296 ‒ Foot health: preventing common injuries, enhancing strength and mobility, & picking footwear

so let's now go from tow strength back to Falls since you said that the measurement of tow strength is one of the greatest predictors of fall risk um it's a huge problem yes the mortality is enormous once you reach the age of about 65 um so what do you think are the most important things that we need to be training to minimize the risk of a fall first and foremost tow strength that is the single biggest predictor of falls in the elderly is a weakness of tow strength it really is I would not have guessed

that and when we get in and start doing these exercises I mean I think it is an imperative you know how kids get scoliosis checks I mean we should be checking kids feet that that's when we need to start paying attention to this stuff because if we start training these things once we get to this age where tow strength is a massive deficit we'll be ready for it hey everyone welcome to the drive podcast I'm your host Peter [Music] AA Courtney awesome to see you thank you for making the trip to Austin it's much better

to be doing this in person I think than by video given all the content we're going to cover thank you so much I'm very excited so I don't know before we kind of get into the foot help me understand your personal obsession with this part of the body um yeah where where did that begin I um I grew up as a ballet dancer and pretty much all through grade school and high school I spent a lot of time on my feet a lot of time in ballet point shoes which as you know are very rigid

stiff you're up on your toes um and I kind of always battled foot pain and then when I decided to choose this as a career I was you know my self exploration and I thought I was going to learn all of this stuff about the foot um and that just didn't happen we really didn't get a lot of Education in regards to how the foot actually functions because you're a chiropractor by training and so you why did you choose that over say Podiatry or something that was purely focused on the foot you know my father

and I have had this conversation so many times I first was going to go down the physical therapy route and then I was like I want to create my own treatment protocols and my dad has always been a big fan of Chiropractics so we just had a lot of conversations and that's kind of where it went I was always been interested in exercise and movement um and it's just seemed like a good fit so as you said you go to school and you're probably not spending that much time on the foot correct I think we

had like half a semester and I was F much right that's actually a lot I would have guessed less but okay um and I just became fascinated by it because it just always intrigued me it's a very complex part of the body and I think with our education it was always viewed as if something hurts in the foot we're either going to put an orthotic under it um or refer for them for some type of surgery and I was blessed enough to have some really good mentors around me that kind of really en you know

increased my appetite for learning about that and that's kind of how it started I ended up graduating from school and working in a couple of orthotic Labs I see so you went straight from school directly into specializing effectively in the foot yeah and changed a lot yeah so orthotic Labs so um this is presumably a place where people come and have custom orthotics made yes so I would work in the front of these offices and there'd be Grinders in the back and they'd be making the Orthotics and so I was just constantly surrounded by by

all of that and that's what we knew is we'd see patients they'd have foot pain and we would cast them for Orthotics and make the Orthotics interesting so even when you came out of school your knowledge was still and your practice was largely still based on the you know conventional way of putting support under the foot hoping for the best yes all right so with that background we can evolve to where you are today which is obviously Leaps and Bounds ahead of that um but let's kind of give folks a bit of a sense of

the complexity of the foot I think most people look at their hands and because of our dexterity um I think people understand the intricacies of the hand I I know once in a while when I'm trying to communicate that to a patient I'll even show them a picture of the homunculus which is the image of the I know you know what this is but just for the listener the image of the cerebral cortex where it it it graphically represents the size of the anatomic features in proportion to how much motor and sensory control they have

and and obviously one of our one of our superpowers as a species is what we can do with these things it differentiates us from all other species um so H how does the complexity of the foot fit into the equation of the human body I think another one of our um superpowers actually is that we're a biped y right so we have so many cutaneous receptors muscle spindles joint proprioceptors on and in our feet that communicate with our vestibular system so we can become upright and bipedal um when you take away those functions it really

Alters how you're moving how you're interacting with your environment I mean it's always so wild to me because when we think about it from Rehabilitation perspective we are very good at rehabbing the low backs we do a lot of core strength we do a lot of glute strength we do a lot of hip strength but you don't hear many people saying I'm doing a lot of foot strength and it's literally our first interface with the ground it's how we contact the ground it's how the whole it's how everything starts so when we take that away

you're really making it much more challenging for yourself and I think it really can alter our survival as well as decrease our quality of life yeah I mean I it's funny you can probably tell looking around how obsessed I am with race cars and um I've made this analogy before but basically there are four things that determine the speed of a car right so it's the you know obvious things the engine um but the chassis the aerodynamics the stiffness uh the driver's capabilities to what they can do in the car but of course the tires

and the analogy here of course is clearly that the tires are the feet and you can have the greatest car in the world the most powerful engine the most remarkable chassis and the best driver if the tires are shot none of it matters you simply can't get the power to to the ground and back so I think there's a lot to be said for um how it is imperative that the in fact I would even go one step further I think feet are even a more important part of the human body than tires are to

the car and here's the reason why as we'll discuss the feet play a role in the suspension more than the tires play a role in the suspension of a car so when you now talk about Force absorption the feet are even more you know of a of a priority and if you can't absorb force in the feet I think we're going to hear that we're we're going to translate that inability to translate force all the way through the body yeah a good friend of mine Jay de Cherry he always says that you can't build a

jet engine on a paper airplane yeah and I just love that because it's we're we're building we're building all of the strength and we're focusing on everything above the knee when in reality so much of this Force I mean gate is shock absorption it's stance stability it's propulsion and all of those things um enable us to become efficient with movement we'll talk about a lot of this stuff when we get into the gym later today and go through some of these things but on a personal level my interest in this probably didn't start until a

couple of years ago when I began to for the very first time in my life experience pain in my feet that wasn't just fleeting obviously like every other knucklehead I had the odd bout of planner fasciitis in my youth that got better with sort of traditional means but it was really only when my volume of rucking started to get really high and the poundage started to get really high that I was starting to experience pains in my feet that I now believe could be attributed to weakness um so let's maybe talk a little bit about

the anatomy of the foot it is truly one of those things that despite not only having gone to medical school but even having been a surgeon meaning I'm relatively familiar with Anatomy it's a freaking Black Box to me like I you know if you told me like show me the navicular bone versus the Talis I'd have a hard time until I started having to go back and relearn this so the fact that I once knew this 20 six years ago or whatever is amazing to me um and I suspect many people listening will be completely

unfamiliar with this so um understanding yeah understanding that some people are going to be listening to this only in audio this will be a great time for people to tune in on video but but for certainly let's assume that most people are watching us and and then let's show them the model here so I noticed you brought your friend here what's his name again Eddie his after uh Eddie veter Pearl Jam is um one of my favorites as as we have both been to the same concert recently um okay so walk us through the anatomy

of the foot so um very important I think especially when it comes to understanding how we're treating the foot and foot pain to understand the anatomy of the foot so there's basically three parts to the foot you have a rear foot a midfoot and a forefoot how many bones here 26 bones 33 joints so it's it's a complex part of our bodies and I think that's why um a lot of rehab treatments and protocols have veered away from really understanding what's happening here so starting in the rear foot the calcinus it's one of my favorite

bones and here's a fun fact a 100b female actually has a larger calcinus than a 350b gorilla wow fun fact but some other fun facts about this the actual bone itself there's two layers to the Bone so there's a thin cortical layer outer layer and then there's a spongy inner layer so the way the calcinus is actually designed designed think of like a rubber ball bouncing it was designed to absorb shock the other thing about the calanus is there's a fat pad that sits outside the calcaneus also two Chambers so there's a thin micro chamber

that is not easily deformable because when we walk most of us as in a walking gate we graze the heel so that outer chamber is not designed to form but there's a macro chamber on the inside of the fat pad that is highly deformable so again we have a fat pad and we have the way the bone has been designed to absorb shock that fat pad by the way is two times a better shock absorber than sorane so sorane it's a material it's a synthetic material like a rubber that um a lot of um performance

orthotics for example are made of designed to dampen vibration and absorb shock and so when I'm talking to my patients I'm like we have a beautifully designed calcus that was designed to handle all of this shock to handle what happens when our heel strikes the ground when we walk so very important structure there now the calcaneus looks like it interacts with another major bone there that sits right under the fibula and the tibia the taus yeah one of the few I remember yes and fun fact about the taist there is zero muscle attachment to that

bone in the foot all ligaments so there was a study Beno who's done a lot of research in in our work um they looked at sectioning the anterior Tao fibular ligament so that's also a very common ligament when we ankle mhm if those ligaments on the outside of the ankle get completely torn you now have this tus that has nothing attached to it so what can happen is the tus can migrate it can adduct so the tibia will internally rotate the taus adducts and then what happens is it kind of bangs into the medial malis

there so patients will often present with pain along the inside of their ankle and it will be diagnosed as say uh tendon dysfunction posterior tibialis when it is an instability at the rear foot because that taus is Shifting and would that patient have necessarily suffered something traumatic to have torn the AF ligament I mean typically when you look at ankle sprains for example mild ankle sprains over and over again actually pose more of a problem from a gate perspective or rehab perspective because people will typically sprain their ankle shake it off and then continue to

walk or play on it and in that situation the ligament is just getting longer and longer and looser and looser and when you have these continuous sprains you have changes to the ligament but here's the cool part the ligament actually heals more of what the issue is is that the superficial peronal nerve so the the nerve on the outside of the foot show where that would be so that would come on the outside of the ankle yep okay those nerves get stretched y sometimes those nerves get torn and once you start changing the neurological input

that's the issue because the ligaments the ligament will heal it's when you lose when you lose the sensory input yes so you're walking down a curb you lose sensory input and you say oh and there's no Hue saying don't do that anymore and then you keep doing it over and over again I had a patient this week that had had multiple um ankle sprains when he was a kid and the last couple sprains that he had he couldn't feel anything and that's when they were like okay we need to take care of this because he

lost all sensory input I kind of wonder how much of that I have going on from all my frequent ankle sprains growing up um but we'll probably figure that out when we do some of the interesting diagnostic stuff so what is that bone that the tus and the calanus look like they're both touching is that the navicular this is the navicular right on the inside yeah so this is the highest point of the medial Arch okay and also an important bone here um posterior tibialis so a very important inverter of the foot so it inverts

the foot it helps stabilizes the arch comes down wraps around the navicular and inserts on the bottom of the navicular it also has eight plus insertion points in the bottom of the foot wow um I'm sure you've seen people that have an accessory navicular so it's almost an extra bone that sticks off that navicular and you can see it when you're um looking at someone it looks like they have a protrusion um because the posterior tib has to come down and wrap around the navicular if you have an extra bone there the vector of force

right is longer so the way I'll describe this to my patients is if you were doing a chest press for example and you starting here imagine having to start all the way back here right it'd be more difficult y so that's where with those patients when you see that or you see that they have an arch that doesn't want to you know recoil or function you have to consider hey we really need to go after after strengthening postor tibialis and or some of these patients if there's too much of a structural variant that's when you

implement things like an orthotic for example got it so is the navicular considered then part of the midfoot midfoot is the calcaneus the only thing that makes up the posterior foot the rear foot and the rear foot yeah and those distinctions are they I guess we I'll let you finish talking about the 4f foot but presumably those distinctions are based on not just their location but have some functional significance yeah I think when you look at the gate cycle I see right so when we talk about the gate cycle we look at different rockers of

the foot so when we're initially walking and our heel strikes the ground that rear foot the calcaneous starts or initiates pronation so then we go into ersion and then you have the midfoot that unlocks and because we're going to use these words so much today let's make sure people understand ersion pronation super of the foot absolutely yeah just show us maybe with your hands pretending your hands are feet so inversion would be going out that's also a supination yep pronation is an unlocking of the foot so this is where the foot flattens and widens Y

and I think we've kind of demonized pronation definitely and we'll talk I know we're going to go through a couple of drills today that you've had me doing to really work on relaxing the foot and letting it pronate without tensing up yeah um ersion same so the calanus when you Evert it's basically allowing that pronation to begin and is that movement all of those movements are they facilitated by muscles or are the tendons pardon me are the ligaments themselves actually deforming I think it's everything um when your heel hits the ground you have body weight

