#296 ‒ Foot health: preventing and treating common injuries, enhancing strength and mobility, picking footwear, and more | Courtney Conley, D.C.

27:13That guy technically should never hit the ground. It's the highest part of the medial arch, but he can get a stress fracture. So you're saying yourself, well, how is that possible? If they're caused by compressive loading, not that guy. He's caused by tensile strain. When you can't handle the foot, pronating and rotating, and you can't handle the movement of the foot, the tendon will start to tug, and you'll start to get that strain at the regular stress reaction leading to stress fracture. So interesting. We think about bones as having this great capacity for contractile force, right? So axially loading.

27:53We don't think of them as requiring as much tensile force, but of course, they're under tremendous tensile force in the opposite. We think of our skeleton as needed to support compressive load, but of course, they have to do both, which actually is a pretty remarkable material. like concrete, for example, is only strong under compression. It's so weak under tension. I think I mentioned this once before in the podcast, without rebar concrete would be useless. Yet our bones have to do both. So you're saying that you can tell, I mean, not to oversimplify, but lateral injuries are likely to be more compressive.

28:30Medial injuries might be more likely to be tensile. And again, I don't know that that matters necessarily other than it explains what caused the injury? Yes, but also with treatment because when you look at compressive loaded stress fractures, so at the heel, at the fifth metatarsal, you have to cushion those. Obviously, let the tissue heal. But that person might need something that's going to give a little bit. The nevicular stress fractures, the metatarsal stress fractures, the Cessmoid stress fractures, because they happened due to an instability, to a tensile strain. You can boot them, but your follow -up with them better be rehabbing the strength of their foot because it's not that they landed too heavy.

29:18It's because they couldn't control their motion. That's why people with Cessmoid injuries, for example. So the sesmoids are the two little bones under the big toe. They're similar to the patella. Meat sesmoids refers to if I recall a bone that is completely surrounded by tendon. Yes, it's like a little joint capsule. Yeah, nothing is exposed of the bone. It's completely embedded within the tendons, correct? Yes. When you get those stress fractures there, they can be extremely painful. And people stop using the big toe, which I'm sure we'll talk about. But if you offload it, these people will be in boots for three months.

29:55And it's okay, the bones healed, go back to your activity. It doesn't work like that. Because even though the bone is healed, the muscles are now even weaker. You are more susceptible to the injury because you've lost whatever strength you once had there. Yeah, how did it happen in the first place? Okay. So let's talk a little bit about the muscles in the foot as well because it is a very muscular structure. We don't think of it that way because we look at it and we can sort of see the bones through the skin, but especially on the bottom, the musculature is incredibly complicated and it is really related to what's happening in the lower leg as well.

30:37Oh yeah. Well, I think we talk about muscles of the foot. We can talk about intrinsic muscles versus extrinsic. So intrinsic muscles they live in the foot. They start and they end in the foot. We have four layers of muscles there. It's just unbelievable. It is. And I think the beautiful thing about the foot is you can look at the foot. It's the only place in the body where you can look at it and say, something is going a rye here because you'll form things like bunions and hammer toes and tailors bunions. And you'll be able to look at your foot. No, this isn't the way it's supposed to look. Maybe I should pay attention to it.

31:17You can't do that in a knee or hip unless you take an X -ray. And when you can get your hands on a foot where you start to see these deformities and they're flexible, you really think about it from a muscular imbalance. So if we wanted to look at some of the intrinsic muscles of the foot, so if we were to start with the big one, Abductor Hallisis, so he sits along the big toe and he's responsible for straightening the big toe. And I think the other thing that will be helpful when we go through this is every medical student and what not has to learn what an adductor versus an abductor is. And since they're always embedded within the names of the muscles, we always remembered this as abductors, abduct.

31:55They take things away. Like a person's being abducted, they pull away from the body, basically. Adductor pulls back towards the body. So with that said, hopefully people will have an easier time remembering some of these terms. So we have our forefoot here. Here's the big toe. So abductor

32:22for a whole lot of time. For example, when I'm in a shoe, which we'll talk about later, it's going to squeeze my toes together. Such as your ballet shoes. Yes. Or most dress shoes. I have 80 doctor now that's shortened and I have AB doctor. It's lengthened. It's lengthened. So you start to get this imbalance at the foot and then you start to see changes in the foot. Bunions are a result of an instability in the foot. Yeah, what exactly is a bunion? Everybody's heard of them. A lot of people have them. It's a transverse instability, not where you see the bunion here. At the meditarsal medial cuneiform, when someone can't control motion at the foot.

33:19Sort of the junction between the mid foot and the forefoot. Correct. Then they will start to have this instability. All a bunion is, by the way, is this bone basically shifting to the outside? Yeah, so anybody who's seen it, what you notice is you're looking down at a person's foot and you'll see this huge outpouching in what's otherwise the widest part of the foot looks like it just got a whole bunch wider and it's pointing out. But when you see the skeleton, it's much easier to understand why that's happening. Yeah, so it's this guy going that way. A lot of people have these surgically repaired.

33:53What are they doing surgically to repair that? We could talk about this for a long time. Just some facts first with those surgeries. A lot of them are not successful. There is a time and a place, but I would be very cautious about getting foot surgeries for symptoms. So what they'll do is they can either shave part of the bone down and then realign the toe. And oftentimes they will pin the metatarsal to the cuneiform, so they stabilize where most people have that instability. Once you start pinning things together, you might take care of alignment. But you've done nothing to strengthen the muscle that allowed this to get there.

34:38Correct. The conversation of my mom has a bunion, my grandma has a bunion, and my response to that is you don't come out of the womb with a bunion. You might inherit connective tissue laxity, for example, or there might be hypermobility issues. But if we know that, just like we talked about with the kids earlier, the earlier interventions, you get them in the right footwear. You make sure they're in shoes, right? That have a toe box where the toes can actually display, especially if you know that your mother has a bunion. I think what's fascinating about the big toes, if you look at your nail bed, some people that have bunions, the nail bed will be flat, and it'll just look like it's adducting.

35:20Here's the bunion. Oh, I see what you mean, yep. But the nail bed is flat. When you see that, it's typically from footwear. When you see the nail bed and it's actually rotated, because you see some of those people right where the nail bed's kind of turned in and there's a, looks like it's a rotational issue. You know for certain they can't control rotation, which is cool because now you're like, okay, one of the reasons I got into all of this was I have bilateral bunions on both of my feet due to the fact that I was constantly in point shoes And then my solution to that was I'm just gonna start bracing my feet because they hurt So they just got weaker and weaker and then I was like this is not right So we started strengthening them getting us in the right shoes and different ballgame And what's a hammer toe while we're at the topic of common pathology?

36:11Yes, so bunion very common hammer toes are basically when the toes Start to hammer the ground all of them are just two through five two through five the big toe can hammer It's just not as common as two through five. This is why when you look at hammer toes. So this would be the top of my foot. We have extensors, short toe extensors, but we also have long toe extensors. So on the top of the foot, the short toe extensors are doing a lot of work and the long toe extensors are not. Yeah, this is one of those things where if you're listening to us, this is very difficult to understand. It's why watching what you're saying makes a lot of sense.

36:53And again, just so folks understand, the extensors would be pulling back. The flexors would curl forward. And so it seems counterintuitive to say, how can a hammer toe be, in part, driven by this extensor phenomenon? Well, if the short extensors, the ones that attach with a shorter moment arm are fired up and the long ones are relaxed, it actually looks like a hyperflexion. Yes. And for people who have pain along the bottom of their foot, so along their metatarsals, if you take out your insert of your shoe and you see a lot of wear underneath the second or third metatarsal, you know you're probably walking around with too much pressure going through there.

37:40So on the bottom of the foot, it's the exact opposite. I have my short flexors that aren't doing anything in my long flexors who are. So hammer toes is a muscle imbalance due to a weakness in the foot. And what do you attribute the root of that to? If the bunion seems predisposed, not putting aside genetics and other things like that, but just environmentally, if the predisposing feature of a bunion is shoes that are pushing the big toe in. What is the environmental trigger that is most commonly driving a hammer toe? I think it's the same thing. I think that we have not been paying attention to our feet for a very long period of time.

38:27And if you were to walk around with your hands and mittens for 20 years, you shouldn't be surprised when your hands don't function. It's the same concept at the foot really that it is everywhere else in the body. I think we just don't think about it. Well, it's not even mittens, right? If you really think about it for most people, if you think back to being a kid, like you could still move your fingers in mittens, it's actually mittens that don't allow you to move your fingers. That's the better analogy. And yeah, if you were to spend 12 hours a day in that situation, it would be obviously cumbersome.

39:02So let's go back to the intrinsic musculature of the foot. I know we're going to talk more about intrinsic and extrinsic foot stabilizers when we get into the gym. There's a couple key muscles. I think they're all key, but we don't have time to go into all of them. But that are responsible for a lot of our foot functions. So for example, flexor digitorum brevis is one of my favorites. So this guy runs from the heel and inserts up into the failing. So into the toes. It's a big muscle. He runs parallel to the plantar fascia. He's responsible for decelerating toe extension when we walk. Remember, it's all about slowing things down.

39:44We want to control it. If I don't have good strength of that muscle, he shares load, if you will, with the plantar fascia. So, one of the biggest predictors for patients that have plantar fasciitis, so this would be an acute plantar fascial pain, is a weakness of flexor -digitorm robust. When you look at treatment protocols on how to get people better with plantar fasciitis, it's like stretching their calves and I'm not saying that's bad, but you also have to look at the strength and stability at the foot. and he is a very big player, very big player in the stability of the foot in decelerating pronation.

40:25You just referred to Planner Fashiaidus, we talked about it a second ago. It's clearly something many people listening will understand. They will also probably have a ballpark sense of what it feels like and how there's a real tenderness in the arch. But can you explain the anatomic structures that make up the Planner Fashia? So the plantar fascia is going to start at the calcaneus and it's going to insert into the deep transverse meditarstal ligament up at the forefoot. The plantar fascia has a very key role, by the way, instability of the foot. I'm going to explain something called a tie bar mechanism.

