Introduction & Shoes and Sitting
Systemic biomechanical issues
Evaluation of lower body dysfunction and corrections
Soft tissue optimization and corrections
Summing it up
Summing it up
Table of Contents
Review
Barefoot and minimalist shoes
Negating sitting
In workouts
With developing or current injury conditions
Conclusion
Other material
Review / To the top
We have extensively looked at the valgus conditions that are prevalent in modern society. These are because shoes and sitting lead to mechanical deficiency that allows problems to develop. Let’s review.
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 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).
These problems tend to lead to inward tracking knees.
Inward tracking knees tends to cause the problems of:
- flat feet / collapsed arches / pes planus
- plantar fasciitis
- achilles tendonitis or rupture
- patellar tendonitis
- ACL sprain or rupture
- quadiceps dominance and tightness
- TFL and IT band tightness
- hamstring weakness and tightness
- joint deformities like bunions, collapsed arches, talipes valgus, knock knees, etc.
Remember, many people may have multiple symptoms described above, but usually they only manifest one injury. Only one or two parts may tend to “break” and cause a person pain before they can do enough damage to incapacitate other parts in the chain.
It is important that everyone evaluate their lower body posture and movement patterns to ensure that such things do not occur.
Barefoot and minimalist shoes / To the top
If you are starting to go barefoot after wearing shoes all your life be wary. Initially, there will be decreased ability to maintain balance. This is because our bodies have “adapted” to shoe use. However, once adaptation back to barefoot or near-barefoot conditions occurs, balance and gait should be significantly improved.
Learn to run and move correctly with minimalist shoes or barefoot. We previously talked about barefoot running in grass being a good alternative to start with. Any type of shoes with extremely thin soles are good as well, but they must have low cut sides that allow proper ankle mobility. Integrate this training with the foot drills and balance training.
Start VERY slow. Since most people’s feet are not adapted to moving around barefoot a lot doing anymore than 400m even in grass is questionable. When you are first starting to exercise you would not do 400 repetitions of pushups, so why would you do as many repetitions running?
Side note – weightlifting shoes are fine for weightlifting since ankle mobility needs to be good to lift well anyway.
As for the minimalist shoes we discussed this in the last segment. This is what we are looking for:
- Quadrangular, to conform to the normal foot configuration, with abundant space for the times.
- Flexible to allow free foot movement [especially at the ankle].
- Flat without elevation of the heel.
- Porous. Uppers should be made of leather or unsealed fabric to avoid skin maceration or fungal infections.
- Moderately tractive. Sole friction should be equivalent to that of the bare foot. Sole that are slippery (leather) or that create excessive friction (some rubber soles) should be avoided.
- Light weight to reduce energy expenditure.
- Extended above the ankle in the toddler to prevent shoe from slipping off during running.
- Acceptable in appearance because children are very sensitive about that.
- Reasonably priced. Medically satisfactory footwear need not be expensive.
I would clearly agree with all of the points except for the last two which need not be followed for proper foot health. Basically, what the study is describing is minimalist shoes. Vibram fivefingers are like that. There are also other minimalist shoes that are made for running such as Puma’s H-street/K-street brand that adhere to most of the points above. These are the types of shoes you should be looking for.
Negating sitting / To the top
Obviously, we cannot eliminate sitting too much. Thus, it is important to be doing a lot of gluteal activation work as well as stretching out our hip flexors. Everyday if possible.
If you are someone who is reading this and exercises you can integrate them into your warmups and cooldowns.
If you are someone who does not exercise then you should exercise! Exercise is not only healthy but a good stress reliever. However, if you still refuse, it is still a good idea to do these exercises sometime in your day whenever you choose.
Now, for those of you looking to get ahead of the game: yes, you can do them at any time. It may be a good idea every 20-30 minutes if you have a desk job to stretch out the hip flexors and do some glute activation work. Just do not let anyone catch you doing glute bridges or other hip thrusting exercises on the floor otherwise it may be awkward. Stretching can probably be explained away though. 