than you're dealing with ground reaction force I think the beautiful thing about gate is that we need to have adequate range of motion but you also have to be able to control that range of motion and that's when things get sticky is when we see people speeding through the gate cycle or they're speeding through pronation and they can't control it then you have the system going slow down and presumably that comes back to Ecentric weakness I mean certainly if you look at um and I'm sure we'll get into specific muscle talk yeah but there's a

lot of Ecentric control that's required when our foot hits the ground all right so three massive bones there we've covered massive certainly on the scale of the foot then what let's keep going down the down down the path there I just want to talk about one more quick thing that I think is really cool this sustentaculum talli that lives kind of it's It's a medial lip off the calcaneus okay it was it's fully oied by the time we're seven years old so they looked at there was a research study ran Joseph looked at 2300 children

and they looked at static Footprints and how Footwear affected the development of their medial Arch which I thought that's a pretty large cohort for a study right so what they found is by the age of 13 these are Kids 4 to 13 by the age of 13 those who did not wear shoes less than three of them presented with what they considered flat feet the ones that wore shoes 9% were considered having flat feet and sorry 3% or three in total 3% okay 3% right so the ones that wore shoes they also noticed the type

of shoe so the ones that wore closed toe box shoes had a higher prevalence for you know and I always say with research let it guide you not shackle you so I thought it was interesting so with a closed toe shoe there was more of a prevalence than even the kids that wore sandals MH so why is that you know did they kick their shoes off and run around Barefoot did they have more toes playay was the foot able to function in a better position but what the conclusion of the study was the researchers said

that this sensory information that was gained by their feet somehow gave them a a protective tone an increase in protective muscular tone that was enabling their Arch to elevate now how is that accomplished because I know that there's going to be many people listening to this who are going to immediately want to think about their kids yeah and you know the the reality of it is most of our kids are in school from a pretty young age and therefore have to kind of be in shoes it's kind you know especially like you live in Colorado

it's not like you're going to send your kid to school in sandals in the middle of the winter so do you get a sense of the the the time requirement being out of shoes if indeed there's causality between time away from shoes and improved foot Health at a young age I think we have the opportunity with the kids I mean when they're at home they're just take their shoes off different um Sand Grass I mean this doesn't have to be all the time but even just a little bit I mean every kid on the planet

the first thing they do is take their shoes and socks off because they're wanting to gain that sensory input yeah so I think even a little bit can go a very long way and then we'll get into Footwear because that's a big one for the kids yep yeah we we definitely want to talk about that for both kids and adults totally and then getting back to the development of this guy the susten Tulum tii so if we know that it oif by age seven and we have this window where we know that between these ages

3 four five six that the arch is developing and we can start to allow um sensory input and start to begin muscle strength the way he develops there's a little lip you see how it lips up so it positions the Tais almost in a with a lateral tilt so it's very important from a um bony architecture perspective on how stable that foot is so you know there are cases where this will develop in a downward slope and then you predispose you could predispose for some type of flat foot deformity in you know in the future

okay Carry On so that's the uh the rear foot okay midfoot if you will moving into the forfoot the forfoot is where we will see most of our injuries because when we're walking there's eight times our body weight that go through the forefoot with propulsion why why that is so hard to Fathom well how about some other numbers here your Achilles tendon is about four times your body weight when you walk meaning it experiences four times your body weight with each step with Force yes and the ailles is the tendon of only the gastro or

the Gastro and the solar gastro andus okay in fact we should just also clarify I'm sure many people know this but when we are referring to tendons we're talking about the attachments of muscles to bones earlier we referred to ligaments which are the attachments between bones so folks understand that and the Achilles tendon which everybody is familiar with yes um is obviously a massive tendon I mean I've seen the size of these things when they're injured when they're severed I mean it's I don't know where it ranks in tendon size for the body but it

is certainly one of the largest I would have to believe I love talking about the Achilles tendon it's just it's beautiful I mean you have the Gastro and the Solus that they twist on each other so it it's can become a very robust tendon and the Solus actually makes up larger fibers of the Achilles tendon um than the gastr the Solus is a Powerhouse mhm um but getting back to that load when we're walking four times when you start running those numbers double so the inside of the arch so the calcano navicular area experiences loads

of up to 11 times your body weight when you're running I mean it's massive but here's the very cool thing is our foot was designed to handle it I mean we have all bone structure muscle tendon that was designed to handle that load the problem is is if you don't use it you will lose it yeah so it's interesting you said that the majority of foot injuries are going to occur in the 4 foot Now by my math there's about what 15 18 no let me think how many bones there 15 in the foref foot

lots of bones in the for foot yeah metatarsals failinks distal failings proximal failings ah distal and proximal there yeah except for the big toe yeah okay um eight times our body weight at propulsion the 4 foot has to be incredibly stable at push off because it handles so much load so when we're walking for example one of the most common injuries at the forefoot will be a generic diagnosis of metatarsalgia or stress fractures so two and three typically will be your metatarsalgia area and one being the big toe five being the pinky toe yeah we'll

get to my we'll get to that favorite guy right there three and four typically you're where you'll see a lot of stress fractures when we're propulsive and tell people what a stress fracture is so a stress fracture basically can be caused by two different things tensile strain or compressive loading it's when you have Force going through the bone and the system just can't handle it so it starts to irritate the tissue if you will when you look at the foot and I think this is important from a re have perspective is depending upon where the

fracture is you'll know what type of stress fracture it is so for example if you have patients that are hitting their heel very hot and heavy right so they might have a rigid foot they might have one that doesn't have good mobility and they hit the heel heavy they can get a stress fracture in the calcinus the fifth metatarsal also very common location for these compressive loading stress fractures because they're they can't handle that compression but on the other side of the foot remember we talked about the navicular that guy technically should never hit the

ground it's the highest part of the medial Arch but he can get a stress fracture so you're saying to yourself well how is that possible if they're caused by compressive loading not that guy he's caused by tensile strain when you can't handle the foot pronating and rotating and you can't handle the movement of the foot the tendon will start to tug and you'll start to get that strain at the navicular stress reaction leading to stress fracture so interesting we don't you know we think about bones as having this great capacity for um contractile Force right

so axial loading we don't think of them as requiring as much tensile force but of course they're under tremendous tensile force in the opposite like you know we think of our skeleton as needed to support compressive load um but of course they have to do both which actually is a pretty remarkable material like concrete for example is only strong under compression it's so weak under tension I think I mentioned this once before in the podcast without rebar concrete would be useless um yet our bones have to do both so you're saying that you can tell

I mean not to oversimplify but lateral injuries are likely to be more compressive medial injuries might be more likely to be tensile and and again I don't know that that matters necessarily other than it explains like what caused the injury yes but also with treatment because when you look at compressive loaded stress fractures so at the heel at the fifth metatarsal you have to cushion those right obviously boot heel let the tissue heal but that person might need something that's going to give a little bit the navicular stress fractures the metatarsal stress fractures the sesm

moid stress fractures because they happened due to an instability to a tensile strain you can boot them but you better your followup with them better be rehabbing the strength of their foot because it's not that they landed to too heavy it's because they couldn't control their motion yeah that's why people with seso injuries for example so the seso are the two little bones under the big toe they're uh similar to the patella me seso refers to if I recall a bone that is completely surrounded by tendon it has it's like a little joint capsule y

it's it has no no nothing is exposed of the bone it's completely embedded within the tendons correct yes yeah um when you get those stress fractures there they can be extremely painful and people stop using the big toe which I'm sure we talk about but if you offload it so they'll these people will be in Boots for three months and they'll say okay the bones healed go back to your activity it doesn't work like that because even though the bone is healed the muscles are now even weaker you are more susceptible to the injury because

you've lost whatever strength you once had there yeah how did it happen in the first place got it right let's talk a little bit about the muscles in the foot as well because it is a very muscular structure we don't think of it that way because we look at it and we can sort of see the bones through the skin but especially on the bottom the musculature is incredibly complicated and it is really related to what's happening in the lower leg as well oh yeah um well I think when we talk about muscles of the

foot we can talk about intrinsic muscles versus extrinsic so intrinsic muscles they live in the foot they start and they end in the foot we have four layers of muscles there which is just unbelievable it is and the I think the beautiful thing about the foot is you can look at the foot it's the only place in the body where you can look at it and say something is going arai here because you'll form things like bun and hammer toes and Taylor's bunions and you'll be able to look at your foot and go this isn't

the way it's supposed to look maybe I should pay attention to it you can't do that at a knee or hip unless you take an x-ray and when you can get your hands on a foot where you start to see these deformities and they're flexible you really think about it from a muscular imbalance so if we wanted to look at some of the intrinsic muscles of the foot so if we were to start with the big one abduct halis so he sits on the along the big toe and he's responsible for straightening the big toe

and I think the other thing that will be helpful when we go through this is you know every medical student and whatnot has to learn what an adductor versus an abductor is and since they're always embedded within the names of the muscles we always remembered this as abductors abduct they take things away like a person's being abducted they pull away from the body basically an adductor pulls back towards WS the body so with that said hopefully people will have an easier time remembering some of these terms so we have um our forefoot here here's the

big toe so abduct oralis is going to straighten the big toe there's also a mus it to the middle pulls it toward middle yep there's an aductor halis it's kind of like a backwards seven so when these guys get out of balance for example if I'm in a shoe which we'll talk about later that's going to squeeze my toes together such as your ballet shoes yes or most dress shoes yep I have aductor now that's shortened mhm and I have AB doctor it's lengthened is lengthened so you start to get this imbalance at the foot

and then you start to see changes in the foot I mean bunch ons are a result of an instability in the foot yeah what exactly is a bunion everybody's heard of them so and a lot of people have them mhm um it's a transverse instability not where you see the bunion here at the metatarsal medial caor when someone can't control motion at the foot sort of the junction between the midfoot and the forefoot correct then they will start to have this instability this bone all AB bunion is by the way is this bone basically shifting

to the outside yeah so anybody who's seen it will what you notice is you're looking down at a person's foot and you'll see this huge outpouching in what's otherwise the widest part of the foot looks like it just got a whole bunch wider and it's pointing out but when you see the skeleton it's much easier to understand why that's happening yeah so it's this guy going that way and a lot of people have these surgically repaired yes what are they doing surgically to repair that we could talk about this for a long time um just

some facts first with those surgeries okay um a lot of them are not successful and I'm not here to you know there is a time and a place there is a time in a place but I would be very cautious about getting foot surgeries right for symptoms so what they'll do is they can either shave part of the bone down and then realign the toe and often times they will pin the metatarsal to the caor so they stabilize where most people have that instability once you start pinning things together you might take care of alignment

right but you've done nothing to to strengthen the muscle that allowed this to correct get there and you know the conversation of um my mom has a bunion my Grandma has a bunion and my response to that is you don't come out of the womb with a bunion you might inherit connective tissue laxity for example or there might be um hypermobility issues but if we know that just like we talked about with the kids earlier the earlier interventions right you get them in the right foot Footwear you make sure they're in shoes right that have

a toe box where the toes can actually splay especially if you know that your mother has a bunny mhm um I think what's fascinating about the big toe is if you look at your nail bed some people that have bunions the nail bed will be flat and it'll just look like it's adducting all right so the here's the bunion oh I see what you mean y right but the nail bed is flat when you see that it's typically from Footwear when you see the nail bed and it's actually rotated cuz you see some of those

people right where the nail bed's kind of turned in and there's looks like it's a rotational issue y you know for certain they can't control rotation which is cool because now you're like okay let's I mean I have one of the reasons I got into all of this was I have bilateral bunions on both of my feet due to the fact that I was constantly in point shoes and then my solution to that was I'm just going to start bracing my feet because they hurt so they just just got weaker and weaker and then I

