Biomechanics of Sport Shoes by Dr. Benno Nigg

A middle-aged woman arrived at my office last week complaining of heel pain and carrying a bag of custom-made foot orthotics (orthotics are custom made arch supports that are fabricated from a mold of the patient’s feet). Each orthotic this woman had with her was expertly fabricated by a different podiatrist and yet none of them had come close to alleviating her heel pain. At first I thought maybe these podiatrists didn’t know what they were doing. But, when I learned their names, I knew this woman had seen competent, skilled and reputable physicians.

I asked myself “how could this be?” More interestingly, no two sets of orthotics were even remotely alike. Further, given that nearly all podiatrists learn similar principles of biomechanics, shouldn’t orthotics for a given patient be the same regardless which podiatrist makes them?

After reading Biomechanics of Sport Shoes, Dr. Benno Nigg’s newest book, I have the answer. It is sobering, disturbing and I don’t want to believe it. Unfortunately, Nigg is one of the top biomechanic researchers in the field sport shoes, foot inserts and foot orthotics in the world. In fact, I imagine that Nigg spends more time thinking about biomechanics than a 17 year old boy spends thinking about sex. 

Foot Orthotics Debunked!

Nigg reveals that foot orthotics, which are devices designed to align misaligned feet, are actually not aligning the skeleton at all. In fact, Nigg’s book reveals many disturbing facts about orthotics, shoes and inserts: including that there is weak evidence orthotics lessen injury. Furthermore, changes in skeletal alignment due to inserts or shoes are inconsistent and minor.
 
Most importantly, Nigg goes on to warn that one of the dangers of the consistent use of orthotics is that they reduce functional demand on muscles may be associated with the deterioration of the muscles’ strength and function. So even though a foot orthotic often helps in the short term, over the long term Nigg warns their use may cause problems.

Repetitive Impact Not As Bad As We Thought!

Beyond orthotics, Nigg dispels the notion that running injuries are due to directly to impact forces and suggest that the new paradigm should be “muscle tuning” and the minimizing of vibration of the runner’s soft tissue. Nigg asserts that injuries are generally a result of intensity, duration, and recovery time.

Excessive Pronation May Not Be A Problem

Nigg then reviews foot, ankle and leg biomechanic research and shows that there is no evidence that excessive pronation when walking or running is a cause of injury. This finding is dramatic because many podiatrists believe excessive pronation is the root of many foot problems. 

Barefoot Running May Not Be Any Better

Despite Nigg debunking shoes, inserts and orthotics, you may be tempted to believe he must be a proponent of barefoot running. Not so. Nigg does not believe there is any evidence currently that barefoot runners sustain fewer injuries than shod runners. However, rather than closing the proverbial shoe box lid on barefoot running, he does say “barefoot training” is important and admits that barefoot running has a “small” performance advantage, but it may only be beneficial for a small group of runners.

He speculates that the functional adaptations of footwear based on the bare foot are positive and may persist, but the fashion adaptations based on the bare foot will disappear in relatively short time. 

Are You Ready To Be Unplugged?

One has to wonder the long term effects of the Biomechanics of Sport Shoes. Clearly, it should be required reading for every podiatrist. However, it may be difficult for some podiatric physicians, particularly those who have spent their life doing sophisticated biomechanical exams on their patients and meticulously fabricating foot orthotics, to open their minds to the content of this book.

Beyond health practitioners, patients themselves still generally believe arch supports, running shoes and foot orthotics are well-understood and the answer to their running injury woes. Until people begin thinking for themselves and asking questions both to themselves, to their doctors, and to the running shoe and arch support companies, the system will feed them what it always has.

I am reminded of a great quote from the film The Matrix:

“The Matrix is a system, Neo. That system is our enemy. But when you’re inside, you look around, what do you see? Businessmen, teachers, lawyers, carpenters. The very minds of the people we are trying to save. But until we do, these people are still a part of that system and that makes them our enemy. You have to understand, most of these people are not ready to be unplugged. And many of them are so inured, so hopelessly dependent on the system, that they will fight to protect it.”

On a personal note, I vigorously applaud Nigg for not only puzzling-out the mysteries sports shoes, orthotics and running, but for having the courage to put his theories into the public domain.

