The Peter Attia Drive - #296 ‒ Foot health： preventing and treating common injuries, enhancing strength and mobility, picking footwear, and more

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:53.200 of a subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Courtney Conley.

00:01:07.080 Courtney is an internationally renowned foot and gait specialist who teaches globally on topics

00:01:12.340 related to foot function, gait mechanics, and strategies to combat foot and ankle pain.

00:01:17.460 She is the founder of Gait Happens, a group of clinicians providing high-quality online cutting-edge

00:01:23.180 foot education. She is also the owner and operator of Total Health Solutions Clinic

00:01:28.260 and gym in Golden, Colorado, where she heads patient care with a focus on restoring gait mechanics and

00:01:34.680 helping people resolve their foot problems. She holds a BA in kinesiology and a BA in human biology

00:01:40.720 and a doctorate in chiropractic medicine. In this episode, we speak about all things related to the

00:01:46.360 foot. We talk in great detail about the anatomy and complexity of the foot, and unfortunately,

00:01:51.200 you do need to understand this if you want to understand why things go wrong in the foot as

00:01:57.420 they so often do. Now, I should mention at this point that I know many of you listen to this podcast

00:02:02.360 in audio only, and that's fine. This, again, might be one of those episodes that is worth watching

00:02:08.480 on video. And the reason for that is that Courtney uses a model of the foot quite a bit when we're

00:02:15.180 talking about anatomy and even when we come back to some of the pathology of the foot,

00:02:18.700 because it's just easier to actually see, for example, why you end up getting a bunion if you

00:02:25.540 understand the biomechanics and anatomy of the foot. So with that said, we speak about loading,

00:02:32.260 balance, falls, control, range of motion, posture. We talk about the common injuries,

00:02:38.040 again, including what I just mentioned, bunions, tendon issues, toe weakness, Achilles injuries,

00:02:43.080 hammer toes, plantar fasciitis, and much more. Through this conversation, we do a deep dive

00:02:48.800 into all the various shoes that people should be looking at, not only as adults, but potentially

00:02:54.260 as children. In addition to this interview that you're about to hear, we also recorded a video

00:03:01.100 in the gym to better explain a number of the concepts that we spoke about. So in this video,

00:03:06.980 we break it down into diagnostic tests that are used to determine mobility, strength, etc. And

00:03:15.480 then we cover the exercises that you should do to improve the outcomes based on the diagnostics.

00:03:22.420 So this interview will be available to everyone. The videos from the gym will only be available to

00:03:27.380 our paid subscribers and they can be found on the show notes page. So without further delay,

00:03:32.040 please enjoy my conversation with Courtney Conley. Courtney, awesome to see you. Thank you for

00:03:42.680 making the trip to Austin. It's much better to be doing this in person, I think, than by

00:03:46.360 video, given all the content we're going to cover. Thank you so much. I'm very excited.

00:03:50.940 So before we kind of get into the foot, help me understand your personal obsession with this part

00:03:56.240 of the body. Where did that begin? I grew up as a ballet dancer and pretty much all through grade

00:04:01.800 school and high school. I spent a lot of time on my feet, a lot of time in ballet pointe shoes,

00:04:07.360 which, as you know, are very rigid, stiff, you're up on your toes. And I kind of always battled foot

00:04:12.660 pain. And then when I decided to choose this as a career, I was my self-exploration. I thought I was

00:04:20.020 going to learn all of this stuff about the foot. And that just didn't happen. Really didn't get a lot of

00:04:25.760 education in regards to how the foot actually functions.

00:04:29.340 Because you're a chiropractor by training. Why did you choose that over, say, podiatry or

00:04:33.460 something that was purely focused on the foot?

00:04:35.800 My father and I have had this conversation so many times. I first was going to go down the

00:04:39.380 physical therapy route. And then I was like, I want to create my own treatment protocols. And

00:04:44.920 my dad has always been a big fan of chiropractic. So we just had a lot of conversations and that's

00:04:49.080 where it went. I was always been interested in exercise and movement. It just seemed like a good fit.

00:04:54.480 So as you said, you go to school and you're probably not spending that much time on the

00:04:58.340 foot.

00:04:58.680 I think we had like half a semester. And I was fascinated.

00:05:01.560 That much?

00:05:02.120 Right?

00:05:02.520 That's actually a lot. I would have guessed less, but okay.

00:05:05.100 I just became fascinated by it because it just always intrigued me. It's a very complex part of

00:05:09.600 the body. And I think with our education, it was always viewed as if something hurts in the foot,

00:05:16.280 we're either going to put an orthotic under it or refer them for some type of surgery.

00:05:21.120 And I was blessed enough to have some really good mentors around me that increased my appetite

00:05:27.560 for learning about that. And that's kind of how it started. I ended up graduating from school

00:05:31.460 and working in a couple of orthotic labs.

00:05:34.440 I see. So you went straight from school directly into specializing effectively in the foot.

00:05:40.280 Yeah. It's changed a lot.

00:05:42.120 Yeah. So orthotic labs. So this is presumably a place where people come and have custom orthotics made.

00:05:47.260 Yes. So I would work in the front of these offices and there'd be grinders in the back and

00:05:53.340 they'd be making the orthotics. And so I was just constantly surrounded by all of that. And that's

00:05:58.380 what we knew is we'd see patients, they'd have foot pain and we would cast them for orthotics and make

00:06:03.740 the orthotics.

00:06:05.040 Interesting. So even when you came out of school, your knowledge and your practice was largely still

00:06:10.780 based on the conventional way of putting support under the foot, hoping for the best.

00:06:16.220 Yes.

00:06:17.000 All right. So with that background, we can evolve to where you are today, which is obviously leaps

00:06:21.900 and bounds ahead of that. But let's give folks a bit of a sense of the complexity of the foot.

00:06:26.200 I think most people look at their hands and because of our dexterity, I think people understand

00:06:32.840 the intricacies of the hand. I know once in a while when I'm trying to communicate that to a patient,

00:06:37.120 I'll even show them a picture of the homunculus, which is the image of the, I know you know what

00:06:42.040 this is, but just for the listener, the image of the cerebral cortex, where it graphically represents

00:06:47.420 the size of the anatomic features in proportion to how much motor and sensory control they have. And

00:06:53.500 one of our superpowers as a species is what we can do with these things. It differentiates us from

00:06:59.660 all other species. So how does the complexity of the foot fit into the equation of the human body?

00:07:07.120 Well, I think another one of our superpowers actually is that we're a biped. So we have

00:07:12.120 so many cutaneous receptors, muscle spindles, joint proprioceptors on and in our feet that

00:07:19.580 communicate with our vestibular system so we can become upright and bipedal. When you take away

00:07:26.540 those functions, it really alters how you're moving, how you're interacting with your environment.

00:07:32.600 I mean, it's always so wild to me because when we think about it from a rehabilitation perspective,

00:07:36.760 we are very good at rehabbing the low backs. We do a lot of core strength. We do a lot of glute

00:07:42.800 strength. We do a lot of hip strength, but you don't hear many people saying I'm doing a lot of

00:07:47.760 foot strength. And it's literally our first interface with the ground. It's how we contact the ground.

00:07:53.260 That's how everything starts. So when we take that away, you're really making it much more

00:07:59.660 challenging for yourself. And I think it really can alter our survival as well as decrease our

00:08:03.780 quality of life. Yeah. It's funny. You can probably tell looking around how obsessed I am with race

00:08:09.000 cars. And I've made this analogy before, but basically there were four things that determine

00:08:13.480 the speed of a car. Obvious things, the engine, the chassis, the aerodynamics, the stiffness,

00:08:18.060 the driver's capabilities, what they can do in the car, but of course the tires. And the analogy

00:08:24.460 here, of course, is clearly that the tires are the feet. And you can have the greatest car in the

00:08:29.420 world, the most powerful engine, the most remarkable chassis, and the best driver. If the tires are shot,

00:08:35.220 none of it matters. You simply can't get the power to the ground and back. So I think there's a lot to

00:08:40.760 be said for how it is imperative. In fact, I would even go one step further. I think feet are even a

00:08:48.040 more important part of the human body than tires are to the car. And here's the reason why.

00:08:52.860 As we'll discuss, the feet play a role in the suspension more than the tires play a role in

00:08:58.660 the suspension of a car. So when you now talk about force absorption, the feet are even more

00:09:04.280 of a priority. And if you can't absorb force in the feet, I think we're going to hear that

00:09:07.760 we're going to translate that inability to translate force all the way through the body.

00:09:11.980 Yeah. A good friend of mine, Jay DeCherry, he always says that you can't build a jet engine on a

00:09:15.880 paper airplane. And I just love that. We're building all of the strength and we're focusing

00:09:20.480 on everything above the knee. When in reality, so much of this force, I mean, gait is shock

00:09:26.720 absorption, it's stance ability, it's propulsion. And all of those things enable us to become

00:09:32.480 efficient with movement. Now we'll talk about a lot of this stuff when we get into the gym later

00:09:36.980 today and go through some of these things. But on a personal level, my interest in this

00:09:41.300 probably didn't start until a couple of years ago when I began to, for the very first time

00:09:47.360 in my life, experience pain in my feet that wasn't just fleeting. Obviously, like every

00:09:54.220 other knucklehead, I had the odd bout of plantar fasciitis in my youth that got better with traditional

00:10:00.040 means. But it was really only when my volume of rucking started to get really high and the

00:10:07.240 poundage started to get really high that I was starting to experience pains in my feet

00:10:13.300 that I now believe could be attributed to weakness. So Courtney, I think it would be much easier

00:10:19.300 for everyone to kind of understand the complexity of the foot if we had a better understanding of

00:10:24.720 the anatomy, myself included. So I noticed you brought your friend here. What's his name

00:10:28.760 again?

00:10:29.320 Eddie.

00:10:30.140 His name is Eddie Vedder.

00:10:32.220 Pro Jam is one of my favorites.

00:10:33.900 As we have both been to the same concert recently. Okay, so walk us through the anatomy of the foot.

00:10:40.000 So very important. I think especially when it comes to understanding how we're treating the foot

00:10:45.580 and foot pain to understand the anatomy of the foot. So there's basically three parts to the foot.

00:10:50.820 You have a rear foot, a mid foot, and a forefoot.

00:10:53.160 How many bones here?

00:10:54.520 26 bones, 33 joints. It's a complex part of our bodies. And I think that's why a lot of rehab

00:11:01.700 treatments and protocols have veered away from really understanding what's happening here.

00:11:08.180 So starting in the rear foot, the calcaneus, it's one of my favorite bones. And here's a fun fact.

00:11:13.540 A 100-pound female actually has a larger calcaneus than a 350-pound gorilla.

00:11:19.640 Wow.

00:11:20.440 Fun fact. Some other fun facts about this. The actual bone itself, there's two layers to the bone.

00:11:26.140 So there's a thin cortical layer, outer layer, and then there's a spongy inner layer. So the way

00:11:32.480 the calcaneus is actually designed, think of like a rubber ball bouncing. It was designed

00:11:38.560 to absorb shock. The other thing about the calcaneus is there's a fat pad that sits outside the

00:11:46.540 calcaneus. Also two chambers. So there's a thin micro chamber that is not easily deformable.

00:11:55.780 Because when we walk, most of us, as in a walking gait, we graze the heel. So that outer chamber is

00:12:02.780 not designed to deform. But there's a macro chamber on the inside of the fat pad that is highly

00:12:10.480 deformable. So again, we have a fat pad, and we have the way the bone has been designed to absorb

00:12:17.520 shock. That fat pad, by the way, is two times a better shock absorber than sorbithane. It's a

00:12:26.140 material. It's a synthetic material.

00:12:27.840 Like a rubber?

00:12:28.280 Mm-hmm. That a lot of performance orthotics, for example, are made of designed to dampen vibration

00:12:38.160 and absorb shock. And so when I'm talking to my patients, I'm like, we have a beautifully designed

00:12:44.120 calcaneus that was designed to handle all of this shock, to handle what happens when our heel strikes

00:12:50.640 the ground when we walk. So very important structure there.

00:12:55.600 Now the calcaneus looks like it interacts with another major bone there that sits right under

00:13:03.620 the fibula and the tibia.

00:13:05.720 The talus.

00:13:06.560 Yeah. One of the few I remember.

00:13:08.620 Yes. And fun fact about the talus, there is zero muscle attachment to that bone.

00:13:14.720 It's all ligaments.

00:13:16.000 Mm-hmm.

00:13:16.520 So there was a study, Ben O'Nigg, who's done a lot of research in our work, they looked at

00:13:21.380 sectioning the anterior talofibular ligament. So that's also a very common ligament when we

00:13:27.940 sprain our ankle. If those ligaments on the outside of the ankle get completely torn, you

00:13:35.240 now have this talus that has nothing attached to it. So what can happen is the talus can migrate,

00:13:43.720 it can adduct. So the tibia will internally rotate, the talus adducts, and then what happens

00:13:52.500 is it kind of bangs into the medial malleolus there. So patients will often present with pain

00:13:59.960 along the inside of their ankle, and it will be diagnosed as, say, a tendon dysfunction, posterior

00:14:05.920 tibialis, when it is an instability at the rear foot because that talus is shifting.

00:14:12.920 And would that patient have necessarily suffered something traumatic to have torn the AF ligament?

00:14:19.640 I mean, typically, when you look at ankle sprains, for example, mild ankle sprains over and over

00:14:25.980 again actually pose more of a problem from a gait perspective or a rehab perspective because people

00:14:32.520 will typically sprain their ankle, shake it off, and then continue to walk or play on it.

00:14:38.400 And in that situation, the ligament is just getting longer and longer and looser and looser.

00:14:44.360 And when you have these continuous sprains, you have changes to the ligament. But here's the cool

00:14:49.320 part. The ligament actually heals. More of what the issue is, is that the superficial peroneal nerve,

00:14:56.120 so the nerve on the outside of the foot.

00:14:57.900 Show where that would be here.

00:14:59.060 So that would come on the outside of the ankle. Those nerves get stretched. Sometimes those nerves

00:15:04.680 get torn. And once you start changing the neurological input, that's the issue. The ligament

00:15:12.220 will heal. It's when you lose the sensory input. Yes. So you're walking down a curb. You lose sensory

00:15:20.120 input and you say, oh. And there's no cue saying, don't do that anymore. And then you keep doing it

00:15:26.460 over and over again. I had a patient this week that had had multiple ankle sprains when he was a kid.

00:15:33.500 And the last couple of sprains that he had, he couldn't feel anything. And that's when they were

00:15:39.480 like, okay, we need to take care of this because he lost all sensory input.

00:15:44.200 I kind of wonder how much of that I have going on from all my frequent ankle sprains growing up,

00:15:48.800 but we'll probably figure that out when we do some of the interesting diagnostic stuff.

00:15:53.200 So what is that bone that the talus and the calcaneus look like they're both touching? Is that

00:16:00.420 the navicular? This is the navicular right on the inside. So this is the highest point of the medial

00:16:06.780 arch. And also an important bone here, posterior tibialis. So a very important inverter of the foot.

00:16:14.980 So it inverts the foot. It helps stabilizes the arch, comes down, wraps around the navicular and

00:16:21.900 inserts on the bottom of the navicular. It also has eight plus insertion points in the bottom of the

00:16:26.440 foot. I'm sure you've seen people that have an accessory navicular. So it's almost an extra bone

00:16:32.440 that sticks off that navicular. And you can see it when you're looking at someone, it looks like they

00:16:38.620 have a protrusion. Because the posterior tib has to come down and wrap around the navicular,

00:16:46.080 if you have an extra bone there, the vector of force is longer. So the way I'll describe this to my

00:16:53.760 patients is if you were doing a chest press, for example, and you starting here, imagine having

00:16:58.620 to start all the way back here. It'd be more difficult. So that's where with those patients,

00:17:03.980 when you see that, or you see that they have an arch that doesn't want to recoil or function,

00:17:10.440 you have to consider, hey, we really need to go after strengthening posterior tibialis and or

00:17:15.180 some of these patients, if there's too much of a structural variant, that's when you implement

00:17:21.060 things like an orthotic, for example. So is the navicular considered then part of the midfoot?

00:17:26.200 Midfoot. Is the calcaneus the only thing that makes up the posterior foot?

00:17:29.820 The rear foot. The rear foot. And those distinctions, I'll let you finish talking about

00:17:33.840 the forefoot, but presumably those distinctions are based on not just their location, but do they

00:17:39.680 have some functional significance? Yeah, I think when you look at the gait cycle.

