Part 1: Introduction & Shoes and Sitting
Part 2: Systemic biomechanical issues
Part 3: Evaluation of lower body dysfunction and corrections
Part 4: Soft tissue optimization and corrections
Part 5: Summing it up
It is a thorough analysis of how many of the common orthopedic problems today arise from shoes and sitting, how to evaluate their development, and finally a look at how to implement prehabilitation or rehabilitative protocol to improve their condition. I sincerely wish that you will read through the whole thing even though it is a monster. I promise you will come out with a new outlook on this topic.
I’ve noticed that the page hits for page 2 and beyond are about 1/5th of this page. Please do note that this is part 1 of a 5 part article. You will have to click on to read the other parts at the bottom of this page.
Many thanks KC Parsons for taking the time to find pictures.
Introduction & Shoes and Sitting
Table of Contents
Introduction
Shoes
Sitting
Introduction / To the top
Shoes and sitting. Two things that are ubiquitous in modern society.
There has been recent media sensationalization of the detrimental effects of shoes. However, there has not been a lot on sitting other than upper body postural issues. Do these two things really have that much of an impact on our lives? Or is it just athletes?
Unfortunately, most information out right now does not look specifically at the effects that injuries have on the body as a system. Rather, most of the solutions to problems tend to focus on only reducing the pain or alleviating the problem at one joint specifically.
For example, shoulder problems often arise up around the ball head of the humerus and usually manifest in rotator cuff problems, but that pain and injury may be from a cascade of problems from loss of thoracic extension, proper scapular movement, and incorrect muscular activation. This is a topic for another article.
In this article, I am going to build a case against shoes and sitting. My eventual conclusion is there is a detrimental effect on most people and not just athletes. I will walk you through this process noting biomechanical and physiological issues. Then we will talk about how to correctly evaluate these conditions, and how to solve them. In the end, all should see the widespread damaging effects of these two things that we have not even considered dangerous.
Shoes / To the top
There have been numerous articles in the past saying how shoes are bad for you. For example,
You Walk Wrong,
The painful truth about trainers: Are running shoes a waste of money?,
Cure all Running Injuries (and Pain) with One Simple Fix….Barefoot Running
Footwear Alters Normal Form And Function Of The Foot
Barefoot running debate – GREAT image that shows some of the dysfunctions we will look at later.
And more recently since this article has been written:
Barefoot Running: How Humans Ran Comfortably and Safely Before the Invention of Shoes
In general, these are true. For example, this abstract published in the Journal of the Southern Orthopaedic Association in 1994 states:
The shod foot and its implications for American women.
Throughout history, members of human societies have gone barefoot, and those societies seemingly had a low incidence of foot deformities and pain. Only one study has addressed the problem of infection through injury to the bare foot; otherwise, the unshod foot seems to have had minimal problems. Initially shoes were made in the shape of the foot and were sandals. Over time, shoes became decorative items and symbols of status and vanity. As the shape of shoes changed, they became deforming forces on the foot and the source of pain. Recent studies by the Council on Women’s Footwear of the American Orthopaedic Foot and Ankle Society have tried to document the problems caused by shoes on the feet of American women. Attempts should continue to educate women on appropriate shoes and proper fit.
These are not the only cases. Another instance is this abstract from the August 1991 issue of Pediatrics. (I have a full text; if anyone is interested post in the comments.)
Shoes for children: a review.
1. Optimum foot development occurs in the barefoot environment. 2. The primary role of shoes is to protect the foot from injury and infection. 3. Stiff and compressive footwear may cause deformity, weakness, and loss of mobility. 4. The term “corrective shoes” is a misnomer. 5. Shock absorption, load distribution, and elevation are valid indications for shoe modifications. 6. Shoe selection for children should be based on the barefoot model. 7. Physicians should avoid and discourage the commercialization and “media”-ization of footwear. Merchandising of the “corrective shoe” is harmful to the child, expensive for the family, and a discredit to the medical profession.
These are some pretty harsh words. However, beyond that let’s dig a little deeper by looking at shoes and running.
The incidence of running injuries before the 1950s was low. But since the 1970s when shoe manufacturers have started to put more and more padding into shoes, the incidence of runners that have some injury every year is up to nearly 60%. Some of the cause could be to due confounding factors such as the rise in obesity, improperly fitted shoes, etc.; however, there is at least some reason to believe otherwise as we will shortly discuss.
Most of the common running shoes have lots of padding in the heel which incorrectly gives the user an impression that heel-toe running is correct. Significant amounts of heel-toe running can potentially cause long term damage in combination with other factors such as obesity, improperly fitted shoes, and strenuous activity, especially in children and the elderly. In heel-toe running, the joints are taking the impacts rather than your musculature dissipating the force correctly with mid- and fore-foot striking. One study showed that shoes mechanically alter stride compared to barefoot running resulting in lower net efficiency.