If you are ready to open your mind to the latest information and theories on running, sport shoes and foot orthotics, I urge you to read Biomechanics of Sport Shoes.

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The Mysterious Foot Orthotic

Orthotics Sales Approach $5 Billion Per Year

The term “Foot Orthotic” refers to everything from the inexpensive drugstore pre-fabricated insoles to costly, custom-made devices specifically molded to the foot. Podiatrists generally consider orthotics to be custom-made devices, specifically made from a mold of the patient. Podiatrists spend a great deal of time and energy understanding the biomechanics of the foot and when designing an orthotic for patients, consider the patient’s biomechanics and other factors. The CMAJ article quoted a study by Global Industry Analysts showing that the orthotics market is booming and could reach total sales of nearly five billion dollars in the next few years.

I Discussed the Problem of Possible Muscle Atrophy

The CMAJ article quoted me in saying that “You can’t guarantee anything is going to work for everyone, because people are so variable. Orthotics can do amazing things for many people, but not for everyone.” I stated that “there isn’t even a consensus on what an orthotic is,” and discussed the risk of foot muscle atrophy when relying on orthotic devices. “When you brace the foot, that may alter the function of the foot for the better, but in doing so it negates the need for many of the muscles in the foot to do anything. Common sense tells us that if you don’t use a muscle, it’s going to weaken.“

The Mechanics Of Orthotics Are Still Largely Unknown

Benno Nigg, professor of biomechanics and codirector of the Human Performance Laboratory at the University of Calgary, Alberta stated that there is no conclusive evidence of the actual mechanism of function of orthotic devices. “Orthotics can work and can have fantastic effects, but we don’t know how they work,” adding that “we don’t really understand what we do.” Nigg discussed the hypothesis that orthotics help shift improper skeletal alignment. “Maybe we should not think of pushing the skeleton around, but rather about finding ways to give signals to the body to do the right thing,” Nigg said.

Dr. Nigg has just published a new book, Biomechanics of Sports Shoes, and I’ll be posting a review of that work in an upcoming blog.

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Is Your Pelvis the Cause of Your Pain?

What happens with a man spends more time thinking about a triangle-shaped bone at the bottom of our back than a teenage boy spends thinking about sex?

The answer is, he discovers a remarkably simple solution to alleviate low back pain and quite possibly, a way to help lessen or completely eliminate other painful bone, muscle and ligament ailments.

Richard DonTigny has spent 40 plus years puzzling out the intricacies of our pelvic ring: the bones, ligaments and muscles that comprise our waist, buttocks and hips.

“Pelvis” is Latin for “basin,” which is what our pelvic ring resembles. In medical-speak the pelvic ring is made up of the hipbones and the sacrum (the triangle-shaped bone at the bottom of your back). The joint between the hipbone and the sacrum is the sacroiliac joint, and that is the linchpin of DonTigny’s work: it is where the secret to pain-relief lies.

DonTigny is a physical therapist who has published over 25 journal articles, written chapters for medical textbooks, lectured extensively, and treated over 8000 patients with sacroiliac joint problems. He is also the author of the Powerpoint CD, “Pelvic Dynamics for the Professional.”

In “Pelvic Dynamics for the Professional,” DonTigny explains how the sacroiliac joint (and the pelvic ring) is prone to becoming out of alignment, setting up a chain reaction of tension and strain on the surrounding muscles, ligaments and other soft-tissue structures. Dysfunction of the sacroiliac joint, DonTigny says, is responsible for at least 85% of low back complaints. Beside the back, he says that a malfunctioning or misaligned sacroiliac joint may also be the culprit in sciatica, piriformis syndrome, and knee, hip, pelvic, or stomach pain, and indirectly cause neck, shoulder or foot problems.

Just one detailed illustration from "Pelvic Dynamics"

DonTigny states: “In 1992 at the First World Congress on the Sacroiliac Joint Dr. Joseph Shaw of the Topeka Bank and Neck Pain Clinic reported that in a series of 1000 consecutive patients he examined for low back pain (LBP) and sacroiliac joint he found that 98% had an SIJ problem. When he addressed that problem, his surgical incidence for herniated disks dropped to 0.2%.”