00:17:44.100 So when we talk about the gait cycle, we look at different rockers of the foot.

00:17:48.300 So when we're initially walking and our heel strikes the ground, that rear foot, the calcaneus

00:17:55.760 starts or initiates pronation. So then we go into eversion and then you have the midfoot that unlocks.

00:18:02.100 And because we're going to use these words so much today, let's make sure people understand

00:18:06.080 eversion, pronation, supination of the foot. Absolutely.

00:18:10.060 Yeah. Just show us maybe with your hands.

00:18:11.420 So inversion would be going out. That's also a supination. Pronation is an unlocking of the

00:18:20.080 foot. So this is where the foot flattens and widens. And I think we've kind of demonized

00:18:26.220 pronation.

00:18:27.280 Definitely. And we'll talk, I know we're going to go through a couple of drills today that

00:18:30.420 you've had me doing to really work on relaxing the foot and letting it pronate without tensing

00:18:37.100 up. Eversion same. So the calcaneus, when you evert, it's basically allowing that pronation to

00:18:44.760 begin. And is that movement, all of those movements, are they facilitated by muscles or

00:18:52.640 are the ligaments themselves actually deforming? I think it's everything. When your heel hits the

00:18:58.840 ground, you have body weight, then you're dealing with ground reaction force. I think the beautiful

00:19:06.460 thing about gait is that we need to have adequate range of motion, but you also have to be able to

00:19:12.440 control that range of motion. And that's when things get sticky, is when we see people speeding

00:19:18.920 through the gait cycle or they're speeding through pronation and they can't control it. Then you have

00:19:24.200 this system going, slow down. And presumably that comes back to eccentric weakness?

00:19:30.080 I mean, certainly. If you look at, I'm sure we'll get into specific muscle talk, but there's a lot

00:19:38.400 of eccentric control that's required when our foot hits the ground.

00:19:42.880 All right. So three massive bones there we've covered. Massive, certainly on the scale of the foot.

00:19:48.500 Let's keep going down the path there.

00:19:50.600 I just want to talk about one more quick thing that I think is really cool.

00:19:53.620 This sustentaculum talli, it's a medial lip off the calcaneus. It's fully ossified by the time we're

00:20:02.120 seven years old. There was a research study, Raoul and Joseph looked at 2,300 children and they looked

00:20:09.480 at static footprints and how footwear affected the development of their medial arch, which I thought

00:20:18.300 that's a pretty large cohort for a study. So what they found is by the age of 13, these were kids

00:20:23.480 four to 13. By the age of 13, those who did not wear shoes, less than three of them, presented with what

00:20:32.000 they considered flat feet. The ones that wore shoes, 9% were considered having flat feet.

00:20:41.380 Sorry, 3% or 3 in total?

00:20:43.920 3%.

00:20:44.440 Okay, 3%.

00:20:45.200 So the ones that wore shoes, they also noticed the type of shoes. So the ones that wore closed

00:20:51.500 toe box shoes had a higher prevalence for, I always say with research, let it guide you,

00:20:57.600 not shackle you. So I thought it was interesting. So with the closed toe shoe, there was more of a

00:21:02.240 prevalence than even the kids that wore sandals. So why is that? You know, did they kick their shoes

00:21:07.180 off and run around barefoot? Did they have more toe splay? Was the foot able to function in a better

00:21:11.900 position? What the conclusion of the study was the researchers said that this sensory

00:21:17.140 information that was gained by their feet somehow gave them a protective tone, an increase in

00:21:25.760 protective muscular tone that was enabling their arch to elevate.

00:21:31.580 Now, how is that accomplished? Because I know that there's going to be many people listening to

00:21:35.700 this who are going to immediately want to think about their kids. The reality of it is most of our

00:21:40.340 kids are in school from a pretty young age, and therefore they have to kind of be in shoes.

00:21:45.440 You live in Colorado. It's not like you're going to send your kid to school in sandals in the middle

00:21:48.620 of the winter. So do you get a sense of the time requirement being out of shoes? If indeed there's

00:21:56.800 causality between time away from shoes and improved foot health at a young age?

00:22:02.620 I think we have the opportunity with the kids. I mean, when they're at home, just take their shoes

00:22:08.720 off. Different sand, grass. I mean, this doesn't have to be all the time, but even just a little bit.

00:22:13.880 I mean, every kid on the planet, the first thing they do is take their shoes and socks off

00:22:17.880 because they're wanting to gain that sensory input. So I think even a little bit can go a

00:22:23.620 very long way. And then we'll get into footwear because that's a big one for the kids.

00:22:26.680 Yep. We definitely want to talk about that for both kids and adults.

00:22:29.260 Totally. And then getting back to the development of this guy, the sustentaculum teli. So if we know

00:22:35.460 that it ossifies by age seven, and we have this window where we know that between these ages,

00:22:42.400 three, four, five, six, that the arch is developing, and we can start to allow sensory input and start

00:22:50.280 to begin muscle strength, the way he develops, there's a little lip. You see how it lips up?

00:22:55.680 So it positions the talus almost with a lateral tilt. So it's very important from a bony architecture

00:23:03.520 perspective on how stable that foot is. There are cases where this will develop in a downward slope,

00:23:10.200 and then you predispose, you could predispose for some type of flat foot deformity in the future.

00:23:17.780 Okay. Carry on.

00:23:18.660 So that's the rear foot, midfoot, if you will. Moving into the forefoot. The forefoot is where

00:23:25.280 we will see most of our injuries because when we're walking, there's eight times our body weight

00:23:32.500 that go through the forefoot with propulsion. That is so hard to fathom.

00:23:38.640 Well, how about some other numbers here? Your Achilles tendon is about four times your body weight when you walk.

00:23:44.340 Meaning it experiences four times your body weight with each step?

00:23:49.360 With force, yes.

00:23:51.300 And the Achilles is the tendon of only the gastroc or the gastroc and the soleus?

00:23:58.640 Gastroc and soleus.

00:24:00.180 Okay. We should just also clarify, I'm sure many people know this, but when we are referring to

00:24:05.500 tendons, we're talking about the attachments of muscles to bones. Earlier, we referred to ligaments,

00:24:11.620 which are the attachments between bones. So folks understand that. And the Achilles tendon,

00:24:16.500 which everybody is familiar with, is obviously a massive tendon. I mean, I've seen the size of

00:24:22.100 these things when they're injured, when they're severed. I don't know where it ranks in tendon

00:24:26.640 size for the body, but it is certainly one of the largest, I would have to believe.

00:24:31.020 I love talking about the Achilles tendon. It's beautiful. I mean, you have the gastroc and

00:24:35.320 the soleus. They twist on each other. It can become a very robust tendon. And the soleus actually

00:24:41.440 makes up larger fibers of the Achilles tendon than the gastroc. The soleus is a powerhouse.

00:24:47.280 But getting back to that load, when we're walking four times, when you start running,

00:24:52.740 those numbers double. So the inside of the arch, so the calcaneo navicular area,

00:24:59.740 experiences loads of up to 11 times your body weight when you're running. I mean, it's massive.

00:25:05.200 But here's the very cool thing is our foot was designed to handle it. I mean, we have

00:25:09.120 all bone structure, muscle, tendon that was designed to handle that load. The problem is,

00:25:15.220 is if you don't use it, you will lose it. It's interesting. You said that the majority

00:25:19.360 of foot injuries are going to occur in the forefoot. Now, by my math, there's about, what, 15 in the

00:25:25.520 forefoot? Lots of bones in the forefoot. Yeah. Metatarsals, phalanx, distal phalanx, proximal

00:25:31.580 phalanx. Ah, distal and proximal there. Yeah. Except for the big toe. Yeah. Okay. Eight times

00:25:36.420 our body weight at propulsion. The forefoot has to be incredibly stable at push-off because it

00:25:44.300 handles so much load. So when we're walking, for example, one of the most common injuries at the

00:25:51.140 forefoot will be a generic diagnosis of metatarsalgia or stress fractures. So two and three

00:25:58.600 typically will be your metatarsalgia area. And one being the big toe. One is the big toe. Five being

00:26:04.920 the pinky toe. Yeah. We'll get to that favorite guy right there. Three and four typically your,

00:26:10.620 where you'll see a lot of stress fractures. Tell people what a stress fracture is.

00:26:14.700 A stress fracture basically can be caused by two different things. Tensile strain or compressive

00:26:21.580 loading. It's when you have force going through the bone and the system just can't handle it. So

00:26:27.760 it starts to irritate the tissue, if you will. When you look at the foot, and I think this is

00:26:33.240 important from a rehab perspective, is depending upon where the fracture is, you'll know what type

00:26:40.740 of stress fracture it is. So for example, if you have patients that are hitting their heel

00:26:45.980 very hot and heavy, so they might have a rigid foot, they might have one that doesn't have good

00:26:51.200 mobility, and they hit the heel heavy, they can get a stress fracture in the calcaneus.

00:26:58.620 The fifth metatarsal, also very common location for these compressive loading stress fractures because

00:27:05.800 they can't handle that compression. But on the other side of the foot, remember we talked about

00:27:12.260 the navicular? That guy technically should never hit the ground. It's the highest part of the medial

00:27:18.240 arch, but he can get a stress fracture. So you're saying to yourself, well, how is that possible? If

00:27:23.320 they're caused by compressive loading, not that guy. He's caused by tensile strain. When you can't

00:27:30.440 handle the foot pronating and rotating, and you can't handle the movement of the foot,

00:27:37.820 the tendon will start to tug, and you'll start to get that strain at the navicular stress reaction

00:27:43.660 leading to stress fracture. So interesting. We think about bones as having this great capacity for

00:27:50.120 contractile force, right? So axial loading, we don't think of them as requiring as much tensile force,

00:27:56.380 but of course they're under tremendous tensile force in the opposite. We think of our skeleton as

00:28:01.480 needed to support compressive load, but of course they have to do both, which actually is a pretty

00:28:07.680 remarkable material. Like concrete, for example, is only strong under compression. It's so weak under

00:28:13.960 tension. I think I mentioned this once before in the podcast, without rebar, concrete would be useless.

00:28:19.380 Yet our bones have to do both. So you're saying that you can tell, I mean, not to oversimplify,

00:28:26.880 but lateral injuries are likely to be more compressive. Medial injuries might be more

00:28:31.580 likely to be tensile. And again, I don't know that that matters necessarily other than it explains

00:28:36.480 what caused the injury. Yes, but also with treatment, because when you look at compressive

00:28:44.020 loaded stress fracture, so at the heel, at the fifth metatarsal, you have to cushion those. Obviously,

00:28:50.000 let the tissue heal, but that person might need something that's going to give a little bit.

00:28:55.660 The navicular stress fractures, the metatarsal stress fractures, the sesamoid stress fractures,

00:29:02.960 because they happened due to an instability, to a tensile strain, you can boot them,

00:29:11.620 but your follow-up with them better be rehabbing the strength of their foot because it's not that

00:29:16.980 they landed too heavy. It's because they couldn't control their motion. That's why people with

00:29:22.620 sesamoid injuries, for example. So the sesamoids are the two little bones under the big toe.

00:29:28.520 They're similar to the patella.

00:29:31.200 Sesamoid refers to, if I recall, a bone that is completely surrounded by tendon.

00:29:36.160 Yes. It's like a little joint capsule.

00:29:38.400 Yep. Nothing is exposed of the bone. It's completely embedded within the tendons, correct?

00:29:42.640 Yes.

00:29:42.860 Yep.

00:29:43.360 When you get those stress fractures there, they can be extremely painful and people stop using

00:29:49.240 the big toe, which I'm sure we'll talk about. But if you offload it, these people will be in

00:29:54.140 boots for three months and they'll say, okay, the bone's healed. Go back to your activity. It

00:30:00.000 doesn't work like that.

00:30:01.120 Because even though the bone is healed, the muscles are now even weaker. You are more susceptible to

00:30:06.700 the injury because you've lost whatever strength you once had there.

00:30:10.740 Yeah. How did it happen in the first place?

00:30:12.920 Okay. So let's talk a little bit about the muscles in the foot as well, because it is a very muscular

00:30:21.520 structure. We don't think of it that way because we look at it and we can sort of see the bones

00:30:25.960 through the skin. But especially on the bottom, the musculature is incredibly complicated and

00:30:33.040 it is really related to what's happening in the lower leg as well.

00:30:37.780 Oh yeah. Well, I think when we talk about muscles of the foot, we can talk about intrinsic muscles

00:30:42.700 versus extrinsic. So intrinsic muscles, they live in the foot. They start and they end in the foot.

00:30:48.780 We have four layers of muscles there.

00:30:51.040 It's just unbelievable.

00:30:51.980 It is. And I think the beautiful thing about the foot is you can look at the foot. It's the

00:30:58.080 only place in the body where you can look at it and say, something is going awry here because

00:31:06.140 you'll form things like bunions and hammer toes and tailor's bunions. And you'll be able to look

00:31:12.920 at your foot and go, this isn't the way it's supposed to look. Maybe I should pay attention to it.

00:31:17.260 You can't do that in a knee or hip unless you take an x-ray.

00:31:19.620 Okay. And when you can get your hands on a foot where you start to see these deformities and

00:31:24.400 they're flexible, you really think about it from a muscular imbalance. So if we wanted to look at

00:31:30.180 some of the intrinsic muscles of the foot. So if we were to start with the big one, abductor

00:31:35.360 halisis. So he sits along the big toe and he's responsible for straightening the big toe.

00:31:41.720 And I think the other thing that will be helpful when we go through this is every medical student and

00:31:46.160 whatnot has to learn what an adductor versus an abductor is. And since they're always embedded

00:31:50.980 within the names of the muscles, we always remembered this as abductors abduct. They

00:31:55.900 take things away. Like a person's being abducted, they pull away from the body basically. Yes.

00:32:01.180 Adductor pulls back towards the body. So with that said, hopefully people will have an easier time

00:32:07.080 remembering some of these terms. So we have our forefoot here. Here's the big toe. So abductor

00:32:14.220 halisis is going to straighten the big toe. There's also a muscle. Pulls it to the middle. Pulls it

00:32:21.060 towards the middle. Yep. There's an adductor halisis. It's kind of like a backwards seven.

00:32:26.740 So when these guys get out of balance, for example, if I'm in a shoe, which we'll talk about later,

00:32:36.080 that's going to squeeze my toes together. Such as your ballet shoes. Yes. Or most dress shoes. Yep.

00:32:43.200 I have adductor now that's shortened and I have abductor. It's lengthened. It's lengthened.

00:32:49.340 So you start to get this imbalance at the foot and then you start to see changes in the foot.

00:32:57.880 Bunions are a result of an instability in the foot. Yeah. What exactly is a bunion? Everybody's

00:33:02.940 heard of them. A lot of people have them. It's a transverse instability, not where you see the bunion

00:33:10.000 here at the metatarsal medial cuneiform. When someone can't control motion at the foot,

00:33:19.340 sort of the junction between the midfoot and the forefoot. Correct. Then they will start to

00:33:24.820 have this instability. All a bunion is, by the way, is this bone basically shifting to the outside.

00:33:31.420 Yeah. So anybody who's seen it, what you notice is you're looking down at a person's foot and you'll

00:33:36.480 see this huge out pouching in what's otherwise the widest part of the foot. It looks like it just

00:33:42.760 got a whole bunch wider and it's pointing out. But when you see the skeleton, it's much easier to

00:33:47.420 understand why that's happening. Yeah. So it's this guy going that way.

00:33:51.060 A lot of people have these surgically repaired. What are they doing surgically to repair that?

00:33:56.300 We could talk about this for a long time. Just some facts first with those surgeries.

00:34:01.820 A lot of them are not successful. There is a time and a place, but I would be very cautious

00:34:06.600 about getting foot surgeries for symptoms. So what they'll do is they can either shave part of the

00:34:15.640 bone down and then realign the toe. And oftentimes they will pin the metatarsal to the cuneiform.

00:34:24.000 So they stabilize where most people have that instability. Once you start pinning things

00:34:30.000 together, you might take care of alignment. But you've done nothing to strengthen the muscle

00:34:35.760 that allowed this to get there. Correct. The conversation of my mom has a bunion,

00:34:40.460 my grandma has a bunion. And my response to that is you don't come out of the womb

00:34:44.020 with a bunion. You might inherit connective tissue laxity, for example, or there might be

00:34:48.900 hypermobility issues. But if we know that, just like we talked about with the kids earlier,

00:34:53.980 the earlier interventions, you get them in the right footwear, you make sure they're in

00:34:57.900 shoes, right? That have a toe box where the toes can actually splay, especially if you know that

00:35:06.460 your mother has a bunion. I think what's fascinating about the big toe is if you look

00:35:10.340 at your nail bed, some people that have bunions, the nail bed will be flat and it'll just look like

00:35:17.600 it's adducting. Here's the bunion. Oh, I see what you mean. Yep.