41:03So the tie bar mechanism of the foot is this, I like to call it free because we need to take advantage of it, where we have a ligament that runs across the meditarsals. When our foot, when we're walking, and we go into mid -foot loading, so when all the pressure comes and our arch starts to flatten in widen, when the four foot plays, it triggers receptors in that deep transverse meditarsal ligament. The plantar fascia inserts into that ligament. So it's kind of like this T. So when the foot plays, it triggers this mechanism of horizontal stability as well as vertical stability. Because the plantar fascia, like a triangle at the forefoot now begins to spread under tension while it's also being elongated vertically.

42:00It's like a fan. So that's the beautiful thing about forefoot split is it's this free mechanism that's basically telling our brains, hey, you're about to push off. You better get real strong and you better get real stable because we're about to take on eight times your body weight. Get's me excited. You take that away. You take away forefoot split. You can forget about the receptors talking to you because you're not getting the tug on them from the deep transverse metatarsal ligament, this display. And you're also not signaling the plantar fascia. What would oppose that? How much compression needs to be on the foot, presumably in the form of a narrow shoe, that would prevent sufficient spraying to activate the plantar fascia in that regard?

42:45There's numbers out there. You say three to five millimeters. I don't expect people to get out and start measuring this. But a good way to look at this is if you were to take out the factory insert of your shoe and you place your foot on it and Then stand on top of the factory insert if your forefoot expands wider than the insert wider than the insert to narrow you can be pretty certain that those toes are getting squeezed That's a great rule of thumb. I would bet that many of my shoes don't pass that test Is it safe to say that it might be tolerable if it's a fashion shoe you're wearing, but you certainly wouldn't want that in an athletic shoe where you're running or rocking or doing something under load?

43:33I mean, you would argue never be in a shoe of that nature, but my daughter is 12, so she always tells me, Mom, why do you make me wear these platypus shoes? Everybody else gets the word, Nike's. I get it. But yes, I mean, the more time we can spend allowing our foot to be in a position where it can function like it's supposed to. The better off we're gonna be. It's very interesting though, Courtney, because I mean, this is not conspiratorial, but there's clearly nothing in the shoe industry that is aligned with that. I mean, shoes are not typically designed to have that degree of width, are they?

44:06No, they're not. And what's interesting, Nike just came out with a baby shoe. This is a couple months ago. And in their report of the shoe, they said, We've done the research. This shoe will help your child's development of their foot. When you say baby shoe, what aid? Toddler. First start walking. Okay. Technically you would argue maybe they shouldn't be in shoes at all though, right? At that age. I mean, they don't need to be if they're walking. Most of their walking is not outdoors, but okay. In the article they said, we've done the research and we've created a shoe that has a white toe box, a flexible thin sole, because we want your child's foot to do what it was designed to do.

44:48And I'm sitting there going, yes, like, but why why would you not carry that through to adulthood? Exactly. But they're starting to realize it. And I think when you look at research from a shoe perspective, at the end of the day, we want something comfortable on our feet. And I would argue that every single one of my patients, once I simply put them in a shoe that allows their toes to play. They will always say, it feels more comfortable. Anything about it from balance? Are you gonna balance better like this? Are you gonna balance better like that? It's just not a hard sell. So, planter fasciitis ,itis of course refers to inflammation of the planter fascia.

45:28What are the most common causes of it? And how do you think about treating it in the acute sense? So somebody shows up for the first time and they've got it. What are your thoughts on the differential diagnosis for what led to it? And how do you go about rehabbing it with an eye towards preventing it in the future? First, you have to make sure that's what it is. There's a differential diagnosis of heel pain. I mean, you have to rule out calcaneal stress fractures, for example. There's backstores neuropathy. So people will have Googled and they'll just immediately say, I have plantar fasciitis.

46:00So first and foremost, you just have to be certain that's what it is. And it's a clinical diagnosis. It's not like you've got an imaging study that confirms it. You have to sort of exclude other things, as you said. Yeah, and you can see a thickening of the plantar fascia. Okay. Although rarely I assume that's done, correct? Yes. You're not likely going to put somebody in an MRI for that. No, and we'll talk about imaging later with all that. But there's a difference between anitis, plantar fasciitis, and plantar fasciopathy, or fasciosis, I should say. By the time most people get into my office, it's no longer in an acute stage.

46:36Because in an acute stage, this is your initial injury. So it is treated very differently. Orthotics often can help in those initial stages of an acute injury because you are offloading. Let's just explain to people again. I'm sorry, I'm all over the place, but the anatomy here is so complicated that I think it helps to talk about pathology to explain it. The reason an orthotic can be acutely helpful is because it prevents the full collapse of the arch. Therefore, it takes some of the stretch off the planter fascia, is that why? Yeah, and when you talk about what exactly an orthotic does, the jury's still out on that.

47:14But we know it has something to do with force. So when the foot starts to unlock, it's a load modifier. An orthotic is a load modifier. So it's going to modify the load that's occurring at the heel. So in an acute situation, that's great. But if I had a penny for every time one of my patients came in with their orthotics that they got 20 years ago for their plantar fasciitis, I mean, I'd be a rich woman because they're like, well, it helped acutely, but research will say two weeks and at the most up to a year and then it's time to get out of those things. There has to be an exit strategy. And while you're planning this exit strategy, you need to be strengthening the foot.

48:04You have to be strengthening things like flexor digitorium bravis to be able to share the load with the plantar fascia. So in an acute setting, they're treated very differently. When it's more of a chronic heel pain, this is degenerative. This is repetitive load. They've been walking around on a foot that can't handle load, then the tissue starts to break down. And in those cases, for me, it is all strength, it's load, it's not D -load. Even for a period of time. I mean, I tend not to go that route. And we have conversations. I mean, there's a lot of education that goes behind this. Irene Davis, who I know you know, she's...

48:47I've had Irene on the podcast, yeah. Her and Sarah Ridge are looking at research right now where they're looking at patients with chronic heel pain. So chronic plantar fasciosis at implementing minimal footwear and getting these patients and seeing what happens with them. If you think of the plantar fascia as a connection to the Achilles tendon. And it is connected, I assume. Yes. The Calcanias think of it like floats in between the plantar fascia and the Achilles tendon. We know that tendons need load. So, think about that from the plantar fascia perspective. You have to load it. You have to load the tissue in order for the tissue to get stronger.

49:31And is the load also necessary to heal the tissue, assuming it's not cut? Yeah, I mean, if we wanted to jump into loading with tendons, it's not that anybody who's had a tendonopathy. We always say, rest is not good for tendons. It's not that rest is bad. You talk to anybody who's had an Achilles tendon opathy, if they rest for a week, they're like, yeah, it feels great. The problem is that when they go to return to sport, or they go to return to walk, without having loaded the tendon, they're gonna be right back where they started from. So when we talk about loading the tendons, is a mechanical transduction.

50:10So when I load a tendon, there's a facial gliding that occurs. So this mechanical stimulus that then gets converted to a chemical stimulus. And then we start to see tendon healing. So in that sense, it's very similar to bones. I mean, we've talked a lot about this on the podcast where the most important thing for strengthening bones is force on the bone. And that's why weight training and grappling, believe it or not, are the two best exercises for bone density because they put the most stress on the bone, both compressive intenseile, and the mechanoreceptors in the bones, which sense the deformation, use estrogen as the chemical signal to signal bone building.

50:58Of course, why estrogen is arguably the most important hormone here. So it's the same thing. it sounds like intendons, presumably different chemical transduction systems, but it's mechanical deformation signals a chemical to build. Yeah, there's the tino sites that kind of live within the fascicles of the tendon. Exactly what you just said. This mechanical gliding kind of shears, the cells, you get a chemical stimulus, and then you start to get the changes within the tendon, which I think is really fascinating. So, let's go back to the person who shows up. So, you've excluded other things. You've diagnosed them with indeed plantar fasciitis.

51:39What are the most typical reasons for that presentation in, let's start within a young person, a young active person? Weakness to the foot for certain. And when you say weakness, specifically within which muscles, which are the prime examples of the muscular children? So, when they come in, now always, I have a toe -dynamometer. So it's this little device. Did you bring it today? I did. OK, good. I always wanted to try one of those. Yes. I'm embarrassed to find out where I stack up, but we'll see. It tests the strength of your toes. So it's a little device. You put a card underneath your big toe.

52:13And I'll have the patient press their big toe into the card. You should be able to produce 10 % of your body weight through your big toe. That's flexor -house as long as. When you put the card underneath two through five, you should be able to produce about seven to eight percent of your body weight. When they're pressing their toes down, there's a couple of rules. They can't lift up their heel and they can't hammer the toes. Remember we talked about that hammering? And that's when you'll see people who love to hammer their toes because it's a compensation for weakness in the foot. So that's how they walk.

53:01It's like I'm clawing my way forward. So when they do that, they have to press their toes down. When you do the big toe, the extensor house as long as our toes two through five, do they need to be off the ground or are they on the ground just not hammered? On the ground not hammered, but you're pressing down 10 % of body weight. You know me, Courtney, I love metrics, right? Because what gets measured gets managed. Is this something anybody can go out and do? Or you can buy these dumb, dumb, and everything? Oh, yeah, you can buy them. I think the other thing that's also easy to measure for someone who's going to do it at home is I have a little laser scanning device.

53:38I also brought this today where you would stand close to a wall and you'd measure from your ambillicus to the wall. Then you keep your body straight. So your hips and shoulders are straight and you lean into the wall as far as you can. It's your toe strength that stops you from smacking your face into the wall. That distance should be 4 .5 inches or more. Got it. So in other words, we could do the trigonometry on that, but basically there's an angle at which you're creating a moment arm that you need to be able to resist. Correct. It's called the anterior fall envelope. Cool. We'll test all these on YouTube.

54:19Oh, boy. But it's really fascinating, right? Toa weakness, by the way, is the single biggest predictor of falls when we age. Really? So, this is really cool. When you think about falling, it typically occurs, we're jumping all over the place, by the way, here. It's the initiation of gate. So if I don't have that anterior fallum to low, if my toes are weak, I'm going to keep going. And so not only can toe weakness be a predictor of things like plantar fasciitis, fasciosis, but also toe weakness can be in is researched by Karen Merkel, one of the single best predictors of falling, which is, I mean, massive.

55:04Yeah, I mean, I think we should spend a few minutes on that in a moment because obviously people who listen to this podcast are no strangers to the importance of fall prevention. We have talked about it typically through the lens of bone density and muscle mass. So low bone density, low muscle mass lead to more catastrophic outcomes during falls. Obviously, the muscle mass is also a great way to help prevent falling, but this is a very specific muscle mass. So athletic person shows up or active person shows up. You've diagnosed the problem. You have a culpable reason for it in weakness. You've already alluded to the fact, which says, look, I'm probably not going to rest you.