Walking, in which the heel does strike the ground first, is a fundamentally different gait from jogging, running, and sprinting which require a mid- and fore-strike to protect the body and operate at a high level.
However, beyond the walking and running mechanics, let us analyze why shoes are a problem.
- Most shoes now have an elevated heel as padding. In walking or running, the knee tracks over the toe as you take a step. With an elevated heel, the foot is already tilted forward which means the ankle does not need to bend as much during movement. Not taking a muscle often to the edge of its range of motion means that the muscles start tightening up. This limits the range of motion (ROM). Thus, with shoes there tends to be a loss of 10-20 degrees range of motion in ankle leading to tight calves.
- The padding in the shoes is problematic as well. Our body and feet have proprioceptors that allow us to feel the ground as we are moving. This gives us the ability to make small corrections to maintain proper posture and movement. The padding in the shoes allows improper corrections to be made (as they will not be punished by awkward landings), and decreases our natural proprioceptive ability and affect ankle coordination abilities. This leads to inactivated muscles on the plantar aspect (bottom) of the foot and decreased ankle stability especially with inversion and eversion corrections. In addition, this may lead to increased frequency of falls in the elderly.
As you can see, shoes are a problem especially compared to barefoot ability. This is even more evident if we are aware of the fact that the plantar aspect of the foot has 3 different muscle layers including the plantar fascia. Let’s now take a look at some more studies supporting the two points above.
Photos from medlineplus and eorthopod
This study showed that “a significant increase in leg stiffness from the barefoot to the “cushioned” shoe condition was noted during hopping. When running shod, runners landed more dorsiflexed (foot tilted upward) but had less ankle motion than when running barefoot. [...] The primary kinematic difference was identified as running speed increased: runners landed in more knee flexion. At the ankle, barefoot runners increased ankle motion to a significantly greater extent than did shod runners as speed increased.” When running barefoot, the forefoot receives the ground* with less than 90 degrees of dorsiflexion. Thus, the comment above regarding dorsiflexion with shoes running is deceptive. Obviously, decreased range of motion is the big thing as I talked about above.
* Note that minimalist shoes like sprinters use with proper technique show similar biomechanical patterns as barefoot running. I will talk about this in the next few segments.
Likewise, flatter foot touchdown and increased leg stiffness was found in barefoot running. Increased “leg stiffness” is good because that means the muscles are taking the brunt of the forces rather than your joints.
One study on ankle sprains showed that awareness of foot position is impaired by shoes. The authors also noted that there was increased muscle activity during inversion with shoes. They concluded that this was the body’s adaptive mechanism to oppose the increased tendency to roll the ankles with shoes as opposed to barefoot.
In a similar vein, this investigation showed that as the “shock ability” of the materials in running shoes decreased, foot control (proprioception) increased. Loss of proprioception is implicated in as much as 50% of running shoe injuries!
“This experiment showed that the shoes not only restricted the natural motion of the barefoot but also appeared to impose a specific foot motion pattern on individuals during the push-off phase.”
The best evidence, however, as far as we are concerned it from actual biomechanical evidence. This can be seen clearly in this study of the biomechanics of shod vs. barefoot running.
Results
Increased joint torques at the hip, knee, and ankle were observed with running shoes compared with running barefoot. Disproportionately large increases were observed in the hip internal rotation torque and in the knee flexion and knee varus torques. An average 54% increase in the hip internal rotation torque, a 36% increase in knee flexion torque, and a 38% increase in knee varus torque were measured when running in running shoes compared with barefoot.
In the next section, we will talk extensively about internal rotation, valgus, and varus states. However, the discussion here provides an ample preview:
“The observed 36% increase in the knee flexion torque with running shoes potentially increases the work of the quadriceps muscle, increases strain through the patella tendon, and increases pressure across the patellofemoral joint. Furthermore, a 38% increase in the knee varus torque implies relatively greater compressive loading on the medial tibiofemoral compartment, an anatomical site prone to degenerative joint changes, as compared with the lateral compartment. Finally, the disproportionately large 54% increase in the hip internal rotation torque may have particularly high clinical relevance, given previous findings that indicate that competitive running may increase the risk of OA of the hip joint.”
The internal rotation torque and quad dominance in particular in conjunction with tight calves are some of the main reasons of the dysfunctions we will discuss later.
Finally, we have this study which indicates that “selecting shoes based on plantar shape had little influence on injury risk.” Basically, no matter how expensive your shoes or how much ’support’ they provide, they don’t decrease your injury risk. This is a very strong case for flats/minimalist shoes/barefoot.
This article on the ankles also provides some relevant material to the discussion.
Note: The loss in range of motion from the calves covers why I do not have to mention why high heels are terrible for women. Even though women look good in them. Similarly, in sports with extensive plantar flexion such as pointing the toes in gymnastics and figure skating it is possible to develop similar problems.
