The two worst things shoes have done to our feet have been to raise the heel and confine the toes.  The elevated heel shifts weight forward, causing more weight to be taken up by the metatarsal heads; tightening the gastroc/soleus/achilles, and altering joint torques at the knees, hips and lower back.  The confinement of the toes may be the biggest culprit to modern foot pain.  Our toes were build to grip the ground and aid in propulsion; not to act as passive elements in the gait cycle.  The smaller muscles of the foot that attach at the toes--the interossei and lumbricales eventually lose their strength over time, allowing (1) development of hammertoes and (2) significant body weight forced onto the metatarsal heads (ball of foot), helping to create many of the podiatric pathology I see daily.  The weakening of these muscles is caused by modern shoes and the corresponding strengthening and tightening of the extensor muscles (top of foot) are caused by the need to lift a heavy shoe to clear the ground through the swing phase of the gait cycle.  
    A new minimalist shoe by Mizuno has just come out, highlighting the importance of the toes.  Based on ancient Japanese design that allowed the toes to hang off the sandal, these minimalist running shoes aim to do the same thing.  One arguement against them may be to question the direct pressure of the distal shoe cushioning on the metatarsal heads, but they do allow gripping action of the toes, which very well may allow for the development of stronger intrinsic foot muscles.  It's an interesting design to say the least, and we'll see if traditional Japanese shoe design can help us out a little ;)

I've been jumping rope a lot more lately as part of crossfit-type exercises I've been doing.  I used to do it quite a bit in college as part of a similar exercise routine; when I was a junior, I took a marine ecology research class on Appledore island off the NH-ME border.  On that wonderful island, I did two forms of exercise.  First, I would jump rope in a gazebo with panoramic Atlantic ocean views. Then, avoiding aggressive nesting seaguls, I trail ran with two girls from the Cornell University XC team.  (Those seemingly kind, nerdy science girls unleashed a pace of abuse for that entire summer) What I started to realize, in rare states of lucidity on those lung-searing runs, was that I felt "springier" that summer.  It was part of a transition that I began at that time:  get off the road and onto the trails. This helped change my gait to a shorter-stride, land-beneath-your center-of-gravity, midfoot  strike.  This was done completely unconsciously; the trails forced me to make this transition.  What I didn't quite realize then was that the jumprope was making this transition easier.
    As many minimal/barefoot converts know, achilles and calf pain/strain is the top complaint when making a gait switch from heel to mid or forefoot.  Landing here turns your achilles into an effective spring, aiding in forward momentum, but if you've never used this complex of muscle and tendon in this manner, it can suffer overuse quickly.  
    This is where the jumprope comes in.  Jumping rope is like running with a mid or forefoot strike, but not actually going forward.  It helps train that gastrocnemius/soleus/achilles tendon into an effective spring.  That springy feeling on a run doesn't come unless you're using this group of muscles/tendon properly.  
    So, in addition to eccentric calf exercises, one legged stands and squats, and the other prepatory exercises mentioned before, jumping rope is ideal to help you in that transition of heel to midfoot (or forefoot) striking.  Add in double unders, one-legged skips, shuffle skips to add some variety, and have fun!!

