, foot health is polluted with so many bad ideas it becomes hard to tease them all apart but many of them stem from fashion and many of them stem from outdated medical models. We have to first recognize that this approach of alignment and strength is a return back, is a return back to how feet have been for 99% of human history. We must also recognize that it's possible for mainstream and establishment medicine to be profoundly wrong about this, right? Not only are they wrong, there is not even a coherent concept of what the foot should be doing in mainstream medicine. We recognize that and then we say okay we have to start with shoes that are shaped like feet, we have to spread our toes back out, we have to progressively work on strength and then address any specific problem with targeted therapy if needed. It will look different for different people but every single person can get better. You may not be able to completely reverse your bunion but you can make it better. You may not be able to ever run barefoot but you can be pain -free. Everyone can get better strength and everyone can get better alignment. I love this work because people don't realize how important the feet are until they have a problem. Feet are like the tires of your car. Feet are the thing that carry us through the world and that connect us to the earth, right? They are the thing that literally ground you, right? Ground you, pun intended. If you want to be active and healthy through your entire life to promote bone health, to promote muscle health, to promote metabolic health, to promote heart health, to promote brain health, to promote digestive health, you cannot neglect your feet. and you cannot expect your feet to be healthy if you never use them. And then on the flip side, on the positive side, you know, having healthy feet has the potential to provide so much simple joy simply by feeling the ground. Think about if you had no foot pain and you could walk on the beach barefoot and feel the sand in the water beneath your feet. Or you could feel the grass between your toes. Or you could get up from bed in the morning and walk to the bathroom and walk to the kitchen to grab a coffee without having to search for your orthotic slippers, right? These very, very simple things like if you don't have foot pain, you don't understand or maybe don't understand how these interruptions and our simple day -to -day stuff can have a huge impact on us. But these are simple. simple joys that can be achieved simply by having good foot health. And we don't even really have the time we need to go through all the specific pathologies and explain the exact mechanisms, but this approach is with certain emphasis, with certain emphases, the cure for plantar fasciitis. We could go over how and why that works, we go over how and why it works for bunions, how and why it works for hammertoes, how and why it works for Morton's neuromas, how and why it works for tendonitis and tendon tears, how and why it works for osteoarthritis, and really any foot condition can get better with this approach in a personalized and focused fashion. The specifics are always tailored and different emphasis put on different conditions with different people for different reasons. This last hour plus has been over sort of the overarching concepts and the basis of why and how all this is happening, but the specific pathologies I see every day, every week, and all of them can get better and do get better. And then the last piece is the use of targeted specific treatments like regenerative medicine in areas that have more advanced pathology that don't just get better with strengthening and alignment alone, although most do. I am I think the most qualified person and the really preeminent expert at the intersection of foot health and regenerative medicine. I've not come across anyone with my combination of foot health knowledge and experience and expertise in musculoskeletal ultrasound. ultrasound guided injections, and regenerative medicine expertise. There is no one that does what I do, how I do it. If you have persistent foot problems and you need platelet -rich plasma, you need MFAT, you need any host of regenerative or injection therapy techniques, I really think that I stand alone at a level of expertise that no one else can match. So please do not think that you're too far gone, everyone can be helped by this, even if something is not fully reversible, everyone can get better alignment, everyone can get better strength, you're not too old, it's not too severe. If you are tired of being told the same counterintuitive and antilogical things from your doctor who barely look at your feet and don't know how feet are supposed to work. Come see me and schedule a visit with me today. There are also lots of great online resources, including the Northwest Foot& Ankle website and YouTube, the Correcto's website and YouTube channel. There's an outfit that I like called Gate Happens, which puts out good content. There's another more broad fitness channel that I like called Strengthside. All these are good areas to explore yourself. So thank you for listening. There's a lot to unpack, but I feel like it's not enough just to say, hey, here's three simple tips to help your plantar fascia or to reverse your bunion. I rarely hear the foot health conversation framed in this specific way, so I wanted to kind of throw my two cents in there. Thank you for listening. Appreciate you. Stay tuned. We'll see you in the next episode. 

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