In workouts / To the top
Now, hopefully most of us have competent trainers who knows correct movement patterns as well as the cues to correct them. However for a lot of people this is not the case.
For the people who do not have anyone to correct their technique during exercise it is a very good idea to invest in a video camera and find a good online fitness community who is willing to take a look at others’ exercises and help them correct any flaws.
Investing in books or reading material online about correct technique for exercises is imperative for anyone who exercises. Books such as Starting Strength have extensive chapters on technique alone to make everything as safe and effective as possible. The best way to improve very quickly is perfect technique because it allows you to lift the most weight or perform at the highest intensity effectively.
With developing or current injury conditions / To the top
You have to know when to listen to your body. Pain is your body telling you that something is wrong. This means you need to stop working out and address the problem.
If you do notice that certain movement patterns are askew, then it is a good idea to get yourself evaluated by a good trainer or get evaluated by a good physical therapist who knows a lot about exercise.
If you have developed a condition, it is not an all or nothing proposition. You do not have to completely stop working out – you can keep doing skill work, upper body, or core work if you have a lower body injury. But you definitely should not be pushing through the pain with a “no pain no gain” attitude.
One last thing that is a very important reminder that I have stated earlier as well. One thing I have noticed in the physical therapy clinic I currently work at is that often those people with darker skin are more prone to pronation in the foot and collapsed arches. This is due to Vitamin D deficiency. If levels of Vitamin D in the blood are low, proper bone growth and mineral density is decreased. Thus, this leads to bones that are softer and more likely to deform to the stresses we put on them. Couple this with the valgus stress of shoes and sitting, and you have an increased likelihood to develop flat feet, plantar fasciitis, and talipes valgus.
Conclusion / To the top
Basically if there was one key take home point I would want you to have learned from this series it is this bit of information.
Essentially, your arch, knee, and lower back problems can be solved by (1) focusing on stability and proprioceptive work at the painful joints in question, and (2) improving your strength and mobility in the hips and ankles. Point 2 is one of the most critical points that is often overlooked by most coaches as well as physical therapists. Remember, I have referenced studies and logically walked you through the physiology that shows arch, knee, and lower back pain can be cured or will show significant improvement through increasing flexibility/mobility and strength in the ankles and hips.
Thus, shoes and sitting are universally detrimental to the development of chronic lower body conditions. Counteracting these stimuli should be focused on restoring proper ankle and hip function, and focusing on stability at the arches, knees, and SI joint/lower back.
- Do mobility work, soft tissue massage, and strengthen/stretch the appropriate musculature.
- Be mindful about posture and your movement patterns.
These two steps are the key to your improvement and overall health. Prehabilitation work is always better than getting an injury have having to take time off out of your schedule to do rehabilitation. If you are rehabilitating, then do everything you can in your power to get back to good health. No one likes to be injured.
Hopefully, this series taught you how to prevent and rehabilitate lower body dysfunctions.
Other material / To the top
Finally, there are some other articles that discuss some of the physiology and corrective nature of the work I am talking about above. If you have more that are useful feel free to post them in the comments, and I will add them.
Neanderthal no more 1-5 (both shoulder and lower body issues):
Part 1
Part 2
Part 3
Part 4
Part 5
Trigger points, More trigger points
Sacroiliac mobilization I, Sacroiliac mobilization II
The low back
Bulletproof that back
lower back savers I, lower back savers II
ACL Injuries & Young Female Athletes
Preventing Hamstring Injuries
The Female Knee, the Athletic Knee
Solving Anterior Knee Pain
Healing the Hips
Teach them to land first
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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.
I’m interested in reading the full text shoes in Pediatrics. I’ve got a ten month old son and he is just beginning to walk. I’m avid that he should run around barefoot because that’s how it’s supposed to be, but I can’t seem to convince my wife. She’s, unfortunately, fallen in to that category where she puts shoes on our son because they are cute; not out of necessity or to serve any functional purpose. For my interest and my sons benefit please email the text. I’d greatly appreciate it.
Fantastic article BTW despite it’s length it was a really good read.
Shoot me an e-mail at “steve” at this website name.
Thanks for the compliments.
