Introduction & Shoes and Sitting
Systemic biomechanical issues
Evaluation of lower body dysfunction and corrections
Soft tissue optimization and corrections
Summing it up
Systemic biomechanical issues
Table of Contents
Review
Valgus
Varus
Review / To the top
Here is what we learned in the previous section. These points will be the key to elucidating how movement dysfunction develops.
Shoes tend 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 limb
Sitting tends to cause the problems of
- Inactivation of the gluteal muscles.
- Tight hip flexors (iliopsoas, rectus femoris, sartorius, tensor fasciae latae [TFL], and adductors longus and brevis).
There are two different ways the body will compensate because of these problems. The first is having the shins angle inwards towards the midline; this is called valgus stress and in extreme cases can be seen as a valgus deformity shown below. The second is having the shins angle outwards away from the midline; this is called varus stress and, similarly, in extreme cases can be seen as a varus deformity which is the opposite of the picture below. In regards to sitting and shoes, valgus stress tends to be more common for multiple reasons, so I will be discussing that most of the time. I will only talk about varus stress briefly. Those that are interested in further reading may contact me later.
Photo from sagepub
Please note again I am only describing the most common way these movement disorders develop. You or someone you know may only have one or a few of the symptoms. Some people have all of them and tend to develop injuries much faster than others. Each case is specific to the individual.
Valgus stress / To the top
Valgus stress is more common because it is a compensation from multiple aspects of shoes and sitting that we have described before. The body naturally compensates when it cannot perform its abilities. For example, if you smash your leg against a corner you naturally compensate with a limp to avoid putting pressure on the injured limb until the pain subsides. Similarly, if your shoulder is hurting you will naturally compensate by side bending in your spine to get your arm overhead.
It is common for the body to naturally compensate with valgus stress because of shoes and sitting. The first “symptom” that usually appears for most people is inward tracking knees. This occurs for multiple reasons.
- First, the loss in 10-20 degrees of ROM from the calves must go somewhere. The next joint above the ankle where the ROM is lost is the knee. Thus, instead of the knee tracking directly over the toe, the lost ROM is compensated by the knee tracking inwards.
- The glutes, especially gluteus maximus and medius, are potent external rotators of the femur. Since the glutes are inactivated with sitting, the femur is allowed to rotate internally in knee bending. This allows the knees to track inwards.
- Adductor longus and brevis are tight and shorter from sitting. The gluteal muscles are also abductors of the femur. Since the glutes are inactivated from sitting, the adductors will tend to pull the knee medially as it bends (eccentric movement).
- Adductor magnus is involved in hip extension. Since the glutes which are primary hip extensors are inactive, a strong OR weak adductor magnus will tend to pull the knee medially as it straightens (concentric movement).
Note: The adductor issues are two separate issues and should not be grouped together. The biomechanical issues with both will have some differences when we discuss how to correct the issues later.
Note 2: It seems there is some confusion on the theory of weak adductors and valgus (Starting Strength pg 46-49). The weakness in adductors is specifically for adductor magnus which let’s the knees cave in during the concentric. As I said, this is a separate issue from the knees caving in on the eccentric.
What happens with a weak adductor magnus is that coming up from the bottom of the squat the hip extensors are at their longest position. Muscles are normally strongest at the middle of their range of motion shown on the force-length curve. This means that the knees cave in to shorten the magnus towards the middle of its range of motion where it is the stronger. If the glutes and abductors were active and stronger this would not happen; however, since they are more inactivated, the adductor magnus along with the hamstrings become primary hip extensors thus pulling the femur medially.
Moving on…
Why is the lost ROM in the calves such a big issue? Well, this study in tennis players shows that restricting ROM in the ankle “may also provoke large internal forces elsewhere.” Stiff shoes were found to the be the worst, and ones that moved better were superior. Obviously, the natural foot itself would be the most flexible in regard, but unfortunately cannot be used by itself extensively on extremely rough surfaces.
Inward tracking knees tends to precipitate a cascade of other postural and biomechanical dysfunctions which affect the other muscles, connective tissue, and eventually the joints within the legs.
Muscle and connective tissue issues
- Flat feet / pes planus / collapsed arches – Internal rotation torque and medial tibial tilt at the talus put most of the weight distribution on the medial arch of the foot. Combine this with inactivated muscles on the plantar foot from the shoes, and the arch collapses. The picture shown below compares a foot with a correct arch (top) to that of a fallen arch (bottom)
Photo from michaeljtodd
You can test this by standing up and allowing the knee to track in. You will see and feel that the tibial torsion at the talus pronates the foot and allows the majority of the weight to rest over the medial arch of the foot.
Likewise, this analysis of increased forefoot loading (from higher heel shoes) leads to greater medial stress on the foot as well.
