Table of Contents
I. Introduction

This is a big problem because the first page was just an introduction to the main stimuli that cause the problems. Other mechanisms and compensations were discussed on the second page. The third page consisted of correcting movement deficiencies, and the fourth page on specific soft tissue corrections and strengthening/stretching procedures. The fifth was an overall summary that was important if the anatomy was too much too handle.

If any page was the least important to consider it would probably be the first page… but most people just quit reading after the first page. I want people to realize that shoes and sitting cause problems, but not at the expense of knowing the mechanisms of why it happens and how to correct those problems. If you or anyone you know were one of those people I implore you to go back and reread the whole article. It’s long, but its worth it especially if you have these types of problems.

Moving on…

This is going to be a spinoff of that topic focusing specifically on the feet since most people have these types of problems especially with pes planus (aka flat feet / fallen arches) nowadays. Some of the material is going to overlap with the above article, so if you wanted to get a more generalized overview of other movement problems that can occur with flat feet I would suggest looking at the above.

Let’s get started.

An arch is one of the fundamental structures within engineering for supporting weight for good reasons. They are able to take weight that is put on top of them and sustain it. Instead of the weight becoming a shear or torsional forces, arches help to distribute the weight into compressive forces.

Well, it just so happens that all of our bones are built to take compressive forces. For example, that is why all of our long bones like the femur and the tibia are oriented so weight bearing occurs vertically. If we look at the femur below we can see that the compact bone is oriented for sustaining vertical stressors. The neck and head of the femur actually have their own type of architecture built in as well; the trabecular (spongy) bone is oriented in such as way that there are multiple arches which help support the weight of the pelvis and the rest of the upper body on the femoral head and neck during weightbearing so that it doesn’t shear off during loading.

Photo from itmonline.org and blogspot.com respectively.

So as we can see with other bones bones in the body, the bone is strongest with compressive forces. However, when there is an angle necessary such as the neck of the femur, the body (e.g. evolution, God, etc.) compensates by building its own internal arches to support the bone so that shear stresses do not destroy it. Shear (lateral) forces, of course, are the main culprit in fractures.

Interestingly, the foot is comprised of 3 arches.

Photo from munfitnessblog.com

The longitudinal arch is compromised of the medial and lateral arches. And there is also a transverse arch of the foot.

The medial arch consists of the calcaneus, talus, navicular, 3 cuneiform bones, and the first 3 metatarsals. In laymans terms it runs on your foot from the heel to the ball of the foot where the first 3 toes are on the big toe side.

The lateral arch consists of the calcaneus, cuboid, and the last two metatarsals. This would be from the heel to the ball of the foot where the ring and pinky toes are.

The transverse arches are comprised of the specific orientation of the tarsal and metatarsal bones. They form a concave C shape underneath which can be seen in the next two photos.

Photos from pilates-pro.com and chestofbooks.com

All of these structures come together to form a stable base of support for the foot during weightbearing.

Photo from craftofpiano.com

Thus, we can think of the 3 arches combined as an oval dome structure; it is structurally sound built to take the forces that we put on them.

On the deep plantar (sole) aspect of the foot there are 3 main ligaments that hold the tarsal bones together in the arch. These ligaments, the spring ligament, long plantar ligament, and short plantar ligament all span the bottom of the arch right underneath where the ankle exerts its weight. As you can see below, the long plantar is more confined to the lateral arch, the short plantar is somewhat in the middle between the lateral and medial arches, and the spring ligament works more to support the medial arch.

Photo from dartmouth.edu

Ligaments tend to function as more of “last line of defense” in supporting a joint structure. For example, everyone knows about the ACL in the knee which prevents anterior displacement of the tibia (relative to the femur). If we rupture that ligament, the knee becomes severely destabilized and likely requires surgery. We will talk about this a bit more later though in the context of the foot.

As we can also see from the above picture, there are tendons from muscles in the deep shin and calf areas namely the peroneus (fibularis) longus and tibialis posterior tendons which wrap around the foot and criss-cross and attach to the metatarsals. If you couldn’t guess by now these muscles are integral as support structures; we can think of them as suspender cables that help to hold up a suspension bridge.

Now, we have only looked at the deepest part of the foot. Let’s quickly cover the rest of the muscles that help support the foot. Besides the deepest layer that serves as “last resort support” there are also *4* layers of muscles on the plantar aspect of the foot not including the plantar aponeurosis (e.g. plantar fascia).

In order from the plantar aponeurosis moving deeper into the foot we have:

Photos courtesy of this site. Visit it for a more in depth anatomy lesson.

I’m not going to delineate all of the specific muscles of the foot and their functions. However, we will conclude that all of these muscles have different functions on the bottom of the foot just like our hands have many muscles in them for grip and dexterity. These muscles are made for stabilizing and reinforcing the arch of the foot itself to hold it together and make sure it functions well to whatever walking, jogging, sprinting task we use them for.

The ligaments on the plantar aspect of the foot serve to function as girders underneath to limit collapsing of the arch under compression. When a downward force it applied to the arch of the foot, the plantar surface of the tarsals and metatarsals start to spread apart; the ligaments which do not stretch very much help to stop this from occurring.

The muscles themselves form the core of what supports the arch. As we saw above, there are two tendons that come down like suspenders from the lower leg area (fibularis longus, tibialis posterior) and criss-criss underneath providing lots of support. In addition to these muscles, there are two other posterior leg compartment muscles (flexor hallucis longus [FHL] and flexor digitorum longus [FDL]) which run with the posterior tibialis behind the medial malleolus which shoot out to the big toe [FHL] and the 2-5th digits [FDL] respectively which also give some support the bony architecture of the foot. The tendons of those two muscles are located in the 2nd layer of the foot.

Photo also courtesy of the great anatomy site the above 5 images are at.