Sitting / To the top
Sitting has become a huge problem in modern society. Sitting is obviously common for school and most jobs. However, throw in decreasing amounts of recess and lack of activity for adults as well as obesity and you have a full blown epidemic.
There has not been much talk of this in the media. However, most of the sports communities knows the problems associated with sitting and its detrimental effects on athletic performance. Even so, the effects of sitting are more widespread than just poor athletic ability. Let us analyze why sitting is a problem.
- In sitting, the butt / gluteal muscles are in a stretched position. When a muscle is allowed to be in a stretched position for extended periods of time such as in school or office jobs, the muscle becomes weaker and thus inactivated. This is the opposite of what happens with the calves in their shorter and tighter position. Thus, with sitting the glutes become weak and inactive.
- The hip flexors which are shortened in hip flexion, like the calves, become shorter and tighter. The hip flexors consist of the iliopsoas, rectus femoris, sartorius, tensor fasciae latae (TFL), and adductors longus and brevis.Thus, with sitting the the hip flexors become short and tight.
Photos from blogpost and chiropractic-help
It has been investigated “whether gluteal muscles could be activated more effectively by stimulating the proprioceptive mechanism during walking.” They came to the conclusion that balance shoes help especially with lower back pain helping fire inactivate gluteal muscles. Ironically, you could just walk barefoot and do balance work to stimulate foot proprioceptors as well as do gluteal activation work. We will get to this later.
There are varying degrees of inactivation. Gluteal inactivation does not mean that the glutes fail to activate altogether. Rather they will fire although with decreased intensity or a delayed pattern which may be ineffective during proper recruitment during certain movements.
There is another interesting study done on a variety of subjects.
RESULTS: There were 1832 deaths (759 of cardiovascular disease (CVD) and 547 of cancer) during 204,732 person-yr of follow-up. After adjustment for potential confounders, there was a progressively higher risk of mortality across higher levels of sitting time from all causes (hazard ratios (HR): 1.00, 1.00, 1.11, 1.36, 1.54; P for trend <0.0001) and CVD (HR:1.00, 1.01, 1.22, 1.47, 1.54; P for trend <0.0001) but not cancer. Similar results were obtained when stratified by sex, age, smoking status, and body mass index. Age-adjusted all-cause mortality rates per 10,000 person-yr of follow-up were 87, 86, 105, 130, and 161 (P for trend <0.0001) in physically inactive participants and 75, 69, 76, 98, 105 (P for trend = 0.008) in active participants across sitting time categories. CONCLUSIONS: These data demonstrate a dose-response association between sitting time and mortality from all causes and CVD, independent of leisure time physical activity. In addition to the promotion of moderate-to-vigorous physical activity and a healthy weight, physicians should discourage sitting for extended periods.
The very intriguing thing to note here is that sitting, even when adjusting for smoking, physical activity, and other mortality factors, has a dose-response association (meaning that the more you sit) the higher your risk of death. The P-value for this is <.00001. P-value is used in studies to incidate significance of data — generally anything under .05 is significant which means that 95% (1-.05) of the time this data is unlikely to occur. This data is particularly strong which means that 1-.00001 = 99.999% of the time this data set would not occur. This indicates that sitting is extremely insidious and dangerous the more you do it.
Another study seems to verify this conclusion. After adjusting for physical activity and other factors, those who sat greater than 6 hours per day were 37% more likely to die than those who sat less than 3. With a lack of physical exercise those who sat greater than 6 and less than 3 hours were 94% and 48% respectively more likely to die. Associations were strongest for cardiovascular disease mortality.
Consider that we now all send our kids to school for 7-8+ hours a day for 15+ years, and have desk jobs for much of our adult lives…. this is not a good sign.
Note: there will be more studies to come on gluteal activation; however, as a lot of them relate to the injuries that is specifically why they will be discussed later. I just want you to know that I do have my position on this topic supported at least as much as I have supported my case against shoes.
Conclusion
In conclusion, we learned that shoes and sitting cause many problems. This is a big problem because they are ubiquitous in modern society. Shoes tend to allow the user to run improperly (heel-toe) and hinder proper ankle biomechanics. In addition,
Shoes tends to cause the problems of
- Tight calves resulting in loss of 10-20 degrees of dorsi-flexion ROM in the calves.
- Inactivation of the muscles on the bottom of the foot and the ankle stabilizers.
- Decreased proprioception of the lower limbs.
Sitting tends to cause the problems of
- Inactivation of the gluteal muscles.
- Tight hip flexors (i.e. iliopsoas, rectus femoris, sartorius, tensor fasciae latae [TFL], and adductors longus and brevis).
In the next segment we will discuss look at the systemic biomechanical issues that arise from these deficits. Click below for the next part.
thanks for this excellent article steven.
question. if with hel striking, the foot is in dorsiflexion, doesn’t this mean that the calves are in a stretched, not contracted position, most of the time?