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.
Hi Steven, as a follow up, my third-world squat has improved (in terms of depth and time I can hold it) quite a bit. But recently I’ve noticed that when I stand up from the squat there is pain on the medial aspect of my knee, and it remains for a while. I notice the same problem occasionally after deadlifts and (of course) squats. Any thoughts?
I don’t know if this is signficant or not, but I did recently notice that the “bump” at the top of my tibia sits somewhat laterally to the kneecap on the affected leg, but not on the other.
Pain on the medial-inferior aspect of the patella, or underneat in the patellofemoral groove, or where?
Remember, I addressed the rotated tibia problem as internal rotation of the femur (valgus knees). Make sure these get aligned properly when doing squats and other movements. If you have to massage tightened muscle tissues, and work on your hip and ankle mobility then so be it. Biceps femoris may also be tight.
Well, when I wrote my comment it was on the inside of the knee, not near the kneecap at all, probably centered on the groove where the femur and tibia slide over each other. The pain was a dull, burning ache that would last for several minutes. But yesterday I did a 5×5 squat workout, and during the last set I felt a sharp burning in the same knee. *This* pain is on the medial side of the kneecap itself; if I could “lift” the medial side of my kneecap, it feels like I could point to the most painful spot, just underneath. It doesn’t hurt when I’m walking around, but if I close the angle between my femur and tibia to less than about 45 degrees it lights up.
Perhaps different things, perhaps related, I don’t know. This knee has been troubling me since June. It all started with pain above and a laterally to the knee, somewhere around where the IT band attached into the knee… That’s when I started to foam roll, tennis ball roll, stretch everything in the leg and hips, third-world squat, etc. I suppose that has helped, but the knee continues to bother me.
Tom,
The first one sounds like mensicus then… if that persists I would get that checked out by an orthopedic doc ASAP.
The latter sounds maybe some patellofemoral symptoms. If you have tight quads the patella can ride up and aggravate the femoral notch there. That’s a bit different than the PF I describe in the article, but the fix is essentially the same. Stretch out your quads and hip flexors, especially rectis femoris, take your fish oil, etc.
It seems like you may have enough problems that you might want to get that evaled by a doc or PT though. If you have any other issues with your feet or your back/hips it might be a good idea to have them evaluate your whole lower body.
This is familiar territory for me, but thanks for a well written article. Since this is from a year ago, are there any updates you’d care to add?
Thanks,
Steven
I need to add updates to about 80% of our articles.
As it is this one could be rewritten a bit clearer with more pictures to make it more accessible to the layperson but it’s pretty good stand alone.
I’m pretty much trying to focus on book work at this point.
Hi Steven, I just read this article and perused most of the associated links. I found this after coming across some of your posts on the CF injury forum. Very good information. Thanks for your research on this.
I have been struggling with a hamstring injury for over a year that worked itself into some hip problems. After a couple of MRIs, an SI joint injection (that did not help) and 4 months of PT, the hip/SI is doing a lot better but the hamstring problem persists and does not seem to have improved at all, although the PT said the weakened area of the hamstring was showing improvement in strength. I can’t run because of the pain and even t-mill walking is painful. Have been working on strengthening my glutes and abductors, which the PT found were weakened. I believe you are in Maryland. I wonder if you can recommend a good sports med doc and/or PT office in the area (I’m in Howard County) who would understand the needs of an athlete like myself. The PT I was working with was very dedicated and competent, but she is not athletic and discouraged things like deadlifts and box jumps. By the end of 4 months of PT, she seemed unsure as to what to try next. Wondering if there is someone who can help me get over this injury so I can get back to running. I have continued to cycle regularly and CF several times a week. But I’m a triathlete, so not running is killing me. Any suggestions? Thanks!
I’m sorry I don’t know anyone in your neck of the woods as I know no one in Howard County. And to be honest, I’m not sure of the better sports related people around even Maryland either. A bunch of the PTs at the clinics I worked as a tech for were good, but they weren’t geared towards more of the stuff I write about and will likely practice in (when the highest DBs you get to work with are 10 lbs that’s not much and no barbells).