Most of the rest of the muscles start from the calcaneal/talus area (heel/ankle) area and run to the metatarsals or phalanges of the foot. They also provide support to compression of the foot from weight above, and also help with the mobility of our distal toe joints during walking activities.

As we stated earlier the most important thing to note is that the arch has its own form of support. The bones form the architecture, and the muscles support it with ligaments as reinforcing beams to provide a last line of defense in case of muscular failure.

The plantar fascia has it’s own role in tensioning relationships called the Windlass mechanism, but primary support with non-dorsiflexion of the toes is done through all of the muscles and ligaments as stated above.

We will discuss why can become a problem in the next section.

If there is a lack of arch development (1) especially in childhood, or (2) if you had arches and they slowly are disappearing then you likely have a dysfunction. This is especially so if we notice valgus features within the hip and knees – e.g. knees collapsing inwards during movements – or have bought into the delusion of wearing excessively padded shoes or orthotics.

Pes planus is a disease of civilization. Much like there are many physiological problems that are created by industrial food processing and sleep dysfunctions from artificial light, there are also movement dysfunctions born out of civilizations.

Let’s review what we learned about movement problems from Shoes, Sitting, and Lower Body Dysfunctions.

Shoes tends to cause the problems of:

• Tight calves resulting in loss of 10-20 degrees of dorsi-flexion range of motion (ROM) in the calves.
• Inactivation of the muscles on the bottom of the foot and the ankle stabilizers.
• Decreased proprioception of the lower limbs.

Why is this?

Shoes are essentially air casts for the feet. What happens when we put a cast on our arm for a broken bone?

Our body is a use-it-or-lose-it system. It does not like devoting energy to things that it deems useless. Thus,

I. When we are immobile our bodies sense that we do not need that particular body part so it starts shortening the muscles through feedback control of gamma motor neurons. Gamma motor neurons regulate muscle spindle sensitivity and start to tighten intrafusal muscle fibers. Muscle spindles are embedded in the intrafusal muscle fibers and regulate length-tension of muscles through the stretch reflex; thus, tightening the gamma motor neurons makes the muscle more resistant to stretch. Hence, the tightness and loss of range of motion in the calves.

II. Likewise, atrophy of the muscles starts to occur which start to weaken all of the intrinsic muscles of the foot and calves. Muscle tissue is expensive to build and maintain for the body, so when we do not use it our body starts to metabolize it to use for energy. Hence, the inactivation and weakening of the ankle stabilizers and intrinsic (all 4 layers) foot muscles.

III. Additionally, since we are not using these muscles the body starts to decrease emphasis of the particular afferent/sensory and proprioceptive/kinesthetic ascending pathways to the central nervous system (spinothalamic, spinocerebellar, and dorsal column medial lemniscal tracts) which in turn decrease output of descending control to both unconcious (medial reticulospinal and lateral vestibulospinal tracts, intermediate hemisphere of cerebellum, possibly lateral cerebellum too) and conscious (lateral corticospinal tract) pathways. The unconscious control is mainly focused on postural and balance corrections, and the conscious tracts facilitate voluntary motion.

Note: I included specific tracts if you wanted to look them up.

The more padding in the shoes, the worse the problem becomes. The padding in the shoe becomes the “support” for the arch; thus the body says to itself it does not need the muscles in the shin/calves and feet anymore and those three big problems occur.

Let’s follow what happens to its logical progression.

• We wear shoes, especially those with padding
• The body senses lack of movement and information from sensory structures
• Thus, the body starts tightening up muscles reducing range of motion, atrophying the muscles, and decreasing foot awareness and control.
• Atrophy of the muscles lead start leading to greater stresses on the ligaments.
• The ligaments start stretching.
• As the ligaments start stretching, the arch starts collapsing
• In many cases, this starts to put pressure on other structures that have nerve fibers. One of the primary places this occurs is the plantar fascia.

The mechanism is pretty straight forward, and that’s the way it happens.

For example, fault biomechanics at the hips and knees through too much sitting can lead to valgus alterations in lumbar, hip, knee, and ankles joints. These changes can tilt the weight foot more onto the medial arch which can be enough to start collapsing in many cases.

Similarly, traumas or impacts can play a factor as well. For instance, one prominent example is the sacroiliac (SI) joint. Sometimes an impact to the leg from an awkward landing or car accident or non-impact scenario can rotate the SI joint out of place. When one side slips or gets stuck in a particular orientation, the loss of mobility at the joint leads to alterations in normal biomechanics of nearby joints. This can cause things further up the chain such as neck or scapular pain, lumbar scoliosis, sciatica, hip and knee pains, etc. mainly through leg length discrepancy. The slipped side usually has the leg become shorter than the other leg (because the SI joint on that side slips downward which tilts the pelvis towards that side making the affected side’s leg shorter).

Photos from sportsinjurybulletin.com and chiropractic-help.com respectively.

I have written some on SI joint dysfunction, but if you suspect this is a problem I would definitely go to a chiropractor or physical therapist who is good with lumbopelvic evaluations to get yourself checked out. You may be able to check yourself with the long sit test – legs will be uneven lying on the back e.g. pelvis oriented upwards, but when you sit up they will be even because the slip doesn’t manifest when the pelvis is oriented forwards.

Even if these issues are fixed you may still have problems later if the issue has been there months or years,so don’t close out your browser on this article yet as you may still need help in this area.

High arches aren’t really a disease of civilization because they aren’t as common, and don’t exist from the same incorrect biomechanical faults as flat feet.

If you have pain from high arches it would be a good idea to get it evaluated by a professional to at least rule out neurological issues.

As we talked about if there are some varus issues (See Shoes, Sitting, and Lower Body Dysfunctions for a longer explanation), it is certainly possible that this problem may stem from bow leggedness or duck walking. It could also just be a postural issue stemming from previous pain incidents or from excessive external rotation of the hip.