Ah, I mentioned this.
“This study showed that “a significant increase in leg stiffness from the barefoot to the “cushioned” shoe condition was noted during hopping. When running shod, runners landed more dorsiflexed (foot tilted upward) but had less ankle motion than when running barefoot. [...] The primary kinematic difference was identified as running speed increased: runners landed in more knee flexion. At the ankle, barefoot runners increased ankle motion to a significantly greater extent than did shod runners as speed increased.” When running barefoot, the forefoot receives the ground* with less than 90 degrees of dorsiflexion. Thus, the comment above regarding dorsiflexion with shoes running is deceptive. Obviously, decreased range of motion is the big thing as I talked about above.”
Basically, in barefoot or minimalist shoes, the ankle receives the ground plantar flexioned then the calves are allowed to eccentrically work as the ankle bends and loads them. This means the ROM expressed is actually a large range of motion. You can try this moving in the grass sometime barefoot.
With a heel first strike, the foot is coming down and the foot is not being plantar flexed at all as the weight is shifted forward to the foot. If you do relax and let the foot strike down this is one of the key eccentrics on the anterior tibialis that leads to shin splints. So as I said the “flexed” foot in heel-toe running is very deceptive because there is actually a lot less net ROM and less overall dorsiflexion of the foot compared to barefoot/minimalist.
thanks for clarifying. I will have too read more closelyl next time! great work, all the articles i have read so far are top notch!
Steven – Had a question for you on the shoes/sitting essay you wrote. Excellent by the way. Like many I read “Born to Run” and was sold on barefoot running. Bought myself a pair of vibrams. Started running again. Loved it… no knee or hip pain like the previously times I had taken up running. Bought myself another pair of vibrams and started upping my distance. Ran one day when my calves were sore and compensated for the calf tightness by running more flat-footed. Ran only 3 miles but the next day both my feet had classic signs of plantar fasciitis, with pain mostly in the arches and the balls. I’m now on day 4 and still have some pain. Interestingly the only time I hurt is really when I’m shod and sitting. Walking, and even a test light jog yesterday seemed to illicit no pain. My question is, “do I need to treat these and not run until the pain is completely gone?” I would plan to run very short and let pain, if any, be my guide. Any thoughts you could share?
Running when the body is sore, or excessively in general is a good way to develop overuse injuries like plantar fasciitis.
I suggest to new people that they start off with < 200m per session, and increment by at most 100m per session. Reason being that your body is learning new movement patterns, and you honestly wouldn't go off and do hundreds of repetitions of new exercises… so why would you do the same with running?
Assuming someone is taking about 2m per stride with two feet that's 50 repetitions per leg per 200m. While it doesn't seem like a lot, it really is for learning new movements. At most I would do 400m if you really wanted to push the envelope. The main problem is that you don't "feel" the problem until it's too late when you're bombarded with massive soreness in the arches and calves the next day since running is so low intensity — but the muscles from previous running have not properly adapted to the stresses.
3 miles on sore calves is definitely excessive, and since the calves wouldn't be able to absorb the impact properly your arches started to do that. When the intrinsic foot muscles get tired, the connective tissue starts bearing the brunt of the stress — namely your plantar fascia.
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I would back off for a bit even if there's no pain running or jogging. Walking at most.
1. Ice if it helps,
2. massage to the plantar aspect of the foot & calves — loosen stuff up,
3. anti-inflams (ibuprofin, etc.) are fine,
4. maintain your mobility in calves and arches by going to edge of ROM but don't push it too much. You just want to keep them active so that nothing tightens up on you.
Obviously, rest and work your way back in slowly. You don't want to develop overuse injuries or reaggravate your conditions.
You're on the right track though… just a little too much so far.
Wow! Great work, really!
Thanks so much for sharing this!
– A flat feeted, hallux valgused, genu varumed, glutes inactivated, hamstring tightened french guy
Steven,
Wow, what an amazingly comprehensive and useful article. I think it’s incredible that you devoted so much time and effort to writing all that, and putting in all the links, for our benefit.
Thank you!
I realize that you can’t answer detailed questions from every reader, but… I guess it can’t hurt to ask, so what the hell!
I got the maintainence staff at my office to jerry-rig a stand-up desk for me a few weeks ago. It’s great. No back pain at the end of the day, and my hip flexors seems to be less tight. It’s all good, except… my feet hurt from standing still in regular shoes for hours at a time.
My office is a pretty high-level department in the government. Dress shoes are basically required. No one has a problem with the standing desk, but if people saw me wearing just socks in my office, it would be regarded as inappropriate.
Any suggestions?
(Btw, stats are: 42, 6′, 200 lbs, 1RM squat = 375)
Well, the question is (1) how adapted are you to barefoot standing/movement, and (2) do you move around a lot during the day?