00:35:22.800 But the nail bed is flat. When you see that, it's typically from footwear. When you see the nail bed

00:35:32.660 and it's actually rotated, because you see some of those people, right, where the nail bed's kind

00:35:36.440 of turned in and there's a, it looks like it's a rotational issue. You know, for certain they

00:35:40.840 can't control rotation, which is cool because now you're like, okay. One of the reasons I got into

00:35:45.780 all of this was I have bilateral bunions on both of my feet due to the fact that I was constantly in

00:35:52.860 pointe shoes. And then my solution to that was I'm just going to start bracing my feet because they

00:35:58.040 hurt. So they just got weaker and weaker. And then I was like, this is not right. So we started

00:36:05.000 strengthening them, getting us in the right shoes and it's different ballgame. And what's a hammer

00:36:09.600 toe while we're at the topic of common pathology? Yes. So bunion, very common. Hammer toes are

00:36:15.260 basically when the toes start to hammer the ground. All of them are just two through five.

00:36:20.700 Two through five. The big toe can't hammer. It's just not as common as two through five.

00:36:24.480 This is why when you look at hammer toes, so this would be the top of my foot. We have

00:36:31.760 extensors, short toe extensors, but we also have long toe extensors. So on the top of the foot,

00:36:39.660 the short toe extensors are doing a lot of work and the long toe extensors are not.

00:36:45.380 Yeah. This is one of those things where if you're listening to us, this is very difficult to understand.

00:36:49.960 It's why watching what you're saying makes a lot of sense. And again, just so folks understand

00:36:54.500 the extensors would be pulling back, the flexors would curl forward. And so it seems counterintuitive

00:37:02.820 to say, how can a hammer toe be in part driven by this extensor phenomenon? Well, if the short

00:37:09.860 extensors, the ones that attach with a shorter moment arm are fired up and the long ones are relaxed,

00:37:17.640 it actually looks like a hyperflexion. Yes. And for people who have pain along the bottom of their

00:37:23.840 foot, so along their metatarsals, if you take out your insert of your shoe and you see a lot of wear

00:37:31.520 underneath the second or third metatarsal, you know, you're probably walking around with too much

00:37:38.220 pressure going through there. So on the bottom of the foot, it's the exact opposite. I have my short

00:37:45.540 flexors that aren't doing anything in my long flexors who are. So hammer toes is a muscle imbalance

00:37:54.960 due to a weakness in the foot. And what do you attribute the root of that to? If the bunion

00:38:01.680 seems predisposed, not putting aside genetics and other things like that, but just environmentally,

00:38:07.480 if the predisposing feature of a bunion is shoes that are pushing the big toe in, what is the

00:38:15.380 environmental trigger that is most commonly driving a hammer toe? I think it's the same thing. I think

00:38:21.380 that we have not been paying attention to our feet for a very long period of time. And if you were to walk

00:38:29.180 around with your hands in mittens for 20 years, you shouldn't be surprised when your hands don't

00:38:36.480 function. It's the same concept at the foot, really, that it is everywhere else in the body. I think we

00:38:42.640 just don't think about it. Well, it's not even mittens, right? If you really think about it, for most people,

00:38:46.240 if you think back to being a kid, like you could still move your fingers in mittens. It's actually

00:38:50.760 mittens that don't allow you to move your fingers. That's the better analogy. And yeah, if you were to

00:38:57.000 spend 12 hours a day in that situation, it would be obviously cumbersome. So let's go back to the

00:39:04.720 intrinsic musculature of the foot. I know we're going to talk more about intrinsic and extrinsic

00:39:10.100 foot stabilizers when we get into the gym. There's a couple key muscles. I think they're

00:39:15.780 all key, but we don't have time to go into all of them, but that are responsible for a lot of our

00:39:21.920 foot function. So for example, flexor digitorum brevis is one of my favorites. So this guy runs

00:39:28.620 from the heel and inserts up into the phalanx, so into the toes. It's a big muscle. It runs parallel

00:39:36.180 to the plantar fascia. He's responsible for decelerating toe extension when we walk. Remember,

00:39:42.800 it's all about slowing things down. We want to control it. If I don't have good strength of that

00:39:49.220 muscle, he shares load, if you will, with the plantar fascia. So one of the biggest predictors

00:39:56.080 for patients that have plantar fasciitis, so this would be an acute plantar fascial pain,

00:40:02.800 is a weakness of flexor digitorum brevis. When you look at treatment protocols on how to get people

00:40:09.760 better with plantar fasciitis, it's like stretching their calves. And I'm not saying that's bad,

00:40:14.300 but you also have to look at the strength and the stability at the foot. And he is a very big player,

00:40:20.100 very big player in the stability of the foot in decelerating pronation.

00:40:26.140 You just referred to plantar fasciitis. We talked about it a second ago. It's clearly something many

00:40:30.780 people listening will understand. They will also probably have a ballpark sense of what it feels

00:40:35.780 like and how there's a real tenderness in the arch. But can you explain the anatomic structures that

00:40:40.560 make up the plantar fascia? So the plantar fascia is going to start at the calcaneus and it's going

00:40:46.620 to insert into the deep transverse metatarsal ligament up at the forefoot. The plantar fascia

00:40:55.180 has a very key role, by the way, in stability of the foot. I'm going to explain something called a

00:41:01.480 tie bar mechanism. So the tie bar mechanism of the foot is this, I like to call it free because

00:41:08.020 we need to take advantage of it, where we have a ligament that runs across the metatarsals.

00:41:14.280 When our foot, when we're walking and we go into mid-foot loading, so when all the pressure comes

00:41:21.680 and our arch starts to flatten and widen, when the forefoot splays, it triggers receptors in that

00:41:30.980 deep transverse metatarsal ligament. The plantar fascia inserts into that ligament. So it's kind

00:41:39.120 of like this T. So when the foot splays, it triggers this mechanism of horizontal stability

00:41:47.820 as well as vertical stability.

00:41:51.340 Because the plantar fascia, like a triangle at the forefoot, now begins to spread under tension

00:41:57.480 while it's also being elongated vertically.

00:42:00.120 It's like a fan. So that's the beautiful thing about forefoot splay is it's this free mechanism

00:42:05.580 that's basically telling our brains, hey, you're about to push off. You better get real strong and

00:42:11.080 you better get real stable because we're about to take on eight times your body weight. Gets me excited.

00:42:17.320 You take that away, you take away forefoot splay, you can forget about the receptors talking to you

00:42:23.680 because you're not getting the tug on them from the deep transverse metatarsal ligament,

00:42:27.940 the splay, and you're also not signaling the plantar fascia.

00:42:32.200 What would oppose that? How much compression needs to be on the foot,

00:42:36.020 presumably in the form of a narrow shoe, that would prevent sufficient splaying

00:42:41.180 to activate the plantar fascia in that regard?

00:42:45.300 There's numbers out there. You say three to five millimeters. I don't expect people to get out

00:42:49.500 and start measuring this, but a good way to look at this is if you were to take out the factory

00:42:54.940 insert of your shoe and you place your foot on it and then stand on top of the factory insert.

00:43:02.020 If your forefoot expands over...

00:43:05.520 Wider than the insert.

00:43:06.860 Wider than the insert.

00:43:08.080 It's too narrow.

00:43:08.820 You can be pretty certain that those toes are getting squeezed.

00:43:12.660 That's a great rule of thumb. I would bet that many of my shoes

00:43:18.000 don't pass that test.

00:43:20.800 Is it safe to say that it might be tolerable if it's a fashion shoe you're wearing,

00:43:26.720 but you certainly wouldn't want that in an athletic shoe where you're

00:43:30.200 running or rucking or doing something under load?

00:43:33.520 I mean...

00:43:34.020 You would argue never be in a shoe of that nature, but...

00:43:36.760 My daughter is 12, so she always tells me,

00:43:39.900 Mom, why do you make me wear these platypus shoes? Everybody else gets the word Nikes.

00:43:42.880 I get it. But yes, I mean, the more time we can spend allowing our foot to be in a position where

00:43:49.060 it can function like it's supposed to, the better off we're going to be.

00:43:52.440 It's very interesting though, Courtney, because I mean, this is not conspiratorial, but there's

00:43:57.280 clearly nothing in the shoe industry that is aligned with that. I mean, shoes are not typically

00:44:02.680 designed to have that degree of width, are they?

00:44:06.420 No, they're not. And what's interesting, Nike just came out with a baby shoe. This was a couple months

00:44:12.940 ago. And in their report of the shoe, they said, we've done the research. This shoe will help your

00:44:21.140 child's development of their foot.

00:44:23.660 When you say baby shoe, what age...

00:44:25.660 Toddler. First start walking.

00:44:27.820 Okay. Technically, you would argue maybe they shouldn't be in shoes at all though, right?

00:44:31.400 Right.

00:44:31.520 At that age. I mean, they don't need to be if they're walking. Most of their walking is

00:44:34.620 not outdoors, but okay.

00:44:37.080 In the article, they said, we've done the research and we've created a shoe that has a wide toe box,

00:44:43.620 a flexible, thin sole, because we want your child's foot to do what it was designed to do. And I'm

00:44:49.080 sitting there going, yes, like, but why...

00:44:51.540 Why would you not carry that through to adulthood?

00:44:53.640 Exactly. But they're starting to realize it. And I think when you look at research from a shoe

00:44:59.240 perspective, at the end of the day, we want something comfortable on our feet.

00:45:03.220 And I would argue that every single one of my patients, once I simply put them in a shoe

00:45:08.640 that allows their toes to splay, they will always say, it feels more comfortable.

00:45:14.820 And you think about it from balance. Are you going to balance better like this?

00:45:18.260 Are you going to balance better like that? It's just not a hard sell.

00:45:21.520 So, plantar fasciitis. Itis, of course, refers to inflammation of the plantar fascia.

00:45:28.440 What are the most common causes of it? And how do you think about treating it in the acute sense?

00:45:36.620 So, somebody shows up for the first time and they've got it. What are your thoughts on the

00:45:40.780 differential diagnosis for what led to it? And how do you go about rehabbing it with an eye towards

00:45:45.100 preventing it in the future?

00:45:46.500 First, you have to make sure that's what it is. There's a differential diagnosis of heel pain. I mean,

00:45:50.860 you have to rule out calcaneal stress fractures, for example. There's Baxter's neuropathy. So,

00:45:56.040 people will have Googled and they'll just immediately say, I have plantar fasciitis. So,

00:46:00.960 first and foremost, you just have to be certain that's what it is.

00:46:03.720 And it's a clinical diagnosis. It's not like you've got an imaging study that confirms it.

00:46:09.340 You have to sort of exclude other things, as you said.

00:46:11.800 Yeah. And you can see a thickening of the plantar fascia.

00:46:14.640 Okay. Although rarely, I assume that's done, correct? You're not likely going to put somebody

00:46:18.940 in an MRI for that.

00:46:20.260 No. And we'll talk about imaging later with all that. But there's a difference between an

00:46:24.300 itis, plantar fasciitis, and plantar fasciopathy, or fasciosis, I should say.

00:46:30.460 By the time most people get into my office, it's no longer in an acute stage. Because in an acute stage,

00:46:37.940 this is your initial injury. So, it is treated very differently. Orthotics often can help in those

00:46:45.460 initial stages of an acute injury because you are offloading.

00:46:50.440 Let's just explain to people again. I'm sorry I'm all over the place, but the anatomy here is so

00:46:54.460 complicated that I think it helps to talk about pathology to explain it. The reason an orthotic

00:46:59.980 can be acutely helpful is because it prevents the full collapse of the arch. Therefore, it takes

00:47:07.300 some of the stretch off the plantar fascia. Is that why?

00:47:10.300 Yeah. And when you talk about what exactly an orthotic does, the jury's still out on that.

00:47:14.880 But we know it has something to do with force. So, when the foot starts to unlock, it's a load

00:47:22.560 modifier. An orthotic is a load modifier. So, it's going to modify the load that's occurring at the

00:47:28.800 heel. So, in an acute situation, that's great. But if I had a penny for every time one of my

00:47:36.480 patients came in with their orthotics that they got 20 years ago for their plantar fasciitis,

00:47:44.340 I mean, I'd be a rich woman because they're like, well, it helped acutely. But research will say two

00:47:51.320 weeks and at the most up to a year. And then it's time to get out of those things. There has to be an

00:47:56.660 exit strategy. And while you're planning this exit strategy, you need to be strengthening the foot.

00:48:03.740 You have to be strengthening things like flexor digitorum brevis to be able to share the load

00:48:09.720 with the plantar fascia. So, in an acute setting, they're treated very differently.

00:48:15.160 When it's more of a chronic heel pain, this is degenerative. This is repetitive load.

00:48:22.400 They've been walking around on a foot that can't handle load. Then the tissue starts to break down.

00:48:27.820 And in those cases, for me, it is all strength. It's load. It's not deload.

00:48:34.940 Even for a period of time?

00:48:36.780 I mean, I tend not to go that route. And we have conversations. I mean, there's a lot of education

00:48:43.980 that goes behind this. Irene Davis, who I know you know, she's-

00:48:47.260 I've had Irene on the podcast, yeah.

00:48:48.660 Her and Sarah Ridge are looking at research right now where they're looking at patients with chronic

00:48:53.600 heel pain, so chronic plantar fasciosis, at implementing minimal footwear in getting these

00:49:00.900 patients and seeing what happens with them. If you think of the plantar fascia as a connection

00:49:06.500 to the Achilles tendon-

00:49:08.600 And it is connected, I assume.

00:49:10.060 Yes. The calcaneus, think of it like floats in between the plantar fascia and the Achilles

00:49:15.780 tendon. We know that tendons need load. So, think about that from the plantar fascia perspective.

00:49:23.600 You have to load it. You have to load the tissue in order for the tissue to get stronger.

00:49:31.220 And is the load also necessary to heal the tissue, assuming it's not cut?

00:49:36.440 Yeah. I mean, if we wanted to jump into loading with tendons, it's not that anybody who's had a

00:49:43.720 tendinopathy, we always say rest is not good for tendons. It's not that rest is bad. You talk to

00:49:48.980 anybody who's had an Achilles tendinopathy, if they rest for a week, they're like, yeah, it feels great.

00:49:52.680 The problem is that when they go to return to sport or they go to return to walk without having

00:50:00.480 loaded the tendon, they're going to be right back where they started from. So, when we talk about

00:50:05.800 loading the tendons, it's a mechanotransduction. So, when I load a tendon, there's a fascial gliding

00:50:14.400 that occurs. So, this mechanical stimulus that then gets converted to a chemical stimulus.

00:50:22.400 And then we start to see tendon healing.

00:50:26.560 So, in that sense, it's very similar to bones.

00:50:28.980 Yeah.

00:50:29.240 I mean, we've talked a lot about this on the podcast where the most important thing for

00:50:34.220 strengthening bones is force on the bone. And that's why weight training and grappling,

00:50:39.780 believe it or not, are the two best exercises for bone density because they put the most stress

00:50:46.120 on the bone, both compressive and tensile. And the mechanoreceptors in the bones, which sense

00:50:52.880 the deformation, use estrogen as the chemical signal to signal bone building. It's, of course,

00:50:59.840 why estrogen is arguably the most important hormone here. So, it's the same thing. It sounds

00:51:04.300 like in tendons, presumably different chemical transduction systems, but it's mechanical deformation

00:51:10.600 signals a chemical to build.

00:51:13.600 Yeah. There's the tenocytes that kind of live within the fascicles of the tendon.

00:51:17.740 Exactly what you just said. This mechanical gliding kind of shears the cells. You get a chemical

00:51:24.020 stimulus and then you start to get the changes within the tendon, which I think is really fascinating.

00:51:31.120 So, let's go back to the person who shows up. So, you've excluded other things. You've diagnosed

00:51:36.160 them with, indeed, plantar fasciitis. What are the most typical reasons for that presentation

00:51:42.740 in, let's start within a young person, a young active person?

00:51:47.180 Weakness to the foot for certain.

00:51:49.100 And when you say weakness, specifically within which muscles, which are the prime examples of

00:51:54.980 the muscular? So, when they come in, I'll always, I have a toe dynamometer. So, it's this little device.

00:52:00.600 Did you bring it today?