55:44What drives you towards temporary orthotic versus no orthotic and just get right to work? So when I've had Planner Fashioned as we've never done an orthotic, I've probably had two bouts of it in my life. It's just been a bit of backing off some of the volume, some manual therapy, ice, and more footwork. What's your typical strategy? It's very individual specific. You definitely have to meet the patient where they are. What is their activity level? What are they willing to do? What age are they? Are they going to do this stuff? From a passive perspective, I do like shockwave into the bottom of the foot.

56:23Medial gastroc. The way the medial gastroc inserts into the Achilles tendon, so that we talked about the gastroc, there's two muscle bellies. The medial gastroc sits on the inside. and how it attaches into the Achilles tendon will prevent ankle dorsi flexion. Tell people what dorsi flexion is. So ankle dorsi flexion is basically this motion. When I am walking, pulling the toes back basically, pulling the foot back. Yes. Yeah. And planter flexion just for the other way. Point the toes. Point the toes extend the foot. That ankle dorsi flexion in a walking gate cycle, we need about 10 to 15 degrees.

57:01you'd be surprised how people like to cheat the system there. So when we get to medial gastroc, we look and see how is their ankle mobility? Is it something I need to address? How is their foot strength? Is it something I need to address? And then how is their capacity? I always say it's never just a foot problem. I wish it was and make it easier for me anyway. But when I'm watching someone walk, walking is this internal rotation when our foot hits the ground. So I don't want the plantar fascia to be down there like a dish rag. So not only am I assessing what's happening at the foot, but I'm looking at the knee, I'm looking at the hip, who's driving the car.

57:43How well can my glute max, for example, control the rotation, control my pronation so that does that have an effect on the structures of the foot? So when I look at those cases, especially with chronic heel pain, it's never just a foot thing. I have to carry it up into the rest of the chain. As you've sort of alluded to the planter fascia because it's so long, you can really have that pain in many different places. The real estate on the bottom of the foot that is susceptible to inflammation or irritation of the planter fascia is pretty long. Is it typically more posterior and close to the heel?

58:20Most of the fibers that were more commonly irritated are that medial. There's a different branches of it, if you will. So most patients will get that pain at the heel, maybe more on the inside of the heel. And it can be pretty classic where it's really painful in the morning. And then as they walk on it, it gets better. That can change its face a little bit depending upon how chronic it gets. Wow. So it's a lot more complicated, but I mean, it seems to me that all roads keep pointing back to the plantar fasciitis is a canary in the coal mine that your feet are weak. Yes. Yes. That tie bar mechanism that we spoke of, that free mechanism of the vertical and horizontal stability that we have at the foot, take advantage of that.

59:06Allow the foot and the toes to display and do a couple of foot strengthening exercises and it doesn't have to be difficult. Yeah. And we're going to give people a lot of those exercises to do when we go to that section in the gym. Let's talk a little bit about the extrinsic stabilizers of the foot. but obviously as their name implies, these are muscles that originate out of the foot, but presumably have tendinous attachments within the foot. Yes. So you have the medial aspect, and you have the lateral aspect, and then you have the posterior aspect. So if we were to start with posterior, and we've talked about that a little bit already.

59:43Gastroxolius communicating through the Achilles tendon down around the calcaneus, and attaching right through the planter fascia to the forefoot. Yes, very big guys here. The solias is the largest muscle of the lower leg. He is the one that produces a lot of that force at the forefoot when we walk. And if I'm not mistaken, the solias has more type 1 fibers than the gas drops. Slow twitch. Yeah. So it's really the workhorse that can keep going and going and going. Maybe not generate as much force as the gas drop, but far more endurance. It's the powerhouse of the lower leg. It does create a lot of force at the forefoot.

1:00:24It's also very important in the prevention of ACL injuries, which I think is... Counterintuitive. Given that it's below the knee. I mean, when you look at any ACL protocol, it's always hamstrings. Fisps femoris, all medial hamstrings, strengthen, strengthen, strengthen. But the research will look at and as shown that it's the strength of the solius that prevents tibial progression. I see. And if you can resist the tibia moving forward, you prevent the stretch on the ACL in that hit. Interesting. Never thought of that. It's fascinating. I know you and I have talked about this before, but if we look at capacity of the solius, there are numbers out there that in a seated calf raise.

1:01:14So when you're seated, the gas shock is not your big play. Immobilized, yeah. So you're focusing on solias. Those numbers, 1 .5 times your body weight. For a single leg calf raise, you realize I still haven't been able to do this. I want people to understand how difficult that is. Because when you told me that, I was like, that is insane. You need a Smith machine to do the test. I don't have a Smith machine. So I was at a friend's house who had a Smith machine and I set up the apparatus. I actually had to download, I was luckily I had my phone. I was able to download the paper you sent that walked through the protocol and you're doing a single leg calf raise where one foot is doing all the work.

1:01:55Obviously, the other one is not. You've got a lot of padding on top of the lower femur so that you can load the bar from this Smith machine directly over the tibia and fibula. I think it was six reps you had to do if I'm not mistaken at 1 .5 times your body weight. And I think I got up to 1 .3 times my body weight and I was like, is there any way a human could do 1 .5 times everybody being clearly there is? But I was blown away at how difficult that was. I generally pride myself in being able to do the metrics that are considered minimum metrics of human performance. This was a fail. It's shocking to me.

1:02:35If it's one of the biggest assessments we will do with our patients because I want a baseline. I want to know where we are. I mean, we have ultra runners, athletes. I mean, they'll come in there and it's like, wow. Oh, I've had many people do this test. Everybody's failed it. And they fail it miserably. And so Kyler Brown, who's talked to me about that because he works with some of the best athletes, I mean, he's pointed this out as I think you have, which is sometimes the better an athlete, you are the better you are at cheating. I'm not suggesting that that's of my issue, but I'm saying like a lot of these times you'll see really good athletes who can do amazing things and yet they have very poor calf strength and you can't understand how that's the case.

1:03:11So how is that the case? I know we're jumping around. I want to come back to the extrinsic stabilizers. But again, this is such a fascinating topic when I see people who can run and jump and do super human things. But when you isolate the solias, it's not even able to move their body weight. They are the very good cheaters. They find a way. But eventually, eventually, something's got to get. And whether that's going to be today with the athlete or it's going to be 10 years down the road, when you are not using your plantar flexors, and I'm talking in a walking gate cycle, when that strength capacity isn't there, it's going to rear its head at some point.

1:03:50And you might be a fast runner, but imagine if you started to actually strength in the muscles that made you fast. Some of the best marathon runners in the world have the longest Achilles tendons. We have the spring of the tendon. We have these gastroconsolious. They can isometrically contract very strong and then transfer this force. I mean, the strength of the lower leg is so powerful to be able to take advantage of that. We have to do it. All right. So, well, obviously, go through some of those things. You mentioned now a lateral and a medial set of muscles. What are those large muscles as well?

1:04:27They seem to cause a lot of pain. Yes. Let's talk about lateral ankle stability. Peronials are the big boys on the outside. So peronias brevis is going to insert on the fifth metatarsal, okay? Powerful e -verter of the foot. So that's gonna take us from this position towards the big toe. Peronias longus also on the outside wraps underneath the foot and inserts on the media's aspect of the foot. Okay, so down on the outside of the foot around and under to the media also. To the big toe. Yeah. So when it contracts, it flattens the arch. When peronious longest contracts, it's the foot. Mm -hmm. Yeah.

1:05:08What he does is he's going to evert the foot, and most importantly, this is why the peronios are a very big stabilizer of your big toe. which is counterintuitive because they're on the opposite side of the foot. Yes. So when peronious long is this is the one that goes underneath the foot. When he's doing his job, we call it dropping the head of the first metatarsal. So basically what that means is it takes that bone, the metatarsal, and it anchors him to the floor so that we have a stable position at push -off. Yes, so one of my favorite exercises is putting a band like an elastic under huge tension on the floor, pulling immediately such that the only part of myself I let contact the floor is the base of the big toe.

1:05:58And then doing single leg balance drills. So that's actually strengthening outer leg. Yes, very important. When patients have ankle sprains, for example, remember we're losing sensation. right? We have a sensory loss, if you will. You can have dysfunction of your perennials. When I'm walking, because perennials long as drops that first metatarsal down, he's anchoring my big toe to the ground. If he's not doing his job, this guy that will stay elevated. So he'll stay lifted a little bit. So now when I'm walking, I don't have this stability at my first ray, And so on me they're gonna go to my outside again, which means there's my another ankle sprain.

1:06:45Or people will complain of a pinching on the top of the big toe. So there's a difference between a bunion. So this is when it goes into this comes out versus people will see a bump on the top of the toe. Those are two different animals. So if I'm walking and I don't have that first metatarsal dropping, when my big toe tries to extend, it doesn't have this nice rolling glide. It kind of jams first. And then you get this irritation on the dorsum aspect of the toe and it'll get red and it'll get irritated. And it's what we would term a functional halux limitus. So a restriction of motion at the big toe.

1:07:34And it all stems because there is not enough muscular force from the lateral musculature of the foot, the parent eels to bring the toe down, the base of the toe down. I mean, in my opinion, unless there's been trauma, like you've dropped a weight on your toe, or you've had turf toe, or things like that, where there's been an accelerated inflammatory your response, then yes, it is a dysfunction at that first ray, which is often caused by a weak foot, this is a common theme here, instability of the outside of the ankle, ankle sprains, and if those movement patterns are not restored and regained, then you start to have this arthritic change at the big toe, and that is not fun for anybody.

1:08:22It will alter gate, it will alter movement. So the big meaty muscle on the outer part of your shin is the tibialis anterior. Correct. And does it attach, it must go down around the lateral malleolus as well. It's on the front of the lateral malleolus, correct? Tib anterior comes down and then tib anterior tendon. You'll see it more in the medial aspect of the foot. It's a dorsiflexer of the foot. Biggest dorsiflexer, right? Yeah. Okay. So we were just talking lateral compartment. You were going around the house. Yep. So now we're in the front of the lower leg. So this is where Tibiaos anterior and all of your extensors live.