was like some this is not right so we started strengthening them getting us in the right shoes and it's different different ball game and what's a hammer toe while we're at the topic of common pathology so bunan very common hammer toes are basically when the toes start to hammer the ground all of them are just two through five two through five the big toe can Hammer it's just not as common as two through five and this is why when you look at hammer toes so this would be the the top of my foot we have

extensors short toe extensors but we also have long toe extensors so on the top of the foot the short toe extensors are doing a lot of work and the long toe extensors are not yeah this is one of those things where if you're listening to us this is very difficult to understand it's it's why watching what you're saying makes a lot of sense and and and again just so folks understand the extensors would be pulling back the flexors would curl forward and so it seems counterintuitive to say how can a hammer toe be in part

driven by this extensor phenomenon well if the short extensors the ones that attach with a shorter moment arm are fired up and the long ones are relaxed it actually looks like a hyperflexion yes and for people who have pain along the bottom of their foot so along their metatarsals um if you take out your insert of your shoe and you see a lot of wear underneath like the second or third metatarsal you know you're probably walking around with too much pressure going through there so on the bottom of the foot it's the exact opposite I

have my short flexors that aren't doing anything in my long flexors who are so hammer toes is it's a muscle imbalance due to a weakness in the foot and what do you attribute the root of that to if the bunion seems predisposed um not putting aside genetics and other things like that but just environmentally if the predisposing feature of a bunion is shoes that are pushing the big toe in what is the Environmental trigger that is most commonly driving a hammer toe I think it's the same thing I think that we have not been paying

attention to our feet for a very long period of time and if you think about if you were to walk around with your hands and mittens yeah for 20 years you shouldn't be surprised when your hands don't function yeah it's literally that it's the same concept at the foot really that it is everywhere else in the body I think we just don't think about well it's not even mittens right if really think about it for most people you know if you think back to being a kid like you could still move your fingers in mittens

it's actually like mittens that don't allow you to move your fingers yeah that is that's the better analogy um and yeah if you were to spend 12 hours a day in that situation it would be um obviously cumbersome so let's go back to the intrinsic musculature of the foot I know we're going to talk more about intrinsic and extrinsic foot stabilizers when we get into the gym there's a couple key muscles you know I think they're all key but we don't have time to go into all of them but that are responsible for a lot

of our foot function so for example flexor digitorum brevis is one of my favorites so this guy runs from the heel and inserts up into the failing so into the toes he is responsible he run big muscle it's a big muscle it runs parallel to the plantar fascia yeah he's responsible for decelerating toe extension when we walk remember it's all about slowing things down we want to control it if I don't have good strength of that muscle he shares um load if you will with the plantar fascia so one of the biggest predictors for patients

that have plantar fasciitis so this would be an acute plantar fascial pain is a weakness of flexor digitorum brevis when you look at treatment protocols on how to get people better with planter fasciitis it's like stretching their calves and I'm not saying that's bad but you also have to look at the strength and the stability at the foot and he is a a very big player very big player in the stability of the foot in decelerating pronation you just referred to planner fasciitis we talked about it a second ago it's clearly something many people listening

will understand they will also probably have a ballpark sense of what it feels like and how there's a real tenderness in the arch but can you explain the anatomic structures that make up the planter fascia so the plantar fascia is going to start at the calcinus and it's going to insert into the deep transverse metatarsal ligament up at the forfoot the plantar fascia has a a very key role by the way in stability of the foot okay so I'm going to explain something called a TI bar mechanism so the ti bar mechanism of the foot

is this um I like to call free because we need to take advantage of it where we have a a ligament that runs across the metatarsals when our foot when we're walking and we go into midfoot loading so when all the pressure comes and our Arch starts to flatten and widen when the forfoot spays it triggers receptors in that deep transverse metatarsal ligament okay the plantar fascia inserts into that ligament so it's kind of like this T so when the foot spays it triggers this mechanism of horizontal stability as well as vertical stability because the

planter fascia like a triangle at the for foot now begins to spread under tension while it's also being elongated vertically it's like a fan yeah so that's the beautiful thing about four foot play is it's this free mechanism that's basically telling our brains hey you're about to push off you better get real strong and you better get real stable because we're about to take on8 times your body weight gets me excited right you take that away you take away 4ot you can forget about the receptors talking to you because you're not getting the tug on

them from the deep transverse metatarsal ligament display and you're also not signaling the plantar fascia what would oppose that how narrow does or how much compression needs to be on the foot presumably in the form of a narrow shoe that would prevent sufficient spaying to activate the planter fascia in that regard you know there's numbers out there you say three 3 to 5 mm you know I don't expect people to get out and start measuring this but a good way to look at this is if you were to take out the factory insert of your

shoe mhm and you place your foot on it and then stand on top of the factory insert if your forefoot expands over wider than the insert wider than the insert it's too narrow you can be pretty certain that those toes are getting squeezed and you know sh that's a great rule of thumb I would bet that many of my shoes M don't pass that test and and is it safe to say that it might be tolerable if it's a fashion shoe you're wearing but you certainly wouldn't want that in an athletic shoe where you're running

or rucking or doing something under load I mean you you would argue never be in a shoe of that nature but but right I mean I my daughter is 12 so she always tells me mom why do you make me wear these platypus shoes every every body else gets the we Nikes um I get it yeah but yes I mean the more time we can spend allowing our foot to be in a position where it it can function like it's supposed to the better off we're going to be it's it's very interesting though Courtney because

it it it I mean not to this is not conspiratorial but there's clearly nothing in the shoe industry that is aligned with that right I mean shoes are not typically designed to have that degree of width are they no they're not and but what's interesting um Nike just came out with a baby shoe this is a couple months ago and in their um report of the shoe they said we've done the research this shoe will help your child's development of their foot when you say baby shoe what age does this shoe toddler right so when

they just start first start walking okay technically you would argue maybe they shouldn't be in shoes at all though right at that age I mean they don't need to be if they're walking most of their walking is not Outdoors but okay in the article they said we've done the research and we've created a shoe that has a wide toe box a flexible thin Soul because we want your child's foot to do what it was designed to do and I'm sitting there going yes like but why why why would you not carry that through to adulthood

exactly but they're they're starting to realize it yeah and I think when you look at research from a shoe perspective at the end of the day we want something comfortable on our feet and I would argue that every single one of my patients once I simply put them in a shoe that allows their toes to sway they will always say it feels more comfortable and you think about it from balance are we going to balance better like this or you going to balance better like that it's just not a hard cell yeah so planter fasciitis

itis of course refers to inflammation of the planter fascia what what are the the most common causes of it and how do you think about treating it in the acute sense so you know somebody shows up for the first time and they've got it what what are your thoughts on the differential diagnosis for what led to it and and how do you go about rehabbing it with an eye towards preventing it in the future yeah it's a great question um first you have to make sure that's what it is I mean there's a differential diagnosis

of heel pain I mean you have to rule out um calcal stress fractures for example there's backers neuropathy so people will have Googled and they'll just immediately say I have planner fasciitis so first and foremost you just have to be certain that's what it is and it's a clinical diagnosis it's not like you've got a a an Imaging study that confirms it you you have to sort of exclude other things as you said yeah and you can see a thickening of the plantar fascia okay although rarely I assume that's done correct you're not likely going

to put somebody in an MRI for that no and we'll talk about Imaging later with all that but you know there's a difference between an itis plantar fasciitis and plantar fasciopathy or fasciosis I should say by the time most people get into my office it is it's no longer in in an acute stage because in an acute stage this is your initial injury so it is treated very differently right um Orthotics often can help in those initial stages of an acute injury because because you are offloading and let's just explain to people again I'm sorry

I'm all over the place but the anatomy here is so complicated that I think it helps to talk about pathology to explain it the reason an orthotic can be acutely helpful is because it prevents the full collapse of the arch therefore it takes some of the stretch off the planter fascia is that why yeah and when you talk about what exactly an orthotic does the jury's still out on that but we know it has something to do with Force so when the foot starts to unlock right it's going to it's a load modifier an orthotic

is a load modifier so it's going to modify the load that's occurring at the heel so in an acute situation that's great yeah but if I had a penny for every time one of my patients came in with their orthodtic that they got 20 years ago for their plantar fasciitis I mean be a rich woman because they're like well it helped acutely but research will say two 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 exit strategy and while the you're

planning this exit strategy you need to be strengthening the foot you have to be strengthening things like flexor digor and brevis to be able to share the load with the plantar fascia so in an acute setting they're treated very differently when it's more of a chronic heel pain this is degenerative this is repetitive load they've been walking around on a foot that can't handle load and this then the tissue starts to break down and in those cases for me it is all strength it's load it's not Del Lo even even for a period of time

I mean I I tend not to go that route great and we have conversations I mean there's a lot of Education that goes behind this um Irene Davis who I know you know she's I've had Irene on the podcast yeah her and Sarah Ridge are um looking at research right now where they're looking at patients with chronic heel pain so chronic um plantar fasciosis at implementing minimal Footwear in getting these patients and seeing what happens with them um um if you think of the plantar fascia as a as a connection to the Achilles tendon and

it is connected I assume yes yeah the calcaneus think of it like floats in between the plantar fascia and the Achilles tendon we know that tendons need load so think about that from the plantar fascia perspective you have to load it you have to load the tissue in order for the tissue to get stronger and is the load also necessary to heal the tissue assuming it's not cut yeah I mean if we wanted to jump into loading with tendons it's not that anybody who's had a tendonopathy we always say rest is not good for tendons

it's not that rest is bad you talk to anybody who's had an Achilles tendonopathy if they rest for a week they're like yeah it feels great yeah the problem is that when they go to return to sport or they go to return to walk without having loaded the tendon they're going to be right back where they started from so when we talk about loading the tendons it's because of the me is a mechano transduction so when I load a tendon there's a fascial gliding that occurs so this mechanical stimulus that then gets converted to a

chemical stimulus yeah and then we start to see tendon healing so in that sense it's very similar to Bones yeah I mean you know we've talked a lot about this on the podcast where you have like the most important thing for strengthening bones is force on the bone and that's why uh weight training and grappling believe it or not are the two best exercises for bone density because they put the most stress on the bone both compressive and pensile and The mechano receptors in the bones which sense the deformation use estrogen as the chemical signal

to Signal bone building it's of course why estrogen is arguably the most important hormone here so it's the same thing it sounds like in tendons presumably different chemical transduction systems but it's mechanical deformation signals a chemical to build yeah there's the ocytes they kind of live within the facles of the tendon very exactly what you just said this mechanical gliding kind of shears the cells you get a chemical stimulus and then you start to get the changes within the tendon which I think is really it's just really fascinating so let's go back to the the

person who shows up so you've you've excluded other things you've diagnosed them with indeed planter fasciitis what are the most typical reasons for that presentation in um let's start with a young person a young active person weakness to the foot for certain and when you say weakness specifically within which muscles which which are the prime examples of the muscular sure so when they come in I'll always I have a toe dynamometer so it's this little device did you bring it today I did okay good I always wanted to try one of these yes um I'm

embarrassed to find out where I stack up but we'll see it tests the strength of your toes so it's a little device you put a like a card underneath your big toe and I'll have the patient press their big toe into the card yep um you should be able to produce 10% of your body weight through your big toe okay that's Flex oralis longus when you put the card underneath 2 through five you should be able to produce about 7 to eight % of your body weight when they're pressing their toes down there's a couple

rules they can't lift up their heel and they can't Hammer the toes remember we talked about that hammering that's when you'll see people who love to hammer their toes because it's a compensation for weakness in the foot so that's how they walk it's like I'm clawing my way forward H so when they do that they have to press their toes down when they when you do the big toe the extensor hysis longus are the are two are toes two through five do they need to be off the ground or are they on the ground just

not hammered on the on the ground on the ground not hammered but you're pressing down 10% of body weight I mean these see I love you know you know me Courtney I love metrics right cuz what gets measured gets managed um is this something anybody can go out and do or do you have to I mean you can buy these D you can buy them I think the other thing that's also easy to measure for if someone's going to do it at home is I have a little um laser scanning device I also brought this