If you could just buy some flat soled dress shoes with ample foot room you can stand/move around in your office. Basically, you want to simulate barefoot condition with your shoes as much as possible. You could have your other dress shoes around for when you have to go out of the office for other stuff.
That’s just a guess at what your conditions are though so…
Feet are going to hurt if you’re not used to be being on them a lot though regardless of if you are bare foot or not if you haven’t done it for a long time, and if your weight is up there which it is. Heck, I’m under 140 lbs and my feet still hurt from standing up hours at a time. Hopefully, this will go away as you adapt better though.
Thanks!
Hey,
Great work in this article. I’m very impressed. I couldn’t agree more especially on the topic of shoes and the natural foot. I’m excited for you to finish your degree and working with you! We need more PTs of your caliber.
I have tight adductors and deep butt muscle tightness. To increase the ROM of these muscles, should I just practice middle splits and the stretch in the included picture everyday? Or are there other stretches that will help with this?
Also, I’ve had flat feet for as long as I can remember. I want to try and correct my posture and build up the strength to have an arch in my feet. All I need to do is simply strengthen the plantar aspect muscles correct? And this can be done by doing the mentioned exercise and http://hubpages.com/hub/Foot-Gymnastics-Exercises-and-Games-for-People-with-Flat-Feet/Us or anything similar?
The stretches provided are the ones I would do. That does not mean there are other stretches that may work as well. If you know of some better ones or want different ones feel free to use them.
Your second scenario is a little more difficult. It depends a lot if you can reform the muscles based on how long it’s been that way. There’s no harm in trying though. And, improving the plantar aspect muscle strength + rolling the plantar fascia and stretching out the calves and hamstrings should help get you there. (The fascia/connective tissue if it’s tight may not allow reformation of the arch thus why you need to do that in conjuction with the strengthening).
Hi Steven… fabulous article, that I just found today (1/6/10). I started barefoot running last year (during the warmer months) after correlating exactly what you said about the feet and legs. I miss it during the cold months; I’m in Maryland also, feeling the winter now. Perhaps not coincidentally, I have been also experiencing the tight hips and weak glutes – I diagnosed myself last week. Have started myself on rehab and improvements. Can’t wait to delve more deeply into the article! Have also passed your article along to not only friends but some colleagues. I also found an article on you in American Parkour (and saw the pics from Primal Fitness, which I recognize
.
Hey Steven,
I followed a link from the CF discussion board to this article. Good stuff. I have passed the link on to several parents from my daughter’s soccer team.
My daughter (age 12) suffers from Sever’s disease in her left heel. The recommended treatment is conservative – ice, stretching and padded shoes. She wears Superfeet inserts in her cleats. Much of her pain is caused by her calf muscle pulling on the growth plate in her heel, but I was wondering if a gradual introduction to barefoot walking/running might help her by strengthening the muscles in her feet and lower legs. What do you think?
Thanks!
Yep, stretching out the calves and hammies will go a long way to help. Similarly, strengthening the muscles of the plantar foot and balance work.
Barefoot may help in time once it calms down like Osgood Schlatter’s does. If it’s active I bet she won’t want to do anything regardless because of the pain.
Steve – do you know any places that sell Puma H-Street or Salohs online (haven’t had any luck finding places that stock them in Australia)? Also, what are your thoughts on Nike Frees as a running shoe?
I know they have some on amazon at the very least (H streets you’re basically outta luck unless you can find some rarely offered ones around… they do have K streets though which are very similar):
PUMA Men’s K-Street II Sneaker
Puma Men’s Saloh Ripstop
As far as Nike frees go too much heel padding for my taste. But if you like them sure.
I would tend to stay away from anything padded if possible. You want as little between your feet and the ground as possible both in the forefoot and the heel.
Make sure you have enough room for the toes as well.
Hi Steven!
You commented on one of my posts on the CF forum about a lower back injury, and I followed you here to this site and am learning a ton. I am living in Japan, and being able to read extensively about back injuries and narrow it down to an SI joint injury was super valuable when dealing with my doctor (in another language, medical terms are difficult.) Thank you.
Now I read this article and am reading Starting Strength, and I’m starting to think about getting some minimalist shoes. You make a convincing argument. I definitely have tight hammies/hips/all of the above. This, combined with some torn ligaments last year and my SI joint injury have me rethinking all of my mechanics, techniques, and outlooks on exercise.
On that note, since I have to build from scratch after injury anyways, would you recommend getting minimalist shoes and starting now? For Crossfit/everyday use, would it be better to get a pair of five fingers or one of the shoes geared towards running? Also, do you think even with a slightly sore lower back that working on walking barefoot etc. would be okay/safe/good to start right aways?
As always, your advice and input is much appreciated.
Of course. Minimalist shoes are good, but if you’re having problems I would definitely not run in them yet.