00:52:01.400 I did.

00:52:01.900 Okay, good. I've always wanted to try one of these.

00:52:03.580 Yes.

00:52:04.060 I'm embarrassed to find out where I stack up, but we'll see.

00:52:06.800 It tests the strength of your toes. So, it's a little device. You put a card underneath your big toe.

00:52:12.740 And I'll have the patient press their big toe into the card. You should be able to produce 10%

00:52:21.280 of your body weight through your big toe. That's flexor hallisus longus. When you put the card

00:52:29.060 underneath two through five, you should be able to produce about seven to eight percent of your body

00:52:38.460 weight. When they're pressing their toes down, there's a couple rules. They can't lift up their

00:52:46.360 heel and they can't hammer the toes. Remember we talked about that hammering? That's when you'll see

00:52:53.240 people who love to hammer their toes because it's a compensation for weakness in the foot.

00:53:00.280 So, that's how they walk. It's like I'm clawing my way forward. So, when they do that, they have to

00:53:05.900 press their toes down.

00:53:08.440 When you do the big toe, the extensor hallisus longus, are toes two through five, do they need

00:53:14.720 to be off the ground or are they on the ground, just not hammered?

00:53:17.480 On the ground, not hammered.

00:53:18.820 But you're pressing down 10% of body weight. You know me, Courtney. I love metrics, right? Because

00:53:24.600 what gets measured gets managed. Is this something anybody can go out and do or you can buy these?

00:53:30.260 Oh, yeah. You can buy them. I think the other thing that's also easy to measure for if someone's

00:53:35.020 going to do it at home is I have a little laser scanning device. I also brought this today where

00:53:39.900 you would stand close to a wall and you'd measure from your umbilicus to the wall. Then you keep

00:53:47.920 your body straight so your hips and shoulders are straight and you lean into the wall as far as you

00:53:53.300 can. It's your toe strength that stops you from smacking your face into the wall. That distance

00:54:00.380 should be 4.5 inches or more.

00:54:04.280 Got it. So, in other words, we could do the trigonometry on that, but basically there's an

00:54:09.240 angle at which you're creating a moment arm that you need to be able to resist.

00:54:13.880 Correct. It's called the anterior fall envelope.

00:54:16.880 Cool.

00:54:17.360 We'll test all these on you today.

00:54:19.100 Oh, boy.

00:54:20.260 But it's really fascinating, right? Toe weakness, by the way, is the single biggest predictor of

00:54:25.980 falls when we age.

00:54:27.420 Really?

00:54:28.400 So, this is really cool. When you think about falling, it typically occurs, we're jumping all

00:54:34.360 over the place, by the way, here. It's the initiation of gait. So, if I don't have that anterior

00:54:41.200 fall envelope, if my toes are weak, I'm going to keep going. And so, not only can toe weakness be a

00:54:48.600 predictor of things like plantar fasciitis fasciosis, but also toe weakness can be, and it is, researched

00:54:55.780 by Karen Merkel, one of the single best predictors of falling, which is, I mean, massive.

00:55:04.440 Yeah. I mean, I think we should spend a few minutes on that in a moment because, obviously,

00:55:08.240 people who listen to this podcast are no strangers to the importance of fall prevention.

00:55:12.140 We have talked about it typically through the lens of bone density and muscle mass. So,

00:55:17.420 low bone density, low muscle mass lead to more catastrophic outcomes during falls. Obviously,

00:55:23.840 the muscle mass is also a great way to help prevent falling, but this is a very specific

00:55:28.320 muscle mass. So, athletic person shows up or active person shows up, you've diagnosed the problem,

00:55:35.400 you have a culpable reason for it in weakness. You've already alluded to the fact which says,

00:55:40.560 look, I'm probably not going to rest you. What drives you towards temporary orthotic versus no

00:55:48.720 orthotic and just get right to work? So, when I've had plantar fasciitis, we've never done an

00:55:52.460 orthotic. I've probably had two bouts of it in my life. It's just been a bit of backing off some of

00:55:59.100 the volume, some manual therapy, ice, and more footwork. What's your typical strategy?

00:56:06.960 It's very individual specific. You definitely have to meet the patient where they are. What

00:56:12.140 is their activity level? What are they willing to do? What age are they? Are they going to do this

00:56:16.640 stuff? From a passive perspective, I do like shockwave into the bottom of the foot. Medial gastroc,

00:56:24.820 the way the medial gastroc inserts into the Achilles tendon. So, we talked about the gastroc. There's

00:56:30.500 two muscle bellies. The medial gastroc sits on the inside and how it attaches into the Achilles tendon

00:56:36.780 will prevent ankle dorsiflexion. Tell people what dorsiflexion is. So, ankle dorsiflexion is

00:56:43.620 basically this motion. When I am walking. Pulling the toes back, basically. Yes. Pulling the foot

00:56:50.180 back. Yes. Yeah. And plantar flexion just for. Point the toes. The other way. Yep. Point the toes,

00:56:55.540 extend the foot. That ankle dorsiflexion, in a walking gait cycle, we need about 10 to 15 degrees.

00:57:01.500 You'd be surprised how people like to cheat the system there. So, when we get to medial gastroc,

00:57:08.520 we look and see how is their ankle mobility? Is it something I need to address? How is their foot

00:57:13.760 strength? Is it something I need to address? And then how is their capacity? I always say it's never

00:57:19.140 just a foot problem. I wish it was. It would make it easier for me anyway. But when I'm watching

00:57:24.620 someone walk, walking is this internal rotation when our foot hits the ground. So, I don't want

00:57:32.560 the plantar fascia to be down there like a dishrag. So, not only am I assessing what's happening at the

00:57:38.220 foot, but I'm looking at the knee. I'm looking at the hip. Who's driving the car? How well can my

00:57:45.140 glute max, for example, control the rotation, control my pronation so that is that having an

00:57:51.120 effect on the structures of the foot? So, when I look at those cases, especially with chronic heel

00:57:56.840 pain, it's never just a foot thing. I have to carry it up into the rest of the chain.

00:58:02.120 As you've sort of alluded to, the plantar fascia, because it's so long,

00:58:05.500 you can really have that pain in many different places. The real estate on the bottom of the foot

00:58:10.680 that is susceptible to inflammation or irritation of the plantar fascia is pretty long. Is it typically

00:58:17.700 more posterior and close to the heel? Most of the fibers that were more commonly irritated are

00:58:23.540 that medial. There's different branches of it, if you will. So, most patients will get that pain

00:58:29.880 at the heel, maybe more on the inside of the heel. And it can be pretty classic where it's really

00:58:36.080 painful in the morning. And then as they walk on it, it gets better. That can change its face a

00:58:42.300 little bit, depending upon how chronic it gets. Wow. So, it's a lot more complicated. But I mean,

00:58:47.820 it seems to me that all roads keep pointing back to the plantar fasciitis is a canary in the coal

00:58:53.980 mine that your feet are weak. Yes. That tie bar mechanism that we spoke of, that free mechanism

00:59:00.140 of the vertical and horizontal stability that we have at the foot. Take advantage of that. Allow

00:59:06.420 the foot and the toes to splay and do a couple foot strengthening exercises. And it doesn't have

00:59:12.780 to be difficult. Yeah. And we're going to give people a lot of those exercises to do when we go

00:59:17.860 to that section in the gym. Let's talk a little bit about the extrinsic stabilizers of the foot.

00:59:23.360 Obviously, as their name implies, these are muscles that originate out of the foot,

00:59:28.260 but presumably have tendinous attachments within the foot.

00:59:31.960 Yes. So, you have the medial aspect and you have the lateral aspect and then you have the

00:59:36.740 posterior aspect. So, if we were to start with posterior, and we've talked about that a little

00:59:41.860 bit already. Right. Gastroc soleus communicating through the Achilles tendon down around the calcaneus

00:59:48.260 and attaching right through the plantar fascia to the forefoot. Yes. Very big guys here. The soleus is

00:59:54.120 the largest muscle of the lower leg. He is the one that produces a lot of that force at the forefoot

01:00:02.380 when we walk. And if I'm not mistaken, the soleus has more type one fibers than the gastroc.

01:00:08.940 Slow twitch. Yeah. So, it's really the workhorse that can keep going and going and going. Maybe not

01:00:14.800 generate as much force as the gastroc, but far more endurance. It's the powerhouse of the lower leg.

01:00:20.940 It does create a lot of force at the forefoot. It's also very important in the prevention of

01:00:28.900 ACL injuries, which I think is... Counterintuitive, given that it's below the knee.

01:00:34.060 I mean, when you look at any ACL protocol, it's always hamstrings, biceps femoris,

01:00:39.980 all medial hamstrings, strengthen, strengthen, strengthen. But the research will look at and has

01:00:46.260 shown that it's the strength of the soleus that prevents tibial progression.

01:00:53.840 I see. And if you can resist the tibia moving forward, you prevent the stretch on the ACL in that

01:01:01.660 hit. Interesting. Never thought of that. It's fascinating. I know you and I have talked about

01:01:06.820 this before, but if we look at capacity of the soleus, there are numbers out there that in a seated

01:01:13.460 calf raise. So when you're seated, the gastroc is not your big player. Immobilized. Yeah.

01:01:20.320 So you're focusing on soleus. Those numbers, 1.5 times your body weight.

01:01:26.600 For a single leg calf raise. You realize I still haven't been able to do this.

01:01:30.680 I want people to understand how difficult that is. Because when you told me that, I was like,

01:01:34.880 that is insane. You need a Smith machine to do the test. I don't have a Smith machine. So I was at a

01:01:39.980 friend's house who had a Smith machine and I set up the apparatus. I actually had to download,

01:01:44.700 I was luckily, I had my phone. I was able to download the paper you sent that walked through

01:01:48.360 the protocol. And you're doing a single leg calf raise where one foot is doing all the work.

01:01:55.080 Obviously the other one is not. You've got a lot of padding on top of the lower femur so that you can

01:01:59.640 load the bar from the Smith machine directly over the tibia and fibula. I think it was six reps you had

01:02:05.280 to do, if I'm not mistaken, at 1.5 times your body weight. And I think I got up to 1.3 times my

01:02:11.720 body weight. And I was like, is there any way a human could do 1.5 times their body weight? And

01:02:17.940 clearly there is, but I was blown away at how difficult that was. I generally pride myself in

01:02:24.780 being able to do the metrics that are considered minimum metrics of human performance. This was a fail.

01:02:32.040 It's shocking to me. It's one of the biggest assessments we will do with our patients because

01:02:38.760 I want a baseline. I want to know where we are. I mean, we have ultra runners, athletes. I mean,

01:02:43.400 they'll come in there and it's like, wow. Oh, I've had many people do this test. Everybody's failed

01:02:48.620 it and they fail it miserably. Yeah. And so Kyler Brown, who's talked to me about that because he

01:02:53.760 works with some of the best athletes. I mean, he's pointed this out as I think you have, which is

01:02:58.400 sometimes the better an athlete you are, the better you are at cheating. I'm not suggesting

01:03:02.820 that that's of my issue, but I'm saying like a lot of these times you'll see really good athletes

01:03:06.140 who can do amazing things and yet they have very poor calf strength and you can't understand how

01:03:10.700 that's the case. So how is that the case? I know we're jumping around. I want to come back to the

01:03:14.760 extrinsic stabilizers, but again, this is such a fascinating topic when I see people who can run and

01:03:19.980 jump and do superhuman things, but when you isolate the soleus, it's not even able to move their body

01:03:26.720 weight. They are the very good cheaters. They find a way, but eventually, eventually something's

01:03:33.960 got to give. And whether that's going to be today with the athlete, or it's going to be 10 years down

01:03:39.760 the road, when you are not using your plantar flexors, and I'm talking in a walking gait cycle,

01:03:45.300 when that strength capacity isn't there, it's going to rear its head at some point.

01:03:49.180 And you might be a fast runner, but imagine if you started to actually strengthen the muscles

01:03:56.900 that made you fast. Some of the best marathon runners in the world have the longest Achilles

01:04:02.020 tendons. We have the spring of the tendon. We have these gastroc and soleus that can isometrically

01:04:07.680 contract very strong and then transfer this force. I mean, the strength of the lower leg

01:04:14.280 is so powerful. To be able to take advantage of that, we have to do it.

01:04:19.380 All right. So we'll obviously go through some of those things. You mentioned now a lateral and a

01:04:24.600 medial set of muscles. What are those large muscles as well? They seem to cause a lot of pain.

01:04:29.080 Yes. Let's talk about lateral ankle stability. Peroneals are the big boys on the outside. So

01:04:33.920 peroneus brevis is going to insert on the fifth metatarsal, okay? Powerful everter of the foot.

01:04:40.680 So that's going to take us from this position towards the big toe. Peroneus longus, also on

01:04:48.300 the outside, wraps underneath the foot and inserts on the medial aspect of the foot.

01:04:55.200 Okay. So down on the outside of the foot, around and under to the medial.

01:05:00.340 To the big toe.

01:05:01.040 Yeah. So when it contracts, it flattens the arch.

01:05:04.240 When peroneus longus contracts, this is what...

01:05:06.680 What he does is he's going to evert the foot. And most importantly, this is why the peroneals

01:05:16.040 are a very big stabilizer of your big toe.

01:05:19.580 Which is counterintuitive because they're on the opposite side of the foot.

01:05:22.200 Yes. So when peroneus longus, this is the one that goes underneath the foot.

01:05:27.680 When he's doing his job, we call it dropping the head of the first metatarsal.

01:05:32.320 So basically what that means is it takes that bone, the metatarsal, and it anchors him to the floor

01:05:38.260 so that we have a stable position at push-off.

01:05:43.360 Yeah. So one of my favorite exercises is putting a band, like an elastic, under huge tension on the

01:05:51.380 floor, pulling medially such that the only part of myself I let contact the floor is the base of

01:05:57.960 the big toe. Yes. And then doing single leg balance drills. So that's actually strengthening

01:06:02.800 outer leg. Yes. Very important. When patients have ankle sprains, for example, remember we're

01:06:11.640 losing sensation, right? We have a sensory loss, if you will. You can have dysfunction of your peroneals.

01:06:18.340 When I'm walking, because peroneus longus drops that first metatarsal down, he's anchoring my big

01:06:26.780 toe to the ground. If he's not doing his job, this guy will stay elevated. So he'll stay lifted a little

01:06:34.660 bit. So now when I'm walking, I don't have this stability at my first ray. And so I'm either going

01:06:41.340 to go to my outside again, which means there's my another ankle sprain, or people will complain of a

01:06:47.420 pinching on the top of the big toe. So there's a difference between a bunion. So this is when it

01:06:56.640 goes into this direction, it comes out versus people will see a bump on the top of the toe.

01:07:03.720 Those are two different animals. So if I'm walking and I don't have that first metatarsal dropping,

01:07:10.200 when my big toe tries to extend, it doesn't have this nice like rolling glide. It kind of jams

01:07:18.340 first. And then you get this irritation on the dorsum aspect of the toe and it'll get red and it'll

01:07:25.140 get irritated. And it's what we would term a functional hallux limitus. So a restriction of

01:07:31.600 motion at the big toe. And it all stems because there is not enough muscular force from,

01:07:40.200 the lateral musculature of the foot, the perineals to bring the toe down, the base of the toe down.

01:07:48.340 I mean, in my opinion, unless there's been trauma, like you've dropped a weight on your toe or you've

01:07:52.440 had turf toe or things like that, where there's been an accelerated inflammatory response, then yes,

01:07:58.340 it is a dysfunction at that first ray, which is often caused by a weak foot. This is a common theme

01:08:05.860 here. Instability of the outside of the ankle, ankle sprains. And if those movement patterns are not

01:08:12.460 restored and regained, then you start to have this arthritic change at the big toe. And that is not

01:08:20.680 fun for anybody. It will alter gait. It will alter movement. So the big meaty muscle on the outer part

01:08:29.700 of your shin is the tibialis anterior? Correct. And does it attach, it must go down around the

01:08:36.800 lateral malleolus as well? It's on the front of the lateral malleolus, correct? Tibial anterior comes

01:08:41.600 down and then tibial anterior tendon, you'll see it more on the medial aspect of the foot. It's a

01:08:47.680 dorsiflexor of the foot. Biggest dorsiflexor, right? Yeah. Okay. So we were just talking lateral

01:08:53.620 compartment. You were going around the house. Yep. So now we're in the front of the lower leg.

01:08:57.940 So this is where tibialis anterior and all of your extensors live. So they extend the toes.