1:09:02So they extend the toes. Sorry to interrupt and maybe you were just about to address this. Why do we have toe extensors out of the foot? When you're walking, we always talk about with gate what's happening in stance phase. So there's stance phase when the foot is on the ground and then swing phase when the foot's in the air. And the reason why a lot of us give so much attention to stance phases because that's where all the magic happens, right? The all the load. But swing phase, when we're walking, you have to clear the ground. So when I'm assessing gate, I will often close my eyes and listen because you'll hear this scuff as I like to call it where they can't clear the ground.

1:09:47These will be your runners that come in and tell you, I keep tripping over, when I'm running, I keep tripping over rocks. I'm like, are you really tripping over rocks or what's happening here? Because if those tissues can't extend the toes and extend the foot, when they're running or walking, they'll scuff the ground and you can hear it. So they're responsible for a clearance and swing phase. But then also at heel strike, here's that eccentric component. When my heel strikes the ground, here's my extensors. They have to be very strong, eccentricly, because they're going to decelerate my foot hitting the ground.

1:10:30So again, I'll close my eyes and I'll listen, because if they don't have good control of those pre -tibial muscles, tibial santerior in your extensors, it's like an elephant's walking down the hallway, because it's foot slap after foot slap. These patients will tell you they have shin splints, they have medial tubial stress syndrome, because they just can't handle the repetitive motion of their foot slapping the ground without control of those muscles. From very interesting. Okay. So we've got these three pockets of extrinsic stabilizers. the intrinsics, let's talk a little bit more about the common pathology that you see.

1:11:14So we've talked about a handful of them already. What are the most common pathologies you see due to the anterior and lateral compartment? We missed the medial aspect too because from the big boy and the medial aspect is where you'll see a lot of injuries is posterior to be allis. So posterior to be allis, like I mentioned earlier, comes down along the medial aspect of the foot and it's a very big stabilizer of the inside of the foot. And it's sort of as I'm feeling my own leg under the table here. It's very difficult to disentangle it from the gastroc. The medial head of the gastroc, isn't it?

1:11:50They seem very close to each other. If you were to put your foot on your knee, point your toe and bring the sole of your foot towards the ceiling, you'll see a tendon that kind of pops up along the media aspect of the foot. That's post -tib. Yeah, and that's the one that when we get into the gym, we're going to work on that exercise of relaxing the post -tib while we allow the arch to descend. Yeah, I mean, post -hero to be Alice decelerates pronation. Fun fact, if you look at EMG activity and call it what you will. Some people don't love EMG activity just because there's a lot of crossover. But post -serietib, you will see activation from that guy from the second the foot on the ground until propulsion.

1:12:38He's one of the only tissues, muscles, where you'll see this constant activation. And therefore, we need to pay attention. Because of its attachment, it rotates. So that tendon has a 45 degree rotation before it inserts. So when we talk about those energy storage tendons of the Achilles and the Post -Tib, very, very important for free energy and propulsion. And because of how it attaches, it has to be trained in those planes in rotation or transverse planes. Let's go back to pathology there. What else do you see? So I think probably the most common diagnoses that we will see, we've discussed one of them already is heel pain.

1:13:22So plant our fasciopathy. Lots of tendon opathies. So your Achilles tendon opathies and your posterior tibialis tendon opathies. We know that these tissues need movement. We know that these tissues need load. And I think it's important to understand it's not that we want and necessarily yes we want strong calves but from a tendon perspective we want a tendon that is healthy which means you have to load it. And that goes for both the Achilles as well as post -tib. as well as your perennial. I mean, many people have perennial tendinitis as well. Interesting. Is that predisposed by lots of ankle sprains?

1:13:59Or is that more a function of just weakness in the musculature? I think there's a lot of factors you have to look at. Do they have the integrity of the musculature? Have they had a history of ankle sprains that have just never been rehabilitated appropriately? But think of the post -tib in the perennial as long as it's like a sling. It's this beautiful sling that stabilizes the foot and they work together. And when you have one side that's not helping out the other side, you can start to have these changes within the foot. So you alluded to imaging earlier. How often does imaging play a role in your diagnoses?

1:14:39Do you tend to rely mostly on the clinical history, the physical exam? what fraction of the time do you recall at reliant imaging? I think the biggest time and the most important time at the foot, especially with imaging, is rolling out stress fractures, especially when you're dealing with runners and things like that. But as far as everything else, I mean, if you look at research on doing MRIs, for example, for tendonopathies that are in Achilles, it really doesn't give you all that much information that's valuable, because you can see a tendon and on an image and it'll be like, wow, what's going on here?

1:15:16And it doesn't correlate with subjective or even... So it's not that different from the back. Yes. Where the MRI, you image a lot of people that feel nothing and you'll see horrible looking backs. You image a lot of people who feel fine and you could reverse. So stress fractures make sense. MRI probably better or CT. What's the diagnostic test of choice for a stress fracture? I mean, I like diagnostic ultrasound. Really? I think it can be more accurate, but yeah, the MRI, I just, I rarely will order that just because it doesn't really give me the information that I'm looking for. Interesting. Let's go back to the Achilles.

1:15:54I don't know what it is in my old age that has made me so paranoid of an Achilles injury. I've had one bout of tendonopathy there that took, God, probably like three months to really resolve. Now in that three months, I didn't really have to do anything different. I mean, I just did a lot of training, but I would wake up every day in quite a bit of pain. It got better as the day went on, but it was uncomfortable, but I had this huge panic that at some point I was going to tear it, doing some of the jumping exercises I do and things like that. And how much of that is, I never want to say the inevitability of age, but how much of that is due to tissue pliability of aging as an additional predisposing factor.

1:16:40Clearly, there's a load component to this, right? There has to be some insult. Well, first, let me say, consider yourself lucky at three months. These tendonopathies at the Achilles, if you look at research, I mean, you're talking years, five years, 10 years, where people will still experience symptom at the Achilles tendon. So a lot of my work in talking to patients with Achilles tendon opathy is just that. It's the education part of it because most people are afraid that they're going to rupture their Achilles tendon. And I have to remind them it is one of the most robust tendons that we have.

1:17:19There's less of a chance of you rupturing it, but you have to be aware of that discomfort is probably going to stick around for a lot longer than you want it to. So when we are rehabbing these, if they wake up in the morning, that's a lot of the times where you'll get feel that tendon stiffness. I tell them, if we're sitting at like a, and I'm not a big fan of VAS scales, I don't like to focus on how bad people are feeling, but for that measure, if they're sitting at like a 5 out of 10, for example, that's green light for us. That is not rest. That is not stop. That is still go. Yeah. And in fairness, I was never above a 5 out of 10.

1:17:58But I'm a guy who's lived at a zero out of 10 in his Achilles. I've had a lot of pain and a lot of other parts of my body. But to wake up and every day be out of five out of 10, we're just walking to the bathroom. I'm like, good lord. I mean, that was very frightening from the standpoint of, is this a harbinger of a catastrophic injury? There's really three different types of an Achilles tendonopathy or injury. And I think that's important to note because they all are looked at very differently. So most when people talk about an Achilles tendonopathy, it's at the mid tendon portion. So if you were to squeeze your Achilles tendon, kind of right in that mid portion, those are typically the easier ones and by easy, I still don't mean easy, but easier ones to treat.

1:18:49Then you have an insertional Achilles tendon opathy where that irritation is at the calcaneus. So right where it inserts, those can be extremely difficult because with those, the Achilles tendon breaks down on the front of the tendon. We know that tendons need load. So for those guys, you have to make sure when you're doing your calf work, for example, that you're getting is high onto your toes, end -range plantar flexion, so that you can start to load that appropriately. Those guys don't like to be stretched all that much. So there's different things that you do based on the location of where that tendon opathy occurs.

1:19:36And sorry, in that case, you would really minimize any dorsiflexion? Emild. You wouldn't go on a super deep dorsiflex. Yeah, like off the stair. Yeah. Everybody likes, loves to do off the stair stuff. and I'm like, can you do it without? How does your form look without going into a negative? Because when you drop that heel down into a negative, if you don't have good mid -foot stability and the whole thing just looks sloppy, I'm like, that's game over for me. And let's again, I want to come back to reinforce these terms. Mid -foot stability. We've talked about what the mid -foot is anatomically now explaining exactly that setting, because that's a very common movement, which is, hey, I want to do a negative when I'm doing a toe press of some sort.

1:20:16what needs to be true of the midfoot for a person to be able to do that. Going back to the anatomic structures, we've already discussed. When you are looking at someone from the back, okay, and if I was looking at them with their heels off the back of a step, as they go into that negative, if they can maintain the integrity of their foot, so in other words, when they drop the heel down, I don't want to see this collapse or this excessive medial drive where the whole foot just looks like it can't even hold itself up. Presumably those are more intrinsic failures or they potentially also extrinsic.

1:20:57It could be a bunch of things, right? It could be everything down to the ligaments. If they have poor ankle dorsiflexion mobility, so if they can't dorsiflex here, they're going to steal it. What's the minimum angle of dorsiflexion you need to be a functional human who can walk? Walking gate, we need about 10 degrees. Running? Running you need a little bit more. But if you think about when I'm training someone, I don't want to train minimum reach. No, of course not. Right? So I want to give people movement variability. The more movement variability someone has, the less, oh no, moments we have.

1:21:38So we have to be able to give people movement options. I have assessments that will do and I'll say, okay, we're at 10 degrees and it's actually really cool. You can just use your iPhone. Because it has a built -in notebook. Right. There's like utilities and it goes to measure. And I'll measure their Dorsey flexion. I like to see about 35 degrees. Wow. You'd be shocked at what people give you. And they'll say, well, I only need 10 degrees in order to walk. Well, do you sit in a chair? Do you walk up and down a stair? Because if you do any of those other motions, you have to be able to have ankle dorsiflexion.

1:22:14And ankle dorsiflexion is a huge lack of range in the foot. And there's three big compensations that you will see for people that don't do that. The first is when they're walking, they'll lift their heel up early. So it's an early heel rise. Now, remember what we talked about with eight times your body weight going through your forefoot. Do I want to increase that load? No, do I want to speed it up? No. So problem number one there. Next what people will do is they'll hyper extend their knee. So it's called a veris thrust gate. So because they can't door see flex, the knee goes, well, let me help you.