In the western world, we tend to think about exercise like we live the rest of our lives:  set goals! confirm to a rigid schedule! try really hard for success and personal bests.  That shouldn't be your primary focus!  Not to say that goals, schedules and hard work are bad things; in fact, most of us need them to stick to a training regimen.  Unfortunately, if your focus is on the goal, or the obsessive need to conform to that daily schedule, or the desire to attain a certain placing or PR, we fall into the same patterns that make us unhappy in society.  The lifestyle of training becomes as confining and demanding as the grind of daily life.  Most of us exercise to lessen the stress from this type of lifestyle we live in the western world, not add to it!
    This post is inspired by a similar one by Mark Sisson of Primal Blueprint (read here: http://www.marksdailyapple.com/detaching-yourself-from-the-outcome/#more-28094).  My own experiences are similar to Mark's (though I was not nearly as good an endurance athlete as he was).  The firm necessity of keeping to an intense schedule can take the fun out of experiencing exercise.  I had this type of revelation twice with running and neither of those times included any wins, PRs or sub 10% body fat. The first was when I took a solo cross country trip in 2002 after not engaging in regular cardiovascular exercise for approximately one year.  Trail running in Texas, New Mexico, Arizona, Utah, Colorado was exciting and gave me a new desire to run primarily for the pleasure of being in nature.  After a similar period of endurance inactivity in 2008 at the end of med school in Florida, I moved to new england for residency and began running the trails of central MA with newfound love of being in the moment and truly enjoying running. 
   This love of the journey itself is important to overall health and wellness; goals and schedules may be used, but not that they become so overbearing to cause injury and depression.  I see patients, especially runners, who are so focused, and have such tunnel vision for running that they are self-destructive--mentally and physically.  Telling an avid runner that they have a stress fracture and shouldn't run for a minimum of 4-6 weeks can elicit a response like telling them a favorite aunt has just died or worse.  This inflexibility is not healthy.  Neither is the refusal of these focused endurance athletes and full time workers to do resistance training.  The simple act of just running or just biking defines them completely.  Humans weren't meant to perform only one physical repetitive task; elements of picking heavy things up, climbing, fighting are all part of our ancestral physical developement.  In doing one daily repetitive task such as running (especially after sitting or standing in one place for 10 hours) we leave ourselves susceptible to physical imbalance and injury.  Incorporating whole body resistance exercise is key to preventing injury in endurance athletes.  In addition to that, a yearly schedule incorporating more and less intense cycles, periods of rest and periods of cross training can combat injury, and mental fatigue.
    Goal set and create schedules that are exciting and bring enjoyment on a daily basis; you shouldn't be focused on one or several possible end results. Your first goal should be to enjoy thoroughly the activity you pursue, and if you are a focused "one-sport" endurance athlete, to add variety and find alternate forms of exercise that you can fall back upon in times of injury.

"Live in the NOW, man"  Garth from Wayne's World

With the push of the barefoot/minimalist ideas over the last several years, there has been attacks from either sides.  Barefoot/minimalist proponents disregard, disrespect and generally don't believe what podiatrists have to say.  On the other hand, podiatrists are not very open to this new trend, and frankly most think this group a bunch of nutters.  Though I fully support the barefoot/minimalist (B/M) movement and live it myself, in practice I use tools from both sides depending on the patient's specific situation.
Here are some thoughts for both sides:
1.  B/Ms:  You're not a doctor!!  Podiatrists are highly trained! (4 yrs med school, 3 years of surgical residency.)  We don't do internet research on your job and then tell you how you should be doing things!   A good sports medicine podiatrist will be your best friend when things go wrong!
2. Podiatrists:  No need to judge and cling to preset ways!  There is plenty of research emerging that supports midfoot striking for decreased injury rate, and much anectdotal evidence from the barefoot running community.  In addition, the evidence showing traditional running shoe design and fit (neutral/stability/motion control) can be potentially harmful is so overwhelming, it should have already pointed us all away from making certain shoe suggestions.  In all other areas of the body, clinicians prescribe physical therapy after an acute period, but why do we put people in orthotics for life?  (We all know specific diagnoses/situations for which we definitely do need permanent bracing, but not EVERY person needs to be in orthotics permanently, and just because they're a runner with overpronation, doesn't mean they need orthotics)
3. B/Ms:  Yes, there is some good research pointing towards certain running styles/footstrike, low incidence of foot problems in habitually barefoot populations (see all of these in my LIBRARY section), but there is also (GASP!!!) good research on using orthotics for running injuries--it's why podiatrists use them so much!!  Here are just two that show effectiveness of orthotics for runners specifically.  (Readers: search in google scholar and you can read the abstracts):
Effectiveness of orthotic shoe inserts in the long-distance runner. 
Gross,M et al. 1991 
Clinical effectiveness of customized sport shoe orthoses for overuse injuries in runners:
a randomized controlled trial.  Hirschmuller, A. 2011.
(Fellow Podiatrists:  Yes, I have cherry picked my reference section.  This website is meant to be about promoting good research and analytical thought on minimalist and barefoot lifestyle, which is definitely not for everyone--or, frankly, most of the patient population we see!)
4. Podiatrists:  Please don't accuse people (biomechanic researchers, fellow podiatrists) of being in bed with certain shoe companies when many of you are part (or complete) owners with financial stake in using orthotics/bracing products. 