Once one delves into DonTigny’s CD—a whooping 600 plus slides—you begin to understand how the pelvic ring is the linchpin of our skeleton. It supports our spine, allows us to walk and do other activities by serving as a powerful fulcrum for our body.

DonTigny shows that even small sacroiliac problems can have far-reaching effects on the body, even altering normal function of the feet.

For example, a misalignment of the pelvis can increase the inward curve of the low back (increase lordosis) while increasing the outward curve of our back at the level of our chest (kyphosis). These actions can cause our hips to rotate outward and our shoulders to hunch inward and lead to our head jutting forward (causing neck pain). Sacroilliac joint dysfunction can also cause a curve of our spine in the frontal plane (scoliosis) and ultimately create what appears to be a leg-length discrepancy (one leg longer than the other). Clearly, the sacroiliac joint is the keystone for good, healthy walking, standing and even sitting.

On his CD, DonTigny brilliantly dissects the complex inner details of sacroiliac joint and through his hundreds of beautifully illustrated slides, he makes understanding this complex joint easy.

The crowning jewel of DonTigny’s CD is a series of adjustments – The DonTigny Method – that a physical therapist (or a patient can do themselves) to properly realign the sacroiliac joint.

One has to wonder why DonTigny’s method is not known more widely and more accepted. Clearly, having a patient do some adjustments prior to seeing an orthopedic man for a back fusion is preferable. Part of the answer may lie in the fact that adjustments to solve back pain (and other bone and muscle problems), are so simple that individuals with a financial stake in back pain may feel their livelihood threatened.

Or perhaps, and much more likely, it may be difficult for those health practitioners who have spent their life doing sophisticated back surgeries, injections and/or a myriad of therapy modalities, to open their minds to such an easy solution.

Beyond the health practitioners, patients themselves still, for the most part, believe the medical system has all the answers. Until people begin thinking for themselves, begin asking questions–both to themselves and to their doctors, the system will feed them what it always has.

I am reminded of a great quote from the film The Matrix:

“The Matrix is a system, Neo. That system is our enemy. But when you’re inside, you look around, what do you see? Businessmen, teachers, lawyers, carpenters. The very minds of the people we are trying to save. But until we do, these people are still a part of that system and that makes them our enemy. You have to understand, most of these people are not ready to be unplugged. And many of them are so inured, so hopelessly dependent on the system, that they will fight to protect it.”

On a personal note, I VIGOROUSLY applaud DonTigny for not only puzzling-out the mysteries of one our body’s most complex muscle-skeletal structures, but for having the COURAGE to put his theories into the public domain. Often, when someone proposes a new, revolutionary theory or solution—especially one that patients can do themselves—they will quickly experience the sharp pang of the medical community’s arrows in their back.

Final thoughts on DonTigny’s Pelvic Dynamics CD

If you are ready to open your mind to what is often the real cause of our muscle-skeletal problems, this CD is worth a look. Be aware: The sacroiliac joint is complicated and I found myself needing to re-read several of the slides, but the effort is worth it and again, the illustrations make understanding the sacroiliac joint much easier. I highly recommend Pelvic Dynamics for the Professional.

For more information on DonTigny’s work (or to purchase his CD), you should visit his site, The Sacroiliac Joint.

Links:

Interview with Richard DonTigny

The Sacroiliac Joint

Sacroiliac Joint on Wikipedia

Sacroiliac Joint Resources

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Recently, EmpowHer invited me to write a column – here it is!

Pain and problems in the female foot are common—four times greater than for men. One study found that eighty-two percent of U.S. women report having foot pain, seventy-two percent have a foot deformity, and of all foot surgeries in the U.S., women undergo ninety percent of them.

Incredibly, it isn’t just the woman’s foot that leads in pain and problems. Females suffer with more ankle, leg, knee, hip, back, and neck problems. Clearly, when it comes to pain, this is one place women have too much equality!

Don’t despair! You can do simple things to prevent and alleviate pain now. Before I get to that, I want to explain why women are more prone than men to experience muscle-skeletal pain and ailments.

The Feet Are Our Body’s Foundation

Feet are your foundation—whether you are man, woman or child. Strong, well-functioning feet and ankles are essential for support and balance. Working in unison with the body, your feet rapidly adapt to maintain balance over a variety of surface, whether you are running, walking, jogging, carrying a backpack, baby, purse, or all three, or even recovering from a sudden stumble. Feet do it all.