If this is a problem take a look at your leg biomechanics. When you run, walk up stairs, squat, and do any other activities are your joints aligned correctly? Are your knees tracking properly over the toes? Are the knees oriented forwards? Is weight properly distributed on the feet or more laterally based on the edge of the foot?

If you can spot issues that may be causing pain, and likely with this condition many inversion sprains then there may be some corrections that you need to do. See pages 3 and 4 specifically of Shoes, Sitting, and Lower Body Dysfunctions for this.

As previously discussed the plantar fascia is involved with the Windlass mechanism. When the toes are dorsiflexed in walking, jogging, etc. it tensions the whole foot through the calcaneus which gives the achilles (and thus the rest of the posterior chain) and stable platform from which it can propel the body forwards. In normal movement, however, there is not constant tensioning on the plantar aponeurosis constantly lest it get easily overused and microtear easier. When compared with the above paragraph I hope you can see the distinction between this mechanism and the normal supports.

Plantar fasciitis pain is not always straight forward. For example, here is a common distribution of the pain patterns. As you can see most often the plantar aponeurosis is aggravated at the heel where it originates from, but pain can be anywhere along the plantar aponeurosis all the way up to the feet.

Photo from yogatuneup.com

Obviously, if you have any variation of lower arches or pes planus, it is more likely that plantar fasciitis is going to show up. Also, very tight calves also puts a large strain on the plantar fascia because they pull the calcaneus from the superiorly which lengthens the arch (through the tensegrity model – here’s one such study).

The prehabilitation and rehabilitation will be grouped together later with the flat feet.

Likewise, remember we showed that the fibularis longus tendon and the tibialis posterior tendon criss-crossed underneath the foot? Well, if the arch is collapsing additional stress is being placed on these tendons. But let’s not forget that shoes also start to tighten up the muscles of the lower leg including these two muscles because of lack of significant use. Therefore, we have the perfect recipe for tendonitis – muscles that are too tight are pulling on the tendon that is already being stretched.

The general areas of pain for these are seen below:

Photos from footclinic.co.uk and joint-pain-solutions.com respectively

As you can see the pain distributions can be moving into the foot from either side or in the lower leg area, but most of the pain is centralized to the tendon area which runs close to the the medial and lateral malleoli respectively because the tendon shealths don’t get a lot of blood flow there.

Typically, peroneal/fibularis longus tendonitis is more seen in people with higher arches / supinated feet (as the foot wants to invert more); however, it’s possible to see it occur with more flat feet as it can get unnecessarily short and tight as the foot pronates excessively.

Tibialis posterior tendonitis is usually more seen in people with flat feet as that is the tendon that is going to take the brunt of the stress, especially in plantar flexion to help support the arch besides the plantar fascia if the muscles are atrophying.

Achilles tendonitis is something I didn’t want to particularly group the plantar fasciitis grouping; however, the issue with this problem is is variable whether the actual cause is due to overuse or problems with pes planus. Typical pes planus can exacerbate the condition significantly because the foot everts and the force vector on the achilles tendon gets distorted sideways alterating the torque to a more oblique pull. This increases the potential for tendonitis and rupture so keep this in mind if you have flat feet. If this is an issue follow similar tendonitis protocol as above.

Photo from risely.com.ae and eorthopod.com

Shin splints, like achilles tendonitis, tend to result from overuse. They can, however, be exacerbated by poor biomechanis of flat feet and especially if the person is a heel strike runner (which by the way is an incorrect way to run). Typically what happens during heel-toe running is that most people get lazy in the stride and allow the foot to slap down while they run. Excessive eccentric loading of the muscle can aggravate both the tendon, the muscle itself, or the origin of the muscle located on the bone.

Photos from latrobe.edu.au and sportlink.co.uk respectively.

As you can see if the tendon is aggravate it can distally radiate pain from the top of the foot all the way to where it inserts down near the big toe and also cause big toe pain. Likewise, aggravation of the muscle can cause pain above the ankle, and the pulling of the muscle on its origin on the upper 2/3rds of the tibia can cause stress fracturing to occur within the tibia itself.

Posterior shin splints can occur as well, but we already talked about that with the tibialis posterior. However, we didn’t talk about the pain that can occur deep inside the calf area on the tibia and fibula from the an overworked muscle and the stress fracturing of those bones. As with the above shin splints take care of them in the same manner!

Suffice to say that both collapsed arches, and supinated feet can cause these for different reason. The most common cause of this is due to ill fitting footwear though. Many older women and men have this problem because of the pointed shoes that were too small back in the day which forced the toes into an inward configuration. Suffice to say this is not good either.

Some cases would fall under diseases of civilization such as some forms of metatarsalgia that may result from hypermobility from the atrophied muscles and stretched out ligaments of collapsing arches.

However, other injuries such as turf toe (typically strain/avulsion of tendon of flexor hallus longus) can sometimes be aggravated by flat feet, but most of the time occur mostly with physical activity and cutting movements such that if you cut out the activity and rehabilitate it properly it will be resolved.

Diabetic neuropathy and gout – especially with extremities – are two examples that have more to do with nutritional diseases of civilization due to poor eating habits leading to excessive inflammation or metabolic insufficiencies. These problems are typically not rooted in the extremities where they exist and rather can be made better systemically. However, in general, mobility to get blood flowing and make sure the limbs are working well is recommended.

I don’t offer any medical advice on these blogs but if you are having problems with diabetes and gout, and it’s causing issues with extremities you had better get your diet and sleep in order. I recommend The Paleolitic diet, at least 8+ hours of sleep if possible, in combination with supplementation of fish oil and daily exercise. Eliminate the inflammation and you’re well on your way to hopefully reversing some of these problems.