01:09:04.980 Sorry to interrupt. And maybe you were just about to address this. Why do we have toe extensors out

01:09:10.720 of the foot? When you're walking, we always talk about with gait, what's happening in stance phase.

01:09:18.140 So there's stance phase when the foot is on the ground and then swing phase when the foot's in the

01:09:22.280 air. And the reason why a lot of us give so much attention to stance phase is because that's where all

01:09:26.460 the magic happens, right? All the load. But swing phase, when we're walking, you have to clear

01:09:33.420 the ground. So when I'm assessing gait, I will often close my eyes and listen because you'll hear

01:09:41.080 the scuff, as I like to call it, where they can't clear the ground. These will be your runners that

01:09:48.440 come in and tell you, man, I keep tripping over. When I'm running, I keep tripping over rocks. I'm like,

01:09:52.300 are you really tripping over rocks or what's happening here? Because if those tissues can't

01:09:58.320 extend the toes and extend the foot, when they're running or walking, they'll scuff the ground

01:10:05.420 and you can hear it. So they're responsible for a clearance and swing phase. But then also

01:10:13.340 at heel strike, here's that eccentric component. When my heel strikes the ground, here's my extensors.

01:10:21.560 They have to be very strong eccentrically because they're going to decelerate my foot hitting the

01:10:29.800 ground. So again, I'll close my eyes and I'll listen because if they don't have good control

01:10:36.200 of those pre-tibial muscles, tibialis anterior and your extensors, it's like an elephant's walking

01:10:43.040 down the hallway because it's foot slap after foot slap. These patients will tell you they have shin

01:10:49.620 splints. They have medial tibial stress syndrome because they just can't handle the repetitive

01:10:57.260 motion of their foot slapping the ground without control of those muscles.

01:11:01.320 Very interesting. Okay. So we've got these three pockets of extrinsic stabilizers, the intrinsics.

01:11:11.040 Let's talk a little bit more about the common pathology that you see. So we've talked about

01:11:15.060 a handful of them already. What are the most common pathologies you see due to the anterior

01:11:21.460 and lateral compartment? We missed the medial aspect too.

01:11:26.320 Oh, let's go back to that.

01:11:27.360 From the big boy and the medial aspect is where you'll see a lot of injuries is posterior tibialis.

01:11:32.980 So posterior tibialis, like I mentioned earlier, comes down along the medial aspect of the foot and

01:11:37.580 it's a very big stabilizer of the inside of the foot. And it's sort of, as I'm feeling my own

01:11:44.160 leg under the table here, it's very difficult to disentangle it from the gastroc, the medial head

01:11:49.180 of the gastroc, isn't it? They seem very close to each other. If you were to put your foot on your

01:11:54.980 knee, point your toe and bring the sole of your foot towards the ceiling, you'll see a tendon that

01:12:03.100 kind of pops up along the medial aspect of the foot. That's post-tib.

01:12:07.320 Yeah. And that's the one that when we get into the gym, we're going to work on that exercise of

01:12:13.720 relaxing the post-tib while we allow the arch to descend.

01:12:18.560 Yeah. I mean, posterior tibialis decelerates pronation. Fun fact, if you look at EMG activity

01:12:27.000 and call it what you will, some people don't love EMG activity just because there's a lot of

01:12:31.060 crossover. But posterior tib, you will see activation from that guy from the second the

01:12:36.580 foot's on the ground until propulsion. He's one of the only tissues, muscles, where you'll see this

01:12:42.440 constant activation. And therefore, we need to pay attention. Because of its attachment, it rotates.

01:12:48.760 So that tendon has a 45 degree rotation before it inserts. So when we talk about those energy

01:12:54.920 storage tendons of the Achilles and the post-tib, very, very important for free energy and propulsion.

01:13:04.200 And because of how it attaches, it has to be trained in those planes, in rotational or transverse planes.

01:13:11.720 Let's go back to pathology there. What else do you see?

01:13:14.760 So I think probably the most common diagnoses that we will see, we've discussed one of them already,

01:13:20.940 is heel pain. So plantar fasciopathy. Lots of tendinopathies. So your Achilles tendinopathies

01:13:27.360 and your posterior tibialis tendinopathies. We know that these tissues need movement. We know

01:13:33.360 that these tissues need load. And I think it's important to understand, it's not that we want

01:13:37.800 necessarily, yes, we want strong calves, but from a tendon perspective, we want a tendon that is healthy,

01:13:44.440 which means you have to load it. And that goes for both the Achilles as well as post-tib,

01:13:49.480 as well as your peroneal. I mean, many people have peroneal tendinitis as well.

01:13:56.600 Interesting. Is that predisposed by lots of ankle sprains?

01:13:59.500 It can be.

01:14:00.020 Or is that more a function of just weakness in the musculature?

01:14:03.040 I think there's a lot of factors you have to look at. Do they have the integrity of the musculature?

01:14:08.800 Have they had a history of ankle sprains that have just never been rehabilitated appropriately?

01:14:13.220 But think of the post-tib and the peroneus longus as like a sling. It's this beautiful sling that

01:14:20.220 stabilizes the foot and they work together. And when you have one side that's not helping out the

01:14:26.540 other side, you can start to have these changes within the foot.

01:14:30.940 So you alluded to imaging earlier. How often does imaging play a role in your diagnoses? Do you

01:14:39.860 tend to rely mostly on the clinical history, the physical exam? What fraction of the time do you

01:14:46.460 rely on imaging?

01:14:47.860 I think the biggest time and the most important time at the foot, especially with imaging,

01:14:53.100 is ruling out stress fractures, especially when you're dealing with runners and things like that.

01:14:58.800 But as far as everything else, I mean, if you look at research on doing MRIs, for example,

01:15:05.560 for tendinopathies and Achilles, it really doesn't give you all that much information that's valuable

01:15:11.040 because you can see a tendon on an image and it'll be like, wow, what's going on here? And it doesn't

01:15:16.560 correlate with subjective or even...

01:15:19.000 So it's not that different from the back where the MRI, you image a lot of people that feel nothing

01:15:24.260 and you'll see horrible looking backs. You image a lot of people who feel fine and you could the

01:15:28.800 reverse. So stress fractures make sense. MRI probably better or CT. What's the diagnostic test

01:15:36.040 of choice for a stress fracture?

01:15:37.780 I mean, I like diagnostic ultrasound.

01:15:40.720 Really?

01:15:41.000 I think it can be more accurate. But yeah, the MRI, I just, I rarely will order that just

01:15:47.540 because it doesn't really give me the information that I'm looking for.

01:15:50.480 Interesting. Let's go back to the Achilles. I don't know what it is in my old age that has

01:15:57.240 made me so paranoid of an Achilles injury. I've had one bout of tendinopathy there that took,

01:16:05.140 God, probably like three months to really resolve. Now in that three months, I didn't really have

01:16:10.480 to do anything different. I mean, I just did a lot of training, but I would wake up every day in

01:16:17.400 quite a bit of pain. It got better as the day went on, but it was uncomfortable. But I had this huge

01:16:22.840 panic that at some point I was going to tear it doing some of the jumping exercises I do and things

01:16:28.480 like that. And how much of that is, I never want to say the inevitability of age, but how much of that

01:16:33.940 is due to tissue pliability of aging as an additional predisposing factor? Clearly, there's a load

01:16:41.240 component to this, right? There has to be some insult. Well, first, let me say, consider yourself

01:16:47.360 lucky at three months. These tendinopathies at the Achilles, if you look at research, I mean, you're

01:16:53.160 talking years, five years, 10 years, where people will still experience symptom at their Achilles

01:17:00.700 tendon. So a lot of my work in talking to patients with Achilles tendinopathy is just that. It's the

01:17:07.820 education part of it. Because most people are afraid that they're going to rupture their Achilles

01:17:13.900 tendon. And I have to remind them, it is one of the most robust tendons that we have. There's less of a

01:17:20.520 chance of you rupturing it, but you have to be aware that discomfort is probably going to stick

01:17:27.460 around for a lot longer than you want it to. So when we are rehabbing these, if they wake up in

01:17:34.220 the morning, that's a lot of the times where you'll feel that tendon stiffness. I tell them, if we're

01:17:39.080 sitting at like a, and I'm not a big fan of VAS scales, I don't like to focus on how bad people are

01:17:43.520 feeling, but for that measure, if they're sitting at like a five out of 10, for example, that's green light

01:17:49.860 for us. That is not rest. That is not stop. That is still go. Yeah. And in fairness, I was never above

01:17:57.360 a five out of 10, but I'm a guy who's lived at a zero out of 10 in his Achilles. I've had a lot of

01:18:02.760 pain in a lot of other parts of my body, but to wake up and every day be at a five out of 10, we're just

01:18:08.940 walking to the bathroom. I'm like, good Lord. Yeah. I mean, that was very frightening from the

01:18:16.000 standpoint of, is this a harbinger of a catastrophic injury? There's really three different types of

01:18:24.480 an Achilles tendinopathy or injury. And I think that's important to note because they all are

01:18:29.460 looked at very differently. So most, when people talk about an Achilles tendinopathy, it's at the

01:18:35.500 mid tendon portion. So if you were to squeeze your Achilles tendon, kind of right in that mid portion,

01:18:41.900 those are typically the easier ones. And by easy, I still don't mean easy, but easier ones to treat.

01:18:50.680 Then you have an insertional Achilles tendinopathy where that irritation is at the calcaneus. So right

01:18:58.020 where it inserts, those can be extremely difficult because with those, the Achilles tendon breaks down

01:19:07.400 on the front of the tendon. We know that tendons need load. So for those guys, you have to make sure

01:19:16.700 when you're doing your calf work, for example, that you're getting as high onto your toes, end range

01:19:22.580 plantar flexion, so that you can start to load that appropriately. Those guys don't like to be

01:19:27.820 stretched all that much. So there's different things that you do based on the location of where

01:19:34.840 that tendinopathy occurs. And sorry, in that case, you would really minimize any dorsiflexion.

01:19:39.860 Mild. You wouldn't go on a super deep dorsiflex. Yeah, like off the stair. Yeah. Everybody loves to do

01:19:46.260 off the stair stuff. And I'm like, can you do it without? How does your form look without going into

01:19:51.720 a negative? Because when you drop that heel down into a negative, if you don't have good midfoot

01:19:56.660 stability and the whole thing just looks sloppy, I'm like, that's game over for me. And let's again,

01:20:01.020 I want to come back to reinforce these terms. Midfoot stability. We've talked about what the

01:20:06.200 midfoot is anatomically. Now explain in exactly that setting, because that's a very common movement,

01:20:11.660 which is, hey, I want to do a negative when I'm doing a toe press of some sort. What needs to be

01:20:18.260 true of the midfoot for a person to be able to do that? Going back to the anatomic structures

01:20:22.640 we've already discussed. When you are looking at someone from the back, okay, and if I was looking at

01:20:28.680 them with their heels off the back of a step, as they go into that negative, if they can maintain

01:20:35.720 the integrity of their foot. So in other words, when they drop the heel down, I don't want to see

01:20:41.540 this collapse or this excessive medial drive where the whole foot just looks like it can't even hold

01:20:50.660 itself up. Presumably those are more intrinsic failures or are they potentially also extrinsic?

01:20:57.260 It could be a bunch of things, right? Could be everything down to the ligaments.

01:20:59.960 If they have poor ankle dorsiflexion mobility. So if they can't dorsiflex here, they're going to

01:21:08.820 steal it. Mm-hmm. What's the minimum angle of dorsiflexion you need to be a functional human who

01:21:15.060 can walk? Walking gait, we need about 10 degrees. Running? Running, you need a little bit more.

01:21:22.500 But if you think about when I'm training someone, I don't want to train minimum degrees, right? So I

01:21:29.920 want to give people movement variability. The more movement variability someone has,

01:21:35.840 the less oh no moments we have. So we have to be able to give people movement options.

01:21:44.060 I have assessments that we'll do and I'll say, okay, we're at 10 degrees. And it's actually really

01:21:48.820 cool. You can just use your iPhone. Because it has a built-in. Right. There's like utilities and

01:21:52.900 it goes to measure. And I'll measure their dorsiflexion. I like to see about 35 degrees.

01:21:57.620 Wow. You'd be shocked at what people give you. And they'll say, well, I only need 10 degrees in

01:22:05.140 order to walk. Well, do you sit in a chair? Do you walk up and down a stair? Because if you do any of

01:22:10.960 those other motions, you have to be able to have ankle dorsiflexion. And ankle dorsiflexion is a

01:22:17.020 huge lack of range in the foot. And there's three big compensations that you will see for people that

01:22:24.680 don't do that. The first is when they're walking, they'll lift their heel up early. So it's an early

01:22:31.460 heel rise. Now, remember what we talked about with eight times your body weight going through your

01:22:36.700 forefoot? Do I want to increase that load? No. Do I want to speed it up? No. So problem number one

01:22:43.100 there. Next, what people will do is they'll hyperextend their knee. So it's called a varus

01:22:49.860 thrust gait. So because they can't dorsiflex, the knee goes, well, let me help you. Let me hyperextend

01:22:58.980 to propel you forward. So these patients will come in and tell you, my knee feels wonky. The back of my

01:23:06.340 knee feels unstable. And you have to look at the ankle because it could be feeding why they're

01:23:12.060 doing it. That hyperextension at their knee could be the reason. How do these people find you?

01:23:17.380 Because your fame is through treating the foot. Are they finding their way to you because they're

01:23:22.480 hearing you on a podcast talking about just that? Or are there other practitioners that are aware

01:23:28.020 enough to recognize knee pain and say, actually, your knee pain is a compensation for your gait?

01:23:33.560 I've been teaching these courses now for a while. And I think a lot of the referrals now are coming

01:23:39.460 from other physicians, other PTs, other doctors. I work with a couple clinics in Colorado. It's been

01:23:47.260 really awesome to see the medical community really starting. I mean, we've had patients will have hip

01:23:53.920 replacements. And the feedback on the other end of this sometimes is you don't need to retrain your

01:24:00.920 gate. And now we're getting a lot of these referrals and going, yes, you do. These are all

01:24:06.260 things you need to pay attention to. So the word is spreading about the importance of what happens at

01:24:12.020 the foot and how that can affect pretty much everything else.

01:24:14.860 Got it. Okay. So we were back to the compensations for weak dorsiflexion.

01:24:18.460 Yeah. So we have early heel rise. We have a hyperextension at the knee. And then the third

01:24:25.120 strategy... Is that collapse, right?

01:24:28.140 Yes. But if we're moving up the chain, the third one that people will do is they'll simply fall

01:24:34.340 forward. They'll bend forward at their hips. They'll use forward momentum to carry them forward.

01:24:41.380 So now they're in your office with low back pain. It's a direct reason because they cannot

01:24:46.660 dorsiflex their ankle. I'm still a bit confused by this. When an individual comes in and let's say

01:24:53.320 you make the diagnosis and the diagnosis is that their range of motion on dorsiflexion is

01:24:58.180 insufficient. They're at eight degrees or even 10 degrees, which we've acknowledged is kind of the

01:25:02.560 bare minimum for walking. What is preventing that person from being at 20 or 30 degrees? Is there

01:25:08.840 something within the bone or is it neurologic where their body doesn't trust itself enough to

01:25:16.080 appreciate a greater angle?

01:25:18.320 When you are assessing pretty much any joint, you want to see consistent patterns. So if we were to

01:25:26.080 take this with a squat, for example, when people try to deep squat, if they can't do it, so they'll go

01:25:33.880 down and do a deep squat and they'll be like, I just can't go any further. And I'll say, well, why is

01:25:38.420 that? Say, well, it's my hip or my ankle. My ankles just feel stiff. And I'll say, okay, I want you to go

01:25:45.660 over to my squat rack and you're going to hold on to the squat rack. And I want you to deep squat

01:25:51.640 again. If they still can't do it, then I know that there's got to be some type of muscle or joint

01:25:59.600 restriction that's preventing them from getting to that range. So that could be muscles that have

01:26:07.520 shortened. We might need to implement stretching protocols. We might have to implement joint

01:26:14.820 mobilizations down at the ankle. Remember the talus. If he kind of floats forward, you can get a

01:26:21.720 pinching. So there can be a pinching in the front of the ankle when people try to stretch. All of those

01:26:27.500 things would be a consistent pattern because there's a muscle or joint restriction. But if they can't

01:26:34.740 squat, but they can go into a deep squat. And I would argue, Peter, most people, as soon as they

01:26:44.120 hold on to something, they go down into this beautiful squat. And that's when you're saying

01:26:49.580 to yourself, there is a neurological inhibition here. This person is screaming for stability.