In summary:  Many B/Ms act like teenagers that "know it all" and there are many complexities and specific biomechanical conditions that podiatrists deal with on a daily basis.  Podiatrists, we need to be open to new research and even anectodal evidence from our own patients.  B/Ms, please seek out the help of a podiatrist who specializes in sports medicine (and is a runner him/herself) who will give you thorough attention.  Podiatrists, resist the urge for that "I told you so" moment when a B/M comes in with a stress fracture, but encourage moderation and slow transition. Let's continue to evaluate all the literature and be as critical as we can!

It's been a bit since the last post, but I wanted to jot down a few updates!
1. My winter minimalist boots.  Unfortunately, there is no winter this year, so I haven't had a chance to really test the waterproof Timberland hiking boots I've refurbished into minimalist boots.  My wife and I did travel to northern Vermont at New Years, and there was barely any snow in the mountains there.  A trip to Bolton Valley found the XC ski conditions terrible, so I walked around a bit in what snow there was in the boots.  Despite not being fully finished, I found the boots to be great! The sole thickness seems just a bit more than the Stems, and I was really suprised at the traction the vibram soles gave me.  I ordered the vibram cherry rubber through invisible shoes.com, and despite having relatively unassuming tread, it was brilliant in the snow.  The snow was very wet, and no leaks were noted through the sole-upper interface.  Now, they're not the most aesthetically pleasing shoes you've seen--but I am a functionalist, and with my large ears and buck teeth, not a pretty man by any means, so why should my shoes be? Shoes need to be practical to allow the natural form and function of the foot, like my large ears allow me to hear the patter of a fruitfly's wings.  Though, I must say, Stem and Vivobarefoot make some very pretty shoes, so if you don't want to look like an idiot, check them out.  I've recently learned that Stem has waterproof boots in the works as well!!
2. Continued research showing the benefits of a forefoot strike for runners.  I've gotten a chance to look at some new articles from the Dan Lieberman camp.  The first, "The Effects of Footwear and Strike Type on Running Economy," concludes that minimalist shoe runners have a significantly better running economy than those with more traditional shoes. They theorize that this may be due to the elastic recoil that comes naturally with using minimal shoes.  This use of your natural lower extremity recoil has been the focus of Newton Shoe company for years now.  The second paper, "Foot Strike and Injury Rates in Endurance Runners: A Retrospective Study," showed that rearfoot strikers have higher rates of repetitive stress injury.  Further critical analysis of these papers to come...
3.  Natural Foot Health and Wellness:  The Next Generation.  My first child, Dennis Daniel Claire, is due in a few short weeks.  I am looking forward to watching his foot development without the influence of restrictive shoes.  He'll defo have some crocs when he's a youngun--to the desperate lament of all you croc-haters. Though, with more and more minimalist shoe development and production, he and the rest of us will have more choices of shoes that promote natural foot health.  But no matter what, he'll  be cooler than his father.

Several months ago, Dr. McClanahan, a podiatrist in Oregon had offered up his Correct Toes product for me to try.  In addition to using the product, I decided to make a full-time switch to completely minimalist shoes at work as well.  That meant bucking the trend of wearing dressy shoes in a very conservative region for medical attire. Though my zero drop timberland black and brown dress shoes were definitely not your typical "classy" dress shoe, they were also only "close enough" to minimalist standards of footwear. Nonetheless, I was ready to go more natural with shoegear at work.
     For at-work shoes, I decided to go with solid black Crocs most days and occasionally wear brown Stems, both of which meet the criteria of allowing and promoting natural foot health. (See the links section for the criteria of choosing a shoe.)  I have been wearing the correct toes approximately 60-80% of the time (including sleeping, running, working), and using a shoe with my 3 specifications 100% of the time. This was very liberating for me, because I was able to "go minimal" at work as well as play, and finally wear shoes corresponding to natural foot function at all times. The crocs and stems were also the only shoes I had that I was physically able to fit in with the correct toes.
    I have to say, I was very skeptical of the correct toes.  There are other "bracing" products on the market, such as yoga toes and flextastic.  Patients seem not to have success with them, but those same patients also continue to wear terrible shoes.  Yoga toes and flextastic are meant to be worn just at the end of the day and never in shoes, but the main feature of the correct toes is that you are supposed to wear them at all times, so I was quite interested to see what they could do.
    The first xray above shows my foot in late August of this year; on that day I was taking an xray to familiarize myself with the system at my new job.  At that point, I had been wearing minimal shoes running for years, but I still had casual shoes that did not meet specifications, and my dress shoes were still relatively narrow in the toebox, but much better than the high-heeled, tapered toebox shoes ("classy") I had used in the past in our podiatry school clinics.  My foot may have felt pretty healthy at the time of the xray, but look at the bunion deformity and look how my toes fit the shape of a modern shoe, similar to the picture in the header of this website.
    Recently, when I remembered I had taken an xray of my foot a few months ago before using the correct toes, I decided to take another to see if there was any measurable progress.  So, after almost 4 months of using minimal shoes 100% of the time, and using the Correct Toes product 75% of the time, this is what the foot looks like now:   