It may be a good idea to call say Howard Community College sports department and ask them who they use as their orthopedic specialist and physical therapists. Any of the colleges in your area may work as well. I think that’s the best way to handle something like this.
Did your PT ever figure out why your hamstring was having issues in the first place and why it’s not responding to rehab as well as it should? It seems like some more systemic things are at work, maybe down in the feet or up in the lumbar spine region.
Thanks for replying to me. The intial injury occured during a race in Oct 2009 and I did not have it treated immediately (1st big mistake) and continued to try to train on it (2nd big mistake). It definitely started in the middle hamstring during the last few miles of a very hilly bike course and I continued the race despite cramping in the hamstring during the run. Anyway, the hip/SI/lumbar area started to get involved a few months later. The 1st MRI was to check for disc involvement in the lumbar region. It looked fine so we did 8 PT visits working mainly on the hamstring. After a couple of months of slight improvement in pain, the PT thought the pain might be referred from the SI joint, so I went back in for a 2nd MRI of the pelvis that showed a couple of non displaced tears in my hip labrum and some arthropathy of the SI joint. So we tried an SI joint injection, which only made me hurt worse for a week. After that, it was more therapy, this time focused on strengthening my abductors and glutes. She did not understand why the hamstring was not responding to the rehab as well as it should. I have maxed out my PT visits for now unless a doctor thinks I need more. I have not felt like going back for more visits when it seems I have not made any progress with the numerous visits and $$$$ I’ve spent. I’ve been doing Kelly Starrett’s mwod and am finding many tight spots. My hips are feeling much better than before but the hamstring still hurts sometimes when I am doing nothing. Running really seems to bother it. I would be willing to see docs in Baltimore city, PG or Montgomery counties if they are good. I already drive to see my rheumatologist in Montgomery Co, so its more important to me that the doc/PT be competent and understand where I am coming from (not going to be satisfied with a light workout but I’m willing to do whatever it takes to get back to normal) than be local. Thanks for the suggestion to call HCC’s sports department. When do you graduate? Going to set up clinic here when you are done? Seems there is a shortage of PTs with your perspective. Thanks.
Hah, I graduate in about 2.25 years. Unlikely clinic when I get out though.. have no capital and no clue what the market is like. I will probably be somewhere in the area though.
It might not be a bad idea to treat the hamstring like a strain and see how it responds with massage, heat, controlled weighted eccentrics, and light mobility work to see if that works in the meantime while you’re looking for something especially if it’s a more sore kind of hurting pain.
Thanks. One question, what would be controlled weighted eccentrics? And in the meantime, other than not running, are there other things I should be avoiding if I’m treating it like a hamstring strain?
So you can do assisted hamstring curls, and then slowly control the weight as it comes down (if you use an ankle weight) or slowly control it as it goes out if you use a machine. Something along those lines. Can be standing or prone with an ankle weight, generally seated with a machine.
If stretching hurts it then obviously don’t do that, but if mobility works helps to keep it loose and mobile then you do want to do that. For a strain, stretching tends to act on it negatively.
Same thing with ice or heat. Whatever helps use it. Generally, if it’s a contractile/hamstring strain issue heat will tend to work better.
It’s probably NOT a strain, but sometimes trigger pointed muscles or tight/irritable muscles respond well to strain rehab protocol so that’s why I’m suggesting that.
Thanks for the info on the eccentric exercises. What do you think about donkey kicks? Weighted donkey kicks? It seems like it gets bothered when it is in extension (not sure if that is the right word). But I noticed last week when I was practicing handstands it felt a bit aggravated from the kick up. I am now nursing a shoulder injury, so I won’t be doing handstands for awhile (or pullups, or push presses . . . )
Donkey kicks are fine for hams/glutes/posterior chain.
If they help then use them for sure.
I have work orthotics since I was a teenager, but still have problems with plantar faciitis, heel pain, etc. when I am active. I am 39, trying to be active, and would like to get my feeet arched and strong enough to no longer need orthotics. How can I achieve this? What sort of medical professional can I work with to help guide my process? The Podiatrist just wants me to pay for orthos for the rest of my life…
I do not even know where to start with this type of stuff online.