Regarding potential fractures and other athletic problems. My stance has and always will be if the pain does not decrease within a week of total rest you should definitely make an appointment with an orthopedic doctor. Make your appointment the within a couple days of having pain as you will usually have to wait a week or two to get into the doctor. If your problem has resolved through proper prehabilitation or rehabilitation then cancel your appointment; if it hasn’t then go to your appointment!

There’s no point in delaying medical treatment if you need it, and if the problem can get worse. By no means is this article supposed to be a diagnosis and treatment option for anything. It is just supposed to be educational. This definitely bears repeating later.

Shoes, Sitting, and Lower Body Dysfunctions did a good job of covering the “evil” of shoes.

Shoes that offer support are not what we are looking for – they are the things that cause the problem in the first place. Just check out this study of people in India. The people who wore shoes had higher rates of flat feet and more laxity in their ligaments. Not only that barefoot was least likely to have flat feet, sandals had higher rates, and closed toed shoes had the highest rates. Hmmm, who woulda thought that?

One of the studies I referenced in Shoes, Sitting, and Lower Body Dysfunctions was a study that the military did on fitting shoes to particular foot type. Injury rates didn’t change versus those who didn’t have their feet fitted to particular shoe types.

Many other studies were done comparing barefoot versus shod running. Torques increased and altered biomechanics persisted coupled with the decreased proprioception for those with shod compared to the barefoot conditions. Universally, we want to stay away from shoes to solve any type of problem we have.

Again, check out the link above. I don’t make this stuff up.

In general, orthotics and their derivatives disgust me. Again, like padded shoes they’re supposed to offer people with flat feet or high arches “support” but in reality we’re just reinforcing the poor patterns that already exist that cause the problem to begin with. You don’t offer more support to muscles that are already weak and ligaments that are already lax. You strengthen them. With foot exercises and going barefoot.

The whole shoe industry and orthotics are an extension of what the pharmaceutical companies are to modern medicine. These companies are trying to turn big profits. I’m sure that many people in those companies mean well, but if we look at the literature it shows that most of these things are ineffective compared to natural solutions.

For example, this study in children showed no significant outcomes in pain reduction or an increase in function.

Yes, your drug may help with heart disease, but it ain’t fixing the problem. Yes, orthotics may temporary relieve your foot pain, but it ain’t fixing the problem. You know what fixes the problem? Getting enough sleep, eating correctly, and exercising. Proper mobility and rehabilitation work for the latter.

Now, there are certain instances where orthotics can be used effectively. For example, if say you are in the military and have foot pain and you absolutely need to keep exercising and orthotics help with that. The same may be true if you have a job that requires you to be on your feet a lot. HOWEVER, remember that orthotics do not fix the problem; make absolutely sure you are concurrently rehabilitating your feet during this so eventually you can get off orthotics.

In most any type of situation with foot pain it is much better to try physical therapy or other rehabilitation methods first before saying screw it and get the “quick fix” of orthotics. Most people that do this don’t bother to rehab after their pain has gone away, and they will be stuck buying these things inevitably forever.

This is not conducive to health. It’s the easy fix. It’s the lap band (on the stomach) instead of eating right and exercising. And speaking of lap bands if they people don’t correct their eating and lack of exercising habits they can still balloon up to the same weight again. That tends to be what happens with orthotics and recurring pain too.

Here are the links specifically for the helpful sections:
The feet
The lower leg

Of the techniques mentioned in the above links I prefer use of sand or other instability factors the best. Foot exercises with foot gymnastics/dexterity work as well, but it’s just easier to use sand as it does the work for you and all you have to do is walk or play around in it as long as it’s not painful. Plus, it’s a good excuse to go on a vacation, right?

Any type of balance work focus on using the musculature of the place you need balance at. For example, what’s the point of using our arms to balance on one leg when its our feet that are our weak link? Put your arms behind your back, don’t let your torso move, and only allow the feet and lower leg muscles to work. That’s what we are aiming for and that is therefore what we should do.

The key for any of this rehabilitation work is to get the tight muscles loosened up, and mobilize as many of the joints as you can. Get your toes, metatarsals, ankles, etc. moving. Get those muscles working and stronger, get the sensory units firing signals up to your brain.

If the arch is in the process of collapsing or recently collapsed it may be possible to save it or reform it. Our tissues are are fairly good in their plasticity that they have the capacity to change.

If you are having issues is pain soft tissue work and non-painful mobility work is extremely important. One of the major factors in eliminating pain is the gate control theory of pain. The gate control theory of pain shows us how to help dull down the pain so the body can heal itself better.

Gate control theory of pain. Photo from health.howstuffworks.com

All of the fibers under ‘gate control’ are sensory afferents from the skin, muscles, ligaments, and joints. The large fibers specifically are the ones that travel fastest – alpha and beta fibers – in humans these are golgi tendon organs and muscle spindles. The small fibers tend to be smaller afferents responsible for nociceptive (pain) input including delta and C fibers.

The theory goes that stimulation of the large alpha and beta fibers can interfere and help dull the body’s sense of pain from the smaller delta and C fibers. What stimulates alpha and beta fibers? That’s right: soft tissue work and movement.

Soft tissue work gets into the muscles and surrounding tissues and stimulates alpha and beta fibers (and also through CNS feedback gets gamma fibers to loosen or knocks out hypoxic trigger points) thus getting tension off the muscles. Good stuff.

Also, non-painful movement uses muscles stimulating the alpha and beta fibers to help create noise to eliminate that pain, and additionally it helps increase blood flow to the area for healing, proprioception/kinesthetic awareness increases, and muscles are being used so they don’t atrophy. Likewise, mobility/flexibility work that doesn’t hurt does similar things.

Reforming an arch?

For adults, feet that have been flat for some period of time may not be able to reform the arch. It MAY be possible with orthotics to reshape an arch (not ones that are fitted to your foot), and proper rehabilitation. However, in general it may not be possible especially if you’ve had the problem for years.