This study showed that there is greater stiffness in the forefoot especially during barefoot running compared to running with shoes. This is good in the respect that the plantar aspect muscles are firing to maintain the arch. A lack of stiffness in the foot indicates that the muscles are not firing effectively and thus a greater flattening of the arch is occurring in strides. Repetitive stress like this may lead to collapsed arches.
- Plantar fasciitis – Like flat feet the inactive muscles on the foot allow the arch to collapse some putting stress on the plantar fascia. Tight calves contribute as the fascia from the plantar foot is continuous up the posterior chain and pulls on the calcaneus.
It is likely that you only develop either flat feet or plantar fasciitis. Although it is possible to develop both. If your plantar fascia is more lax and stretches easier, it is easier to have the arch collapse all the way even before plantar fasciitis may develop. When the intrinsic muscles of the foot are inactive, the plantar fascia is the last stopgap that holds the medial arch together before it collapses. Since the connective tissue is not built to take that kind of stress, it gets inflammed and painful.
Extremely tight calves, and extended time with heel elevated shoes may lead to this condition solely. A lot of it is variable depending on the person. Remember, I am just describing some of the cases.
- Achilles tendonitis and rupture – the internal rotation torque and medial tilt of the tibia at the talotibial joint in combination with plantar flexion in movement increases the likelyhood of damaging the achilles. All tendons and ligaments work best when pulled on directly like a piece of paper, but when you twist a piece of paper and pull it tears more easily.
Photo from jaapa
In respect with past runners the incidence of achilles injuries has decreased. This is because the calves were involved more when footwear was minimal. But now, with decreased ROM in the calves, the injuries tend to migrate elsewhere. We will see this in the following points.
The torque at the ankle and thus achilles tendon especially in movements on the toes makes this injury appear more frequently than it should. This is in combination with very tight calves.
- ACL sprains and tears – like the achilles the inward tracking knee tends to torque the ACL. Thus, spraining and tearing the ACL is more likely.
Note the inward tracking does also stress the MCL. But for time purposes I am not including this. Just know that in the event of a torn ACL with twisting there is often accompanying MCL sprain or tearing as well. In severely traumatic injuries the unhappy triad (ACL + MCL + meniscus tear) often occurs.
Q-angle
Photo from doctorkolstad
At this point we need to note that women have increased incidence of ACL injury especially because of Q-angle. Womens’ hips are wider for child birthing and thus their knees have to travel further in at an angle under them to support their weight. This greater angle obviously leads to increased torque on the connective tissues at the knee.
This analysis demonstrated that valgus knee angle puts more stress on the ACL as their experiment showed that women land more often in knee valgus position. However, they found no different in gluteus medius activation between the sexes. I do not find the difference in gluteus medius activation troubling since both men and women are both sitting for 7-8+ hours a day in the classroom and doing homework. It would be an interesting comparison if they compared athletically dominant men and women versus the rest of the population though.
- Quadriceps dominance and tightness – the body senses the stress on the ACL from its proprioceptors. If the knees cave in too much obviously it is going to stretch out the ligaments or tear them. To stop this it strongly strengthens the quadriceps, especially the lateral aspect of the quad.
Women as well as men both develop this problem because everyone has a Q-angle. In addition, because the glutes are inactivated, the decreased force output of the hip extensors is compensated by the quads which are the knee extensors. This is also why women tend to be less athletically inclined than men, and also why quad dominant men are not-so-good athletically. For example, this study shows higher vastus lateralis development, higher quad to hamstring strength ratio, and lower gluteal activation in women because of Q-angle and valgus knee stress. This quad dominance in women is indicative of a higher risk of ACL injury than men. Similar results were obtained in this study examining Q:H imbalance in both the medial and lateral aspects of both the quads and hamstrings.
This study showed that increasing heel height (especially with high heels) increases quadriceps activation. There were no intensity increases but with muted glute function we do not need increases in repetitive intensity to see quadriceps dominance to develop. After all what we practice we get better at. If we practice “activating” the quads, we will develop quad dominance. This will also be a key later in redeveloping gluteal activation and strength.
Quad dominance does not only have to do with ACL injuries. Increased quad eccentric loading has been shown to be implicated in the development of patellar tendonopathy/tendonitis.
- Tensor fasciae latae (TFL) and iliotibial band (IT Band) strength and tightness – since the glutes (especially gluteus medius) are weak, the TFL compensates for the body to maintain proper abduction abilities. In addition, increased stress is placed on the TFL and IT band when the knees cave in which strengthens these structures.
Photo from realbodywork
TFL and IT Band tightness, in combination with lateral aspect quad dominance often lead to patellofemoral syndrome where the patella starts tracking off to the lateral side of the knee. In addition, this may cause chondromalacia patellae which is wearing down the articular cartilage on the underside of the patella causing pain.