01:26:54.920 And that's when we're wasting a bunch of time going, I want you to stretch your calves for the next 30

01:26:59.740 years and you're not going to see anything because that's not what they need. And then it comes down

01:27:04.000 to proximal stability. How do we create stability? How do we create a safe environment for their brain

01:27:10.460 and their body so that they want to go into a deep squat because they need to go into a deep squat?

01:27:16.120 Yeah. I mean, I've shared this story before and it's worth sharing again, which is that when a person

01:27:22.720 is under anesthesia, they can be stretched into positions that they would never imagine if they're not

01:27:29.540 under anesthesia. And you might say, well, okay, so what? But they're probably going to get hurt,

01:27:34.260 but they don't. You can take a person who can't touch their toes. And again, when they're under

01:27:38.920 anesthesia, you could almost fold them in half. You could get their palms past their toes. And when

01:27:44.400 they wake up from anesthesia, they will not have torn a hamstring. And you ask the question,

01:27:48.460 how is that possible? And it's possible because neurologically they are being inhibited from doing

01:27:54.940 that because the body says you are not stable in that position. I'll give you an example one more

01:27:59.800 time. I had a guy that once, when I first was learning this, I was in a lot of back pain and I

01:28:05.080 was so stiff, I couldn't touch my toes. And he took me through a 30 minute exercise of increasing

01:28:10.720 intra-abdominal pressure. And within 30 minutes, the entire palm was past my toes. Did I get more

01:28:17.420 flexible in 30 minutes? Of course not. But by generating high degrees of intra-abdominal pressure,

01:28:23.920 my back relaxed enough that it allowed my body to move to that spot. This to me is one of the most

01:28:31.060 difficult things to both identify, but more importantly, to be able to train. Because in a

01:28:37.480 way, it is a light switch. The circuit has to be grooved a lot for that to become the new default. So

01:28:43.640 how do you go about doing that given A, it's ubiquity and B, it's complexity?

01:28:50.140 I think that assessing patients for proximal stability is mandatory. It's absolutely mandatory.

01:28:58.780 And I'm a foot person. If I'm far away from where we consider proximal stability and creating

01:29:04.100 intra-abdominal pressure. But if you were to look at someone, I'm always going to take this down to

01:29:10.740 the foot. If you think of your pelvis as like a bowl of water, if I were to stand and dump out all

01:29:16.860 the water, all right, you have a forward tilt to the pelvis. That also can happen when the rib cage

01:29:23.620 would flare. Okay. And we call it an open scissor posture. So when I'm assessing these patients,

01:29:30.040 I'm looking at, can they stack their rib cage over their pelvis? Do they have good breathing patterns?

01:29:37.480 Can they breathe 360 degrees around their belly? Can they expand their rib cage? Because if they

01:29:46.380 cannot do those things and they stay in this posture, if you were to stand up and dump all the

01:29:54.360 water out, tell me what would happen to your feet. Because I'll tell you, you will feel all of this medial

01:30:02.620 pressure along your big toes. You'll feel your arches collapse, if you will.

01:30:09.420 And this is where pronation gets a bad name.

01:30:11.800 Yes. In genuvalgum. Everybody's in, don't let your knees knock. I'm like, tell that to a hockey

01:30:17.020 goalie who stands there for three periods in a valgus position at the knee. I don't believe there's any

01:30:23.260 bad posture positions. It's only bad if you can't control it and you can't get out of it.

01:30:28.520 You have to be able to do these things. I have to be able to protract my shoulder. I have to be able

01:30:34.760 to arch my back. You just better control it and be able to get in and out of it.

01:30:40.440 Yeah. I think this is worth maybe double clicking on a bit, Courtney, because A, it's not a conventional

01:30:45.360 view. It's not a mainstream PT view and I'm not throwing PT under the bus. It's not a mainstream

01:30:50.840 anybody view. And yet I've heard it enough from the people who I think are hands down the best at

01:30:58.980 movement that we should reiterate the point. There isn't a bad posture per se, but control is what

01:31:07.020 matters. And you could argue that the best movers on the planet frequently engage in what would be

01:31:14.740 viewed as quote unquote bad posture. Yes. I mean, I don't think we were all designed to look like

01:31:22.260 these robots and be in these like perfect postural positions. It's just not realistic. I'm just

01:31:27.900 thinking of golf. My father was a big golfer and we used to watch Arnold Palmer swing a lot. And if

01:31:33.080 you've ever watched Arnold Palmer swing, you'd be like, how's this guy so good? Being able to create

01:31:38.320 this stability to your system and to be able to control these different postural positions is key.

01:31:44.980 It's key to be able to get in and out of. And if you think about that at the foot,

01:31:49.240 it's not that pronation is bad. We have to do it. It's our first opportunity for shock absorption.

01:31:56.440 When we walk, we have to be able to then get out of it. Yeah. And the person most commonly who is in

01:32:04.480 the open scissor pattern, they're stuck in that position. They aren't able to get out of it. And

01:32:10.600 therefore they're equally ineffective at shock absorption. Yes. And there's this disconnect,

01:32:15.600 Peter. It's when I have patients stand in front of me, I'll have them tilt their pelvis forward

01:32:20.220 and I'll ask them, what do you feel at your feet? Half the time I'm like, nothing. There's this

01:32:27.100 disconnect between my pelvic motion and what my foot should be doing. When my pelvis dumps forward,

01:32:33.280 you should feel the feet drop. When you tuck the pelvis back, you should feel the arches lift.

01:32:40.000 And that's this motion, this dynamic motion that the foot is capable of doing.

01:32:46.480 You said something earlier when we were speaking about how our proprioception and sensory

01:32:52.560 appreciation of the universe changes as we age. Now that I'm over 50, what's changed in my

01:32:59.720 sensory apparatus of the foot? We talked earlier about how falls are prevalent and how there's

01:33:06.760 really factors that contribute to these falls. We know one, we've talked about this as a weakness

01:33:13.100 in toe strength. That changes. And I think the numbers are like a 35% decline in strength.

01:33:19.940 Over what period of time? I'm not sure. Between presumably something young and something old.

01:33:25.360 Correct. And especially there's a very big change when you look at the jump from 50 to 80,

01:33:31.880 for example. So we're looking at the 35% decline right in those ranges. So not only does strength

01:33:38.780 decrease, but we have four different types of receptors, a couple of fast adapting and some

01:33:46.460 slow adapting receptors. They're responsible for gaining information so that we can maintain our

01:33:53.640 center of mass, for example. As we get older, so let's start at age 50, you lose 20%. It takes 20%

01:34:03.380 more pressure to stimulate these receptors. Now versus when I was 20.

01:34:09.840 Correct. So as we age, the sensitivity of the receptors decreases. Now here's where it gets a little

01:34:16.680 scary. When we go from 50 to 85, at 85, we now have 75% decreased sensitivity to these receptors.

01:34:29.200 That's a lot. What's driving that?

01:34:30.760 I think it is a lack of strength at the foot because here's the good news. Exercise, we know,

01:34:38.640 increases circulation to the sensory nerves. If we exercise, we're going to have increased

01:34:43.780 circulation to our sensory system. We have increased nerve fiber branching when that happens.

01:34:50.320 With increased nerve fiber branching, we have increased sensation. And that has been found

01:34:57.580 to decrease pain and improve sensation even in patients with peripheral neuropathies.

01:35:04.240 So maintaining strength and function at your foot, I think obviously will decrease the decline

01:35:11.440 of toe strength, but also increase the ability for us to feel the ground, which is imperative

01:35:18.620 from being able to walk upright and being able to prevent us from falling.

01:35:25.100 And this sensory decline, how much of it is superficial, meaning you can test it and assess it using the

01:35:33.760 standard metrics of, you know, like take an alcohol pad or a cotton swab on the cutaneous branches

01:35:39.780 and how much of it is much deeper. I mean, I'm guessing more of it is this deep part that is

01:35:44.700 dependent on significant pressure, but I don't really understand.

01:35:48.740 I did bring it to, there's a 256 frequency vibration tool. And what you can do is you'll

01:35:57.040 have the patient laying down and you take this 256 tool and I'll tap it on the ground and I'll put it

01:36:02.800 on the base of their heel and you get three chances. You're changing what you're doing and can they

01:36:10.060 pick up the vibration? The accuracy of that test has been shown to be more accurate than the nylon

01:36:17.440 pricking of the foot.

01:36:19.900 Interesting. Vibrational sensation. That makes sense because that strikes me as a more complete form of

01:36:27.560 sensation than, because the nylon thing is mostly cutaneous. Okay. Well, before we go to falls,

01:36:33.660 I want to round out a couple of other injuries. Okay. There are a couple other toe injuries that

01:36:37.440 are pretty common. Yes. Let's talk about those. Okay. Happy to. You want to start with hallucis

01:36:41.940 restrictus? Yeah. We will see this a lot. And I think a lot of it has to do with poor footwear

01:36:47.320 selections. We've talked about the chronic ankle sprains and the inability to allow the first

01:36:52.980 metatarsal to drop, but a functional hallux limitus, we need about 40 to 45 degrees of range

01:36:59.760 of motion at the big toe in order to have an efficient walking gait. Yeah. This is my only

01:37:06.340 superpower. I'm probably like 90 degrees at my hallux. Excess range of motion is great as long

01:37:12.460 as you can control it. Remains to be seen. So if I wanted to sprint though, I would need 65 degrees,

01:37:19.280 right? Cause you're more on your toes. Yeah. And this is where I've seen a lot of former NFL players

01:37:25.480 who get horrible turf toe that have what literally looks like 10 degrees.

01:37:32.040 If you can catch these patients, so there's stages. So what will start to happen is you'll

01:37:38.040 get an inflammation on the top of the big toe. Is the primary pathology just the repeated jamming

01:37:42.920 of that toe? The instability at the first ray, they can't drop the first met down. So they start

01:37:48.380 to irritate the top of the joint. It'll be red. It'll be swollen. And these patients suffer.

01:37:52.920 I'm on a Facebook group for hallux rigidus. It's a support group. And the reason I'm on it

01:37:58.640 is because it's a constant battle for these people for footwear. They're like, I need a shoe that's

01:38:05.980 going to eliminate me using my big toe because it hurts when they try to extend it.

01:38:12.660 And have these patients all experienced trauma?

01:38:16.700 No. If they've had like something fall on their toe, if they've had turf toe, then yes. But a lot

01:38:22.980 of them, this is weakness. This is poor footwear. That's why I think a lot of these diagnoses at the

01:38:29.020 foot can be prevented. This is proactive healthcare. I mean, you want to talk about your eggs in your

01:38:33.780 book? I love that story. There's no better way to stop the eggs from being thrown than by taking care

01:38:39.860 of our feet from the ground up. But I digress.

01:38:43.200 So let's assume that the trauma was in the past. It's not an acute issue. Is the treatment the same

01:38:49.240 where you have to get mobility back by strengthening?

01:38:52.640 I always say earlier intervention is better. Even if there's been trauma, you do not want to

01:38:58.600 immobilize something. We know that. When you immobilize, it starts this cascade where you start

01:39:05.260 to change the neurological input to the tissue. It just really will create an environment where

01:39:10.520 movement will be altered. So even in those initial stages, we're doing like big toe ranges of motion.

01:39:17.600 I always tell my patients, if I don't get excited about you exercising your big toe, but you have to

01:39:22.780 be.

01:39:23.040 Now, sometimes remember when I had my little toe injury three months ago, which still hurts like

01:39:27.940 not as bad, but it's amazingly sore still. That first weekend, the thing was black and blue.

01:39:35.700 You still had me doing isometrics. I'm still doing them, by the way. Anytime I'm in pain,

01:39:41.780 five minutes of isometrics actually makes me feel better. Why is that?

01:39:46.780 I call isometrics my pain meds for my patients.

01:39:49.780 Yeah. So tell people the exercise you had me do and why it's helpful.

01:39:52.980 With the big toe, what we'll have if there's an irritation in the joint per cent?

01:39:57.380 And just so people know the injury, I had an injury where I got hit on the front of the toe.

01:40:02.780 So it just jammed the toe back. And I sent you a photo the next day. I've never seen,

01:40:10.040 I mean, you've probably seen this for me. The entire side of the foot was just black and blue.

01:40:15.740 I didn't get anything x-rayed because I didn't think anything was broken. I was going to ride it out.

01:40:19.200 And within a few days, I knew nothing was actually broken because I could touch the bone.

01:40:22.980 The pain all seemed to be ligament pain. And to this day, it's still very tender to touch the

01:40:30.360 side. If someone looks at their foot and they see that, they're like, oh my gosh, I better just

01:40:35.480 do nothing. Do nothing. But yes, right away, what we had you do was put the toe in a position of a

01:40:42.560 little bit of extension or something that was comfortable. And then you're basically just

01:40:46.660 contracting on both sides of the joint. So you're pressing down and then you're trying to lift up,

01:40:51.360 but you're getting some type of movement. Isometrics, the reason I call them my pain meds

01:40:57.540 is I will tell my patients, whenever you feel pain, isometrics are safe for you to do because

01:41:03.700 what they do is they decrease cortical inhibition. So when we have an injury, think of it, we'll go

01:41:11.360 to a race car. We have a cortical accelerator. So information coming from our brain and we also have

01:41:16.880 brakes. We want to the accelerator and the brake to be in balance of one another. When we have an

01:41:22.920 injury, our brains, our foot's on the brake. So if I'm trying to change my movement or improve my

01:41:30.260 movement pattern, I got to let off the brake. And that's what isometrics do. They decrease

01:41:36.620 that cortical inhibition. And to be able to do that right out of the gates is extremely important.

01:41:42.020 Yeah. Before the damage sets in and you create a long-term pattern of rigidity.

01:41:47.620 Yes. So when you can find these patients that still have, when you're doing a calf raise,

01:41:53.760 for example, someone who has pain at their big toe, they'll be like, I cannot do that. It hurts too

01:41:58.300 much. It's pinching. I'll put a band around their ankle, for example, and I'll pull it to the outside.

01:42:04.720 Remember, that's where peroneus longus lives, on the outside of the leg. So I'll challenge it a

01:42:09.600 little bit so that they really have to press through their big toe to keep their big toe

01:42:14.460 on the ground. When they do that, they're like, wow, that pinching is better because I dropped the

01:42:20.900 head of the first. Yeah. There is something so magical about using bands for lateral and medial

01:42:29.140 tension to produce the necessary engagement of the foot stabilizing muscles when you go and do other

01:42:36.700 things. The kinesthetic cueing, I think, is so important. So important, especially in those

01:42:43.100 planes. That's why the foot's this multidirectional, like beautiful thing that we can train so many

01:42:49.180 ways. So what else are you doing for the rigidus patient? Obviously, isometrics, a big part of it.

01:42:57.640 How do you get the range of motion? How do you slowly introduce that range of motion back?

01:43:02.080 If they are in a functional hallux limitus, which means that they can still utilize their big toe

01:43:10.180 based on if I increase strength of peroneus longus, for example, if we work on range of motion at the

01:43:16.060 big toe, all of those things are key. If you don't do it then, it will progress into hallux rigidus,

01:43:25.520 and I don't consider those the same diagnosis. Hallux rigidus, there's been so much arthritic

01:43:31.460 change to the joint that now you maybe have five degrees. So the toes basically fused almost.

01:43:40.120 So rigidus you're associating with the bony arthritic changes, whereas limitus is you still

01:43:46.360 can anatomically move. You are limited because of the musculature. I mean, on a film, you may start

01:43:52.700 to see like an exostosis or like lipping. There is, you know, wolf's law. They'll start to have

01:43:58.000 changes within the bone, but it's still a functional joint. And that's when I get excited

01:44:03.980 because I'm like, let's do this. Let's fix this thing. Because if not, if that progresses

01:44:09.060 to hallux rigidus, it's game over. Now our treatment has completely changed, meaning that I have to look

01:44:17.540 at putting them in a certain type of shoe that's going to rocker them through their toe because they

01:44:24.620 now have lost four foot rocker. They cannot rocker through their toe.

01:44:29.460 What percentage of people with hallux limitus will progress to that phase of disease?

01:44:36.680 Unfortunately, quite a bit.

01:44:37.840 Wow.