A couple weeks/months to get yourself acclimated, and do all of the necessarily prehab/rehab work (section 4) that you need to do to do before you start jogging/running in them.
Depending on where you are five fingers may be OK. If there’s a lot of uneven terrain or gravel or whatever else have you then it may be a better idea to get specific minimalist running shoes.
For flat feet: “For those of you who have flat feet/collapsing arches or plantar fasciitis, you know you tend to put more weight on the medial edge of the foot.”
Isn’t that the opposite of what I should be doing. Since my weight is already always medial which causes my arch to collapse. Shouldn’t more time be spent with my weight on the outer foot -5th MTP- (pinky bone)?
Yep. I said:
“you know you tend to put more weight on the medial edge of the foot.”
Which means that you know it happens, which means you want to distribute more weight to the lateral edge of the foot.
Thanks for catching that though I can definitely rewrite that to make it more clearer.
Steven,
I thought I had strong, healthy feet (I do hill sprints on grass with Vibrams once a week; lift in Puma’s), but maybe not!
I have a stand-up desk at work and kick off my shoes whenever I can. I brought in a golf ball today to roll under my feet. I was _shocked_ at how “lumpy” my plantar fascia felt, and how many very sensitive trigger points I have. Even mild pressure is painful on some spots. Is this normal!
Thanks for all your effort on this great blog, btw.
Yes, it’s normal if you’ve never done it before. Even in unsymptomatic laypeople and athletes.
Our bodies can tolerate a lot before they start to break down. When things start to become painful that means your body is letting you know that things are in very bad shape. Things can be in pretty bad shape without pain at all as exemplified by our poor posture with the shoulders and neck, in non-painful valgus conditions like flat feet and bunions, and other such orthopedic maladies.
Good stuff, thank you.
Steven, I am plagued with knee pain, my knee pain is in most areas of the knew except the outsides. Middle, top, front, bottoms all give me negative feed back when exercising. After reading this article I noticed my feet are always splayed outward at about 30-40 degrees angle when standing relaxed. They also turn outward when I am walking, but the Vibrams are helping a bit.
I was thinking I should just get a reverse hyper and go to town on my glutes every day while simultaneously stretching everything out. But what do you think would be best? The knee pain is definitely the biggest thing that slows my training progress down and I would like to eradicate it once and for all.
Do everything on page 4. Take notes see what helps and what hurts for a week. Whatever hurts drop for a bit and come back to it later. If it helps, then great keep doing that.
You should be able to figure out what helps and what doesn’t… but if you still can’t then post your notes here and we’ll discuss.
OK so I was doing some cleans the other day and the pain got pretty unbearable. I tried to do a pistol and I collapse from pain. I went to see a PT and he said I have chondromalacia. He told me I have the tightest hammys he had ever seen and I need to stretch them as well as strengthen my glutes. So pretty much the same thing you said.
I told him I have been working on my hammys for about an hour a day after reading this and I have not gotten so much as a millimeter out of them so far. He referred me to this thingamajig from hamstretch.com so I ordered 2.
Will update on knee pain but I don’t think the hammys will budge..been doing PNF a lot too.
Sometimes less is more.
What is your current routine for all of the days of the week?
Well it was CrossFit every day and maybe take Sunday off, but now…. Gonna work more on stamina for pull ups/pushups….press strength & glute strength. And of course hamstring flexibility (still have my doubts that they will actually loosen up).
I’m thinking of doing the strength exercises followed by some type of upper body metcon (this is going to be pretty limited variety w/o being able to bend my knees).
I will probably rotate chest&shoulder strength / pull up strength and core strength / glute strength on a three day cycle and follow each with a metcon of some sort. Foot drills, light glute work with hamstring and hip adductor stretching every day.
If you can put heat on your hammies before you stretch them. Also stretch everything in your posterior chain — plantar fascia, calves, hammies, glutes and low back.
Make sure you get enough magnesium too.
I really meant what are you doing for stretching? How long are the holds? How many sets? What type of PNF are you doing? What frequency?
I refuse to believe that if you are doing it correctly that you are making no progress.
“I really meant what are you doing for stretching? How long are the holds? How many sets? What type of PNF are you doing? What frequency?”
Daily Stretching
-Warm-up with rolling every part of my legs with “The Stick”
-Dynamic stretching with kick the hand drills…I can’t quit get up to chest height yet.
Calves – Put foot against a pole (as seen in Kstar’s your calves are tight BRO) with knee straight and get a deep stretch for 5 seconds then I flex the calve by pressing the ball of my foot into the pole (heel is on ground) for 5 seconds. As soon as I release the flex I immediately go into a deeper stretch for 10 seconds and after that I flex for 10 seconds…….I do this in 5 second increments until I get to 30 seconds. Once I complete this with each leg I do it again with the knee bent. Once I complete it with knee bent on each leg I do it a final time with leg straight once again.