Having incredibly dynamic feet is great until something with them goes wrong. The smallest imbalance in your feet shows up as larger problems up above—in your knees, hips, back, and/or neck. Thus, a misaligned foot leads to a misaligned hip and/or back and/or neck.

Our body depends on agonist-antagonist muscles pulling against each other around our dozens of joints, and any joint imbalance will cause weakness of the muscles on one side of the joint and tension and strain of the muscles on the other side. The result is pain.

Further, these muscle-skeletal misalignments are more likely to occur due to the unique shape of the woman’s “normal” foot.

How is Woman’s Foot Unique?

Compared with males, the female’s foot is generally shorter, narrower, and the length of instep is not as long. The average woman wears a size 8.5 (her foot is approximately twenty-four centimeters or 9.5 inches in length, about an inch shorter than the foot of the average male). The woman’s heel is narrower when compared to the ball of foot, which is wider and has a larger girth relative to the rest of the foot. 

Overall, the woman’s foot is flatter than the male foot. This lower (or more pronated) foot is the root cause of the many of the body’s structural problems.

When feet flatten more than necessary (or over-pronate), the legs compensate by rotating excessively inward. This increased internal rotation creates abnormal stress on the knees causing them to become painful and deteriorate (osteoarthritis). With the knees now strained and out of alignment, a “ripple effect” can occur, causing imbalances, pain and arthritis in the hips, back and neck  Since a woman’s foot is already on the flat-side, she is more predisposed to this painful cascade of events. (For those people whose feet are high arched (or supinated), a similar cascade of joint misalignment occurs leading to pain, imbalance and osteoarthritis.)

To make this chain-of-events even worse, a foot—male or female—that is on the flat side (excessively pronated) is more prone to become even weaker through a vicious downward foot-flattening cycle. Ultimately, this progressive flattening of the foot results in even more foot problems and more muscle-skeletal problems throughout the body.

What You Can Do About Foot, Knee, Hip, Back and Neck Pain

To restore normal alignment to your body, you need to restore balance. The best way to do this is by strengthening agonist and antagonist muscles around your major joints with the goal of improving posture.

This sounds complicated, but there is a very simple way to start: walk barefoot. Shoes act as braces for your feet, altering the alignment of your body and negating the need for many muscles to work at all. Walking barefoot or in minimalist footwear (very flexible shoes such Terra Plana’s Vivo Barefoot), allows your body to “feel” the ground. Do as much walking barefoot as safely possible.

Barefoot activity allows your body’s muscles to develop and remarkably, an innate biofeedback system kicks in that tells your body how to make subtle, unconscious adjustments in the way you walk (your gait). To walk correctly takes a lot of work and study, and is beyond this article, but barefoot walking is a great way to start.

When you must wear shoes, less is more. As mentioned, wear minimalist shoes or very flexible, thin shoes that provide basic protection but still let your feet sense the ground beneath them.

Final Thoughts on Muscle-Skeletal Pain

Now, you can begin to understand the effect of foot misalignment and other joint imbalances on your body. The simplest way to start to strengthen your muscles and rebalance your body is through your feet, and how by losing your shoes, you will be on your way to losing the pain.

If you have any questions or foot, ankle or walking-related topics you would like to learn about, please post in our Forum Section.

References:

Bingefors K, Isacson D. Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain–a gender perspective. Eur J Pain. 2004 Oct;8(5):435-50.

Stubbs D, Krebs E, Bair M, Damush T, Wu J, Sutherland J, Kroenke K.Sex Differences in Pain and Pain-Related Disability among Primary Care Patients with Chronic Musculoskeletal Pain.

Khang YH, Kim HR. Gender differences in self-rated health and mortality association: role of pain-inducing musculoskeletal disorders. J Womens Health (Larchmt). 2010 Jan;19(1):109-16.

Terrier P, Dériaz O, Meichtry A, Luthi F. Prescription footwear for severe injuries of foot and ankle: effect on regularity and symmetry of the gait assessed by trunk accelerometry. Gait Posture. 2009 Nov;30(4):492-6. Epub 2009 Aug 25.

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Everywhere you look someone is telling us the benefits of exercise. Of course, exercise can help our hips and gut, but could it also be the answer to foot and ankle pain and problems?