1:22:57Let me hyper extend to to propel you forward. So these patients will come in and tell you, my knee feels the wonky. The back of my knee feels unstable and you have to look at the ankle because it could be feeding why they're doing it. That hyper extension at their knee could be the reason. How do these people find you? Because your fame is through treating the foot. Are they finding their way to you because they're hearing you on a podcast talking about just that or are there other practitioners that are aware enough to recognize knee pain and say actually your knee pain is a compensation for your gait.

1:23:33I've been teaching these courses now for a while and I think a lot of the referrals now are coming from other physicians, other PT's, other doctors. I work with a couple clinics in Colorado. It's been really awesome to see the medical community really starting. I mean, we've had patients who have hip replacements And the feedback on the other end of this sometimes is you don't need to retrain your gate. And now we're getting a lot of these referrals and going, yes, you do. These are all things you need to pay attention to. So the word is spreading about the importance of what happens at the foot and how that can affect pretty much everything else.

1:24:14Got it. Okay. So we were back to the compensations for weak dorsiflexion. Yeah. So we have early heel rise. Yes. We have a hyper extension at the knee. And then the third strategy is that collapse, right? Yes, but if we're moving up the chain, the third one that people will do is they'll simply fall forward. They'll bend forward at their hips. They'll use forward momentum to carry them forward. So now they're in your office with low back pain. It's a direct reason because they cannot dorsiflex their ankle. I'm still a bit confused by this. When an individual comes in and let's say you make the diagnosis and the diagnosis is that their range of motion on dorsiflexion is insufficient.

1:24:59They're at 8 degrees or even 10 degrees, which we've acknowledged is kind of the bare minimum for walking. What is preventing that person from being at 20 or 30 degrees? Is there something within the bone or is it neurologic where their body doesn't trust itself enough to appreciate a greater angle. When you are assessing pretty much any joint, you want to see consistent patterns. So if we were to take this with a squat, for example, when people try to deep squat, if they can't do it, so they'll go down and do a deep squat and they'll be like, I just can't go any further. And I'll say, well, why is that?

1:25:38So it's my hip or my ankle. My ankle just feels stiff and I'll say, okay, I want you to go over to my squat rack and you're going to hold on to the squat rack and I want you to deep squat again. If they still can't do it, then I know that there's got to be some type of muscle or joint restriction that's preventing them from getting to that range. So that could be muscles that have shortened. We might need to implement stretching protocols. We might have to implement joint mobilization. Sound at the ankle. Remember the tailless. If he kind of floats forward, you can get a pinching. So there can be a pinching in the front of the ankle when people try to stretch.

1:26:26All of those things would be a consistent pattern because there's a muscle or joint restriction. But if they can't squat, but they can go into a deep squat and I would argue Peter most people Most people Most people is soon as they hold on to something they go down into this beautiful squat And that's when you're saying to yourself there is a neurological inhibition here This person is screaming for stability and that's when we're wasting a bunch of time going I want you to stretch your calves for the next 30 years and you're not going to see anything because that's not what they need And then it comes down to proximal stability.

1:27:06How do we create stability? How do we create a safe environment for their brain and their body so that they want to go into a deep squat because they need to go into a deep squat? Yeah, I mean, I've shared this story before and it's worth sharing again, which is that when a person is under anesthesia, they can be stretched into positions that they would never imagine if they're not under anesthesia. And you might say, well, okay, so what? But they're probably going to get hurt. But they don't. You can take a person who can't touch their toes. And again, when they're under anesthesia, you could almost fold them in half.

1:27:41You could get their palms past their toes. And when they wake up from anesthesia, they will not have torn a hamstring. Can you ask the question, how is that possible? And it's possible because neurologically, they are being inhibited from doing that because the body says you are not stable in that position. I give you an example one more time. I had a guy that once when I first was learning this, I was in a lot of back pain and I was so stiff I couldn't touch my toes and he took me through a 30 -minute exercise of increasing intra -addominal pressure and within 30 minutes, the entire palm was past my toes.

1:28:16Did I get more flexible in 30 minutes? Of course not. But by generating high degrees of intradominable pressure, my back relaxed enough that it allowed my body to move to that spot. This, to me, is one of the most difficult things to both identify, but more importantly to be able to train. Because in a way, it is a light switch. The circuit has to be grooved a lot for that to become the new default. So how do you go about doing that given a it's ubiquity and b it's complexity? I think that assessing patients for proximal stability is mandatory. It's absolutely mandatory and I'm a foot person. If I'm far away from where we consider proximal stability and creating intra -abdominal pressure.

1:29:05But if you were to look at someone, I'm always going to take this down to the foot. If you think of your pelvis as like a bulb water, if I were to stand and dump out all the water, all right, you have a forward tilt to the pelvis. That also can happen when the rib cage would flare. Okay, and we call it an open scissor posture. So when I'm assessing these patients, I'm looking at, can they stack their rib cage over their pelvis? Do they have good breathing patterns. Can they breathe 360 degrees around their belly? Can they expand their ribcage? Because if they cannot do those things and they stay in this posture, if you were to stand up and dump all the water out, tell me what would happen to your feet.

1:29:57Because I'll tell you, you will feel all of this medial pressure along your big toes. You'll feel your arch collapses if you will. And this is where pronation gets a bad name. Yes. In Genue of Algon. Everybody's in. Don't let your knees know. I'm like, tell that to a hockey goalie. Who stands there for three periods in a valgus position at the knee. I don't believe there's any bad posture positions. It's only bad if you can't control it and you can't get out of it. You have to be able to do these things. I have to be able to protract my shoulder. I have to be able to arch my back. You just better control it and be able to get in and out of it.

1:30:40Yeah, I think this is worth maybe double clicking on a bit, Courtney, because A, it's not a conventional view. It's not a mainstream PT view and I'm not throwing PT under the bus. It's not a mainstream anybody view. And yet I've heard it enough from the people who I think are hands down the best at movement that we should reiterate the point. there isn't a bad posture per se, but control is what matters, and you could argue that the best movers on the planet frequently engage in what would be viewed as, quote unquote, bad posture. Yes, I mean, I don't think we were all designed to look like these robots and be in these like perfect postural positions.

1:31:25It's just not realistic. I'm just thinking of golf. My My father's a big golfer and we used to watch Arnold Palmer swing a lot. And if you've ever watched Arnold Palmer swing a bike, how's this guy so good? Being able to create this stability to your system and to be able to control these different postural positions is key. It's key to be able to get in and out of. And if you think about that at the foot, it's not that pronation is bad. We have to do it. It's our first opportunity for shock absorption when we walk. We have to be able to then get out of it. Yeah, and the person most commonly who is in the open scissor pattern, they're stuck in that position.

1:32:08They aren't able to get out of it and therefore they're equally ineffective at shock absorption. Yes, and there's this disconnect, Peter. It's when I have patients stand in front of me, I'll have them tilt their pelvis forward, and I'll ask them, what do you feel at your feet? Half the time, I'm like, nothing. There's this disconnect between my pelvic motion and what my foot should be doing. When my pelvis dumps forward, you should feel the feet drop. When you tuck the pelvis back, you should feel the arch is lift. And that's this motion, this dynamic motion that the foot is capable of doing. You said something earlier when we were speaking about how our proprioception and sensory appreciation of the universe changes as we age.

1:32:56Now that I'm over 50, what's changed in my sensory apparatus of the foot? We talked earlier about how falls are prevalent and how there's really factors that contribute to these falls. We know one, we've talked about this as a weakness and toast strength. That changes and the numbers are like a 35 % decline in strength. over what period of time? I'm not sure. Between presumably something young and something old. Correct. And especially there's a very big change when you look at the jump from 50 to 80, for example. So we're looking at the 35 % decline right in those ranges. So not only does strength decrease, but we have four different types of receptors, a couple fast adapting and some slow adapting receptors.

1:33:47They're responsible for gaining information so that we can maintain our center of mass, for example. As we get older, so let's start at age 50. You lose 20%, it takes 20 % more pressure to stimulate these receptors. Now, versus when I was 20. Correct. So, as we age, the sensitivity of the receptors decreases. Now here's where it gets a little scary. When we go from 50 to 85, at 85, we now have 75 % decrease sensitivity to these receptors. That's a lot. What's driving that? I think it is a lack of strength at the foot because, here's the good news, exercise. We know, increase the circulation to the sensory nerves.

1:34:41If we exercise, we're gonna have increased circulation to our sensory system. We have increased nerve fiber branching when that happens. With increased nerve fiber branching, we have increased sensation. And that has been found to decrease pain and improve sensation, even in patients with peripheral neuropathies. So maintaining strength and function at your foot, I think obviously will decrease the decline of toe strength, but also increase the ability for us to feel the ground, which is imperative from being able to walk upright and being able to prevent us from falling. And this sensory decline, how much of it is superficial, meaning you can test it and assess it using the standard metrics of, you know, like take an alcohol pad or a cotton swab on the cutaneous branches and how much of it is much deeper.

1:35:42I mean I'm guessing more of it is this deep part that is dependent on significant pressure but I don't really understand. I did bring it to there's a 256 frequency vibration tool and what you can do is you'll have the patient laying down and you take this 256 tool and I'll tap it on the ground and I'll put it on the base of their heel. And you get three chances, you're changing what you're doing. And can they pick up the vibration? The accuracy of that test has been shown to be more accurate than the nylon pricking of the foot. Interesting. Vibrational sensation. That makes sense, because that strikes me as a more complete form of sensation than, because the nylon thing is mostly cutaneous.

1:36:30Yes. Okay. Well, before we go to falls, I want to round out a couple of other injuries. Okay. There are a couple other toe injuries that are pretty common. Yes. Let's talk about those. Okay. Happy to. You want to start with halicis, restrictis? Yes. Yes. Yes. Yes. Yes. Yes. I think a lot of it has to do with poor footwear selections. We talked about the chronic ankle sprains and the inability to allow the first metatarsal to drop. But a functional halux limit is we need about 40 to 45 degrees of range of motion at the big toe in order to have an efficient walking gate. Yeah, this is my only superpower.

1:37:07I'm probably like 90 degrees at my halux. Excess range of motion is great as long as you can control it. It remains to be seen. So if I wanted to sprint though, I would need 65 degrees, right? Because you're more on your toes. Yeah. And this is where I've seen a lot of former NFL players who get horrible turf toe that have what literally looks like 10 degrees. If you can catch these patients, so there's stages. So what will start to happen is you'll get an inflammation on the top of the big toe. Is the primary pathology just the repeated jamming of that toe? The instability at the first ray. They can't drop the first met down, so they start to irritate the top of the joint.