today where you would stand um close to a wall and you'd measure from your umbilicus to the wall then you keep your body straight right so your hips and shoulders are straight and you lean into the wall as far as you can it's your toe strength that stops you from smacking your face into the wall that distance should be 4.5 in or more got it so in other words you we could do the trigonometry on that but basically there's an angle at which you're creating a moment arm that you you need to be able to

resist correct it's called the anterior fall envelope cool we'll test all these on YouTube oh boy but it's really fascinating right because those are toe weakness by the way is the single biggest predictor of Falls when we age really so this is really cool most um when you think about falling it typically occurs we're jumping all over the place by the way here um at the initiation of gate so if I don't have that anterior fope if my toes are weak I'm going to keep going and so not only can tow weakness be a predictor

of things like planer fasciitis fasciosis but also toe weakness can be it and is researched by Karen Merkel a one of the single best predictors of falling which is I mean massive yeah I mean I think we should spend a few minutes on that in a moment because obviously we people who listen to this podcast are no strangers to the importance of fall prevention we have talked about it typically through the lens of bone density and muscle mass so low bone density low muscle mass lead to more catastrophic outcomes during Falls obviously the muscle mass

is also a great way to help prevent falling but this is a very specific muscle mass um so athletic person shows up or active person shows up you've diagnosed the problem you have a culpable reason for it in weakness you've already alluded to the fact which says look I'm probably not going to rest you what drives you towards temporary orthotic versus no orthotic and just get right to work so when I've had planer fasci is we've never done an orthotic I've probably had two bouts of it in my life it's just been at work uh

a bit a bit of backing off some of the volume some manual therapy ice and more footwork what's your typical strategy I think it's very individual specific I think you have you definitely have to meet the patient where they are what is their activity level what are they willing to do um what age are they are they going to do this stuff um from a passive perspective um I do like shock wve into the bottom of the foot um medial gastr um the way the medial gastro inserts into the Achilles tendon so we talked about

the gastro there's two muscle bellies the medial gastro sits on the inside and how it attaches into the Achilles tendon is one of the um will prevent ankle dorsy flexion tell people what dorsy flexion is so ankle dorsy flexion is basically this motion when I am walking pulling the toes back basically pulling the foot back yes yeah and planter flexion just for point the toes the other way y point the toes extend the foot yep um that ankle dorsy flexion in a walking gate cycle we need about 10 to 15° you'd be surprised how people

like to cheat the system there so when we get to medog gastr we look and see how is their ankle Mobility is it something I need to address how is their foot strength is it something I need to address and then how is their capacity you know when we are looking at um I always say it's never just a foot problem you know I wish it was it make it easier for me anyway but when I'm watching someone walk remember it's all walking is this um internal rotation when our foot hits the ground so I

don't want the plantar fascia to be down there like a dish rag so not only am I assessing what's happening at the foot but I'm looking at the knee I'm looking at the hip who's driving the car how well can my glute Max for example control the rotation control my pronation so that you know does that having an effect on the structures of the foot so when I look at those cases especially with chronic heel pain it's never just a foot thing I have to carry it up into the rest of the chain and as

you've sort of alluded to the planter fascia because it's so long you can really have that pain in many different places right I mean the the the real estate on the bottom of the foot that is susceptible to inflammation or irritation of the plant or fascia is pretty long is it typically more posterior and close to the heel most of the fibers that were more commonly you know irritated is that medial you know there's a different branches of it if you will so most patients will get that pain kind of at the heel maybe more

on the inside of the heel um and it can be pretty classic where you know it's it's really painful in the morning and then as they walk on it it gets better um that can change its its face a little bit um depending upon how chronic it gets wow so it's a lot more complicated but I mean it it seems to me that all roads keep pointing back to this the the planter fasciitis is a canary in the coal mine that your feet are weak yes and you know that tie bar mechanism that we spoke

of that free mechanism of the vertical and horizontal stability that we have at the foot take advantage of that you know allow the the foot and the toes to splay and do a couple foot strengthening exercises and you know it doesn't have to be difficult yeah and we're going to give people a lot of those exercises to do when we go to that uh section in the gym let's talk a little bit about the extrinsic stabilizers of the foot obviously as their name implies these are muscles that originate out of the foot but presumably have

tendonous attached ments within the foot yes so we have on the you know you have the medial aspect and you have the lateral aspect and then you have the posterior aspect so if we were to start with posterior and we've talked about that a little bit already right gastrock Solus communicating through the Achilles tendon down around the calanus and attaching right through the planter fascia to the forefoot yes um very big guys here the Solus is the largest muscle of the lower leg he is the one that produces a lot of that Force at the

forefoot when we walk and if I'm not mistaken the Solus has more type one fibers than the gastrock slow twitch yeah so it's really the Workhorse that can keep going and going and going maybe not generate as much force as the gastro but far more endurance it is it is the uh it's the PowerHouse of the lower leg um it does create a lot of force at the for it's also very important in the prevention of ACL injuries which I think is counterintuitive given that it's below the knee I mean when you look at any

ACL um protocol it's always hamstrings right so biceps femoris all medial hamstrings strengthen strengthen strengthen but the research will look at and has shown that it's the strength of the Solus that prevents tibial progression I see and if you have if you can resist the tibial moving for the tibia moving forward you prevent the stretch on the ACL in that hit interesting never thought of that it's fascinating yeah and I know you and I have talked about this before but if we look at capacity of of the Solus you know there are numbers out there

that in a seated calf raay so when you're seated the gas shck is is not your biged y so you're focusing on Solus um those numbers 1.5 times your body weight for a single leg calfas you realize I still haven't been able to do this I I want people to understand how difficult that is cuz when you told me that I was like that is insane and then I found my way you need a Smith machine to do the test I don't have a Smith machine so I was at a friend's house who had a

Smith machine and I set up the apparatus I actually had to download I was luckily I had my phone I was able to download the paper you sent that walked through the protocol and you're doing a single leg calf raise where one one foot is doing all the work obviously the other one is not you got a lot of padding on top of the lower femur so that you can load the bar from the Smith machine directly over the tibia and fibula and you I think it was six reps you had 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 body weight and I was like is there any way a human could do 1.5 times their body being clearly there is but I was blown away at how difficult that was um I I I mean I generally pride myself in being able to do the metrics that are considered minimum yeah metrics of human performance I this was a fail it's shocking to me so it's one of the the biggest assessments we will do with our patients cuz I

want a baseline I want to know where where we are I mean we have Ultra Runners athletes I mean they'll come in there and it's like wow oh I've had many people do this test everybody's failed it and they fail it miserably and so and Kyler Brown who's talked to me about that because he works with some of the best athletes I mean he's pointed this out as I think you have which is sometimes the better an athlete you are the better you are at cheating oh yeah I'm not suggesting that that's of my issue

but I'm saying like a lot of these times you'll see really good athletes who can do amazing things and yet they have the they have very poor calf strength and you can't under you can't understand how that's the case so how is that the case that I know we're jumping around I want to come back to the extrinsic stabilizers but again this this is such a fascinating topic when I see people who can run and jump and do superhuman things but when you isolate the Solus it's it's not even able to move their body weight

they are the very good cheaters they find a way you know um but eventually eventually something's got to give and whether that's going to be today with the athlete or it's going to be 10 years down the road when you are not using your plantar flexors and I'm talking in a walking gate cycle when that strength capacity isn't there it's going to rear its head at some point and you might be a fast runner but imagine if you started to to actually strengthen the muscles that made you fast you know the some of the best

marathon runners in the world have the longest to killes tendons right we have the spring of the tendon we have these gastr and Solus that can isometrically contract very strong and then transfer this Force I mean that the strength of the lower leg is so powerful to be able to take advantage of that we have to do it all right so we we'll obviously go through some of those things you mentioned now a lateral and a medial set of muscles what are those large muscles as well they they seem to cause a lot of pain

yes um let's talk about lateral ankle stability okay so you have your peronal or the or the big boys on the outside so pronus brevis is going to insert on the fifth metatarsal okay powerful everter of the foot okay okay so that's going to take us from this position towards the big toe okay pronus longus also on the outside wraps underneath the foot and inserts on the medial aspect of the foot okay so down on the outside of the foot around and under to the medial to the big toe yeah so when it contracts it

flattens the arch when pronus longus contracts this prates yep what he does is he's going to Evert the foot and most importantly this is why the the perenials are a very big stabilizer of your big toe which is counterintuitive because they're on the opposite side of the foot yes so when pronus longus this is the one that goes underneath the foot when he's doing his job he drop we call it dropping the head of the first metatarsal so basically what that means is it takes that bone the metatarsal and it anchors him to the floor

so that we have a stable position push off yeah so one of my favorite exercises is putting a band uh like an elastic you know under huge tension on the floor pulling medially such that and the only part of myself I let contact the floor is the base of the big toe and then doing single leg balance drills so that's actually strengthening outer leg yes very important when patients have ankle sprins for example remember we're losing sensation right we have a a sensory loss if you will you can have dysfunction of your perenials when I'm

walking because Peron is long is drops that first metatarsal down he's anchoring my big toe to the ground if he's not doing his job this guy will stay elevated so he'll stay lifted a little bit so now when I'm walking I don't have this stability at my first Ray and so I'm either going to go to my outside again which means there's my another ankle sprain or people will complain of a pinching on the top of the big toe so there's a difference between a bunion so this is when it goes into the this direction

comes out versus people will see a bump on the top of the toe those are two different animals so if I'm walking and I don't have that first metatarsal dropping when my big toe tries to extend it doesn't have this nice like rolling Glide it kind of jams first and then you get this irritation on the Dome aspect of the toe and it'll get red and it'll get irritated and it's what we would term a functional Alix limitus so a restriction of motion at the big toe and it all stems because there is not enough

muscular force from the lateral musculature of the foot the parent heels to bring the toe down the base of the toe down I mean in my opinion unless there's been trauma like you've dropped a weight on your toe or you've had turf toe or things like that where there's been an accelerated inflammatory response M then yes it is a dysfunction at that first aray which is often caused by a weak foot this is common theme Here instability of the outside of the ankle ankle sprains and if those movement patterns are not um restored and regained

then you start to have this arthritic change at the big toe and that is not fun for anybody it will alter gate it will alter movement so the big meaty muscle on the outer part of your shin is the tibialis anterior correct and does it attach it must go down around the lateral malis as well it's on the front of the lateral malis correct tip anterior comes down and then tip anterior tendon is kind of you'll see it more on the medial aspect of the foot it's a dorsy flexor of the foot biggest dorsy flexor

right so the yeah okay so now we're T so we were just talking lateral compartment mhm we've now shifted you were going around the house y so now we're in the front of the lower leg yep so this is where tibialis anterior and all of your extensors live so they extend the toes there's a couple reasons interesting is sorry to interrupt and maybe you were just about to address this why do we have toe extensors out of the foot when you're walking we always talk about with gate what's happening in stance phase so there's stance

phase when the foot is on the ground and then swing phase when the foot's in the air and the reason why a lot of us give so much attention to stance phase is because that's where all the magic happens right the all the load but swing phase when we're walking you have to clear the ground so when I'm assessing gate I will often close my eyes and listen because you'll hear the scuff as I like to call it where they can't clear the ground these will be your Runners that come in and tell you I

keep tripping over when I'm running I keep tripping over rocks I'm like are you really tripping over rocks or what's happening here because if those tissues can't extend the toes and extend the foot when they're running or walking they'll Scuff the ground and you can hear it so they're responsible for a clearance and swing phase but then also at heel strike here's that Ecentric component when my heel strikes the ground here's my extensors yep they have to be very strong eccentrically because they're going to decelerate my foot hitting the ground so again I'll close my