Anecdotal reports from people who regularly engage in barefoot activity—particularly barefoot running—reveals that exercise can improve abnormal biomechanics in our feet and ankles. Many barefoot runners claim that they have actually seen the arches of their increase in height.

Dr. Nirenberg “Experiments” on Himself

Fascinated with these claims, I decided to do a simple “experiment” on myself. I took a weight-bearing x-ray of the side of my foot prior to embarking on barefoot running and then after a few weeks, took another x-ray. Before I talk about what I discovered, I want to touch on some other important points.  

Podiatrists Debate Benefit of Exercise

The debate on whether strengthening and/or stretching foot muscles can affect the biomechanics of the foot was reinvigorated in recent days in the podiatry community. Within this group of doctors, there are those who advocate muscle-strengthening activity,  those who don’t, and those who fall inbetween. As a result, the arguments can be very heated.

Dr. Stephen Pribut, Past President of the American Academy of Podiatric Sports Medicine and writer of the blog 98.6, was interviewed for the Jewish Exponent article, Is Barefoot Better for the Sole. Pribut stated that over-pronation–or excessive rolling inward of the foot–happens because of bone structure and will not be corrected by strengthening the feet. In reply, Dr. Ray McClanahan, inventor of Correct Toes and president of Northwest Foot & Ankle, posted a lengthy reply on PM News.

McClanahan asserts that shoes are the cause of some biomechanical – not the cure. He explains that as shoes push the great toe inward (toward the other toes), pronation is increased. He advocates moving the great toe outward (away from the foot) to limit pronation. To achieve this McClanahan recommends avoiding shoes which taper inward at the big toe and using Correct Toes, a device he invented to move the big toe outward. Read his full article HERE.

(McClanahan has said that scientific proof is not required to prove his theory (that moving the great toe away from the foot limits pronation) because it is easily observable by simply trying it on your foot.) I commend McClanahan for thinking out-of-the-box and having the courage to pursue a new, cheap device that may prove more beneficial than expensive, complex orthotics.

Pribut replied by explaining that his quote in the article was essentially a sound bite and that this complicated subject matter does not lend itself to sound bites. He explained that injuries in runners he believes are multi-factorial with overuse being the primary cause of injury. Read his full reply HERE. (Pribut has taken a rational, middle of the road approach based on known factual science while recognizing a potential possible benefit of foot strengthening.) As of this writing, this debate continues to rage on.

A common argument against muscle strengthening exercise is that the there is not enough scientific proof of the benefits of exercise or barefoot activity. This is true, but initial research is leaning in the direction that muscle strengthening is beneficial.

Preliminary Research Leans in Favor of Muscle Strengthening Exercise

In 2008, breakthrough research was published that proved muscle fatigue (or muscle weakness) results in a lower arch. Specifically, fatigue of the plantar muscles of the foot cause flattening of the foot (worsening pronation) (Headlee et al).

Further, Dr. Benno Nigg, one of the world’s foremost experts on biomechanics of the foot, has said that strengthening muscles can, in principle, increase the arch of the foot, though he hasn’t seen a clinical study to prove this yet.

In my own foot I noticed changes with barefoot running. Clinically, the arch of my foot increased. The foot looked stronger, more robust. I then took an x-ray of the side of my foot while bearing weight and compared the x-ray with the one I took before barefoot running–the height of the arch had not changed. 

Is this proof barefoot activity fails to increase the height of the arch? Not at all. In fact, this little “experiment” is not proof of anything. Interestingly, there were other radiographic changes on the side-view x-ray of my foot: my foot shortened in length ever so slightly. Specifically, the metatarsals (the bones in my forefoot) had become more angled downward (more plantarflexed) and as a result my foot shortened. This finding has occurred with other barefoot runners and was documented in a research paper by Steven Robbins as an incidental finding in a barefoot-related paper.

Final Thoughts on Foot Strengthening

Without the strength of our foot muscles, the mechanical stress of walking is borne solely by our bones, ligaments and connective tissue, and without good muscular support, these structures become more likely to sustain injury: foot or ankle strain or sprain. An alternative to maintaining strong, supportive muscles is using a strong supportive arch support, shoe or orthotic.