1:37:49It'll be red, it'll be swollen, and these patients suffer. I'm on a Facebook group for Alex Rigidus. It's a support group. And the reason I'm on it is because it's a constant battle for these people for footwear. They're like, I need a shoe that's going to eliminate me using my big toe because it hurts when they try to extend it. And have these patients all experienced trauma? No. If they've had something fall on their toe, if they've had turf toe, then yes. But a lot of them, this is weakness. This is poor footwear. That's why I think a lot of these diagnoses at the foot can be prevented. This is proactive healthcare.

1:38:31I mean, you want to talk about your eggs in your book. I love that story. There's no better way to stop the eggs from being thrown than by taking care of our feet from the ground up. But I digress. So let's assume that the trauma was in the past. It's not an acute issue. Is the treatment the same where you have to get mobility back by strengthening? I always say earlier intervention is better. Even if there's been trauma, you do not want to immobilize something. We know that. When you immobilize, it starts this cascade where you start to change the neurological input to the tissue. It just really will create an environment where movement will be altered.

1:39:12So even in those initial stages, we're doing like big toe ranges of motion. I always saw my patients. If I don't get excited about you exercising your big toe, but you have to be. Now sometimes, remember when I had my little toe injury three months ago, which still It's like not as bad, but it's amazingly so or still. That first weekend, the thing was black and blue. You still had me doing isometrics. I'm still doing them, by the way. Anytime I'm in pain, five minutes of isometrics actually makes me feel better. Why is that? I call isometrics my pain meds for my patients. Yeah, so tell people the exercise you had me do with why it's helped.

1:39:53With the big toe, what will have if there's an irritation in the joint percent? and just so people know the injury, I had an injury where I got hit on the front of the toe, so it just jammed the toe back, and I sent you a photo the next day. I've never seen, I mean, you've probably seen this for me. The entire side of the foot was just black and blue. I didn't get anything x -rayed because I didn't think anything was broken. I was gonna ride it out, and within a few days I knew nothing was actually broken because I could touch the bone. The pain all seemed to be ligament pain. And to this day, it's still very tender to touch the side.

1:40:31If someone looks at their foot and they see that they're like, oh my gosh, I better just do nothing. Do nothing. But yes, right away what we had you do was put the toe in a position of a little bit of extension or something that was comfortable. And then you're basically just contracting on both sides of the joint. So you're pressing down and then you're trying to lift up. But you're getting some type of movement. isymetrics. The reason I call them my pain meds is I will tell my patients whenever you feel pain. Isymetrics are safe for you to do because what they do is they decrease cortical inhibition.

1:41:08So when we have an injury think of it, go to a race car. We have a cortical accelerator, so information coming from our brain and we also have breaks. We want to the accelerator in the brake to be in balance of one another. When we have an injury, our brains are foot on the brake. So if I'm trying to change my movement or improve my movement pattern, I got to let off the brake. And that's what isometrics do. They decrease that cortical inhibition and to be able to do that right out of the gates is extremely important. Yeah. Before the damage sets in and you create a long -term pattern of rigidity.

1:41:47Yes. So when you can find these patients that still have, when you're doing a calf raised, for example, someone who has pain at their big toe, they'll be like, I cannot do that. It hurts too much. It's pinching. I'll put a band around their ankle, for example, and I'll pull it to the outside. Remember, that's where peronious longest lives on the outside of the leg. So I'll challenge it a little bit so that they really have to press through their big toe to keep their big toe on the ground. When they do that, they're like, wow, that pinching is better, because I dropped the head of the first. Yeah, there is something so magical about using bands for lateral and medial tension to produce the necessary engagement of the foot stabilizing muscles when you go and do other things.

1:42:37The kinesthetic queuing, I think, is so important. So important, especially in those planes. That's why the foot's this multi -directional, like, beautiful thing that we can train so many ways. So what else are you doing for the rigidist patient? Obviously, isometrics a big part of it. How do you get the range of motion? How do you slowly introduce that range of motion back? If they are in a functional, howl -exlimitist, which means that they can still utilize their big toe based on if I increase strength of peronious longest, for example, if we work on range of motion at the big toe, all of those things are key.

1:43:20If you don't do it then, it will progress into Halux rigidus and I don't consider those the same diagnosis. Halux rigidus, there's been so much of our thritic change to the joint that now you may be have five degrees. So the toes basically fuse almost. So rigid is your associating with the bony arthritic changes, whereas limit is is you still can anatomically move. You are limited because of the musculature. I mean on a film you may start to see like an exos tosis or like lipping. There is you know, we'll start to have changes within the bone, But it's still a functional joint. And that's when I get excited because I'm like, let's do this.

1:44:05Let's fix this thing because if not, if that progresses to Halux Rigidus, it's game over. Now our treatment has completely changed. Meaning that I have to look at putting them in a certain type of shoe that's going to rocker them through their toe because they now have lost four foot rocker. They cannot rocker through their toe. What percentage of people with how slim it is will progress to that phase of disease? Unfortunately, quite a bit. Wow. Because this message isn't quite out there as much as it needs to be. Because those two diagnoses are often married. When people start to see our thridic change at the toe, they're like, wow, this is how ex -regidist.

1:44:51I'm like, no, it isn't actually. If I drop your metatarsal down, I can still give you 40, 45 degrees. Hold on a second. Let's train this thing. But without knowing that and you start to have pain at your big toe, the initial intervention is a carbon plate under the toe. So they sell these little inserts where you can put in your shoe so that your big toe isn't bending at all. Some type of orthotic or very stiff shoe and these patients would be like, oh, this feels great. And I'm like, yes, because you're not moving it anymore. But... If you stay on my path too long, you'll lose the ability forever.

1:45:28Correct. And you want to talk about what happens up the chain. When I see patients walk with Halux rigidists, for example, they can't roll through their foot. So they can't push off at 45 degrees out of their big toe. So now what they have to adopt is this is what their foot looks like. So they have more knee flexion, for example. And then their hip has to be right. And it's like, what are you doing? But I always want to and still hope because there's always hope. You have to do that. And even if patients have a fusion in their big toe, even if they have Halux rigidis, you've lost range at one joint, but you haven't lost range at your ankle and you haven't lost range at your knee or your hip.

1:46:17Those ranges of motion will be compromised. But let's just train them. Let's rocker you through the big toe. Let's give you drills to give you knee extension, to give you hip extension because we know you're not going to have access to it any longer. So let's just give you things to work on. And that's where I think I want the two worlds to marry. Oftentimes there is a time and a place for these surgical interventions. But once that's done, there's so much more that can be done so that we don't start seeing sequela of that up the kinetic chain. How often are you seeing people that have kind of autoimmune forms of arthritis in the foot and ankle?

1:47:02It's a smaller percentage of my patient base, but they do make their way into my office. And a lot of the times where I will see that as more at the midfoot, But, we'll have a lot of this arthritic change at the midfoot. And aside from obviously the medical management of that with pharmacologic agents, what are the most important things you're doing for those patients to foster midfoot mobility and strength? Again, we're meeting patients where they are. You'd be surprised even patients that have had three and four foot surgeries because that's typically what I will see. little things like Toyota, right?

1:47:40So being able to lift the big toe only, lift the four toes, lift all the toes and spread them. All of those little things are sending information to your brain that these people haven't seen in a very long period of time, if ever. So with midfoot issues, isometrics, if I can get a little bit, even a little bit of isometric activity out of them, we're doing it. We're going to talk about falls in a second. We can use toast strength which is part of the reverse of some of those things you just talked about is toe strength mostly a midfoot intrinsic capacity? Well, flexor digitorium brevis is a big muscle in regards to toe strength.

1:48:21When we do one of the videos I'll talk about the wink sign, okay, because that's a sign you can see in the toes to know you're engaging the muscle appropriately. That forward leaning, we want to be able to feel the intrinsic muscles of the foot. So feel the arch A lot of that helps these patients with this midfoot instability. The intrinsic muscles of the foot, you know, when people do like the short foot exercise, I kind of call it the clam shell of the foot because it's a good place to start. But it's not functional because the intrinsic muscles of the foot come into play when the heel comes off the ground, at forward propulsion, when those toes need to be strong.

1:49:01I mean, if I was treating you for hip pain and I gave you, I want you to lay on your side and do clamshells forever. I mean, great. But is it functional? Do you ever do that? So we have to marry these treatment plans with function. And I think especially with toast strength, you got to really work on that type of movement and tissue strength. So let's now go from toast strength back to falls. Since you said that the measurement of toast strength is one of the greatest predictors of fall risk. It's a huge problem. The mortality is enormous once you reach the age of about 65. So what do you think are the most important things that we need to be training to minimize the risk of a fall?

1:49:49First and foremost, toe strength. That is the single biggest predictor of falls in the elderly is a weakness to a strength. It really is. that. When we get in and start doing these exercises, I mean, I think it is imperative. You know how kids get school, they host us checks. I mean, we should be checking kids' feet. That's when we need to start paying attention to this stuff. Because if we start training these things, once we get to this age where toe strength is a massive deficit, we'll be ready for it. So toe strength for certain... I'm very worried about what my toe strength is going to be when we bust out the denominator.

1:50:23Well, neuroplasticity is a real thing, so we can train that up for you. Very good. So toe strength, ankle mobility. That's another one that we look at. More important in the planter dorsi plane or in the inversion eversion plane. In both. So when I assess, I have a fall prevention protocol. Dr. Tommy showed his put together an excellent fall prevention protocol. And him and I have worked a lot together on this. So we'll look at ankle dorsi flexion. So we want that to be about 35 degrees. but then we'll also look at inversion and eversion, which is basically going in and then going back out again.

1:51:02A lot of the receptors on the foot live on this outside lateral aspect of the foot. So we talked about how a lot of falls occur with the initiation of gate. The other plane where people will fall is to the outside. So when they go to step, if I have less sensitivity to these receptors on the outside of the foot, I can't feel where am I going? I'm going to the outside. So that's why we'll look at the ability of the ankle. Do I have good range of motion both in and out and going forward? The other thing, obviously, that we'll look at is balance. Really cool studies looking at vestibular function, and modulating activity of abductor halisus.