eyes and I'll listen because if they don't have good control of those pre-tibial muscles tibialis anterior and your extensors it's like an elephants walking down the hallway cuz it's foot slap after foot slap these patients will tell you they have shins splints they have medial tibial stress syndrome because they just can't handle the repetitive motion of their foot slapping the ground without control of those muscles very interesting Okay so we've got these three pockets of extr extrinsic um stabilizers the intrinsics let's talk a little bit more about the common pathology that you see so we've

talked about a handful of them already what are the most common pathologies you see due to the interior and lateral compartment yeah and we missed the uh medial aspect too because oh let's yeah let's go back to that from um so the medial the big boy on the medial aspect is where you'll see a lot of injuries as poed postor tibialis so posterior tibialis like I mentioned earlier comes down along the medial aspect of the foot and it's a very big stabilizer of the inside of the foot and it's sort of as I'm feeling my

own leg under the table here it it it's it's very difficult to disentangle it from the gas Rock the medial head of the gas Rock isn't it they they seem very close to each other when you if you were to um put your foot on your knee Point your toe m mhm and bring the sole of your foot towards the ceiling yeah you'll see a tendon that kind of pops up along the medial aspect of the foot that's post tib yeah and that's the one that when we get into the gym we're going to work

on that um exercise of relaxing the post tib while we allow the arch to descend yeah I mean posterior tibialis decelerates pronation mhm it has to be and you know fun fact if you look at EMG activity and call it what you will some people don't love EMG activity um just because there's a lot of a crossover y but posterior tib you will see activation from that guy from the second of foot's on the ground until propulsion he's one of the only tissues muscles where you'll see this constant activation and therefore we need to pay

attention um because of its attachment it rotates so that tendon has a 45 Dee rotation before it inserts so when we talk about those energy storage tendons of the Achilles and the post tib very very important for um you know free energy and propulsion and because of how it attaches it has to be trained in those planes in rotational or transverse planes okay um let's go back to pathology there yeah what else do you see so I think probably the most common diagnosis that we will see we've discussed one of them already is heel pain

so plantar fasciopathy um lots of tendonopathy so your Achilles tendonopathy and your posterior tibialis tendonopathy um we know that these tissues need Movement we know that these tissues need load and I think it's important to understand it's not that we want necessarily you know yes we want strong calves but from a tendon perspective we want a tendon that is healthy which means you have to load it and that goes for both the Achilles as well as post tib as well as your peronal I mean many people have peronal tendinitis as well interesting is that predisposed

by lots of ankle sprains or is that more a function of just weakness in the musculature um I think there's a lot of factors you have to look at you know do they have the Integrity of the musculature um um have they had a history of ankle sprains that have just never been re rehabilitated appropriately but think of you know the post Tib and the pronus longus is like a sling it's this beautiful sling that stabilizes the foot and they work together and when you have one side that's not helping out the other side you

can start to have these changes within the foot you alluded to Imaging earlier how often does Imaging play a role in your diagnosis do you tend to rely mostly on the clinical history the physical exam and then IM like yeah what what fraction of the time do you rely on Imaging I think the biggest time and the most important time at the foot especially with imaging is ruling out stress fractures especially when you're dealing with uh Runners and things like that um but as far as everything else I mean if you look at research on

doing MRIs for example for tendonopathy that in Achilles it really doesn't give you all that much information that's valuable because you can see a tendon on an image and it'll be like wow what's going on here and it doesn't correlate with subjective or even so it's not that different from the back where the MRI you know you're going to you you image a lot of people that feel nothing and you'll see horrible looking backs you image a lot of people who feel fine and you could you know the reverse so um stress fractures make sense

MRI probably better or CT what's the diagnostic test of choice for a stress fracture I mean I like diagnostic ultrasound really mhm I think it can be more um accurate um but yeah the MRI I just I rarely will order that just because it doesn't really give me the information that I'm looking for interesting um let's go back to the Achilles I I don't know what it is in my old age AG that has made me so paranoid of an Achilles injury I've had one bout of you know tendonopathy there that took God probably like

3 months to really resolve now in that three months I didn't really have to do anything different I mean I just did a lot of training but I would wake up every day in quite a bit of pain it got better as the day went on but it you know it it was it was it was uncomfortable but I had this huge Panic that at some point I was going to tear it you know doing some of the jumping exercises I do and things like that and um you know how much of that is um

I I never want to say the inevitability of age but how much of that is due to tissue pliability of Aging as a as an additional predisposing Factor yeah clearly there's a load component to this right there has to be some insult um well first let me say consider yourself lucky it's 3 months mhm um these tendinopathies at the Achilles if you look at research I mean you're talking years 5 years 10 years where people will still experience symptom at their Achilles tendon so a lot of um my work in talking to patients with Achilles

tendonopathy is just that it's the education part of it because most people are afraid that they're going to rupture their Achilles tendon and I have to remind them that is it is one of the most robust tendons that we have um there's less of a chance of you rupturing it but you have to be aware that discomfort is probably going to stick around for a lot longer than you want it to so when we are rehabbing these um if they wake up in the morning that's a lot of the times where you'll get feel that

tendon stiffness I tell them if we're sit sitting at like a and I'm not a big fan of e scales I don't like to focus on how bad people are feeling but from for that measure if they're sitting at like a five out of 10 for example that's green light for us that is not rest that is not stop that is still go yeah and In fairness I was never above 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 pain

in a lot of other parts of my body but to wake up and every day be at of five out of 10 we're just walking to the bathroom I'm like good Lord yeah I mean that was very uh frightening from the standpoint of is this a harbinger of a catastrophic injury oh yeah and you know there's really three different types of an Achilles tendonopathy or injury and I think that's important to note because they all they all are looked at very differently so most when people talk about an Achilles tendon aathy it's at the mid

tendon portion mhm so if you were to you know squeeze your Achilles tendon yep kind of right in that mid portion those are typically the easier ones and by easy I still don't mean easy but easier ones to treat then you have an insertional Achilles tendonopathy where that um irritation is at the calcinus so right where it inserts those can be extremely difficult because with those the Achilles tendon breaks down on the front of the tendon we know that tendons need load so for those guys you have to make sure when you're doing your calf

work for example that you're getting as high onto your toes end range plantar flexion so that you can start to load that appropriately those guys don't like to be stretched all that much so there's there's different things that you do based on the location of where that tendonopathy occurs sorry in that case you would really minimize any dorsy flexion mild you just would you wouldn't go on a super deep dorsy Flex yeah like off the stair yeah everybody likes loves to do off the stair stuff and I'm like can you do it without how does

your form look without going into a negative yeah because when you drop that heel down into a negative if you don't have good midfoot stability and the whole thing just looks sloppy I'm like that's game over over for me and let's again because I I I I want to come back to reinforce these terms midfoot stability we've talked about what the midfoot midfoot is anatomically now explain in exactly that setting because that's a very common movement right which is hey I want to do a negative when I'm doing a tow press of some sort what

needs to be true of the midfoot for a person to be able to do that going back to the anatomic structures we've already discussed when you are looking at someone from the back okay and if I was looking at them with their heels off the back of a step as they go into that negative if they can maintain the Integrity of their foot so in other words when they drop the heel down I don't want to see this collapse or this excessive medial drive right where the whole foot just looks like it can't can't even

hold itself up and which presumably those are more intrinsic failures or are they potentially also extrinsic it could be a bunch of things right could be everything down to the ligaments if they have poor anle dorsy flexion Mobility so if they can't dorsy Flex here they're going to steal it mhm what's the minimum angle of dorsy flection you need to be a functional human who can walk Walking gate we need about 10 degrees running running you need a little bit more but if you think about when I'm training someone I don't want to train minimum

deg course not right so I want to give people movement variability the more movement variability someone has the less um I won't swear the less uh oh no moments we have right so we have to be able to give people movement options so when PE I have assessment that we'll do and I'll say okay we're at 10° and it's actually really cool you can just use your um iPhone right there's because it has a built-in utilities then it goes to measure and I'll measure their dorsy flexion I like to see about 35° wow you'd be

shocked at what people give you and they'll say well I only need 10 degrees in order to walk well do you sit in a chair do you walk up and down a stair because if you do any of those other motions you have to be able to have ankle dorsy flexion and Ankle dorsy flexion is a huge lack of range in the foot and there's three big compensations that you will see for people that don't do that the first is when they're walking they'll lift their heel up early so it's an early heel rise MH

now remember what we talked about with eight times your body weight going through your forefoot do I want to increase that load no do I want to speed it up no so problem number one there next what people will do is they'll hyperextend their knee so it's called a Varys thrust gate so because they can't dorsiflex the knee goes well let me help you let me hyperextend to propel you forward so these patients will come in and tell you um my knee feels wonky the back of my knee feels unstable and you have to look

at the ankle because it could be feeding why they're doing that hyper extension at their knee could be the reason how do these people find you because you're you're you know your your your Fame is through treating the foot are they finding their way to you because they're hearing you on a podcast talking about just that or are there other practitioners that are aware enough to recognize knee pain p and say actually your knee pain is a compensation for your gate yeah I mean I've been teaching these courses now for a while and I think

a lot of um the referrals now are coming from other Physicians other pts other doctors um I work with uh a couple clinics in Colorado so and it's really it's been really awesome to see the medical community really starting I mean we've had patients who um you you know we'll have hip replacements and the feedback on the other end of this sometimes is you don't need to retrain your gate and now we're getting a lot of these referrals and going yes you do like these are all things you need to pay attention to so the

word is spreading about the importance of what happens at the foot and how that can affect above the about pretty much everything else got it okay so we were back to the compensations for weak dorsiflexion yeah so we have early heel rise yep we have a hyperextension at the knee yep and then the third strategy is that collapse right um yes but if we're moving up the chain oh okay the third one that people will do is they'll simply fall forward they'll take they'll Bend forward at their hips they'll use forward momentum to carry them

forward so now they're in your office with low back pain and it's it's coming it it's a direct reason because they cannot dorsy Flex their ankle so I'm still a bit confused by this um when an individual comes in and let's say you make the diagnosis and the diagnosis is that their range of mo motion on dorsy flection is insufficient they're at you know 8 degrees or even 10 Dees which we've acknowledged is kind of the bare minimum for walking um what is preventing that person from being at 20 or 30° is there something within

the bone or is it neurologic where their body doesn't trust itself enough to appreciate a greater angle it's such a great question when you are assessing pretty much any joint you want to see consistent patterns so if we were to take this with a squat for example when people try to deep squat if they can't do it right so they'll go down into a deep Squat and they'll be like I just can't go any further and I'll say why is 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 over to my squat rack and you're going to hold on to the squat rack and I want you to deep squat again if they still can't do it then I know that there's got to be some type of muscle or joint restriction that's preventing them from getting to that range so so that could be muscles that have shortened we might need to implement um stretching protocols we might have to implement joint mobilizations down at the ankle remember the taus if he kind of floats forward you can get a

pinching so there can be a a pinching in the front of the ankle when people try to stretch okay all of those things would be a consistent pattern because there's a muscle or joint restriction but if they can't squat but they can go into a deep Squat and I would argue Peter most people can most people as soon as they hold on to something they go down into this beautiful Squat and that's when you're saying to yourself there is a neurological inhibition here this person is screaming for stability and that's when we're wasting a bunch

of time going I want you to stretch your calves for the next 30 years and you're not going to see anything that's not what they need and then it comes down to proximal stability how do we create stability how do we create a safe environment for their brain and their body so that they want to go into a deep squat because they need to go into a deep squat yeah I mean I I I've shared this story before and um it's it's worth sharing again which is that um when a person is under anesthesia they

can be stretched into positions that they never imagine if they're not under anesthesia and you might say well okay so what but they're probably going to get hurt but they don't right like you can take a person who can't touch their toes and again when they're under anesthesia you could almost fold them in half right you could get their palms past their toes and when they wake up from anesthesia they will not have torn a hamstring yep and you ask the question how is that possible and it's possible because neurologically they are being inhibited from