The scientific literature recognizes the value of orthotics and arch supports, and is starting to recognize the value of foot strengthening exercises. In 2006 Jam states: Efforts should be made to address the dynamic control of pronation through neuromuscular exercises rather than purely through mechanical means. In 2003 Fiolkowski et al and Franco in 1987 advocated: Strengthening of the intrinsic and extrinsic muscles may help to increase muscular support of the arch.

If you are going to start barefoot activity or foot exercise, be sure to start slow and build up gradually. Feel free to peruse some introductory foot exercises HERE.

References:

Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M. Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 2003 Nov-Dec;42(6):327-33.

Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J. Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyogr Kinesiol. 2008 Jun;18(3):420-5. Epub 2007 Jan 8.

Robbins SE, Hanna AM. Running-related injury prevention through barefoot adaptations. Med Sci Sports Exerc. 1987 Apr;19(2):148-56.

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The purpose of shoes is to protect feet and provide warmth. Beyond these basics, some shoes are a fashion accessory, while others supposedly help us run faster, walk better, tone our legs, or even alleviate foot ailments.

Comparing the feet of people who did not and currently do not wear shoes with those who wore shoes and currently wear shoes provides insight into the consequences of wearing shoes.

1. Shoes Weaken Bones in Our Feet

According to renowned anthropologist Erik Trinkaus of Washington University, humans began habitually wearing shoes 40,000 years ago. He reached this conclusion by examining the toe bones of people who lived in the range of 10,000 to 100,000 years ago and found that at 40,000 years ago, the bones became less robust. That is, when humans began wearing shoes the bones in our toes (digits 2 to 5) became less thick and strong; or in other words, the toe bones became more delicate and smaller.

Bones adapt to the loads placed under them. In response to increased loads (or forces), bones become stronger and thicker. Conversely, if the loading on a bone decreases, the bone will become weaker and thinner (Wolff’s Law).

Wearing shoes changes how we walk and how weight (or the ground’s loading force) spreads out across the bottom of our feet. Trinkaus describes our toes as being large and robust for most of human history, but suddenly with the wearing of shoes, they became “wimpy.”

Essentially, shoes limit the peak force on our toes by distributing loading across the entire forefoot and shoes eliminate the traction role of our toes. The result is weaker bones, leaving them at increased risk for fractures or other problems.

Shoes don’t just limit the peak forces on toes, they change the way our feet work. The actually working of our feet is referred to as the foot’s biomechanics and within shoes, our feet function differently. Essentially, shoes alter the foot’s natural motion. 

2. Shoes Limit and Alter the Normal Motion of Our Feet

Changing the way our feet work, can lead to problems. Earlier we discussed how supportive shoes obviate the need for many foot muscles to the point where, during normal walking, they are not used. Muscles that are not used weaken. Weak muscles on the bottom of our feet increase pronation motion (Headlee et al). Up to a point, foot pronation is normal. Too much pronation or over-pronation can cause foot pain, problems, and deformities. 

Sebastian Wolf at the University of Heidelberg compared foot motion of children 8 years old when barefoot and in shoes and found significant differences in biomechanics. Wolf found that shoes impaired the foot’s normal motion and shoes limit the normal widening of the forefoot while walking.

Interestingly, Wolf found that the foot’s need to widen while walking was more limited in the average commercial children’s shoe than in a much thinner, more flexible shoe even though the width of both shoes in the forefoot was identical.

Previously, the culprit for many foot ailments (such as Morton’s Neuroma or hammertoes) has been the tight-fitting shoe. Based on Wolf’s findings, perhaps we need to add to add to “tight-fitting,” the inflexible shoe and the thick-soled shoe.

In October of 2009, foot and shoe data from the prestigious Framingham Study of 3,378 subjects over the years 2002 to 2008 found past shoewear use in women was associated with hindfoot pain. Meaning, even if a woman’s shoe is not causing foot pain now, it could later—even after the woman has long stopped wearing the shoe.

Specifically, the Framingham study states:

“Young women should make careful choice regarding their shoe type in order to potentially avoid hindfoot pain later in life.”

The Framingham study faults the use of high heel shoes and encourages women who persist in wearing these types of shoes to perform stretching exercises to decrease the likelihood of foot pain occurring later.