    This is really an astounding change for 4 months!  The bunion deformity is decreased and the toes are more rectus (straight) and appear to have freed themselves from the influence of a modern, tapered-toebox shoe.  Even the metatarsus adductus angle (metatarsal bones pointing inward) seems lessened, though I haven't  confirmed this by drawing out the angles. I don't know if my eyes are playing tricks, but my arch seems less cavus as well.
    Because of the combined influence of the correct toes and the switch to wearing minimal shoes full-time, I can't say what contributed more to the positive changes.  I can say, though, that I have been wearing minimal casual and running shoes for 2+years, and the bunion and cavus deformities still looked pretty significant 4 months ago.  The correct toes seemed to have helped me strengthen my intrinsics with the toes in a corrected position.  
    Here's a comparison:  when I do short sprint workouts (200 meter or less) I wear one of two pairs of shoes.  One is my traditional cross country racing waffle, which I have run in for years.  Those shoes are very minimal (zero heel drop, minimal to no cushioning) but have a significantly tapered toebox.  The other is my vibram five fingers.  After a hard sprint workout in the VFFs, I can feel a good post-workout soreness in the foot intrinsics, which I have never felt in any other shoe.  Like the correct toes, the VFFs hold the toes themselves in a more natural, rectus position (they way they probably would've developed without the influence of modern shoes).  Holding the toes in this position may better allow for the proper development of those intrinsic foot/toe muscles (versus doing exercises, using minimal shoes without that bracing).  So far, the correct toes seem to be an invaluble tool for regaining natural foot health and function in people who have helped deform their feet with modern shoegear. I'll continue to keep a critical eye on them and report back in the future!

Check the correct toes out for yourself on Dr. McClanahan's website:

Unless you are the "iceman," Wim Hof, who is known for his feats of tolerating cold in his skivvies, you are unlikely to be doing much barefooting in winter.  To keep your feet strong in thick wintry boots over the winter months, I've garnered some suggestions.  
    1.  Make your winter boots into minimalist boots!  (see previous blog entry).   I am actually in the process of doing this, and will report back regularly on their status over the winter months.
    2.  Keep your shoes off in the house in winter.  Walking around barefoot can maintain that muscular strength you've developed  over the summer. We podiatrists see a rash of plantar fasciitis in  the spring/summer because people take their weak, atrophied feet out of their thick, supportive boots and put them in flip flops with no transition.  To prevent this, keep the feet strong.
3.  Pick shoes based on my shoe selection rules 1. Zero drop (heel shouldn't be higher than the forefoot), 2.  No toe spring (shouldn't be an upward curve at the front of the shoe), and 3. Wide toebox! (again, the hardest qualification to find in most shoes. The ones that do this well are: basic crocs, altras, stems, vivobarefoot, and a handful of other shoe brands).   Vivobarefoot makes a good waterproof winter boot, and you can find moccasins and mukluks that fit all specifications, but they aren't waterproof.

4. Yoga.  Keep up your yoga all winter to strengthen your feet.  The downward dog pose helps keep your calf/achilles  flexibility and poses like warrior 3 really strengthen the instrinsics of your feet and muscles of the lower leg as well as being excellent for improving ankle proprioception.
5. Functional fitness indoors.  Keep hitting the gym with your five fingers or other flat bottomed shoes.  Besides being good for the foot alone, they put your entire body in better alignment for lifts, especially if you are doing crossfit (see previous blog post on this).  Better yet, if you have your own home gym, exercise barefoot (or see if its acceptable in your public gym--its much more sanitary than bare  hands on all the machines!).  Laird Hamilton is among many who do this.  (Check out his youtube workout session for good functional fitness exercises: http://www.youtube.com/watch?v=s3sMjz6dtX0&feature=related). 
6. Keep doing all the "transition to barefoot/minimalist exercises" I've mentioned in previous posts:  hip flexor; calf/achilles; bottom and top of foot stretches, and eccentric calf; toe-push; towel pickup; heel walking; and one-legged stand strengthening exercises.
7.  Exercise the feet in the boots.  If you have to be in big clunky boots outside for work all winter, first make sure you pick boots with enough room in the toebox, and that have zero drop heel:forefoot ratio, and with a thin sole as possible.  No matter what, do toe curls, and big toe push exercises in the shoe several times throuought the day--it'll help keep those toes warm too!