1:51:53So remember, that's the muscle that straightens the big toe. Abductor halisus is slow twitch muscle fibers. So that guy's not real good at movement coordination per se, but he can last all day. And from a balanced perspective, it's the muscles that are receptors that can really hold our bodies up. And that abductor halisus is a big boy. So we look at single leg balance, for example. We also want to look up the chain. So when we look at fall prevention, it's how stable are my hips. When my foot is on the ground, it's my glute. When I go to heel strike, that guy is in charge. So I want to make sure I have good capacity going up into the chain.

1:52:35And how much of that is the glute mead versus max? Depends on where we are in the gate cycle. So when I'm walking at heel strike, that's all glute max. As you start to propel, you need the need to stabilize. And what do you externally, at this point, you need to be able to abduct the hip. Yeah, so I'm walking at heel strike. Think of it as a skewer. So I have gravity at heel strike that's causing everything to internally rotate. It's my glute max. That is a very big controller of torque. He's going to slow things down coming from the hip. Once I get into mid foot stance or loading, now I need to make sure that I'm not swaying all over the place.

1:53:28That's glute me. So all of those tissues come into play to help stabilize my body and slow everything down. My boys are so obsessed with talking about butts right now that over the weekend in some lame attempt to shut them up. I said, guys, the butt can be better described as the gluteus maximus. And it's the largest muscle in the body if you want a little fun fact, which now turns into them running around the house screaming gluteus maximus gluteus maximus. And I'm like, I don't think I had - It's a good father, I think. I'm like, I don't know that I've done any better here. This is just as annoying.

1:54:08I pity their teachers. Well, I mean, if you think about it, because I'll have patients that do this, because they'll think that when I'm walking, it's gonna be this big old glutexercise. And as they go to push off, they'll squeeze their butt. And I'm like, it's a wrong spot. You want to squeeze your butt, you want to try to control it, right? And I really don't ever give people gate cues when they're walking, because it's just too difficult. But that's not when you're pushing off. If you squeeze your butt when you push off, all you're going to do is throw yourself into too much lumbar extension.

1:54:38It's that at heel strike, and that's when we have that eccentric control. I'm looking forward to seeing what the fall prevention protocol looks like, especially as far as the tests that we can do. Let's talk a little bit about shoes. We've talked about it a bit at the outset, but I know that it's going to be a topic that anybody who's listening to us right now is going to want to understand, hey, what can I do for myself, presumably as an adult? And I do think there's going to be a lot of people who listen to us who have kids. We're going to also say, hey, if I've taken anything away from this, I've taken away the idea that this begins early in life.

1:55:12And therefore, I want to maybe even save my kids some of the challenges I've had. What can I do for them? I love this question. I could talk about shoes for a very long time. If we talk about kids first, I think first and foremost, just let their feet fit. the background is often as they can. All different types of surfaces. There are way more shoe and footwear companies now than there were when I started this whole thing 20 years ago. I think the board is catching on and we're realizing the importance of all of this. With the kids obviously, and this is with everybody, the toes need to be able to display.

1:55:49A wide toe box for me is non -negotiable. Are we defining that by the insert test, meaning put your foot on the insert and make sure that when your weight is on your foot, you can still see insert? It's probably the easiest way to access that, but I will caution you that these companies are getting smarter. I've called all of them pretty much. The last of the shoe, this is the last of the shoe. In order to change the last of the shoe, it's very expensive. So what the companies will do is they'll change the upper of the shoe. So they'll put like mesh. So when you go to put your foot in there, it feels like you have all this room and it's not because the shoe is wider, it's just because they put a material on there where your foot can actually expand in it.

1:56:40There's also a very big difference between a wide tow box and a wide shoe. Those are two very different things. A wide shoe, which most shoe companies have, will give you with here, but it will still taper at the toe. And now what we want, remember the tie bar mechanism. I have to have that four foot display to trigger the response of, hey, I better get stable it push off. So that's when I need my toes to be able to display as well. So wide toe box is mandatory with kids footwear, adult footwear, whatever. What are the shoes that have would that be considered a wide toe box? Yes. So this is a zero.

1:57:27I'm a big fan of these shoes. There are so many companies out there right now. Vivo Barefoot Tullis. I mean, I could go on and on and on about those. I have a list of them too. We'll put that list in the show notes so that people can sort of see what you would consider shoes that make a wide enough toe box for the purpose. And I have them listed according to category, right? This is an athletic shoe. This is a casual shoe. And we have so many resources for that. It can get very confusing. People will be like, I'm in a wide shoe. I'm like, you're not in a wide shoe. So that's kind of rule number one.

1:57:59The other thing with functional footwear is looking at the heel and the toe. Where they sit. So this is a zero drop. This is a zero drop where the heel and the toe sit on the same plane. Okay? That just makes sense, doesn't it? That's how we were designed to walk. Most shoes, and I won't throw out names here, but most athletic shoes, most running shoes, if you Google the model of the shoe and Google heel to toe drop. It'll tell you how many millimeters it drops. tell you how many millimeters the heel is higher than the toe. Anything that's not a zero drop, by the way, in my world is a high heel.

1:58:39Interesting. I switched my rocking to a shoe that has an, I think, an eight millimeter drop. Once I was having all of that Achilles tendonopathy, and I have enjoyed that shoe much more. So I no longer rock in a minimalist shoe, probably because I'm carrying a lot of weight. and I want more cushion. I don't care about, I'll throw out the brand. I use the GoRuck shoe. So it is kind of a minimalist shoe. I can show you what I use later. But the reason I bring it up is there's something about having that little bit of drop that's not huge. It looks like a zero drop, but I've never had a Nikkeles. I've never had pain again since doing that.

1:59:20Is that a mistake? No, and I think it's such a good conversation to have. Think about the whole super shoe, the Nike Alpha fly for example. That's like the big craze. I don't even know what that is. It's the shoe that has a carbon plate. It's a big shoe. Oh, okay. Right. Oh, is this the super running shoe? This is the super running shoe. Oh, yeah, yeah, yeah, got it. That actually gives you a little bit of, presumably it gives you more energy. Yes, so there's like certain characteristics to that shoe. It has a carbon plate. It has a difference in the midsole. It's basically a shoe in the research will tell you, gives you a 4 % advantage.

1:59:57Now, if I'm running an erase and the guy next to me has this shoe that's going to give him a 4 % advantage, don't I want to be able to compete with him? Well, of course, I do. But I always say you have to earn your right to get into that shoe because it does change things. For example, because it's going to propel you, it might cause you to stride longer. with longer strides you have to consider hamstring in Achilles possible or potential injuries. So guess what you better be doing. A lot of hamstring strength and a lot of calf work for example. It has an additional stack height on it which can also cause that kind of longer stride.

2:00:42Again you better be able to handle that. So when you talk about shoes like that I call them a performance shoe.

2:00:56You have to do the foundation work. You're right, yes. Because use a training shoe. Get your foot stronger. Give yourself the best possible outcome when you put that performance shoe on. Because if you're just relying on the shoe, I can guarantee you'll probably end up in my office. Because I see it all the time. So with Achilles injuries, for example, now you're adding like, you know, 50 or 50 60 pounds. That takes work to be able to handle that amount of load in a minimal shoe. If you had a history of an Achilles tendonopathy, if your baseline capacity isn't where we know it should be, then if you need to wear that change, there is a time and a place for everything.

2:01:41So if you are going to wear a shoe that has an 8 -millimeter heel to toe drop, just do the work when you're out of the shoe. Make sure you have plenty of ankle mobility because what are you doing? You're shortening the post to your compartment. Make sure you're still doing all of your plantar flexion strength. Yeah, that's a great point. Let's talk about any other characteristics of the shoe. So you've highlighted two, the width of the toe box and the drop. Yes. Let's talk of the sole. So this is where I'll give people a little bit of leeway if you will. So I like to put patients, like I said, number one, wide toe boxes non -negotiable.

2:02:19But you will get patients that often and other doctors have said this to me, well, we weren't designed to walk on manmade surfaces. Okay, fine. Nor were we designed to walk with our toes looking like this. Hence the wide toe boxes are non -negotiable. But if you're standing on concrete all day long, if you work in a grocery store, for example, if you're in an airport, having a little bit of cushion underneath the sole of the foot is going to be more comfortable. But this is where you need to consider both ends here. The more stack height on the shoe, okay, so this is the more cushion, it changes the rate of loading.

2:02:57It speeds us through pronation. This is very important. So the more stuff I have, it's going to change the rate of loading. We've been talking about that all morning how we want to do what to it. We want to slow it down We want to control it and now I'm going to put something underneath the foot that's potentially going to speed it up You better have what a very strong foot and very strong extrinsic muscles to control that pronation So consider what you're doing in the shoe if you're standing still of fine You want a little bit of cushion but know that when you start walking with that thing with this more stack height, with this more cushion, you're gonna alter the rate of loading.

2:03:39So that's where the thinner sole can come into play. If you walk with a shoe on, that allows you to feel things. Okay, so Steven Sashin knowns zero and he has this ad that I just love. He's like, I don't wear comfortable shoes and you shouldn't wear comfortable shoes either. I think it's really funny, but he's right because when we're walking, Remember, we talked about that calcaneus and how beautifully it's designed it is to handle shock absorption. We also have receptors in the heel that tell us, hey, don't land so heavy because it hurts. Such a great point. I've seen the ad, I know Stephen well.

2:04:19I think it's important for people to understand that it's okay for your feet to be giving you a signal. 100%. This is totally off topic, but one of the things I'm also interested in understanding better is the importance of negative emotions. We live in a world where we've become so sterile to this and nobody wants to feel a negative emotion. You don't want to feel sad, you don't want to feel anxious, you don't want to feel depressed, you don't want to feel angry. And it's like, understandably, we don't want to feel those things, but there's an opportunity to understand why am I feeling that thing.

2:04:53And if I can understand why I'm feeling that thing, maybe I can get to the root of what's actually going on. Actually I think that the way you described that made me make that connection, which is gosh, we should actually think through foot pain. If we're in the right shoe, if we're in a shoe that we deem a correct shoe and something hurts, maybe the signal is telling us, what are you doing wrong? It gives us so much information when you can actually feel the ground. I mean everything, the proprioception, the receptor activity. And when we have a lot of stuff underneath the foot, I can over stride and land really heavy.