doing that because the body says you are not stable in that position to me and and I'll give you an example one more time I I had a guy that once when I first was learning this I was in a lot of back pain and I was so stiff I couldn't touch my toes and he walked he he took me through a 30-minute exercise of increasing intraabdominal pressure and within 30 minutes my Palms my you know the my entire Palm was past my toes I mean again did did I get more flexible in 30 minutes

of course not but by generating High degrees of intraabdominal pressure my back relaxed enough that it allowed my body to move to that spot um this to me is one of the most difficult things to both identify but more importantly to be able to train because in a way it is a light switch right but then it h the the the circuit has to be grooved a lot to for that to become the new default so how do you go about doing that given a its ubiquity uh and B its complexity I think that assessing

patients for proximal stability is mandatory it's absolutely mandatory and I'm a foot person so I'm if I'm far away from where we consider proximal stability and creating intraabdominal pressure but if you were to um look at someone and I'm I'm always going to take this down to the foot there's something called call it a you know my if you think of your pelvis as like a bowl of water yeah right if I were to stand and dump out all the water right you have a forward tilt to the pelvis that also can happen when the

the rib cage would flare okay and we call it an open scissor posture so when I'm assessing these patients I'm looking at can they stack their rib cage over their pelvis do they have good breathing patterns can can they breathe 360° around their belly can they expand their rib cage because if they cannot do those things and they stay in this posture if you were to stand up and dump all the water out tell me what would happen to your feet cuz I'll tell you you will feel all of this medial pressure along your big

toes you'll feel your arch kind of collapse if you will and this is where pronation gets a bad name yes you know in genu valgum right everybody's in don't let your knees not I'm like tell that to a hockey goalie who stands there for three periods in a valgus position at the knee I I don't believe there's any bad posture positions it's only bad if you can't control it and you can't get out of it you have to be able to do these things I have to be able to protract my shoulder I have to

be able to Arch my back you just better control it and be able to get in and out of it yeah I think this is worth maybe double clicking on a bit Courtney because a it's not a conventional view it's not a mainstream PT View and I'm not throwing PT under the bus it's not a mainstream anybody View and yet I've heard it enough from the people who I think are hands down the best at movement that we should reiterate the point there is isn't a bad posture per se but control is what matters and

you could argue that the best movers on the planet frequently engage in what would be viewed as quote unquote bad posture yes yes I mean I don't think we were all designed to look like these robots and be in these like perfect postural positions it's just not realistic you know I think some of um I'm just thinking of golf my father was a big golfer and we used to watch um Arnold Palmer swing a lot and if you've ever watched Arnold Palmer swing you be like how's this guy so good you know um but being

able to create this stability to your system and to be able to control these different postural positions is key it's key to be able to get in and out of and if you think about that at the foot it's not that pronation is bad we have to do it it's our first opportunity for shock absorption when we walk we have to be able to then get out of it yeah and the person most commonly who is in the open scissor pattern they're they're stuck in that position they they aren't able to get out of it

and therefore they're equally ineffective at shock absorption yes and there's this disconnect Peter it's when I have patients stand in front of me I'll have them tilt their pelvis forward and I'll ask them what do you feel at your feet and half the time like nothing there's this disconnect between my pelvic motion and what my foot should be doing when my pelvis dumps forward you should feel the feet drop when you tuck the pelvis back you should feel the Arches lift and that's this kind of motion this Dynamic motion that the foot is capable of

doing you said something earlier um when we were speaking about how our propri acception and sensory um appreciation of the universe changes as we age um now that I'm over 50 what what's what's changed in my a sensory apparatus of the foot we talked earlier about um how Falls are are prevalent and how there's really factors that contribute to these Falls we know one we've talked about this is a weakness and toe strength that changes and I think the numbers are like a 35% decline in strength right over what period of time that's a good

question um I'm not sure um when you look at between presumably something young and something old correct and especially there's a very big change when you look at the jump from 50 to 80 for example mhm so we're looking at the 35% decline right in those ranges so not only does strength decrease but we have four different types of receptors couple fast adapting and some slow adapting receptors they're responsible for gaining information so that we can maintain our Center of mass for example as we get older so let's start at age 50 you lose 20%

it takes 20% more pressure to stimulate these receptors Now versus when I was 20 correct so as we age the sensitivity of The receptors decreases now here's where it gets a little scary when we go from 50 to 85 at 85 we now have 75% decreased sensitivity to these receptors that's a lot what's driving that I think is a lack of strength at the foot because here's the good news exercise we know increases circulation to the sensory nerves so we if we exercise we're going to have increased circulation to our sensory system we have increased

nerve fiber branching when that happens with increased nerve fiber branching we have increased sensation and that has been found to decrease pain and improve sensation even in patients with peripheral neuropathies so maintaining strength in function at your foot I think obviously will decrease the decline of toe strength but also increase the um ability for us to feel the ground which is imperative from being able to walk upright and being able to prevent us from falling and this sensory decline how much of it is superficial you know meaning you can test it and assess it using

the standard metrics of you know like Tak an alcohol pad or a cotton swab on the you know cutaneous branches and how much of it is much deeper I mean I'm guessing more of it is this deep part that is dependent on significant pressure or but I don't really understand there's a um I did bring it too there's a 256 uh frequency uh vibration tool okay and what you can do do is you'll have the patient laying down and you take this uh 256 tool and I'll tap it on the ground right and I'll put

it on the base of their heel and you get three chances right you're you're changing what you're doing and can they pick up the vibration and it's it's actually the um accuracy of that test has been shown to be um more accurate than the like the nylon you know pricking of the foot interesting and I it's it's an easy vibrational sensation is and and by the way that that's that makes sense because that strikes me as a more complete form of sensation than because the nylon thing is mostly cutaneous yeah um okay well as we

talked about a minute ago actually you know what let me do something before we go to Falls I want to round out a couple of other injuries there are a couple other toe injuries that are pretty common yes let's let's talk about um so you want to start withis restrictus yeah so um we will see this a lot and I think a lot of it has to do with um poor Footwear selections right we talked about The Chronic ankle sprains and the inability to you know allow the first metatarsal to drop um but a functional

HX limitus we need about 40 to 45 degrees of range of motion at the big toe in order to have an efficient walking gate yeah this is this is my only superpower I'm I'm probably like 90 degrees at my HX and you know excess range of motion is great as long as you can control it remains to be seen so if I wanted to Sprint though I would need 65 degrees right cuz you're more on your toes yeah and this is where I've seen a lot of former NFL players who get horrible turf toe that

have what literally looks like 10° if if you can catch these patients before they've had so there's stages right so the what will start to happen is you'll get an inflammation on the top of the big toe yeah okay then and and is the primary pathology just the repeated jamming of that toe right the instability at the the first Ray and then you they can't drop the B the first metd down so they start to irritate the top of the joint it'll be red it'll be swollen and these patients suffer um I'm on a Facebook

group for Alex rigidus um it's a support group and the reason I'm on it is because I find it like there it's a constant battle for these people for Footwear because they just need they're like I need a shoe that's going to eliminate me using my big toe because it hurts when they try to extend it and have these patients all experienced trauma no if they've had like something fall on their toe if they've had turf toe then yes but a lot of them this is weakness this is poor Footwear that's why I think a

lot of these diagnoses at the foot can be prevented this is proactive Healthcare MH you know I mean you want to talk about your eggs in your book I love that story okay there's no better way to stop the eggs from being thrown than by taking care of our feet from the ground up but I digress so your is your treatment let's assume that the trauma was in the past they're not it's not an acute issue is the treatment the same where you know you have to get Mobility back by strengthening yeah I mean when

I I always say earlier intervention is better even if there's been trauma you do not want to immobilize something we know that when you immobilize it starts this Cascade where you know you start to change the neurological input to the tissue MH um and it it just really will create an environment where movement will be altered so even in those initial stages we're doing like big toe ranges of motion I mean it seems so um I always tell my patients if I don't get excited about you exercising your big toe but you have to be

now sometimes remember when I had my little toe injury three months ago which still hurts like not as bad but it's amazingly sore still um that first weekend when I was you know the thing was black and blue you still had me doing isometrics I'm still doing them by the way and they do any time I'm in pain five minutes of isometrics actually makes me feel better why is that I am I call isometrics my pain meds for my patients yeah so tell people what I'm doing yeah tell people the exercise you had me do

and why it's help with the big toe what we'll have if there's um an irritation in the joint per se and and just so people know the injury I had an injury where I got hit on the front of the toe so it just jammed the toe back and I I sent you a photo the next day the I've never seen I mean you've probably seen this for me the entire side of the foot was just black and blue um I didn't I didn't get anything x-rayed cuz I didn't think anything was broken I was

going to ride it out and within a few days I knew nothing was actually broken cuz I Could Touch the bone the pain all seemed to be ligament pain it was and to this day it's still very tender to touch the side and I think when if someone looks at their foot and they see that they're like oh my gosh I better just do nothing do nothing but yes right away what we had you do was you know put the toe in a in a position of a little bit of extension or something that was

comfortable and then you're basically just Contracting on both sides of the joint so you're pressing down and then you're trying to lift up but you're getting some type of movement um isometrics um the reason I call them my pain meds is I will tell my patients whenever you feel pain isometrics are safe for you to do because what they do is they decrease cortical inhibition so when we have an injury think of it we'll go to a race car okay we have a cortical accelerator right so information coming from our brain and we also have

brakes we want the accelerator and The Brak to be in balance of one another when we have an injury our brains our foots on the break so if I'm trying to change my movement or improve my movement pattern I got to let off the break and that's what isometrics do they decrease that cortical inhibition and to be able to do that right out of the gates is extremely important yeah before the damage sets in you create a long-term pattern of rigidity yes so when you can find these patients that still have you know when you're

doing a calf race for example someone who has pain at their big toe they'll be like I cannot do that it hurts too much it's pinching but I'll have I'll put a band around their ankle for example and I'll pull it to the outside remember that's where pronus longest lives on the outside of the leg so I'll challenge it a little bit so that they really have to press through their big toe to keep their big toe on the ground when they do that they're like wow that pinching is better because I dropped the head

of the first yeah there is something so magical about using bands for lateral and medial tension to produce the necessary engagement of the foot stabilizing muscles when you go and do other things yeah I mean it's the k aesthetic queuing I think is so important so important especially in those planes that's why the foot's I mean it's this multi-directional like beautiful thing that we can train so many ways so what else are you doing for the rigid as patient so you obviously isometric is a big part of it how do you get the range of

motion how do you slowly introduce that range of motion back if they are in a functional halex limitus which which means that they can still um utilize their big toe based on if I increase strength of pronus longus for example if we work on range of motion at the big toe all of those things are key if you don't do it then it will progress into HX rigidus and I don't consider those the same diagnosis halex rigidus there's been so much arthritic change to the Joint that now you maybe have five degrees so the toe

is basically fused almost so rigidus you're associating with the Bony arthritic changes whereas limitus is hey your bon you still can anatomically move you are limited because of the musculature and you'll see some type on I mean on a film you may start to see like an exostosis or like lipping right because they there is you know Wolf's Law they'll start to have changes within the bone but it's still a functional joint and that's when I get excited cuz I'm like let's do this let's fix this thing because if not if that progresses to H

rigidus it's game over now our treatment has completely changed meaning that I have to look at putting them in a certain type of shoe that's going to rocker them through their toe because they now have lost 4ft rocker they cannot rocker through their toe what percentage of people with h limitus will progress to that phase of disease unfortunately quite a bit wow because this uh message isn't quite out there as much as it needs to be because those two diagnoses are often um married when people start to see um arthritic change at the toe they're

like wow this is halex rigidus I'm like no it isn't actually you still if I drop your metat tarsel down I can still give you 40 45° hold on a second let's train this thing but without knowing that and you start to have pain at your big toe the very you know the initial intervention is carbon plate under the toe so they sell these little inserts where you can put in your shoe so that your big toe isn't bending at all some type of um orthotic or very stiff shoe and these patients are be like

oh this feels great and I'm like yes because you're not moving it anymore but if you stay on that path too long you'll lose the ability forever correct and you want to talk about what happens up the chain when I see patients walk with halex rigidus for example they can't roll through their foot so they can't push off at 45° out of their big toe so now what they have to adopt is this is what their foot looks like so they have more knee flexion for example and then their hip has to be flection right

and it's like what are you doing but you know I always want to instill hope because there's always hope you have to um do that and even if patients have a fusion in their big toe even if they have Helix rigidus you've lost range at one joint but you haven't lost range at your ankle and you haven't lost range at your knee or your hip those range of motion those ranges of motion will be compromised but let's just train them let's rocker you through the big toe let's give you drills to give you knee extension

to give you hip extension because we know you're not going to have access to it any longer so let's just give you things to work on and that's where I think I want the two worlds to marry right like often times there is a time and a place for these surgical interventions but once that's done there's so much more that can be done so that we don't start seeing sequella of that up the kinetic chain how often are you seeing people that have kind of autoimmune forms of arthritis in the in the Foot and Ankle

it's a smaller percentage of my patient base but they do make their way into my office and a lot of the times where I will see that is more at the midfoot where they'll have a lot of this arthritic change at the midfoot and aside from obviously the medical management of that with you know pharmacologic agents what are the most important things you're doing for those patients to Foster midfoot mobility and strength again we're meeting patients where they are you'd be surprised even patients that have had three and four foot surgeries because that's typically what