Hamstrings – Feet together I bend down and give it everything I’ve got to try and touch my toes. I do 3 sets 30 seconds each. Then I get against a wall and sit with my feet together and push down on my knees to stretch the adductors for 5 seconds, then I resist for 5 seconds and so on up to 30 seconds. One set.
Then I kick my leg up on the desk (not an easy task) and stretch forward on it 5 five seconds, then I drive my heel into the desk with knees straight for five seconds and so on up to 30 seconds. I do 3 sets on each leg. The main thing that hurts when I do all these stretches is the tendons behind my knee more so than the muscles themselves. If I have some time I lay on the ground in supine position, one leg up with a rope tied around my foot and I pull it back as much as I can and do similar PNF just laying on the ground. I also ordered the devices from hamstretch.com to help with this.
That’s pretty much it. At the end of it all I can put my finger tips under my toes just barely, but when I wake up the next day I can’t even touch my toes.
The PNF is too short.
Leave the contraction phase at 5s, but let yourself stretch for 10-15 seconds.
You do not always have to do PNF either. I would alternate days where you just relax in your stretch and let your body normalize. 30-60s for the regular ones.
Too much PNF as you’ve found especially with short holds/contraction phases are counter productive.
OK thanks, I will try this and the heat and get back to you in a couple weeks with results.
Steven,
After searching through youtube for Hallux Valgus corrections, all I find are surgeries. Please tell me there’s something else I can do about it. So far I’ve been stretching them passively. If I try actively, all I get are my 2nd to 5th MTPs rising. The toe doesn’t move!
It’s possible you can get orthotics to fix some stuff. But if it’s really bad and immobile (at the joint itself)… then you’re likely going to have to get surgery for it. IF the muscles are atrophied then maybe not.
There’s stuff like toe spreaders that may help. If the arched is collapsed then you have to fix that first though.
Hi Steven,
I just have a quick question about shoes. What about running on concrete or any other hard surfaces? Would a minimalist shoe, like the above mentioned Puma be suitable to run on concrete? Wouldn’t it be too hard on the joints?
Great site BTW! Lots of excellent info!
Thanks in advance!
If your muscles are working properly they should absorb the force.
The only reason your joints would be taking the force is if you are running heel-toe.
Like the studies have shown (that I linked) there are more forces involved with running poorly than running with minimalist shoes.
I’ve been searching for dress shoes I can wear to work and I finally found some that are working well for me. I just take the inserts out so you can see the green on the bottom inside of the shoe and they feel pretty good. I need to dress professionally but work at a job where I am on my feet 8 hours a day and walking multiple miles, so I’m glad I finally found something. Just thought I’d share in case anyone else was looking because I haven’t really found anything else that would work.
http://www1.macys.com/catalog/product/index.ognc?ID=448092&PseudoCat=se-xx-xx-xx.esn_results
I hope its ok to post this link, if not feel free to take it down
Nice find. Hopefully that will be helpful to others.
Brendan, thanks for that link!
Hi Steven,
First off, awesome article! Really comprehensive, the most comprehensive approach to this issue in a systems-based approach that I’ve seen!
I will take issue with one thing you’ve mentioned in this section, however. From my experience, squatting should be done first without load, and effort should be made to enable the individual to squat “naturally” (like this guy – http://tinyurl.com/2fxfuyh). That’s how most of the world “sits,” and how most humans, I would imagine, sat for most of our existence.
My next issue is with the “optimal desk arrangement.” I’d rather see people sit at a very-low desk (having to sit cross-legged or squat) or a standing desk. As Dr. Michael Leahy said a bunch of years ago in his “Law of Repetitive Motion” – the body conforms to the position its in the majority of the time. Fixing a desk-space doesn’t change the flexion of the hips…and remember that people sit like that in their cars and at home, too. Get them sitting on the floor more (like most of the world’s population still does)…I think that’s a better recommendation.
Finally, have you seen the book “Assessment and Treatment of Muscle Imbalance: The Janda Approach.” The reflex neuromotor aspect of gait that is disrupted by covering the surface of the foot has a huge impact on general body patterning as well…..
Thanks for the great post!
Josh
Good addition…check out Deric Stockton’s foam roll sequence for opening the hips: http://www.youtube.com/watch?v=yXty_MpgQt4&feature=digest
he also has an article about his method in the most recent issue of PLUSA:
http://www.powerliftingusa.com/current_issue.php
Josh,
Hey yeah good stuff. I’ve actually been meaning to add a lot of other information to this and you brought up some I was going to add and some I didn’t even think about as well.
Definitely agree about the “third world squat” and the rest of it.
I’ll add in a lot of that shortly. Unfortunately, I have not read that book you mentioned; it sounds good though. I am quite short on money right now so I’m try to spare the expense of purchasing any extra things.
Hey Steven –
Love your stuff. I too have an undergrad degree in Biochem and am applying to PT school in the fall. Your approach makes a ton of sense to me.