01:44:38.160 Because this message isn't quite out there as much as it needs to be. Because those two diagnoses are

01:44:44.200 often married. When people start to see arthritic change at the toe, they're like, well, this is

01:44:50.380 hallux rigidus. I'm like, no, it isn't actually. If I drop your metatarsal down, I can still give you

01:44:56.320 40, 45 degrees. Hold on a second. Let's train this thing. But without knowing that, and you start to

01:45:03.080 have pain at your big toe, the initial intervention is a carbon plate under the toe. So they sell these

01:45:09.820 little inserts where you can put in your shoe so that your big toe isn't bending at all. Some type

01:45:16.360 of orthotic or very stiff shoe. And these patients would be like, oh, this feels great. And I'm like,

01:45:22.100 yes, because you're not moving it anymore. But-

01:45:25.980 If you stay on that path too long, you'll lose the ability forever.

01:45:28.680 Correct. And you want to talk about what happens up the chain. When I see patients walk with hallux

01:45:34.780 rigidus, for example, they can't roll through their foot. So they can't push off at 45 degrees out of

01:45:42.920 their big toe. So now what they have to adopt is this is what their foot looks like. So they have

01:45:48.960 more knee flexion, for example. And then their hip has to be hiked with every step.

01:45:54.640 And it's like, what are you doing? But I always want to instill hope because there's always hope.

01:46:00.520 You have to do that. And even if patients have a fusion in their big toe, even if they have hallux

01:46:07.620 rigidus, you've lost range at one joint, but you haven't lost range at your ankle and you haven't

01:46:14.300 lost range at your knee or your hip. Those range of motion, those ranges of motion will be compromised,

01:46:21.760 but let's just train them. Let's rocker you through the big toe. Let's give you drills to give you knee

01:46:29.340 extension, to give you hip extension, because we know you're not going to have access to it any longer.

01:46:34.740 So let's just give you things to work on. And that's where I think, I want the two worlds to

01:46:41.120 marry. Oftentimes there is a time and a place for these surgical interventions. But once that's done,

01:46:47.540 there's so much more that can be done so that we don't start seeing sequela of that up the kinetic

01:46:54.000 chain. How often are you seeing people that have kind of autoimmune forms of arthritis in the foot and

01:47:00.620 ankle? It's a smaller percentage of my patient base, but they do make their way into my office.

01:47:08.160 And a lot of the times where I will see that is more at the midfoot, where they'll have a lot of

01:47:12.740 this arthritic change at the midfoot. And aside from obviously the medical management of that

01:47:18.840 with pharmacologic agents, what are the most important things you're doing for those patients

01:47:24.520 to foster midfoot mobility and strength? Again, we're meeting patients where they are.

01:47:30.940 You'd be surprised, even patients that have had three and four foot surgeries, because that's

01:47:35.540 typically what I will see. Little things like toe yoga, right? So being able to lift the big toe only,

01:47:43.000 lift the four toes, lift all the toes and spread them. All of those little things are sending

01:47:49.340 information to your brain that these people haven't seen in a very long period of time, if ever.

01:47:54.840 So with midfoot issues, isometrics, if I can get a little bit, even a little bit of isometric

01:48:00.760 activity out of them, we're doing it. We're going to talk about falls in a second. We can use toe

01:48:05.960 strength, which is part of the reverse of some of those things you just talked about. Is toe strength

01:48:11.100 mostly a midfoot intrinsic capacity? Well, flexor digitorum brevis is a big

01:48:18.120 muscle in regards to toe strength. When we do one of the videos, I'll talk about the wink sign,

01:48:24.460 okay? Because that's a sign you can see in the toes to know you're engaging the muscle

01:48:28.380 appropriately. That forward leaning, we want to be able to feel the intrinsic muscles of the foot.

01:48:34.920 So feel the arch. A lot of that helps these patients with this midfoot instability.

01:48:40.660 The intrinsic muscles of the foot, you know when people do like the short foot exercise,

01:48:44.940 I kind of call it the clamshell of the foot because it's a good place to start, but it's not

01:48:51.560 functional because the intrinsic muscles of the foot come into play when the heel comes off the

01:48:57.100 ground at forward propulsion, when those toes need to be strong. I mean, if I was treating you for hip

01:49:04.220 pain and I gave you, I want you to lay on your side and do clamshells forever. I mean, great,

01:49:08.940 but is it functional? Do you ever do that? So we have to marry these treatment plans with function.

01:49:17.280 And I think especially with toe strength, you got to really work on that type of movement and tissue

01:49:23.220 strength. So let's now go from toe strength back to falls since you said that the measurement of toe

01:49:29.000 strength is one of the greatest predictors of fall risk. It's a huge problem. Yes. The mortality

01:49:35.260 is enormous once you reach the age of about 65. So what do you think are the most important things

01:49:43.400 that we need to be training to minimize the risk of a fall? First and foremost, toe strength. That is

01:49:51.200 the single biggest predictor of falls in the elderly is a weakness of toe strength. It really is.

01:49:57.840 I would not have guessed that. When we get in and start doing these exercises, I mean,

01:50:01.400 I think it is an imperative. You know how kids get scoliosis checks? I mean, we should be checking

01:50:05.940 kids' feet. That's when we need to start paying attention to this stuff. Because if we start

01:50:10.720 training these things, once we get to this age where toe strength is a massive deficit,

01:50:16.540 we'll be ready for it. So toe strength for certain. I'm very worried about what my toe strength is going

01:50:21.180 to be when we bust out the dynamometer. Well, neuroplasticity is a real thing. So we can train that up for

01:50:27.080 you. Very good. So toe strength, ankle mobility. That's another one that we'll look at.

01:50:32.580 And more important in the plantar dorsi plane or in the inversion eversion plane?

01:50:37.700 In both. So when I assess, I have a fall prevention protocol. Dr. Tom Michaud has put together an

01:50:44.000 excellent fall prevention protocol. And him and I have worked a lot together on this. So we'll look at

01:50:49.200 ankle dorsiflexion. So we want that to be about 35 degrees. But then we'll also look at

01:50:55.840 inversion and eversion, which is basically going in and then going back out again. A lot of the receptors

01:51:03.640 on the foot live on this outside lateral aspect of the foot. So we talked about how a lot of falls

01:51:14.880 occur with the initiation of gait. The other plane where people will fall is to the outside. So when

01:51:22.280 they go to step, if I have less sensitivity to these receptors on the outside of the foot, I can't

01:51:30.240 feel where am I going? I'm going to the outside. So that's why we'll look at the ability of the ankle.

01:51:37.220 Do I have good range of motion both in and out and going forward? The other thing obviously that we'll

01:51:43.380 look at is balance. Really cool studies looking at vestibular function, modulating activity of

01:51:51.520 abductor hallisis. So remember, that's the muscle that straightens the big toe. Abductor hallisis is

01:51:56.580 slow twitch muscle fibers. So that guy's not real good at movement coordination per se, but he can last

01:52:02.100 all day. And from a balance perspective, it's the muscles that are receptors that can really hold our

01:52:11.320 bodies up. And that abductor hallisis is a big boy. So we look at single leg balance, for example. We also want

01:52:18.960 to look up the chain. So when we look at fall prevention, it's how stable are my hips? When my foot is on the

01:52:25.380 ground, it's my glute. When I go to heel strike, that guy is in charge. So I want to make sure I have good

01:52:33.100 capacity going up into the chain. And how much of that is the glute mead versus max?

01:52:41.140 Depends on where we are in the gait cycle. So when I'm walking at heel strike, that's all glute max.

01:52:49.200 As you start to propel, you need the mead to stabilize. And what are you externally? At this

01:52:55.660 point, you need to be able to abduct the hip. Yeah. So I'm walking, I heel strike. Think of it

01:53:03.640 as a skewer. So I have gravity at heel strike that's causing everything to internally rotate.

01:53:11.040 It's my glute max. That is a very big controller of torque. He's going to slow things down coming

01:53:19.640 from the hip. Once I get into midfoot stance or loading, now I need to make sure that I'm not

01:53:26.400 swaying all over the place. That's glute mead. So all of those tissues come into play to help

01:53:32.740 stabilize my body and slow everything down. My boys are so obsessed with talking about butts right now

01:53:41.120 that over the weekend in some lame attempt to shut them up, I said, guys, the butt can be better

01:53:49.680 described as the gluteus maximus. And it's the largest muscle in the body. If you want a little

01:53:54.980 fun fact, which now turns into them running around the house, screaming gluteus maximus, gluteus

01:54:01.840 maximus. And I'm like, I don't think I have father. I'm like, I don't know that I've done any better

01:54:06.300 here. This is just as annoying. I pity their teachers. Well, I mean, if you think about it,

01:54:11.780 because I'll have patients that do this because they'll think that when I'm walking, it's going

01:54:16.500 to be this big old glute exercise. And as they go to push off, they'll squeeze their butt. And I'm

01:54:22.020 like, it's the wrong spot. You want to squeeze your butt. You want to try to control it. Right. And I

01:54:26.220 really don't ever give people gate cues when they're walking because it's just too difficult,

01:54:30.120 but that's not when you're pushing off. If you squeeze your butt, when you push off,

01:54:34.540 all you're going to do is throw yourself into too much lumbar extension. It's that at heel strike.

01:54:40.620 And that's when we have that eccentric control. I'm looking forward to seeing what the fall

01:54:46.520 prevention protocol looks like, especially as far as the tests that we can do. Let's talk a little

01:54:51.460 bit about shoes. We've talked about it a bit at the outset, but I know that it's going to be a topic

01:54:56.000 that anybody who's listening to us right now is going to want to understand, Hey, what can I do for

01:55:01.240 myself? Presumably as an adult. And I do think there's going to be a lot of people who listen

01:55:05.640 to us who have kids who are going to also say, Hey, if I've taken anything away from this, I've

01:55:09.340 taken away the idea that this begins early in life. And therefore I want to maybe even save my kids.

01:55:15.980 Some of the challenges I've had, what can I do for them?

01:55:19.660 I love this question. I could talk about shoes for a very long time. If we talk about kids first,

01:55:25.280 I think first and foremost, just let their feet feel the ground as often as they can.

01:55:30.040 All different types of surfaces. There are way more shoe and footwear companies now than there

01:55:36.360 were when I started this whole thing 20 years ago. I think the word is catching on and we're realizing

01:55:41.700 the importance of all of this. With the kids, obviously, and this is with everybody, the toes

01:55:47.240 need to be able to splay. A wide toe box for me is a non-negotiable.

01:55:52.520 Are we defining that by the insert test? Meaning put your foot on the insert and make sure that

01:56:01.240 when your weight is on your foot, you can still see insert?

01:56:04.500 It's probably the easiest way to access that. But I will caution you that these companies are

01:56:11.520 getting smarter. I've called all of them pretty much. The last of the shoe. This is the last of

01:56:17.940 the shoe. In order to change the last of the shoe, it's very expensive. So what the companies will do

01:56:26.580 is they'll change the upper of the shoe. So they'll put like mesh. So when you go to put your foot in

01:56:32.700 there, it feels like you have all this room and it's not because the shoe is wider. It's just because

01:56:37.820 they put a material on there where your foot can actually expand in it. There's also a very big

01:56:42.660 difference between a wide toe box and a wide shoe. Those are two very different things.

01:56:49.420 A wide shoe, which most shoe companies have, will give you width here, but it will still taper

01:56:58.360 at the toe. And not what we want. Remember the tie bar mechanism. I have to have that four foot

01:57:06.160 splay to trigger the response of, Hey, I better get stable at push off. So that's when I need my

01:57:13.360 toes to be able to splay as well. So a wide toe box is mandatory with kids footwear, adult footwear,

01:57:21.780 whatever. What are the shoes that have, would that be considered a wide toe box? Yes. So this is a zero.

01:57:27.740 I'm a big fan of these shoes. There are so many companies out there right now. Vivo Barefoot

01:57:34.080 toe list. I mean, I could go on and on and on about those. I have a list of them too.

01:57:38.680 We'll put that list in the show notes so that people can sort of see what you would consider

01:57:43.220 shoes that make a wide enough toe box for the purposes. And I have them listed according to

01:57:46.920 category, right? Like this is an athletic shoe. This is a casual shoe. And we have so many resources

01:57:52.160 for that. It can get very confusing. People will be like, I'm in a wide shoe. I'm like, you're not in a

01:57:56.700 wide shoe. So that's kind of rule number one. The other thing with functional footwear is looking at the

01:58:03.520 heel and the toe where they sit. So this is a zero drop. This is a zero drop where the heel and the

01:58:11.060 toe sit on the same plane. Okay. That just makes sense, doesn't it? That's how we were designed to

01:58:16.860 walk. Most shoes, and I won't throw out names here, but most athletic shoes, most running shoes,

01:58:25.120 if you Google the model of the shoe and Google heel to toe drop. It'll tell you how many millimeters.

01:58:30.940 It'll tell you how many millimeters the heel is higher than the toe. Anything that's not a zero

01:58:37.180 drop, by the way, in my world is a high heel. Interesting. I switched my rucking to a shoe that

01:58:44.160 has an, I think an eight millimeter drop. Once I was having all of that Achilles tendinopathy and I

01:58:50.720 have enjoyed that shoe much more. So I no longer ruck in a minimalist shoe, probably because I'm carrying

01:58:57.960 a lot of weight and I want more cushion. I don't care about, I'll throw out the brand. I use the

01:59:03.040 go ruck shoe. So it is kind of a minimalist shoe. I can show you what I use later, but the reason I

01:59:09.940 bring it up is there's something about having that little bit of drop. That's not huge. It looks like

01:59:15.340 a zero drop, but I've never had an Achilles. I've never had pain again since doing that. Is that a

01:59:20.760 mistake? No. And I think it's such a good conversation to have. Think about the whole

01:59:26.060 super shoe, the Nike Alpha Fly, for example. That's like the big craze. I don't even know

01:59:31.760 what that is. It's the shoe that has a carbon plate. Oh, okay. Right. Oh, is this the super

01:59:37.820 running shoe? This is the super running shoe. Oh yeah, yeah, yeah. I got it. That actually gives

01:59:40.840 you a little bit of, presumably it gives you more energy. Yes. So there's like certain

01:59:44.580 characteristics to that shoe. It has a carbon plate. It has a difference in the midsole.

01:59:50.780 It's basically a shoe and the research will tell you, gives you a 4% advantage. Now, if I'm running

01:59:58.480 in a race and the guy next to me has this shoe that's going to give him a 4% advantage, don't I

02:00:04.400 want to be able to compete with him? Well, of course I do. But I always say you have to earn your right

02:00:09.880 to get into that shoe because it does change things. For example, because it's going to propel

02:00:18.740 you, it might cause you to stride longer. With longer strides, you have to consider hamstring

02:00:25.140 and Achilles possible or potential injuries. So guess what you better be doing? A lot of hamstring

02:00:31.480 strength and a lot of calf work, for example. It has an additional stack height on it, which can also

02:00:39.100 cause that kind of longer stride. Again, you better be able to handle that. So when you talk

02:00:47.060 about shoes like that, I call them a performance shoe. Fine, but it's a performance. Save that shoe

02:00:55.200 for icing on the cake. Your speed workouts. You have to do the foundational work. Yes. Because use a

02:01:01.720 training shoe. Get your foot stronger. Give yourself the best possible outcome when you put that

02:01:08.160 performance shoe on. Because if you're just relying on the shoe, I can guarantee you'll probably end up

02:01:13.140 in my office because I see it all the time. So with Achilles injuries, for example, now you're adding

02:01:19.540 like, you know, 50, 60 pounds. That takes work to be able to handle that amount of load in a minimal

02:01:26.740 shoe. If you had a history of an Achilles tendinopathy, if your baseline capacity isn't where we know it

02:01:34.920 should be, then if you need to wear that change, there is a time and a place for everything.

02:01:41.340 So if you are going to wear a shoe that has an eight millimeter heel to toe drop,

02:01:45.100 just do the work when you're out of the shoe. Make sure you have plenty of ankle mobility because

02:01:50.200 what are you doing? You're shortening the posterior compartment. Make sure you're still doing all of

02:01:54.780 your plantar flexion strength. Yeah, that's a great point. Let's talk about any other characteristics

02:02:02.040 of the shoe. So you've highlighted two, the width of the toe box and the drop.

02:02:07.080 Yes. Let's talk of the sole. So this is where I'll give people a little bit of leeway, if you will.