I will see little things like um toe yoga right so being able to lift the big toe only lift the four toes lift all the toes and spread them all of those little things are sending information to your brain that these people haven't seen in a very long period of time if ever so with midfoot um issues isometrics if I can get a little bit even a little bit of isometric activity out of them we're doing it we're going to talk about Falls in a second and that we can use toast strength which is part

of the you know the reverse of some of those things you just talked about is toast strength most a midfoot intrinsic capacity um well flexor digitorum brevis is a big muscle in regards to toe strength um when we do one of the videos I'll talk about the wink sign okay okay because that's a a sign you can see in the toes to know you're engaging the muscle appropriately okay um that like forward leaning we want to be able to feel the intrinsic muscles of the foot so feel the arch um a lot of that help

helps these patients with this midfoot instability you know the intrinsic muscles of the foot you know when people do like uh the short foot exercise okay I kind of call it the clamshell of the foot because it's a good place to start but it's not uh functional because the intrinsic muscles of the foot come into play when the heel comes off the ground at forward propulsion when those toes need to be strong right I mean if I was treating you for hip pain and I gave you I want you to lay on your side and

do clam shells forever I mean great but is it functional do you ever do that right so we have to marry these um treatment plans with function and I think especially with toe strength you got to really work on that type of you know movement and tissue strength so let's now go from tow strength back to Falls since you said that the measurement of toe strength is one of the greatest predictors of fall risk um it's a huge problem yes the mortality is enormous once you reach the age of about 65 um so what do

you think are the most important things that we need to be training to minimize the risk of a fall first and foremost tow strength that is the single biggest predictor of falls in the elderly is a weakness strength it really I would not have guessed that and when we get in and start doing these exercises I mean I think it is an imperative you know how kids get scoliosis checks I mean we should be checking kids feet that that's when we need to start paying attention to this stuff because if we start training these things

once we get to this age where toe strength is a massive deficit we'll be ready for it so toe strength for certain I'm very worried about what my toe strength is going to be when we when we bust out the uh the dynometer well neuroplasticity is a real thing so we can train that up for you very good um so toe strength um ankle Mobility that's another one that we'll look at and more important in the planter dorsy plane or in the inversion ersion plane in both so when I assess um you know I have

a fall prevention protocol Dr Tommy sh has put together an excellent F prevention protocol um and him and I have worked a lot together on this so we'll look at um ankle dorsy flexion so we want that to be about 35° but then we'll also look at inversion and ersion which is basically going in and then going back out again um a lot of The receptors on the foot live on this outside lateral aspect of the foot so we talked about how a lot of Falls occur with the initiation of gate the other plane where

people will fall is to the outside so when they go to step if I have less um sensitivity to these receptors on the outside of the foot I can't feel where am I going I'm going to the outside M so that's why we'll look at the ability of the ankle do I have good range of motion both in and out and going forward the other thing obviously that we'll look at is balance um really cool studies looking at vestibular um function modulating activity of abductor halis so remember that's the muscle that straightens the big toe

abductor how is is slow twitch muscle fibers so that guy's not real good at movement coordination per se but he can last all day yeah and from a balanced perspective it's the um um muscles that you know are receptors that can really hold our bodies up and that AB ductor hysis is a big boy so we look at single leg balance for example we also want 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 ground it's my glute right when I

go to heel strike that guy is in charge so I want to make sure I have good capacity going up into the chain and how much of that is the glute me versus max depends on where we are in the gate cycle so when I'm walking at heel strike that's all glute Max okay I think people as you start to propel you need the Mead to stabilize and what do you externally at this point you need to be able to abduct the hip right yeah so I'm walking I heel strike mhm okay I have think

of it as a skewer so I have gravity at heel strike that's causing everything to internally rotate it's my glute Max that is a very big controller of torque he's going to slow things down coming from the hip once I get into midfoot stance or loading now I need to make sure that I'm not swaying all over the place that's glut me so all of those tissues come into play to help stabilize my body and slow everything down my boys are so obsessed with talking about butts right now that over the weekend in some lame

attempt to shut them up I said guys the butt can be better described as the gluteus maximus and it's the largest muscle in the body if you want a little fun fact which now turns into them running around the house screaming glus Maximus glus Maximus and I'm like I don't think I I'm like I don't know that I've done any better here this is just as annoying um and I I pity their teachers well I mean if you think about it because I'll have patients that do this right because they'll think that you know when

I'm walking I'm going to like you know it's going to be this big old glute exercise and as they go to push off they'll squeeze their butt and I'm like it's the wrong spot you want to squeeze your butt you want to try to control it right and I really don't ever give people gate cues when they're walking because it's just too difficult but that's not when you're pushing off if you squeeze your butt when you push off all you're going to do is throw yourself into too much lumbar extension yeah it's that at heel

strike and that's when we have that Ecentric control well I I'm looking forward to seeing what the fall um prevention protocol looks like especially as far as the tests that we can do yeah let's talk a little bit about shoes we've yes talked about it a bit at the outset but um I know that it's going to be a topic that anybody who's listening to us right now is going to want to understand hey what can I do for myself presumably as an adult um and I do think there's going to be a lot of

people who listen to us who have kids who are going to also say hey if I've taken anything away from this I've taken away the idea that this begins early in life and therefore I want to maybe even save my kids some of the challenges I've had what can I do for them yeah um I love this question I could talk about shoes uh for a very long time if we talk about kids first I think first and foremost just let their feet feel the ground as often as they can all different types of surfaces

um there are way more um shoe and Footwear companies now than there were when I started this whole thing 20 years ago um I think the word is catching on and we're realizing the importance of all of this um with the kids obviously the and this is with everybody the toes need to be able to splay that's a wide toe box for me is a non-negotiable and are we defining that by the insert test meaning the St put your foot on the insert and make sure that when your weight is on your foot you can

still see insert it's probably the um easiest way to you know kind of access that but I will caution you that these companies are getting smarter I've called all of them pretty much the last of the shoe I'll grab a shoe I have one so this is oh this is the last of the shoe okay in order to change the last of the shoe it's very expensive so what the the companies will do is they'll change the upper of the shoe so they'll put like mesh so when you go to put your foot in there

it feels like you're you have all this room and it's not because the shoe was wider it's just because they put a material on there where your foot can actually expand in it and there's also a very big difference between a wide toe box and a wide shoe those are two very different things a wide shoe which most shoe companies have will give you width here but it will still taper at the toe and not what we want right because I want remember the tie bar mechanism I have to have that 4 foot to trigger

the response of hey I better get stable at push off so that's when I need my toes to be able to SP as well so a wide toe box is mandatory with kids footwear adult Footwear whatever um I mean I what are the shoes that have wde would that be considered a wide toe box yes so this is a zero yep okay I'm a big fan of these shoes um there are so many companies out there right now um Vivo Barefoot toist I mean I could go on and on and on about those I have

a list of them too um so we'll we'll put that list in the show notes so that people can sort of see what you would consider wide you know shoes that make a wide wide enough toebox for yes and I have them listed according to category right like this is a athletic shoe this is a casual shoe this is and we have so many resources for that because it it can get very confusing because you're people will be like I'm in a wide shoe I'm like you're not you're not in a wide shoe um so

that's kind of Rule Number One MH the other thing with functional Footwear is looking at the heel and the toe where they sit so so this is a zero drop this this is a zero drop where the heel and the toe sit on the same plane okay that just makes sense doesn't it that's how we were designed to walk most shoes and I won't throw out names here but most athletic shoes most running shoes if you Google the model of the shoe and Google Heel To Toe drop it'll tell you how many millimeters it will

tell you how many millimeters the heel is higher than the toe any thing that's not a zero drop by the way in my world is a high heel interesting now I have started I switched my rucking to a shoe that has an I think an 8 mm drop once I was having all of that Achilles tendonopathy and I have enjoyed that shoe much more so I no longer Ruck in a minimalist shoe probably because I'm carrying a lot of weight and I want more cushion um but i' I I I don't care about I'll throw

out the brand I use the G Ruck shoe okay so it is kind of a minimalist shoe you I I can show you what I use later but the reason I bring it up is there's something about having that little bit of drop that's not huge it looks like a zero drop but um it's made it I've never had an Achilles I've never had pain again since doing that is that a mistake no and I think it's it's such a good conversation to have right think about the whole um super shoe like the Nike alphafly

for examp example right that's like the big craze I don't even know what that is it's the shoe that um uh has the big shoe oh okay right oh is this the super running shoe this is the super running shoe oh yeah yeah yeah I got it that has a that actually gives you a little bit of like presumably it gives you more energy yes so there's like certain characteristics to that shoe it has a carbon plate yeah it has a uh difference in the midsole right it's basically a shoe and the research will tell

you gives you a 4% Advantage okay now if I'm running in a race and the guy next to me has this shoe that's going to give him a 4% Advantage don't I want to be able to compete with him well of course I do but I always say you have to earn your right to get into that shoe because it does change things for example because it's going to propel you it might cause you to stride longer with longer strides you have to consider hamstring and achilles possible or potential injuries so guess what you better

be doing a lot of hamstring strength and a lot of you know calf work for example um it has an additional stack height on it which can also cause that kind of longer stride again you better be able to handle that so when you talk about shoes like that I call them a performance shoe yeah fine but it's a performance save that shoe for icing on the cake yeah your speed workout you have to do the foundational work yes because use a training shoe get your foot stronger give yourself the best possible outcome when you

put that performance shoe on because if you're just relying on the shoe I can guarantee you'll probably end up in my office cuz I see it all the time so with Achilles injuries for example now you're adding like you know 50 60 pounds okay that takes work to be able to handle that amount of load in a minimal shoe right if you had a history of you know an Achilles tendonopathy if your Baseline capacity isn't where we know it should be then you know if you need to wear that change there is a time and

a place for everything so if you are going to wear shoe that has an 8 mm Heel To Toe drop just do the work when you're out of the shoe make sure you have plenty of ankle Mobility because what are you doing you're shortening the post to your compartment make sure you're still doing all of your you know plantar flexion strength yeah that's a great Point um let's talk about um any other characteristics of the shoe so you've highlighted two the width of the toe box and the drop yes let's talk of the Soul yeah

right so this is where um I'll I'll give people a little bit of leeway if you will so I like to put patients like I said number one wide toebox is non-negotiable but you will get patients that often and other um doctors have said this to me well we weren't designed to walk on man-made surfaces okay fine but that doesn't mean nor were we designed to walk with our toes looking like this hence the wide toe box is a non negotiable but if you're standing on concrete all day long if you work in a grocery

store for example if you're in an airport having a little bit of cushion underneath the sole of the foot is going to be more comfortable but this is where you need to um consider both ends here the more stack height on the shoe okay so this is the more cushion it changes the rate of loading it speeds us through pronation H this is very important so the more stuff I have it's going to change the rates of loading we've been talking about that 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 going to put something underneath the foot that's potentially going to speed it up you better have what a very strong foot and very strong extrinsic muscles to control that pronation so you know consider what you're doing in the shoe if you're standing still of you know fine right you want a little bit of cushion but know that when you start walking with that thing with this more stack height with this more cushion you're going to alter the rate of loading so that's where the thinner