Beyond altering the normal motion of our feet, wearing shoes can actually change the normal structure and shape of our feet. 

3. Shoes Deform Our Feet

Overwhelming evidence shows that wearing shoes deforms our feet. Foot deformities can potentially cause pain and other problems.

Udaya Rao at the Department of Orthopaedic Surgery, Kasturba Medical College, Karnataka, India compared flatfoot deformity in children (age 4 to 13) who wore shoes with those unshod. He found the incidence of flatfoot was 8.6% in those who wore shoes and 2.8% in those who did not wear shoes.

Further, Rao discovered that flatfoot occurred most often with children who wore closed-toe shoes and less often when children wore sandals, slippers, and least in those children who walked barefoot. He concluded that shoe wearing in childhood is detrimental to the development of the foot’s normal arch.

Simon Mays in the Physical Journal of Anthropology published a study on bunions. Bunions are painful protrusions of bone on the inside of our feet and are associated with the big toe drifting toward the other toes. Mays states that the majority of bunions result from wearing shoes; few are hereditary.

Mays says bunion deformities are rare in non-shoe wearing populations until the people start wearing shoes. Then the incidence of bunions rises sharply.

Further, Mays says that incidence of bunions in a population is related to the type of shoes worn. In populations wearing more constrictive Western-style shoes as opposed to loose-fitting footwear, the incidence of bunion deformities increased.

Kristiann D’Aout compared barefoot and shoe-wearing populations and found differences in both foot shape and the peak pressures under the foot. Barefoot peoples have wider feet and exhibit more equally distributed peak pressures. Shoe-wearing peoples had narrower feet and showed higher focal pressures at the heel, big toe and ball of the foot.  These higher peak pressures put the foot at more risk for injuries, such as metarsalgia, capsulitis, fracture or tendonitis.   

Further, Dr. Bernhard Zipfel at the University of the Witwatersrand has dedicated his academic career to the evolution of the human foot. Zipfel’s research paper “Shod versus unshod: The emergence of forefoot pathology in modern humans?” concluded that shoes were a factor in the development of foot pathology. 

Ways to Protect Our Feet from Shoes

Dr. Lynn Staheli, Director of Orthopedics at Children’s Hospital and Medical Center in Seattle asserts that, optimum foot development occurs when barefoot.

Clearly, in general, shoes are not good for the development of our feet. The best shoe merely protects feet from the environment.

When it comes to toddlers and children, the best advice I can give parents is try to have their children go barefoot as much as possible. I cannot emphasize this enough!

Of course, going barefoot is not without risks. Parents must find areas where it is safe to walk without shoes. Further, when possible have your child walk barefoot on uneven terrain to encourage his or her feet to use as many muscles as possible.

During times when children must wear shoes, choose the most flexible, barefoot-like shoe you can find. If my child had to wear a shoe, I would put them in soft shoe or even a sandal or flip-flop before a big, stiff well-padded running shoe.

For the shoe-wearing adult who has healthy feet and no concomitant medical problems (i.e. diabetes or poor circulation), to stop wearing shoes suddenly, would likely cause foot pain and problems.

These adults should start by SLOWLY transitioning to less supportive, more barefoot-like shoes. They should look for shoes with a wide toe-box (wide around the toes) and less stiff, more flexible shoes. Some shoes that help simulate barefoot activity while providing some degree of protection include, Vibram Five Fingers, Nike Free and Terra Plana’s Vivo Barefoot.

In addition, adults transitioning out of stiff, supportive shoes should do foot strengthening and stretching exercises. Years of wearing supportive shoes will have weakened many of the small muscles in the arch, ball and toes of the feet, and these muscles need to get strong again. Gradually, these adults should begin barefoot activity.  

Lastly, persons with foot problems, such as impaired sensation (i.e. diabetics), poor circulation or other problems or deformities should not go barefoot or try barefoot-like shoes without first checking with their podiatrist. 

Where Do Podiatrists Stand on Shoes?

The American Podiatrist Medical Association (APMA) has issued a statement on going barefoot, entitled “Podiatrists Urge Americans to Think Twice Before Going Barefoot.” You can read the APMA’s statement by clicking HERE. 

Final Thoughts on Shoes and Foot Problems

Podiatrists are quick to point out that there are people who have never worn shoes and suffer from foot pain and problems, including flatfeet, bunions, hammertoes and other problems. This is true.