02:02:14.900 So I like to put patients, like I said, number one, wide toe box is non-negotiable. But you will get

02:02:20.760 patients that often, and other doctors have said this to me, well, we weren't designed to walk on

02:02:24.740 man-made surfaces. Okay, fine. Nor were we designed to walk with our toes looking like this. Hence,

02:02:30.440 the wide toe box is a non-negotiable. But if you're standing on concrete all day long,

02:02:35.800 if you work in a grocery store, for example, if you're in an airport, having a little bit of

02:02:41.620 cushion underneath the sole of the foot is going to be more comfortable. But this is where you need to

02:02:48.600 consider both ends here. The more stack height on the shoe, okay, so this is the more cushion,

02:02:54.920 it changes the rate of loading. It speeds us through pronation. This is very important.

02:03:03.300 So the more stuff I have, it's going to change the rate of loading. We've been talking about that

02:03:09.100 all morning, how we want to do what to it. We want to slow it down. We want to control it. And now I'm

02:03:14.680 going to put something underneath the foot that's potentially going to speed it up. You better have

02:03:19.340 what? A very strong foot and very strong extrinsic muscles to control that pronation. So consider what

02:03:27.020 you're doing in the shoe. If you're standing still, fine. You want a little bit of cushion, but know

02:03:31.880 that when you start walking with that thing, with this more stack height, with this more cushion, you're

02:03:37.180 going to alter the rate of loading. So that's where the thinner sole can come into play. If you walk

02:03:45.480 with a shoe on, that allows you to feel things, okay, so Stephen Sashen owns Zero, and he has this ad that I

02:03:53.080 just love. He's like, I don't wear comfortable shoes, and you shouldn't wear comfortable shoes either. I think

02:03:57.520 it's really funny, but he's right. Because when we're walking, remember we talked about that calcaneus and how

02:04:04.180 beautifully it's designed it is to handle shock absorption. We also have receptors in the heel that tell us, hey,

02:04:12.760 don't land so heavy because it hurts. Such a great point. I've seen the ad. I know Stephen well. I think

02:04:19.400 it's important for people to understand that it's okay for your feet to be giving you a signal.

02:04:26.560 100%. This is totally off topic, but one of the things I'm also interested in understanding better

02:04:33.480 is the importance of negative emotions. We live in a world where we've become so sterile to this, and

02:04:39.040 nobody wants to feel a negative emotion. You don't want to feel sad. You don't want to feel

02:04:43.880 anxious. You don't want to feel depressed. You don't want to feel angry. And it's like,

02:04:48.040 understandably, we don't want to feel those things, but there's an opportunity to understand why am I

02:04:52.920 feeling that thing? And if I can understand why I'm feeling that thing, maybe I can get to the root

02:04:57.500 of what's actually going on. Actually, I think that the way you described that made me make that

02:05:03.740 connection, which is, gosh, we should actually think through foot pain. If we're in the right

02:05:09.080 shoe, if we're in a shoe that we deem a correct shoe and something hurts, maybe the signal is

02:05:15.500 telling us, what are you doing wrong? It gives us so much information when you can actually feel the

02:05:20.940 ground. I mean, everything, the proprioception, the receptor activity. And when we have a lot of stuff

02:05:28.380 underneath the foot, I can overstride and land really heavy. I'm not going to feel it. That's

02:05:33.800 not what we want. Walking is a grazing of the heel. We want to feel what happens when our heel hits the

02:05:40.260 ground. Now, very few people today, competitive runners or otherwise, will run in a minimalist

02:05:45.540 shoe like that. It's a very infrequent occurrence. Do you recommend people do that? And if so, how long

02:05:53.940 does it take to strengthen the foot enough to be able to run in a shoe like that?

02:05:58.560 I know I keep saying this, but it is very patient specific. You look at their history of traumas.

02:06:03.320 You look at their history of injuries. I will always implement some type of functional footwear

02:06:10.140 regardless. It's just a matter of what we're going to be doing with it. So for example, if I'm working

02:06:16.560 with just someone who wants to walk, for example, we'll put them into a ultra, for example, wide toe

02:06:25.120 buck shoe, zero drop, and we'll just have them start like five or 10 minutes, see how they feel.

02:06:31.180 And then we can start to transition the stack height. So if they're used to wearing this big,

02:06:37.120 bulky cushion shoe, you don't want to take them into something like this too soon. They'll be like,

02:06:42.400 this sucks and I don't want to do it. And then you lose them right out of the gates.

02:06:45.520 For a person to run in a shoe like that, must they give up a heel strike in running?

02:06:51.700 When you change your footwear, you start to change how your body feels the ground. So with

02:06:59.740 runners, for example, everybody gets all up in arms about heel strike. Heel striking is bad. Heel

02:07:06.020 striking is bad. It's not that it's bad. It's just where the load is going. When I'm running,

02:07:11.580 it's not necessarily how my foot is striking, but where my foot is striking. So over striding

02:07:20.200 is the enemy. I don't want to have my foot well in front of my body when I'm running.

02:07:27.660 There's too much ground reaction force happening there. We want the foot to strike as close to the

02:07:33.760 center of mass as possible. There have been runners who have won marathons with a heel strike that's

02:07:42.540 at their center of mass. They just have more knee flexion, for example.

02:07:47.180 That would almost feel like they're falling forward, wouldn't it?

02:07:50.320 Almost. So when I'm striking with a heel strike that's in front of my center of mass,

02:07:56.360 when I heel strike, I have a lot of ground reaction force going through my knee, through

02:08:02.020 my hip, and through my low back. When I switch and run to a midfoot or forefoot strike, all I'm doing

02:08:10.560 is taking the load out of the knee, hip, and back and putting that into the foot and to the calf.

02:08:17.480 Theoretically, given the structure, it seems like that's how it should be, isn't it? I mean,

02:08:22.240 I have no dog in this fight as a non-runner, but what do most elite runners do?

02:08:27.420 You will see all across the board different strike patterns. You truly will. When you are

02:08:32.180 running, though, efficiently, when you look at cadence and you look at, I call them running

02:08:37.220 fairies because it just looks like they can run forever, their foot will be close to their center

02:08:41.840 of mass, and it is more likely that they will be at a midfoot and forefoot strike when their foot is

02:08:47.940 underneath them.

02:08:48.640 Yeah, it seems like, exactly, just anatomically, if you can bring the strike towards the center of

02:08:54.160 your body, you're much more likely to be not heel striking because it would be very awkward to heel

02:08:59.080 strike at that angle.

02:09:00.160 And you take out, you know, when you're running. So if I have heel strike, then I have to go to my

02:09:04.300 forefoot, and then I have to drop that heel down again versus just running midfoot, forefoot, which,

02:09:10.760 yes, I think that is a more ideal position to run in from an efficiency perspective. With that being

02:09:16.920 said, if you have a history of heel pain, Achilles tendinopathy, and you tell your runners,

02:09:23.600 hey, we're going to take you out of this heel strike, and we're going to get you to run on

02:09:26.460 your forefoot, you better prepare them for it. They better have good capacity at their foot and at

02:09:32.320 their calf, or else what you're going to give them is more foot and calf problems.

02:09:36.700 Yeah. Are there any other characteristics of a shoe besides the big three you've mentioned that,

02:09:41.220 I mean, you have pretty strong feelings about all of them, but in descending order of the

02:09:46.780 three we talked about it, your strongest feelings were at the outset.

02:09:50.320 Yeah. I mean, you want to put the foot in its most functional position. I think that's the rule.

02:09:56.600 And that means allowing the foot to splay and trying to keep it on a level ground.

02:10:01.120 And then you can play around with, based on activity, with the amount of stack height.

02:10:08.800 But they have shoes now where they have the wide toe box, but they'll still give you like a three

02:10:13.500 to five millimeter heel to toe drop, the Topo Athletic, for example. Ultra actually now has a

02:10:18.740 four millimeter heel to toe drop. So I'll kind of transition them. If I know this person has poor

02:10:24.040 ankle mobility and poor foot strength, I'm going to say, listen, we're going to get you in a wide toe

02:10:28.200 box. I'm going to drop you down from your 10 into say a five, slowly bring them there. They're

02:10:34.080 going to be like, Oh, this feels great. Cause they always do. And then we start working on their

02:10:37.940 strength and then we can continue to drop them down into a more functional shoe. But you think

02:10:44.000 about hockey players, rock climbers, where shoes are just what they are. You can't, I'm not asking

02:10:52.280 everybody to run around barefoot all the time. It's not reality. If you do want to run in a super shoe

02:10:57.520 or you do play hockey a lot, don't panic. Just do the stuff. Do the work outside. Do the work

02:11:03.520 outside. Get a pair of minimal shoes, grab some toe spacers and walk around for 30 minutes a day.

02:11:08.680 Keep it simple. Is a good rule of thumb that a shoe is a wide enough toe box. If you can wear the

02:11:14.020 toe spacers in the shoes, I've never seen you not wearing toe spacers. Do you sleep in them?

02:11:18.640 I don't sleep in them. You don't. Okay. Good to know. But I do wear them all the time. I wear them

02:11:22.680 when I run as well. I have that history of bunions, the hallux valgus. So my foot has gotten so much

02:11:29.940 stronger over the last 10 years. My prognosis was they wanted to surgically correct my bunions. And

02:11:37.180 I was like, that's not happening. I'm way too active for my mental health for that to sideline me.

02:11:43.880 Cause I see it all the time. It's a high rate of failed surgery. Most foot surgeries are.

02:11:48.080 So I wear them all the time. I wear them in all of my shoes and it's helped me immensely.

02:11:55.320 And it has helped so many of my patients.

02:11:58.600 The brand that you wear is the brand I have as well. What's it called?

02:12:03.780 The toe spacers that we have is from a company, Podiatry Essentials.

02:12:07.240 Okay. They're clear and they fit in between. Yeah. Show us.

02:12:11.880 Yeah.

02:12:12.080 Yeah. And then they fit the outer part of the foot is not experiencing the spacing.

02:12:17.940 Yeah. So if I were to put it here. Yeah. So it's easier to fit into a shoe basically.

02:12:23.060 Now I notice you have a little rigid thing in there. I don't. What's that thing for?

02:12:27.520 So I put cork into the toe space or in between the first and second toe,

02:12:33.300 especially if that person tends to have, if they have a bunion,

02:12:36.540 I want to have a little more resistance there. But I mean, most forefoot diagnoses, I mean,

02:12:42.840 we didn't even talk about neuromas, which is so common. And it literally feels like your foot

02:12:46.880 is broken when you're pushing off of a foot that has a neuroma in it. In that toe splay,

02:12:52.700 it gives the foot room. You have all these nerves that run in between the toes. They don't want to be

02:12:58.900 squished together.

02:12:59.560 So your recommendation would be for a person who's never worn a toe spacer. And again,

02:13:04.480 in the show notes, we will link to all of these devices. Your recommendation would be to start

02:13:09.760 how limited, how small, how many minutes a day?

02:13:12.760 I will tell a patient, here's your toe spacers. You're going to walk around barefoot in your house

02:13:17.420 for five minutes. That's it. On their weaker foot, because they don't have toe splay,

02:13:24.380 the toes rub against the toe spacer. And you can get like a callus or a corn, and that can be very

02:13:32.500 painful. And they'll want to rip this thing off. It happened to me. It took me probably six months

02:13:37.680 on my weaker foot before I could wear these all day long. And now it's like, it takes me 0.05 seconds

02:13:45.180 to put these on because I just spread my toes and they slide right on. In the beginning, when you're

02:13:49.340 trying to put these on, I'll see people like trying to like wrench their toes apart because they simply

02:13:53.940 can't spread their toes. It's wild. So they start with five minutes a day and they just slowly

02:13:59.760 increase their time. Then they get a shoe where they can wear the toe spacer in the shoe. Think of

02:14:05.740 it as like just doing an exercise for your foot. Sarah Ridge did a study looking at strength of the

02:14:13.200 foot. And so what she looked at, there was a control group, a group that just did foot strengthening

02:14:18.340 exercises and just wore functional footwear. And they looked at four different muscles. So

02:14:23.880 flexor digitorum brevis, one we talked about that supports the plantar fascia. Abductor

02:14:28.640 halisis, the one that straightens the big toe. Quadratus plantae, we didn't talk about that

02:14:34.680 guy, but he helps straighten the fourth and fifth toes. What was the other one? I think

02:14:40.860 it was flexor halisis brevis, so the one that bends the big toe. At the end of the study,

02:14:45.380 the foot strengthening group and the functional footwear group were almost neck and neck.

02:14:53.480 Really?

02:14:54.340 Yes.

02:14:54.960 The functional foot people didn't actually do exercise. They just wore corrective shoes.

02:15:00.320 And the only muscle that didn't get stronger was flexor halisis brevis. There was one muscle that

02:15:05.320 didn't quite get there.

02:15:07.540 Does that surprise you?

02:15:08.500 I mean, not really.

02:15:11.120 That's great news for the average person who doesn't want to do the work because you're

02:15:15.520 just saying, basically, all I have to do is change my shoes and things will get significantly

02:15:19.440 better.

02:15:20.160 Imagine if you did both though.

02:15:21.560 Well, of course.

02:15:22.600 Right? But I mean, you think about meeting a patient where they are. Now, by the time people

02:15:28.320 get into my office, I have some go-getters. They're like, I've had foot pain. I want to get

02:15:32.900 this job done. So they're going to go shoe. We're going to go toe spacers and we're going to go foot

02:15:37.120 strength. Now I have other people that I know where I'm like, start with one.

02:15:41.360 You got to start with one factor. And if I had to do that, where am I going to get the most bang

02:15:45.820 for my buck? Put them in the right shoe.

02:15:48.800 When it comes to kids, anything different? Same principles. You know, my kids, my boys,

02:15:53.560 not my daughter, my boys have never owned a pair of shoes that aren't zeros. These exact shoes.

02:15:58.720 I keep waiting for the day when they come home and they say, I want Nikes or I want whatever the

02:16:03.600 popular shoe of the day is. And I mean, knock on what it hasn't happened yet. They love the shoes

02:16:08.160 and that's the end of it.

02:16:09.040 It brings me so much joy to hear you say that because I can guarantee you, because my daughter

02:16:15.060 is the same. She's in middle school and she wanted a pair of Nikes. And I was like,

02:16:20.380 I will do pretty much anything for you, but I am not buying you a pair of Nikes.

02:16:23.900 But my brother was like, I want to be the good uncle.

02:16:27.140 The cool uncle.

02:16:27.600 And I was like, okay, I'm going to let you make your own decision here. Every day when she goes

02:16:33.860 to school, she has her shoe option and she walks out of that door with her ultras on because she's

02:16:40.300 going to tell me, listen, she's like, it doesn't feel good. They'll make the right decision because

02:16:45.320 it's just based on comfort. So if we start them saying, hey, this is what your foot should feel

02:16:50.560 like, then it's an easier decision. And if we can be proactive with the children, because

02:16:57.140 they haven't been on the planet long enough to see structural deformity in the foot, which

02:17:02.080 is exactly what it is. When you see bunions and hammer toes, it should be a signal to you

02:17:08.340 going, something is wrong here. Something is wrong. Where is this aberrant load coming

02:17:13.120 from?

02:17:14.160 Now, what do you say to men and women who's, I want to say their job requires them because

02:17:19.800 it's really, you could argue in this day and age, that's not really the case anymore.

02:17:23.080 But look, they want to wear more fashionable shoes, be it at work or in social settings,

02:17:28.740 especially women wearing. I mean, I watched some of the shoes that women wear and I think,

02:17:32.840 God bless you. How, how do you actually wear that shoe? So do you put that in the same category as

02:17:38.460 performance shoes, which is look, if you really want to wear the most pointy toed Ferragamo,

02:17:43.160 then you just have to make up for it when you're not wearing that shoe and you have a higher burden

02:17:48.480 of responsibility that comes with the privilege of being able to wear that shoe?

02:17:52.880 100%. I mean, if you have a history of any type of forefoot pain, bunions, neuromas,

02:17:58.440 especially, and you want to wear a four inch stiletto, number one, be my guest, have fun with

02:18:03.640 that. Number two, you better do the work on the other end of it or else it's, and I'll tell my

02:18:09.520 patients, you got to work with me a little bit. You want to go on a date, you want to do this,

02:18:13.720 fine. I'm all for it, but do the work before do the work after. Yeah. Well, Courtney, this has been

02:18:20.200 fantastic. I'm excited to now go and get into the gym and actually show people a bunch of the

02:18:26.260 exercises and some of the diagnostics as well so that folks can begin the, uh, the do it yourself

02:18:31.900 process. Yes. Thank you so much. Thank you for listening to this week's episode of the drive.

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The Peter Attia Drive - April 01, 2024

#296 ‒ Foot health： preventing and treating common injuries, enhancing strength and mobility, picking footwear, and more ｜ Courtney Conley, D.C.

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