Extremely tight TFL and IT Band also may cause IT band syndrome as well. In IT band syndrome, the IT band and TFL get extremely tight and start rubbing against the femur itself or other muscles in the area. This creates pain and inflammation.
Bringing up the strength of the glutes to take forces away from the knee and back properly to the hip, like this one case study with gluteus maximus and medius strengthening showing improvements in patellofemoral pain. The same is true in this study of iliotibial band syndrome.
There are even cases where a tight IT band and TFL with a weak gluteus medius can contribute to lower back pain.
- Hamstring weakness and tightness – as we have discussed, the quads become extremely strong and tight, this anteriorly translates the tibia with respect to the femur. This also puts stress on the ACL. To protect joint integrity (anterior-posterior) the body will lock down the hamstrings into extreme tightness to protect the ACL from sprain and rupture.
All quad dominant men have extremely tight hamstrings which are often extremely weak. Women, who tend to have less muscle mass overall, also have their hamstrings lock down. However, since there is less mass to protect the joint it also increases the likelihood of ACL rupture.
We’ve been talking about it before but increased Q-angle, quad dominance, and this all contribute to the 3:1 ratio of women:men in ACL tears.
Athletically inclined quad dominant males and females will often have tight strong hamstrings. This is the other alternative, so it does not necessarily mean hamstring weakness is universal. Since the glutes are inactivated, the hamstring takes over the hip extension and will thus be stronger. Tight, strong hamstrings are notoriously difficult to loosen up.
However, tight hamstrings are often prone to hamstring and groin strains/pulls as well. Incidentally, the decreased activation of the glutes increases the propensity of hamstring overloading and strain.
Note: hamstring tightness may also be instigated or exacerbated from sitting in slouched positions for longer periods of time.
- Deep intrinsic butt muscles tightness – as we know the gluteal muscles are inactivated, so the deep intrinsic muscles lock down to protect hip joint integrity.
Normally this is not as important as the other dysfunctions, but some conditions can arise from this such as piriformis syndrome, SI joint, and lower back pain. In some of the population the sciatic nerve runs through the piriformis muscle in the buttocks. Thus, when the piriformis becomes tight and locked down because of gluteal weaknesses you will often see pain in the glute area and often radiating on down into the leg.
Gluteal weakness (2) and problematic activation patterns (2), (3), (4). Similar findings are true with SI joint pain (2). Now what causes gluteal weakness and incorrect activation patterns? Yes, sitting.
Also, as we stated before decreased hip ROM / mobility refers the mobility to another joint. The next joints in line are the SI joint and lower back. The SI joints and lower back are not meant to be mobile. When you increase the range of motion in those joints you often see increased incidence of sharp pain in the SI joint, potential for bulging and herniated discs, and asymptomatic lower back pain.
Joint issues. I put these last because usually it takes months or years within the aforementioned muscle and connective tissue imbalances to develop joint issues. Our bones remodel to the stress we put on them, and bone tissue is turned over every ~3 months or so. If our posture and biomechanics are out of alignment it will stress the bones and will eventually result in deformity.
In the case of valgus stress, most of the joint deformities are listed in this wikipedia article on valgus deformity.
- hallux valgus – or bunions are formed by repetitive inward tracking stress and weight distrbution over the medial arch.
Photo from twoshots.blogg.se
There are actually two cases of how this occurs.
Repetitive stress over the medial arch plus the talar medial tilt will start to collapse the arch. Since all of the bones of the foot are connected, the stress from the collapse must go somewhere. The stress does not deform at the ankle where the bones and ligaments are the stronger. Rather the stress translates out to the farther part of the arch which is at the 1st metatarsal-phalangeal joint. Since the foot is on the ground and has the 2nd metatarsal next to it, hallux valgus forms by pushing the head of the 1st metatarsal outward. This is the place of least resistance (rather than upwards). Thus, most of these types of bunions are associated with collapsing arches / flat feet.
Alternatively, in some cases the inward stress at the knees pushes the ankle into varus (or higher arches). A varus ankle will twist the proximal metatarsals laterally and superiorly. This makes the head of the 1st metatarsal deviate medially and inferiorly. Obviously, since it cannot deviate inferiorly, it only deviates medially forming the bunion.
- Collapsed arches – the intrinsic muscles of the foot are inactive plus more medial weight lead to the collapse.
We already discussed this before, but permanent collapse is possible if allowed to last too long. The bones of the foot will adopt a more permanent planar foot configuration often with bunion formation.