I have listed many good exercises that may be beneficial, but that can only go so far sometimes.
For an individualized case it is best if you found a physical therapist or chiropractor who believes in barefoot training and is willing to work with you to try to solve your issues.
On Q-angle – can’t you just spread your legs? I know there’s plenty of cultural pressure for women to keep their legs together, but I don’t see any biological reason for it.
Q-angle is not a product of culture and women holding their legs together.
Bringing the legs together or apart does not change the relationship of the angle at the knee in measurements — e.g. knee structure does not change whether your legs are together or apart.
Q-angle is greater in women because both ASIS are set farther apart from each other because women have structurally wider hips and the measurement is thusly reflected in the structure at the knees.
Therefore, Q-angle reflects a purely anatomical difference between the sexes which unfortunately predisposes women to greater knee injuries because of greater potential for twisting torques at the knee joint. This is why proper strength and conditioning and technique is important for women in sports. ACL injuries rates between men and women in sports reflect why this is an important area to look at.
Hey, went back to check this post out, when I saw it linked to from the article on feet specifically. I’m still working through it, but noticed that you had implicated sitting as shortening the hip flexors. I was curious whether you’d seen this http://toddhargrove.wordpress.com/2011/05/29/does-excessive-sitting-shorten-the-hip-flexors/ and whether it had any effect on your assessment.
I actually read that when I came out.
I think it’s honestly multifactorial, and sitting is one factor.
No one doubts that high heels do damage to the body (chronic shortening of calves, etc.), but sitting likely does similar things even in dynamic vs. static positions.
When you look at the populations you see that women, on average, tend to have increased anterior pelvic tilt compared to males. However, on average, I do not expect to see a difference between women and men in regards to time spent sitting.
As you’ll read, women have increased Q-angle over males. Whether this ia causative factor for quadriceps dominance and related to chronic hip flexor shortening, gluteal weakness, hamstring lengthening, abdominal weakness, etc. is up for some debate. I think that sitting plays some role in all of this as it encourages a lot of the states of tissues above.
When you have a myriad of risk factors it is very hard to determine what may actually be the factor that sets it off. Maybe it’s a combination. Maybe it’s a single event. Do you see where I’m going with this?
I do agree that sitting is not a causative factor (but likely a significant risk factor or correlative factor — perhaps a causative in some) and will update that with my analysis once I have time.
Thanks for the comment.
Yeah, I see what you mean. And of course, it’s just a detail in the larger picture–there’s no arguing with the high morbidity rates, etc. associated with sitting, even if that’s just displacement–time spent sitting is not spent doing something, anything, just to keep the body moving.
And I’m 100% with you that ‘corrective shoe’ is an oxymoron. My dad has been wearing orthotics in his shoes for years, and is surprised he still has bursitis, tight calves, and a host of other things. It’s actually painful just to *look* at the man’s feet, and I’m convinced it has a lot to do with the fact that he only takes his shoes off to sleep, and sometimes not even then.
You can’t go around on crutches all day, and then wonder why your legs are stiff.
Hi. I get knee pain walking or running. I was accessed by a orthotic specialist, and prescribed insoles for my shoes, which apparently correct the way my feet land on the ground, which is the reason why I have apparently got knee pain. I am very tight in the muscles. I have two short questions. 1. If you say walking in bare feet is good, but my foot is naturally landing incorrectly on the ground, wouldn’t walking in bare feet be worse for me, than wearing shoes, with corrective orthotics fitted? Since I would still be landing incorrectly on the ground in bare feet. And, If I stretch a lot and become flexible, could the way my feet land on the ground change over time? Thank you
Jacob,
Because barefoot movement would be painful the way you’re currently automatically walking (and yes, worsen your situation), you are forced to fix the way you walk to make it less painful (and this usually consequently fixes the mechanics that are a major cause of the knee pain).