I think we can all be happy though that the body is remarkably adaptive and can cope and be strengthened enough in certain positions to avoid pain altogether even with the deformation of flat feet. Just make sure you do your exercise and rehabilitation!

The arch naturally develops during the time where we are learning to walk well (somewhere in 2-6 years old) because of the stressors placed on our feet aid in this developmental process.

Since children are still growing proper foot strengthening will likely help reform an arch. Anyone up to about the age of 21 with flat feet should be made aware of this. The long bones in your feet are still growing with proper care and strengthening it may be possible to change the foot structure significantly enough to reform an arch.

Fibularis longus tendonitis, tibialias posterior tendonitis, tibialis anterior tendonitis, achilles tendonitis, etc.

Tendonitis issues depend on a lot of factors so beware. I’ll try to educate you as best I can.

Okay, so the initiate phase of tendonitis is inflammatory – there is inflammation and the RICE protocol tends to work best with it. Most of these cases resolve with purely rest. Massage and RICE may help.

After the tendonitis becomes chronic – tendonosis – which tends to occur after about 3-4 weeks of continued exercise aggravating tendonitis OR a period of at least a week or two rest from which the tendonitis does not resolve.

Tendonosis responds better to an opposite protocol namely eccentric exercise, heating instead of ice, and massage to the muscles that are aggravated – not the tendon itself because it is degenerating. If these things do not resolve chronic tendonosis then more drastic measures may be needed, but you can check out alternative stuff in the article posted.

Shin Splints

Shin splints rehabbing typically is very hard to pinpoint. If the tissue is more down in the foot and ankle I would say treat it more like a tendonitis case. If the muscle itself is sore, or the bones of the shins are getting sore then we have a different issue.

If the muscle itself seems to be the biggest cause of pain then rest and let it heal. It’s being overworked. Massage can help via the gate control theory above but don’t overdo it. Light mobility work will help. After the muscle itself heals over usually a weeks time, we can start to strengthen it by doing toe raises or loading weight onto the toe and doing toe raises. One of my favorites is to put weight into a backpack and sit on a countertop/ledge and do toe raises with the backpack hanging off the foot.

If the pain is more bony is nature that tends to mean stress fracturing. Unfortunately, for this condition rest is the solution. DO NOT TAKE NSAIDs FOR THE PAIN. While the NSAIDs help with inhibiting the pain, they also inhibit inflammatory pathways that are critical for healing and proliferation of the bone to increase cortical bone density. If you are taking NSAIDs for your pain and have this issue stop immediately. It’s counterproductive to your healing rates, and will make your rehab take that much longer.

Very light mobility work to get blood flowing, and massage tends to be good as well. Direct ice massage tends to be helpful a lot. But the key here is rest.

This was glossed over in the Shoes, Sitting, and Lower Bodies Dysfunction article, so I figure that I should mention it now.

The fact that we are not only wearing shoes a lot more, but also sitting indoors a lot now (and not getting much vitamin D) is frankly disturbing to me and a huge factor in the movement diseases of civilization.

Rickets is not a prominent disease in our culture now due to prevalent food sources, yet things such as osteomalacia, osteopenia, and osteoporosis. The fact is that over 80-90% of people in U.S. are deficient or severely deficient in vitamin D. This is a big problem. Why?

Softening of bones due calcium malabsorption will lead to softening of the bones of the arches of the foot. This can clearly lead to a higher prevalence of flat feet.

Those with darker skin are more at risk, especially in moderate climates because sunlight conversion of 7-dehydrocholesterol from UV to vitamin D precusors occur slower in those with more melanin.

Vitamin D analysis and recommendations are here. Either get out in the sun at least 30-60 minutes per day or take a supplement if you’re indoors a lot like me. It’s not worth being deficient in this vitamin, especially with all of its positive benefits as you’ll see by reading the above link.

Sunscreen, even SPF 8 tends to block almost 80-90% of vitamin D production. So don’t be afraid to let the kids out after school (when the suns not even the highest) to soak up the rays. In fact, we should be encouraging they go outside not just for the vitamin D but for the exercise as well!

It’s funny how everything fits together (and that I’m referencing tons of previous articles).

Rickets. Photo from thachers.org

Hmm, it’s interesting how childhood rickets tends to look like valgus problems which can lead to flat feet in older children. You know, right about the time we put them in school for 7 hours a day and bog them down with homework so that they don’t get out of the house in the sun any…. and take away recess. For younger children it’s varus problems.

NSAIDs and acetaminophen/tylenol: a lesson

I started to touch briefly on this topic in the previous section on shin splints.

NSAIDs while great for pain relief often help slow the healing rates of issues that you are trying to fix with rehab. For example, typical NSAIDs prescribed for pain and inflammation are over the counter such as aspirin and ibuprofen. Things you may typically get with a prescription are stronger such as naproxen.

Image from altair.chonnam.ac.kr

The mechanism of typical NSAIDs is to inhibit the cyclooxygenase pathway of inflammation as seen above (aspirin, indomethacin). This is great because it eliminates the pain by inhibiting the PGE substrates that aggravate the delta and C sensory fibers within the area like we talked about before. However, this is bad because it also inhibits the prostacylins and HHTs which are responsible for drawing in white blood cells and platlets that help clean up the damaged tissues, and release growth factors to move on to the more proliferative phase of healing. Here’s a few studies showing this.

Now, I’m sure we tend to all think of Tylenol/Acetominophen the same as the other NSAIDs, but it is in fact actually not and anti-inflammatory agent. Thus, if you’re having pain with this, it would be recommended to take this over any of the NSAIDs because of healing rates.