Collapsed arches is one of the other ways valgus stress can be initiated. For example, collapsed arches tilt the talus. This makes the foot pronate. The pronated foot ‘encourages’ the tibia to internally rotated and tilt medially as well. You may see valgus stress appear in people with severely pronated feet even if their upper leg and patella are still oriented forward compared to the foot pointing outward.
- talipes valgus – inward tracking knees and talar medial tilt results in the ankle joint being deformed to the stress.
Photo from dinc
This deformity is usually associated with flat feet as well. When the arch collapses the talus is permanently tilted medially. Thus, the ankle bone is allowed to deform as weight bearing continues.
- genu valgum / knock knees – the medially and internal rotation tilt of the tibia and femur may lead to this.
This deformity is rarer than the ankle ones. It is usually seen in kids, but it can be present in adults if there is too much valgus stress at the knees.
- coxa valga – this deformity is actually not that noticeable by the layperson. Fortunately, it does not really need to be that noticeable because it is mainly only seen in children.
The reason coxa valga is for the most part only seen in children is because there is more weight and thus stress at the lower extremities than at the hips. Thus, it is way more likely to develop a different disorder at the knees, ankle, or feet. This is especially true with adults who have more total weight over their knees, ankles, and feet.
Notes:
One of the reasons why soccer is the sport with one of the highest incidences of injury is because of extreme amounts of repetitive use combined with improper strength and conditioning. For example, this study on soccer shows that it exacerbates the valgus related stresses because most of the weight is distributed medially in soccer movements.
Valgus stress and pronation has been indicated in weight distribution over a smaller area of the foot. This is an increased weight to surface area ratio which means that it is more likely to develop injuries with the valgus condition compared to the varus. Another reason why valgus injuries are more common.
Also, remember that my descriptions are only one way to develop such injuries. Some people with flat feet just have decreased proprioception from shoes and that is enough to allow their arch to collapse. That then tilts the talus and the knee tracks inward from there. So there are definitely many cases for how different injuries arise.
The one thing we must keep in mind is that the body functions as a unit and usually it goes until it breaks in one area. Thus, we generally only have the propensity for developing one such injury at a time. On the other hand, it is certainly possible to develop multiple injuries depending on the person. In most people I have seen with at least one of the injuries described above, they have at least 2-4 if not more of the symptoms of valgus stress on their lower body. Keep this is mind later when you are analyzing yourself.
Varus Stress / To the top
I am only going to be briefly talking about this because for one it is not very common to have issues relating to this stress deformity.
Now, the other way that the loss of range of motion in the calves is compensated for is with external rotation of the hip. This may result in varus stress especially if the knees come outward. However, this is rare.
External rotation of the hip is most common in the elderly. As we sleep all of our muscles relax. If you sleep on your back (which is how you should sleep), most people allow their legs to relax with the feet pointed out. When you are in this position for 8 hours, much like sitting this allows the external rotators of the hip to become tight and the internal rotators to be stretched out and weak. Thus, hip, knee, foot turned out posture is developed from both sleeping, and loss of range of motion the calves.
The “most” common symptoms are at the feet and ankles again because of increased weight distribution on the lateral aspect of the foot. Fortunately, the associated conditions are high arches and the increased propensity to roll the ankles. This is in comparison to development of hallux equinovarus / club foot which is more common in children with developmental problems.
Suffice to say for most people with high arches or chronic ankle rolling it is important to avoid shoes especially with padding because they encourage this nonsense. We will talk about this later as well.
Conclusion
In conclusion, we learned that the valgus stress of inwards tracking knees is propagated by shoes and sitting because
- The lost ROM from the ankles is gained at the next joint which is the knees.
- Inactivated glutes which are external rotators allow the femur to rotated internally which encourages inwards knee tracking.
- The tight adductor longus and brevis in conjunction with the inactive glutes pull the knee medially in eccentric movement.
- Adductor magnus in conjunction with in inactive glutes pull the knee medially in concentric movement.
These often lead towards the muscle, connective tissue, and joint issues of
- flat feet / collapsed arches / pes planus
- plantar fasciitis
- achilles tendonitis or rupture
- ACL sprain or rupture
- quadriceps dominance and tightness
- tensor fasciae latae dominance and tightness
- iliotibial band tightness
- hamstring tightness (weakness or strength)
- deep butt muscle tightness
- SI joint or lumbar back pain
- hallux valgus / bunions
- talipes valgus
- genu valgum / knock knees
- coxa valga, while possible, is usually a developmental issue
After having reread the Neanderthal No More Part one article, Cressey and Robertson have come to a lot of the same conclusions I did (before me of course). It’s worth a read for their take on the same thing as well.
In the next segment, we will talk about how to evaluate dysfunctions and some corrections you can make.
Part 3: Evaluation of lower body dysfunction and corrections
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.