Soul can come into play um you know if you walk with a shoe on that allows you to feel things okay so Stephen sash owns uh zero and he has this ad that I just love he's like I don't wear comfortable shoes and you shouldn't wear comfortable shoes either I think it's really funny but you know he's he's right because when we're walking remember we talked about that calcinus and how beautifully it's designed it is to to handle shock absorption we also have receptors in the heel that tell us hey don't land so heavy cuz

it hurts that's such a great point right I've seen the ad I know Stephen well um I think it's important for people to understand that it's okay for your feet to be giving you a signal 100% I I actually you know this is totally off topic but one of the things I'm also interested in understanding better is the importance of negative emotions right like we live in a world where we've become so sterile to this and nobody wants to feel a negative emotion right you don't want to feel sad you don't want to feel anxious

you don't want to feel depressed you don't want to feel angry and it's like understandably we don't want to feel those things but there's an opportunity to understand why am I feeling that thing and if I can understand why I'm feeling that thing maybe I can get to the root of what's actually going on and I actually I think that the way you described that made me make that connection which is gosh we should actually think through foot pain if we're in the right shoe if we're in a shoe that we deem a correct shoe

and something hurts maybe the signal is telling us what's what are you doing wrong right I mean that's it gives us so much information when you can actually feel the ground I mean everything the the proprioception the receptor activity and when we have a lot of stuff underneath the foot I can overstride and land really heavy I'm not going to feel it that's not what we want walking is a grazing of the heel we want to feel what happens when our heel hits the ground now very few people today competitive runners or otherwise will run

in a minimalist shoe like that it's a very you know very infrequent um uh occurrence do you recommend people do that and if so how long does it take to strength the foot enough to be able to run in a shoe like that I know I keep saying this but it is very patient specific you look at their history of traumas you look at their history of injuries um I will always Implement some type of functional Footwear regardless it's just a matter of what we're going to be doing with it so for example if I'm

working with you know just someone who wants to walk for example we'll put them into a a um Ultra for example wide toebox shoe zero drop and we'll just have them start like 5 or 10 minutes see how they feel and then we can start to transition the stack height so if they're used to wearing this big bulky cushion shoe you don't want to take them into something like this too soon they'll be like this sucks and I don't want to do it and then you lose them right out of the gates for a person

to run in a shoe like that must they give up a heel strike in running um oh you get all these good questions when you change um your Footwear you start to change how your body feels the ground so with Runners for example everybody gets all up in arms about heel strike right heel striking is bad heel striking is bad it's not that it's bad it's just where the load is going when I'm running it's not necessarily Um how my foot is striking but where my foot is striking so over striding is the enemy I

don't want to have my foot well in front of my body when I'm running there's too much ground reaction force happening there we want the foot to strike as close to the center of mass as possible there have been Runners who have won marathons with a heel strike that's at their Center of mass they just have more knee flexion for example the further the foot is away that would almost feel like they're run they're falling forward wouldn't it almost yeah wow so when I'm striking with a heel strike that's in front of my center of

mass okay when I heal strike I have a lot of ground reaction force going through my knee through my hip and through my low back H when I switch and run to a midfoot or 4-foot strike all I'm doing is taking the load out of the knee hip and back and putting that into the foot and the calf and theoretically isn't I mean that just seems like given the structure it seems like that's how it should be isn't it I I don't want to I mean I have no dog in this fight as a non-runner

yeah so um but but what what do most elite Runners do um you will see all across the board different strike patterns you truly will um when you are running though efficiently when you look at Cadence and you look at um you know I call them running fairies because it just looks like they can run forever their foot will be close to their Center of mass and it is more likely that they will be at a midfoot and four foot strike when their foot is underneath them yeah it seems like exactly just anatomically if you

can bring the strike towards the center of your body you're much more likely to be not heel striking correct because it would be very awkward to heal strike at that angle and you take out you know when you're running right so if I have heel strike then I have to go to my forefoot and then I have to drop that heel down again versus just running midfoot forefoot which yes I think that is a more ideal position to run in from an efficiency perspective with that being said if you have a history of heel pain

Achilles tendonopathy and you tell your Runners hey we're gonna take you out of this heel strike and we're going to get you to run on your forefoot you better prepare them for it they better have good capacity at their foot and at their calf or else what you're going to give them is more foot and calf problems are there any other characteristics of a shoe besides the big three you've mentioned that you you I mean you have pretty strong feelings about all of them but in descending order right of the three we talked about it

the yeah I mean you want to put the foot in its most functional position I think that's the rule and that means allowing the foot topl and trying to keep it on a level ground and then you can play around with you know based on activity with the amount of Stack height but they have shoes now right where they have the wide toe box but they'll still give you like a 3 to 5 millimeter heel to tow drop the too athletic for example okay Ultra actually now has a 4 mm heel to tow drop so

I'll kind of transition them if I know this person has poor ankle mobility and poor foot strength I'm going to say listen we're going to get you in a wide toe box I'm going to drop you down from your 10 into say a five right slowly bring them there they're going to be like oh this feels great because they always do and then we start working on their strength and then we can continue to drop them down into a more functional shoe but you know you think about um hockey players rock climbers um where shoes

are just what they are you can't you know I'm not asking everybody to run around Barefoot all the time it's not it's not reality so when if you do want to run in a Super Shoe or you do play hockey a lot Don't Panic it's just do the stuff do the work outside do the work outside get a pair of minimal shoes grab some toes spacers and walk around for 30 minutes a day keep it simple is a good rule of thumb that a shoe is a is a wide enough toe box if you can

wear the toes spacers in the shoes and if you and you you you're pretty much in I've never seen you not wearing toes spacers do you sleep in them I don't sleep in them you don't okay good to know but I do wear them all the time I wear them when I run as well okay you know I have that his their history of bunions thealex vgas so my foot has gotten so much stronger over the last 10 years um my you know prognosis was they wanted to surgically correct my um bunions and I was

like that's not happening I'm way too active um for my mental health for the for that for me that to sideline me because I see it all the time it's a it's a high rate of failed surgery most foot surgeries are so you know I wear them all the time I wear them in all of my shoes and um it's helped me immensely and it has helped so many of my patients um the brand that you wear is the brand I have as well it's what's it called it's the the toast spacers that we have

is from a company Podiatry Essentials okay they're clear and they fit in between yeah show us yeah yeah and then they fit in so so basically you're the outer part of the foot is not experiencing the spacing yeah so if I were to put it here yeah so it's easier to fit into a shoe basically now I notice you have a little rigid thing in there I don't what's that thing for so I put um I have cork that I will put into um the toe spacer in between the first and second toe especially if

that person tends to have if they have a bunion right I want to have a little more resistance there okay um but I mean most 4-foot diagnoses I mean we didn't even talk about Aromas which is so common and it literally feels like your foot is broken when you're pushing off of a foot that has an aroma in it and that toes it gives the foot room you have all these nerves that run in between the toes they don't want to be squished together so your recommendation would be for a person who's never worn a

toast Baker and again in the show notes we will link to all of these devices your recommendation would be to start how limited how small how many minutes a day I was tell a patient here's your toes spacers you're going to walk around barefoot in your house for 5 minutes that's it that's it on their weaker foot because they don't have toes the toes will like rub against the toes spacer and you can get like a callus or a corn and that can be very painful and they'll want to rip this thing off it happened

to me it took me probably 6 months on my weaker foot before I could wear these all day long and now it's like I mean I can like it takes me5 seconds to put these on because I just spread my toes and they slide right on in the beginning when you're trying to put these on I'll see people like trying to like rench their toes apart because they simply can't spread their toes it's wild MH so they start with five minutes a day then they just slowly increase their time then they get a shoe where

they can wear the toes spacer in the shoe and think of it as like um just doing an exercise for your foot I mean they looked at Sarah Ridge did a study looking at strength of the foot and so what she looked at there was a control group a group that just did foot strengthening exercises and just wore functional Footwear and they looked at four different muscles so flexor digitorum brevis one we talked about that supports the planer fascia abductor halis the one that straightens the big toe quadrus Plante we didn't talk about that guy

but he helps straighten the fourth and fifth toes okay and um what was the other one I think it was flexor halis brevis so the one that bends the big toe at the end of the study the foot strengthening um group and the functional Footwear group were almost neck and neck really yes the functional foot people didn't actually do exercise they just wore corrective shoes and the only muscle that didn't get stronger was flexor house brevis there was one muscle that didn't quite get there does that surprise you I mean not really I mean when

you have your foot in that's great news for the average person who doesn't want to do the work cuz like you're just saying basically all I have to do is change my shoes and things will get significantly better imagine if you did both though well of course right so but I mean you think about meeting a patient where they are yeah now by the time people get into my office I have some go-getters like they want to they're like I've had footprint pain I want to get this job done so they're going to go shoe

we're going to go toes spacers and we're going to go foot strength y now I have other people that I know where I'm like you're probably start with one you got to start with one factor and if I had to do that where am I going to get the most bang for my buck put them in a right put them in the right shoe when it comes to kids anything different same principles you know my kids um my boys not my daughter my boys have never owned a pair of shoes that aren't zeros yeah the

these these exact shoes um and again I don't I I keep waiting for the day when they come home and they say I want Nikes or I want like whatever the popular shoe of the day is and I mean knock on what it hasn't happened yet they love the shoes and that's that's the end of it it like brings me so much joy to hear you say that because I can guarantee you cuz my daughter is the same and um all the she's in middle school and she wanted a pair of Nikes and I was

like I will do pretty much anything for you but I am not buying you a pair of Nikes but my brother was like I want to be the good uncle the cool Uncle the cool uncle and I was like okay you just I'm going to let you make your own decision here every day when she goes to school she has her shoe option and she walks out of that door with her Ultras on because she's gonna tell me listen she's like it doesn't feel good so they'll make the right decision because it's just based on

comfort so if we start them saying hey this is what your foot should feel like yeah then it's an easier decision and if we can be proactive with the children because they haven't been on the planet long enough to see structural deformity in the foot which is exactly what it is when you see bunions and hammer toes it should be a signal to you going something is wrong here something is wrong where is this a barant load coming from now what do you say to men and women who whose I don't want to say their

job requires them because it's really you could argue in this day and age that's not really the case anymore but but look they want to wear more fashionable shoes right be it at work or in Social settings right especially women wearing I mean I watched some of the shoes that women wear and I I think God bless you how how do you actually wear that shoe so do you put that in the same category as performance shoes which is look if you really want to wear the most pointy toed famo um then you just have

to make up for it when you're not wearing that shoe and a higher burden of responsibility that comes with the privilege of being able to wear that shoe 100% yeah I mean if you have a history of any type of forfoot pain bunions neuromas especially and you want to wear 4in stiletto number one be my guest have fun with that number two you better do the work on the other end of it or else it's and I'll tell my patients you got to work with me a little bit you want to go on a date

you want to do this fine I'm all for it but do the work before do the work after yeah well Courtney this has been fantastic I'm excited to now go and get into the gym and actually show people a bunch of the exercises uh and some of the diagn ICS as well so that folks can begin the uh the do-it-yourself process yes thank you so much [Music]