This also applies in reverse though. If you suffer a traumatic injury to the ankle such as a sprain and it’s inflammed and swelling up then avoid acetominophen in this case. It’s not going to help with what we need which is the anti-inflammatory factors. We would want to do the RICE protocol, NSAIDs, massage, mobility work, etc. in these cases.

I would try to avoid using NSAIDs for anything related to pain where tissues need to heal if there isn’t excessive inflammation. The cyclooxygenase pathway is a critical step of that inflammatory phase that is needed for any sort of tissue regeneration whether it be muscle, tendons, ligaments, bones, etc. If it hurts bad then use different anti-pain medications like tylenol. It’s only when the inflammation gets so out of control such as with lots of swelling or fever where NSAIDs start to become more useful.

Warmness of the skin area is a good indicator of acceptable levels of inflammation (as prostagladins of the cyclooxygenase are fever inducing), but when there starts to be a lot of redness and swelling/puffyness symptoms it may be time to help cut down on excessive inflammation with NSAIDs. For example, a couple days after workout the muscles are usually warmer because of the inflammation and healing process that is occur; it is unlikely unless there is severe DOMS or rhabdomyolysis that any NSAIDs may be needed for this.

Fish oil is also a good anti-inflammatory if needed, and of course eating right is going to help the most.

These are things are probably not told to you by your doctor or any other healthcare professional (heck, I didn’t even know about NSAIDs vs tylenol until I was taught that in class a few weeks ago). Keep this type of stuff in mind.

Thus, it’s not such a huge stretch to see that women will probably have more issues with flat feet in general with men. We talked about the SI joint a bit earlier, and women are also more at risk for slipping the SI joint there as well with the additional upper body weight (pregnancy, swelling breasts) in addition to the relaxin.

If that wasn’t enough women also wear high heels. Yes, high heels limit ankle mobility and also lead to the problems described in this article from tight calves.

Be aware women. Unfortuantely, some issues are more prevalent with gender. Biomechanical issues and foot issues tend to be one of them.

I would suggest getting minimalist shoes if they are absolutely required for your job or the area is littered with broken glass. Vibrams are highly recommended.

My other conclusions on things that may help with integrating solutions with workouts, barefoot running, some integration with sitting, and other systemic evaluations are in the conclusion of Shoes, Sitting, and Lower Body Dysfunctions.

If you are heel-toe runner you should definitely check out the barefoot running resources, and start trying to learn how to run properly. CHI running and POSE are two different methods that teach proper running technique; however, sprinters and other elite runners (besides very few long distance runners) tend to naturally run with proper mechanics that occur with barefoot.

The key to any of this is to start off slow and build up. The focus in barefoot running should be (1) relaxing meaning we are only using the muscles that should be used, and (2) moving silently which means that our muscles are absorbing all of the impact and less or none of the force is being put on our joints or ligaments.

If you haven’t read through the whole article (this one or Shoes, Sitting, …) by now you should! Or at least you should read the conclusion if you don’t want to read everything else.

photo from shodless.com

Ah the joys of barefoot running….. and if you notice the other competitors use race flats which are minimalist shoes. Who would’ve thought that’s the most effective way to run, right? Our bodies weren’t made for this for nothing.

I hope everyone learned something. If you like this article please send it to people you know who have these issues or publicize it on your facebook or other sites. We like to get the word out there, but we can’t do it by ourselves. We welcome all feedback or discussion! Thanks for listening.

It is a thorough analysis of how many of the common orthopedic problems today arise from shoes and sitting, how to evaluate their development, and finally a look at how to implement prehabilitation or rehabilitative protocol to improve their condition. I sincerely wish that you will read through the whole thing even though it is a monster. I promise you will come out with a new outlook on this topic.

I’ve noticed that the page hits for page 2 and beyond are about 1/5th of this page. Please do note that this is part 1 of a 5 part article. You will have to click on to read the other parts at the bottom of this page.

Many thanks KC Parsons for taking the time to find pictures.

Note: We have an in-depth article on the feet as well, however, it does refer back to this article so I would suggest reading both if you have foot issues.

Shoes and sitting. Two things that are ubiquitous in modern society.

There has been recent media sensationalization of the detrimental effects of shoes. However, there has not been a lot on sitting other than upper body postural issues. Do these two things really have that much of an impact on our lives? Or is it just athletes?

Unfortunately, most information out right now does not look specifically at the effects that injuries have on the body as a system. Rather, most of the solutions to problems tend to focus on only reducing the pain or alleviating the problem at one joint specifically.

For example, shoulder problems often arise up around the ball head of the humerus and usually manifest in rotator cuff problems, but that pain and injury may be from a cascade of problems from loss of thoracic extension, proper scapular movement, and incorrect muscular activation. This is a topic for another article.

In this article, I am going to build a case against shoes and sitting. My eventual conclusion is there is a detrimental effect on most people and not just athletes. I will walk you through this process noting biomechanical and physiological issues. Then we will talk about how to correctly evaluate these conditions, and how to solve them. In the end, all should see the widespread damaging effects of these two things that we have not even considered dangerous.

There have been numerous articles in the past saying how shoes are bad for you. For example,

You Walk Wrong,
The painful truth about trainers: Are running shoes a waste of money?,
Cure all Running Injuries (and Pain) with One Simple Fix….Barefoot Running
Footwear Alters Normal Form And Function Of The Foot
Barefoot running debate – GREAT image that shows some of the dysfunctions we will look at later.

And more recently since this article has been written:
Barefoot Running: How Humans Ran Comfortably and Safely Before the Invention of Shoes

In general, these are true. For example, this abstract published in the Journal of the Southern Orthopaedic Association in 1994 states:

The shod foot and its implications for American women.