Anyway, I poked around but couldn’t find too much on your take to piriformis syndrome. I have a couple of clients with diagnosed piriformis syndrome and I am wondering if there is self-treatment they can do in between trips to a PT? Piriformis stretching and SMR with a lacrosse/TriggerPoint type ball is given. I have had them do some hip capsule mobilization I picked up from Starrett’s mobility seminar. Anything else I’m missing?
Thanks again…I am always happy to send people to your site because of the quality of info and your responses to them.
Brandon
Piriformis syndrome is a bit tricky from what I’ve seen.
Sometime it’s actually the piriformis pinching down on the sciatic nerve, but sometimes the complications occur much higher up in the chain in the lumbar spine or SI joint. Length length discrepancy or rotated pelvis may be a good thing to check for as well (in regards to SI joint and such).
Check to see if they have tight hip flexors, rectus abdominus, quadratus lumborum, or paraspinals & erectors. Mobilize these muscles too and you might get some better results.
Also, I would also check how well they internally and externally rotate their hips. If one side is tight and affected that can tell you something as well.
Also, get the glutes firing correctly with bridging, etc. so the hip doesn’t have to have the piriformis lock up on you. The only reason the deep muscles such as piriformis get tight is if there is a problem stability-wise with the whole lumbo-pelvic area. It’s like the rotator cuff muscles and scapular muscles locking down the shoulder after something traumatic or instability from weak posterior scapular muscles.
Let me know if this helps any of your clients. Always looking for feedback on to what tends to help and what doesn’t because it’s sometimes a bit different from person to person especially with hip/pelvic dysfunction.
Steven –
Yes, with one the hip flexors are crazy tight; same side as the piriformis issue. Noticed it when I was doing a hip assessment and observed the tight side lower than the other.
Running is at least a correlative factor if not a causative one. Both clients have been 30+ lbs. overweight and running is the mythical treatment that each thinks has contributed greatly to their weightloss. Working on POSE with each but they are only about 50% POSE in a given run.
Regarding lumbar/other SI issues, yes they are tight and mobilization is a priority. Right now one can’t move well enough to stretch on his own.
I would assume the ramp-up to full activity needs to be a slow process after they are cleared for exercise?
Thanks,
Brandon
If you can get them to change shoes towards more flat soled ones that goes a long way to help correcting proper running technique. There’s absoultely no way you can heel-toe run with no padding.
To be honest though a lot of mobilization work with the foam roller and things such as third world squat mobility work ARE workouts in themselves especially for people that are overweight. It may be beneficial to use that as part of not just warm up but in skill work and possibly workouts if you can find a good way of integrating it.
Ramp up to activity is definitely recommended especially if they have orthopedic issues like you mentioned.
Do you think it’s enough to just squat (like the man in the image Josh showed) 8 hours a day without any tension in the hip flexors to make them tight? Or do you think there has to be tension in order to get tight muscles?
I read Esther Gokhale’s book and she wrote that women in burkina faso sit on the ground with the back against a wall for a long time every day. I suppose there is no tension in the psoas in this position. They don’t develop and back problems. That would suggest that the psoas won’t get short if there is no tension, even if it’s short for long periods of time. What do you think?
Most people who sit a lot have pretty tight psoas because of the extended periods in hip flexion. Tension is not required for this to happen.
For example, what happens when your muscles are in a cast? This is just like sitting down 8+ hours a day. Your muscles are immobilized and they start to tighten up. When you get the cast off, everything is extremely tight and you generally have to stretch repeatedly to get back range of motion and proper movement. The same is true with this.
Tight psoas themselves aren’t enough to cause back pain. There’s many females with insane amounts of anterior pelvic tilt with no pain. It’s when there’s multiple issues and they compound you get back pain.
Steven,
I’ve been working on my third-world squat, and find that when I’m in position there is a lot of stress on the muscles along my shins. Also, it feels as though my weight wants to sit out the outside edge of my feet. (No real stress in the quads, hamstrings or glutes.) Does this point to any particular tightness?
Thanks, and thanks for the interesting article.
Well, it’s likely a lot of your groin muscles are tight and inhibited proper stance. I would strongly suggest stretching everything in your hip area (hamstrings, adductors, abductions, etc.) as well as widening your stance a bit. Also, try to loosen up your flexors and extensors in your legs too. That should help.
Okay, I’ll continue to work on stretching the hips. (I think groins and some hip flexors are still pretty tight, since I often feel a burning/pinching sensation in the crease of my hips when squatting below parallel.) I hope all of this will help my knees, too, which have become pretty grumpy as I’ve switched to crossfit WODs during the last six months.
By the way, widening my stance to beyond shoulder width results in similar burning in the shin muscles (especially near the knee) and weight shifting to the *inside* of my foot. But all of this may clear up as my flexibility improves.