Proper stretching aimed at the correct musculature will be a generally beneficial thing to do since improved flexibility (along with knowledge of proper technique during both exercise and daily life activities) tends to be a MAJOR contributor to avoiding orthopedic issues throughout life.
Tangentially, the shoes you were prescribed will simply help fix the symptoms but not much of the root problem. This would be much like taping flashlights to the front of your car because your headlights are broken.
Jacob,
Pretty much what KC said.
Issues like these are often correctable by proper stretching and strengthening of certain muscles, and re-education and posture and gait. So yes, your mechanics can be changed over time to potentially remove orthotics completely.
Since you have pain now orthotics would be good to help control it, but that does not mean you shouldn’t be stretching/strengthening/working on proper mechanics. Unless you want to be in orthotics for the rest of your life.
I notice you have some core exercises up there and one of them are (planks with the pelvis posterior tilted), which teaches you to do the plank with a posterior pelvic tilt, but every other expert that I have read about so far, has told people to do the plank with a neutral pelvis, a slight lumbar curve. It was just interesting to see that your video says otherwise.
PPT planks focus more of the work onto the abdominals and less onto the hip flexors. Generally speaking, this is better for those who already have anteriorly rotated pelvises (tight hip flexors, weak abdominals) which is a hallmark of adaptations to sitting posture. This is consistent with what I have addressed in the article.
In a vacuum with no dysfunctions, then yes you would want to keep a neutral pelvis.
Steven,
I am an Olympic Weightlifter and I have been dealing with some pain when I squat. My low back (erectors) gets really tight in the hole as well as a sharp pain in the tendon where it attaches at the top and lateral part of the patella on my left leg only; my knee generally pops as well when I squat or catch it in the receiving position; I have tight hip flexors, hamstrings, and calves; Every now and then I get pain in my SI joint as well; and I sometimes get pain in the back of my knee (moreso the left)and top of my calve from doing posterior chain work (glute ham). I’m really struggling to find a proper corrective exercise strategy that caters to all of these ailments, which is keeping me from competeting as heavy as I ought to be. Keep in mind I am in college and I sit a fair amount during the day and that I use a lifting shoe with a .75 inch heel for training. I have good flexibility in the squat (ironically enough) and can go ATG while keeping my spine pretty vertical. If you can, I would greatly appreciate some ideas or pointing me in the right direction. Thanks!
P.S. My friend gave me a pair of vibrams, and when I wear them throughout the day, my lower extremities don’t seem to hurt as much compared to my regular tennis shoes.
The number stuff is what you probably need to do. Rest is just explanations.
1. I would definitely stick with the vibrams if they’re helping.
2. If you’re having trouble in the hole with weight it may be a good idea to back off the weight until you can work with it non-painfully.
Just from a general perspective the fact that calves and hammies are tight plus low back is getting tight deep in the hole tends to mean you’re not getting enough anterior rotation of the pelvis. To compensate your knees will come forwards more putting more quad emphasis at expense of glutes.
Glute ham — since the calves are also knee flexor, that means your hammies aren’t doing most of the work there. That probably also means they’re tight and weak which is generally a bad combination.
3. To emphasize more hammy/glute work I would go with some romanian deadlifts and cut the GHR for now. And work on a good hip hinge exercise such as good mornings or other variant.
4. Increase your mobility in calves/hammies. It also might be a good idea to look at your thoracic extension if low back is an issue. Use a foam roller for this. Also target your glutes to decrease quad emphasis with something like weighted hip thrusts although if you do have gluteal amnesia you should start with glute bridges and focus on activation and squeezing the muscles for 10s each rep for 20-30 reps and a couple sets.
There’s so many issues here it may be a good idea to get to a physical therapist to get them all sorted out regardless, but I think the above is a good place to start.
Thanks Steven, I really appreciate it. I think it’s great that this site available.
In response to keeping a posterior pelvic tilt in the plank exercise for people with an anterior pelvic tilt, do you think this would also translate to exercises such as bird dogs? Thanks, last post from me.
Since the main target of the bird dog is usually the back, glutes, etc. and not the abs I would generally say no. Keep a neutral spine (with slight lumbar arch) for these.