Throughout history, members of human societies have gone barefoot, and those societies seemingly had a low incidence of foot deformities and pain. Only one study has addressed the problem of infection through injury to the bare foot; otherwise, the unshod foot seems to have had minimal problems. Initially shoes were made in the shape of the foot and were sandals. Over time, shoes became decorative items and symbols of status and vanity. As the shape of shoes changed, they became deforming forces on the foot and the source of pain. Recent studies by the Council on Women’s Footwear of the American Orthopaedic Foot and Ankle Society have tried to document the problems caused by shoes on the feet of American women. Attempts should continue to educate women on appropriate shoes and proper fit.

These are not the only cases. Another instance is this abstract from the August 1991 issue of Pediatrics. (I have a full text; if anyone is interested post in the comments.)

Shoes for children: a review.

1. Optimum foot development occurs in the barefoot environment. 2. The primary role of shoes is to protect the foot from injury and infection. 3. Stiff and compressive footwear may cause deformity, weakness, and loss of mobility. 4. The term “corrective shoes” is a misnomer. 5. Shock absorption, load distribution, and elevation are valid indications for shoe modifications. 6. Shoe selection for children should be based on the barefoot model. 7. Physicians should avoid and discourage the commercialization and “media”-ization of footwear. Merchandising of the “corrective shoe” is harmful to the child, expensive for the family, and a discredit to the medical profession.

These are some pretty harsh words. However, beyond that let’s dig a little deeper by looking at shoes and running.

The incidence of running injuries before the 1950s was low. But since the 1970s when shoe manufacturers have started to put more and more padding into shoes, the incidence of runners that have some injury every year is up to nearly 60%. Some of the cause could be to due confounding factors such as the rise in obesity, improperly fitted shoes, etc.; however, there is at least some reason to believe otherwise as we will shortly discuss.

Most of the common running shoes have lots of padding in the heel which incorrectly gives the user an impression that heel-toe running is correct. Significant amounts of heel-toe running can potentially cause long term damage in combination with other factors such as obesity, improperly fitted shoes, and strenuous activity, especially in children and the elderly. In heel-toe running, the joints are taking the impacts rather than your musculature dissipating the force correctly with mid- and fore-foot striking. One study showed that shoes mechanically alter stride compared to barefoot running resulting in lower net efficiency.

Walking, in which the heel does strike the ground first, is a fundamentally different gait from jogging, running, and sprinting which require a mid- and fore-strike to protect the body and operate at a high level.

However, beyond the walking and running mechanics, let us analyze why shoes are a problem.

• Most shoes now have an elevated heel as padding. In walking or running, the knee tracks over the toe as you take a step. With an elevated heel, the foot is already tilted forward which means the ankle does not need to bend as much during movement. Not taking a muscle often to the edge of its range of motion means that the muscles start tightening up. This limits the range of motion (ROM). Thus, with shoes there tends to be a loss of 10-20 degrees range of motion in ankle leading to tight calves.
• The padding in the shoes is problematic as well. Our body and feet have proprioceptors that allow us to feel the ground as we are moving. This gives us the ability to make small corrections to maintain proper posture and movement. The padding in the shoes allows improper corrections to be made (as they will not be punished by awkward landings), and decreases our natural proprioceptive ability and affect ankle coordination abilities. This leads to inactivated muscles on the plantar aspect (bottom) of the foot and decreased ankle stability especially with inversion and eversion corrections. In addition, this may lead to increased frequency of falls in the elderly.

As you can see, shoes are a problem especially compared to barefoot ability. This is even more evident if we are aware of the fact that the plantar aspect of the foot has 3 different muscle layers including the plantar fascia. Let’s now take a look at some more studies supporting the two points above.

Photos from medlineplus and eorthopod

This study showed that “a significant increase in leg stiffness from the barefoot to the “cushioned” shoe condition was noted during hopping. When running shod, runners landed more dorsiflexed (foot tilted upward) but had less ankle motion than when running barefoot. [...] The primary kinematic difference was identified as running speed increased: runners landed in more knee flexion. At the ankle, barefoot runners increased ankle motion to a significantly greater extent than did shod runners as speed increased.” When running barefoot, the forefoot receives the ground* with less than 90 degrees of dorsiflexion. Thus, the comment above regarding dorsiflexion with shoes running is deceptive. Obviously, decreased range of motion is the big thing as I talked about above.

* Note that minimalist shoes like sprinters use with proper technique show similar biomechanical patterns as barefoot running. I will talk about this in the next few segments.

Likewise, flatter foot touchdown and increased leg stiffness was found in barefoot running. Increased “leg stiffness” is good because that means the muscles are taking the brunt of the forces rather than your joints.

One study on ankle sprains showed that awareness of foot position is impaired by shoes. The authors also noted that there was increased muscle activity during inversion with shoes. They concluded that this was the body’s adaptive mechanism to oppose the increased tendency to roll the ankles with shoes as opposed to barefoot.

In a similar vein, this investigation showed that as the “shock ability” of the materials in running shoes decreased, foot control (proprioception) increased. Loss of proprioception is implicated in as much as 50% of running shoe injuries!

“This experiment showed that the sandals not only restricted the natural motion of the barefoot but also appeared to impose a specific foot motion pattern on individuals during the push-off phase.”

The best evidence, however, as far as we are concerned it from actual biomechanical evidence. This can be seen clearly in this study of the biomechanics of shod vs. barefoot running.

Results

Increased joint torques at the hip, knee, and ankle were observed with running shoes compared with running barefoot. Disproportionately large increases were observed in the hip internal rotation torque and in the knee flexion and knee varus torques. An average 54% increase in the hip internal rotation torque, a 36% increase in knee flexion torque, and a 38% increase in knee varus torque were measured when running in running shoes compared with barefoot.