2:05:32I'm not going to feel it. That's not what we want. Walking is a grazing of the heel. We want to feel what happens when our heel hits the ground. Now very few people today, competitive runners or otherwise, will run in a minimalist shoe like that. It's a very infrequent occurrence. Do you recommend people do that? And if so, how long does it take to strengthen the foot enough to be able to run an issue like that? I know I keep saying this, but it is very patient -specific. You look at their history of traumas. You look at their history of injuries. I will always implement some type of functional footwear, regardless.

2:06:11It's just a matter of what we're going to be doing with it. So for example, if I'm working with just someone who wants to walk for example, we'll put them into a Ultra for example, wide toe buck shoe, Zero drop and we'll just have them start like five or ten minutes. See how they feel and then we can start to transition the stack height So if they're used to wearing this big bulky cushion shoe You don't want to take them into something like this too soon and they'll be like, this sucks and I don't want to do it. And then you lose them right out of the gaze. For a person to run in a shoe like that, must they give up a heel strike and running?

2:06:51When you change your footwear, you start to change how your body feels the ground. So with runners, for example, everybody gets all up in arms about heel strike. Heel strike is bad, heel strike is bad. It's not that it's bad, it's just where the load is going. When I'm running, it's not necessarily how my foot is striking, but where my foot is striking. So, over -striving is the enemy. I don't want to have my foot well in front of my body when I'm running. There's too much ground reaction force happening there. We want the foot to strike as close to the center of mass as possible. There have been runners who have won marathons with a heel strike that's at their center of mass.

2:07:44They just have more neflection for example. That would almost feel like they're falling forward wouldn't it? Almost. So when I'm striking with a heel strike that's in front of my center of mass, when I heel strike I have a lot of ground reaction force going through my knee, through my hip and through my low back. When I switch and run to a mid foot or four foot strike, all I'm doing is taking the load out of the knee hip and back and putting that into the foot into the calf. Theoretically given the structure, it seems like that's how it should be, isn't it? I mean, I have no dog in this fight as a non -runner, but what do most elite runners do?

2:08:27You will see all across the board different strike patterns. You truly will. When you are running though, efficiently, when you look at cadence and you look at I call them running fairies, it just looks like they can run forever. Their foot will be close to their center of mass and it is more likely that they will be at a mid -foot and four -foot strike when their foot is underneath them. Yeah, it seems like exactly just anatomically if you can bring the strike towards the center of your body you're much more likely to be not heel strike. Correct. Because it would be very awkward to heel strike at that angle.

2:09:00And you take out, you know, when you're running. So if I have heel strike, then I have to go to my forefoot and then I have to drop that heel down again versus just running midfoot forefoot. Which, yes, I think that is a more ideal position to run in from an efficiency perspective. With that being said, if you have a history of heel pain, a killi's tendonopathy, and you tell your runners, hey, we're going to take you out of this heel strike and we're going to get you to run on your forefoot, you better prepare them for it. They better have good capacity at their foot and at their calf or else what you're going to give them is more foot and calf problems.

2:09:36Are there any other characteristics of a shoe besides the big three you've mentioned that I mean you have pretty strong feelings about all of them, but in descending order of the three we talked about it. Your strongest feelings were at the outset. Yeah, I mean, you want to put the foot in its most functional position. I think that's the rule. And that means allowing the foot to display and trying to keep it on a level ground. And then you can play around with based on activity with the amount of stack height. But they have shoes now where they have the wide toe box, but they'll still give you like a three to five millimeter heel to toe drop.

2:10:15The topo athletic, for example, ultra actually now has a four millimeter. meter, heel to toe drop. So I'll kind of transition them. If I know this person has poor ankle mobility and poor foot strength, I'm going to say, listen, we're going to get you in a wide toe box. I'm going to drop you down from your 10 into say a five, slowly bring them there. They're going to be like, oh, this feels great because they always do. And then we start working on the strength and then we can continue to drop them down into a more functional But you think about hockey players, Brock climbers, where shoes are just what they are.

2:10:50You can't, I'm not asking everybody to run around barefoot all the time. It's not reality. If you do want to run in a super shoe, or you do play hockey a lot, don't panic. Just do the stuff. Do the work outside. Do the work outside. Get a pair of minimal shoes, grab some toast spacers, and walk around for 30 minutes a day. Keep it simple. Is a good rule of thumb that a shoe is a wide enough toe box if you can wear the toes spacers in the shoes. Yes. I've never seen you not wearing toes spacers. Do you like them? I don't sleep in them. You don't. Okay. Good to know. But I do wear them all the time.

2:11:22I wear them when I run as well. I have that history of bunions, the Alex Vagas. So my foot has gotten so much stronger over the last 10 years. My prognosis was they wanted to surgically correct my bunions. and I was like, that's not happening. I'm way too active for my mental health, for that to sideline me, because I see it all the time. It's a high rate of failed surgery. Most foot surgeries are. So I wear them all the time. I wear them in all of my shoes, and it's helped me immensely. And it has helped so many of my patients. The brand that you wear is the brand I have as well. What's it called?

2:12:03The tow spacers that we have is from a company podiatry essentials. Okay, they're clear and they fit in between, yeah, show us. Yeah. Yeah, and then they fit. The outer part of the foot is not experiencing the spacing. Yeah, so if I were to put it here. Yeah, so it's easier to fit into a shoe, basically. Now I notice you have a little rigid thing in there. I don't. What's that thing for? So I put cork into the toe space or in between the first and second toe, especially if that person tends to have, if they have a bunion, I want to have a little more resistance there. But I mean, most four foot diagnoses.

2:12:42I mean, we didn't even talk about neuromas, which is so common. And it literally feels like your foot is broken when you're pushing off of a foot that has a neuroma in it. In that toast play, it gives the foot room. You have all these nerves that run in between the toes. They don't want to be squished together. So your recommendation would be for a person who's never worn a toast bacer and again in the show notes, we will link to all of these devices. Your recommendation would be to start how limited, how small, how many minutes a day. I will tell a patient, here's your toast bacer's, you're going to walk around barefoot in your house for five minutes.

2:13:19That's it. On their weaker foot, because they don't have toesplay, the toes rub against the toesbaser. And you can get like a callus or a corn and that can be very painful. And they want to rip this thing off. It happened to me. It took me probably six months on my weaker foot before I could wear these all day long. And now it's like, it takes me 0 .05 seconds to put these on because I just spread my toes and they slide right on. In the beginning, when you're trying to put these on, I'll see people like trying to like wrench their toes apart because they simply can't spread their toes. It's wild.

2:13:56So they start with five minutes a day and they just slowly increase their time. Then they get a shoe where they can wear the toe space or in the shoe. Think of it as like just doing an exercise for your foot. Sarah Ridge did a study looking at And strength of the foot. And so what she looked at, there was a control group, a group that just did foot strengthening exercises in just war functional footwear. And they looked at four different muscles. So flexor did you torn, Brevis, when we talked about the sports of plantar fascia? Abductor halisus, the one that straightens the big toe. Quadratus plantae, we didn't talk about that guy, but he helps straighten the fourth and fifth toes.

2:14:38What was the other one? I think it was flexor -halosus -brevis, so the one that bends the big toe. At the end of the study, the foot strengthening group and the functional footwear group were almost neck and neck. Really? Yes. The functional foot people didn't actually do exercise. They just wore corrective shoes. Just corrective shoes. And the only muscle that didn't get stronger was flexor -halosus -brevis. There was one muscle that didn't quite get there. Does that surprise you? I mean, not really. That's great news for the average person who doesn't want to do the work. Because you're just saying basically all I have to do is change my shoes and things will get significantly better.

2:15:20Imagine if you did both though. Well, of course. Right, but I mean, you think about meeting a patient where they are. Now, by the time people get into my office, I have some go getters. Like they want other like, I've had foot pain. I want to get this job done. So they're going to go shoe, we're going to go toe spacers and we're going to go foot strength. Now I have other people that I know or I'm like start with one you got to start with one factor and if I had to do that Where am I going to get the most bang for my buck? Put them in the right shoe When it comes to kids anything different? Same principles you know my kids my boys not my daughter my boys have never owned a pair of shoes that aren't zeros These exact shoes I keep waiting for the day when they come home and they say I want Nike's or I want whatever the popular shoe of the day is.

2:16:05And I mean, knock on what it hasn't happened yet. They love the shoes and that's the end of it. It brings me so much joy to hear you say that because I can guarantee you, because my daughter is the same. She's in middle school and she wanted a pair of Nike's and I was like, I will do pretty much anything for you, but I am not buying you a pair of Nike's. But my brother was like, I wanna be the good uncle and the great uncle. The cool uncle, right now. And I was like, okay, I'm gonna let you make your own decision here. Every day when she goes to school, she has her shoe option and she walks out of that door with her altruzon.

2:16:39Because she's going to tell me, listen, she's like, it doesn't feel good. They'll make the right decision because it's just based on comfort. So if we start them saying, hey, this is what your foot should feel like. Then it's an easier decision. And if we can be proactive with the children, because they haven't been on the planet long enough to see structural deformity in the foot, which is exactly what it is. When you see bunions and hammer toes, it should be a signal to you going, something is wrong here. Something is wrong. Where is this a -barant load coming from? Now, what do you say to men and women who's, I want to say their job requires them because it's really, you could argue in this day and age that's not really the case anymore, But look, they want to wear more fashionable shoes, be it at work or in social settings, especially women wearing.

2:17:29I mean, I watched some of the shoes that women wear and I think, God bless you. How do you actually wear that shoe? So, do you put that in the same categories, performance shoes, which is, look, if you really want to wear the most pointy -toed, ferragamo, then you just have to make up for it when you're not wearing that shoe. And if I'm a higher burden of responsibility that comes with the privilege of being able to wear that shoe. 100%. I mean, if you have a history of any type of forefoot pain, bunions, neuromas, especially, and you want to wear a foreign stiletto, number one, be my guest. Have fun with that.

2:18:04Number two, you better do the work on the other end of it. Ross, it's, and I'll tell my patients, you got to work with me a little bit. You want to go on a date, you want to do this fine. I'm all for it. But do the work before, do the work after. Yeah, well Courtney this has been fantastic. I'm excited to now go and get into the gym and actually show people a bunch of the exercises and some of the diagnostics as well so that folks can begin the the do -it -yourself process. Yes, thank you so much. Thank you for listening to this week's episode of The Drive. It's extremely important to me to provide all of this content without relying on paid ads.

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