Over the last decade, the world of health and  wellness has had a "primal reawakening."  Answers to many health questions are already part of our genetic structure; what was once routine for us hundreds and thousands of years ago, has been clouded by modern changes.  
    These recent throwbacks began with our obsession with food and weight.  Books such as the Primal Blueprint suggested following a primal diet, which allowed many to become healthy and fit.  By avoiding a high grain-based and sugary-fatty foods that are so easy to quickly obtain, many people have been able to transform their lives by copying our ancestors. Just a decade or two ago, we thought 40 and 50 year old people were old; over the hill in many ways and unable to regain any sense of youth or fitness.  We are now impressed at 50 and 60+ somethings that are strong and fit.  These are not new revelations; in ancient Greece, Spartans were warriors for life and it would not be odd to see old men in battle.  Many modern afflictions can be fully reversed with lifestyle changes. 
    I have been recently reading Dr. Karp's Happiest Baby on the Block book, which suggests its own primal wisdom.  It centers around colicky crying and why it doesn't exist in many "uncivilized" cultures.  Many answers lie in this ancient simplicity we once considered backward.  
    This simplicity and minimalist movement has come to feet and footwear.  Anthropological evidence points to foot problems only developing with the advent of shoes and modern lifestyle.  Like dieticians, podiatrists have evolved to fix conditions that humans have created through a discord with nature. 
    Hopefully we will continue to realize these benefits of past lifestyles and do our best to weave them into our daily routine.   We can find peace of mind and body in this simplicity we abandoned for 'bigger, faster and better.'  How have you changed your life by reverting to an ancient, primal or more simplistic approach? 

As I see it, there's only one true argument against being barefoot, and that's: what do you do in the winter?!  Well, we can look back at our ancestors, who used animal skins--moccasins and mukluks, but they were not waterproof.  In our modern world, we don't have lovely powder everywhere; we have relatively warm roads and sidewalks and de-icing salt, that make that beautiful hue of brown and gray snow and slush.  A serious winter needs serious waterproofing.  
    Vivobarefoot has some winter boots that are waterproof, and so do several other minimalist companies.  Unfortunately, like the title of my post in a previous blogsite, "minimalist is maximalist in price." Most of these boots are $200 minimum.  Now, if you already own a pair of thick-soled and thick-heeled boots like I do, you can create your own minimal winter, waterproof boots.  Please check out this blogsite, and, take a crack at changing your boots into minimalist winterwear:

One of my favorite quotes comes from one of America's brilliant minds; Thomas Edison said in 1903: "The doctor of the future will give no medicine, but will instruct his patient in the care of the human frame, in diet and in the cause and prevention of disease."
    Medicine has certainly turned in this direction.  The more we know about a disease process, the more we adjust treatments accordingly.  When we know what causes a disease, we can avoid acquiring it.  In the newest realm of medicine, even stem cell research has this potential to prevent or reverse genetic disease.  
    Much of our basic health has to do with diet and exercise.  We know adjusting preventable causes of disease can garner amazing results.  Most of the time these lifestyle adjustments don't just repair physical well being, but mental and spiritual health as well. 
    Just a few decades ago, doctors warned against exercise; "you'll have a heart attack!" We now know that this sentiment is outdated; it is akin to discouraging someone from going to school because they may fail. The benefits outweigh the risks, and those benefits can help people love and enjoy life.  
    My specialty of podiatry is now at the beginning of a revolution to bring preventative medicine to our feet. Helping the foot to function as it was intended, without the influence of modern shoes and orthotics, can be lifechanging!  Like you would consult a doctor before beginning an exercise regimen, you want to visit myself before you begin discarding orthotics, using minimal running or casual/dress shoegear or going barefoot!