In the next section, we will talk extensively about internal rotation, valgus, and varus states. However, the discussion here provides an ample preview:

“The observed 36% increase in the knee flexion torque with running shoes potentially increases the work of the quadriceps muscle, increases strain through the patella tendon, and increases pressure across the patellofemoral joint. Furthermore, a 38% increase in the knee varus torque implies relatively greater compressive loading on the medial tibiofemoral compartment, an anatomical site prone to degenerative joint changes, as compared with the lateral compartment. Finally, the disproportionately large 54% increase in the hip internal rotation torque may have particularly high clinical relevance, given previous findings that indicate that competitive running may increase the risk of OA of the hip joint.”

The internal rotation torque and quad dominance in particular in conjunction with tight calves are some of the main reasons of the dysfunctions we will discuss later.

Finally, we have this study which indicates that “selecting shoes based on plantar shape had little influence on injury risk.” Basically, no matter how expensive your shoes or how much ’support’ they provide, they don’t decrease your injury risk. This is a very strong case for flats/minimalist shoes/barefoot.

This article on the ankles also provides some relevant material to the discussion.

Note: The loss in range of motion from the calves covers why I do not have to mention why high heels are terrible for women. Even though women look good in them. Similarly, in sports with extensive plantar flexion such as pointing the toes in gymnastics and figure skating it is possible to develop similar problems.

Sitting has become a huge problem in modern society. Sitting is obviously common for school and most jobs. However, throw in decreasing amounts of recess and lack of activity for adults as well as obesity and you have a full blown epidemic.

There has not been much talk of this in the media. However, most of the sports communities knows the problems associated with sitting and its detrimental effects on athletic performance. Even so, the effects of sitting are more widespread than just poor athletic ability. Let us analyze why sitting is a problem.

• In sitting, the butt / gluteal muscles are in a stretched position. When a muscle is allowed to be in a stretched position for extended periods of time such as in school or office jobs, the muscle becomes weaker and thus inactivated. This is the opposite of what happens with the calves in their shorter and tighter position. Thus, with sitting the glutes become weak and inactive.
• The hip flexors which are shortened in hip flexion, like the calves, become shorter and tighter. The hip flexors consist of the iliopsoas, rectus femoris, sartorius, tensor fasciae latae (TFL), and adductors longus and brevis.Thus, with sitting the the hip flexors become short and tight.

Photos from blogpost and chiropractic-help

It has been investigated “whether gluteal muscles could be activated more effectively by stimulating the proprioceptive mechanism during walking.” They came to the conclusion that balance shoes help especially with lower back pain helping fire inactivate gluteal muscles. Ironically, you could just walk barefoot and do balance work to stimulate foot proprioceptors as well as do gluteal activation work. We will get to this later.

There are varying degrees of inactivation. Gluteal inactivation does not mean that the glutes fail to activate altogether. Rather they will fire although with decreased intensity or a delayed pattern which may be ineffective during proper recruitment during certain movements.

There is another interesting study done on a variety of subjects.

RESULTS: There were 1832 deaths (759 of cardiovascular disease (CVD) and 547 of cancer) during 204,732 person-yr of follow-up. After adjustment for potential confounders, there was a progressively higher risk of mortality across higher levels of sitting time from all causes (hazard ratios (HR): 1.00, 1.00, 1.11, 1.36, 1.54; P for trend <0.0001) and CVD (HR:1.00, 1.01, 1.22, 1.47, 1.54; P for trend <0.0001) but not cancer. Similar results were obtained when stratified by sex, age, smoking status, and body mass index. Age-adjusted all-cause mortality rates per 10,000 person-yr of follow-up were 87, 86, 105, 130, and 161 (P for trend <0.0001) in physically inactive participants and 75, 69, 76, 98, 105 (P for trend = 0.008) in active participants across sitting time categories. CONCLUSIONS: These data demonstrate a dose-response association between sitting time and mortality from all causes and CVD, independent of leisure time physical activity. In addition to the promotion of moderate-to-vigorous physical activity and a healthy weight, physicians should discourage sitting for extended periods.

The very intriguing thing to note here is that sitting, even when adjusting for smoking, physical activity, and other mortality factors, has a dose-response association (meaning that the more you sit) the higher your risk of death. The P-value for this is <.00001. P-value is used in studies to incidate significance of data — generally anything under .05 is significant which means that 95% (1-.05) of the time this data is unlikely to occur. This data is particularly strong which means that 1-.00001 = 99.999% of the time this data set would not occur. This indicates that sitting is extremely insidious and dangerous the more you do it.

Another study seems to verify this conclusion. After adjusting for physical activity and other factors, those who sat greater than 6 hours per day were 37% more likely to die than those who sat less than 3. With a lack of physical exercise those who sat greater than 6 and less than 3 hours were 94% and 48% respectively more likely to die. Associations were strongest for cardiovascular disease mortality.

Consider that we now all send our kids to school for 7-8+ hours a day for 15+ years, and have desk jobs for much of our adult lives…. this is not a good sign.

Note: there will be more studies to come on gluteal activation; however, as a lot of them relate to the injuries that is specifically why they will be discussed later. I just want you to know that I do have my position on this topic supported at least as much as I have supported my case against shoes.

In conclusion, we learned that shoes and sitting cause many problems. This is a big problem because they are ubiquitous in modern society. Shoes tend to allow the user to run improperly (heel-toe) and hinder proper ankle biomechanics. In addition,

Shoes tends to cause the problems of

• Tight calves resulting in loss of 10-20 degrees of dorsi-flexion ROM in the calves.
• Inactivation of the muscles on the bottom of the foot and the ankle stabilizers.
• Decreased proprioception of the lower limbs.

Sitting tends to cause the problems of

• Inactivation of the gluteal muscles.
• Tight hip flexors (i.e. iliopsoas, rectus femoris, sartorius, tensor fasciae latae [TFL], and adductors longus and brevis).

In the next segment we will discuss look at the systemic biomechanical issues that arise from these deficits. Click below for the next part.

Part 2: Systemic biomechanical issues