Foot deformities and problems are not always due to wearing shoes, and can occur due to a myriad of reasons: congenital, ligamentous laxity, rheumatoid arthritis, obesity, structural factors within the foot (metatarsal head shape, first ray hypermobility), over-pronation, trauma, diabetes, polio, vascular problems and the list goes on.

When it comes to foot deformities and foot problems, shoes are one possible factor. Shoes may be part of the problem for a particular person or the whole problem.  

Interesting Links:

Take Off Your Shoes and Walk

Parents for Barefoot Children

Naturally and Healthy Barefoot Activities

Why Shoes Make Normal Gait Impossible

Living Barefoot

References:

Dufour AB, Broe KE, Nguyen US, Gagnon DR, Hillstrom HJ, Walker AH, Kivell E, Hannan MT. Foot Pain: Is Current or Past Shoewear a Factor? Arthritis Rheum. 2009 Sep 29;61(10):1352-1358.

Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J.  Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyogr Kinesiol. 2008 Jun;18(3):420-5. Epub 2007

Mays SA. Paleopathogical study of hallux valgus. Am J Phys Anthropol. 2005 Feb;126(2):139-49.

Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br. 1992 Jul;74(4):525-7.

Staheli LT. Shoes for Children: a review. Pediatrics. 1991 Aug;88(2):371-5.

Trinkaus E. Anatomical evidence for the antiquity of human footwear use. Journal of Archaeological Science, Volume 32, Issue 10, October 2005, Pages 1515-1526.

Tinkaus E, Hong S. Anatomical evidence for the antiquity of human footwear: Tianyuan and Sunghir. Journal of Archaeological Science, 35(7):1928-1933.

Wolf S, Simon J, Patikas D, Schuster W, Armbrust P, Döderlein L. Foot motion in children shoes: a comparison of barefoot walking with shod walking in conventional and flexible shoes. Gait Posture. 2008 Jan;27(1):51-9. Epub 2007 Mar 13.

Zipfel, B., Berger, L.R. 2007. Shod versus unshod: The emergence of forefoot pathology in modern humans? The Foot. 17: 205-213

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Treating Corns Wrong Could Lead to Serious Problems

Deidre writes:  I tried to get rid of two corns, one on each of my second toes. First, by using a drugstore corn remover medication and then with a tca peel. Now both my toes are extremely darker than all the other toes (my toes look burnt) and the corns are still there. I now wear better shoes and i scrub it everyday, but nothing.

Dr. Nirenberg replies:

A corn on our toe or between our toes can be very painful, and can interfere with our ability to walk normally. However, corn remover products are not always the best solution and may, in fact, prove harmful.

When a corns forms on our toe it is usually the result of an abnormality or misalignment of the bones inside the toe. The bone under the area of the corn may be abnormal and may have a spur or some other kind of growth, or the toe itself may be bending (contracting) and you may have a mallet toe or hammertoe deformity. A deformity of the toe or misalignment of the bones causes pressure on the skin from within and rather than the skin breaking open, it toughens and forms the corn (to protect it). A hammertoe (or mallet toe) is the number one cause of corns on the toes. Often patients may have several hammertoes, but not all of them will have a corn.

Corns can also form in response to pressure from outside our foot, such as when a tight-fitting shoe rubs on the toe. Again, the skin will toughen and the corn will protect the skin from the opening.

Many drugstore remedies for corns use a medicated solution to soften and remove the corn. These “medications” are usually an acid that burns away the corn. Putting acid on a corn (or burning the corn) will make the corn look burnt, as you describe. The problem is, if you use too much acid it can burn through the skin. In my podiatry practice, I have even seen patients put on so much acid that it burned to bone and/or caused infection or gangrene. Some patients have needed the toe amputated. Essentially, the acid does not stop after destroying the corn and goes through the good tissue, resulting in gangrene or infection in the toe or worse, the bone.

The other problem with using these remedies is that the patient is not addressing the corn’s cause: the bone. At best, the acid is briefly alleviating the corn. Without addressing the bone beneath the corn, the corn is likely to return. For all these reasons, I advise patients never to use drugstore medications for corns.

Whether your corns are due to hammertoes, mallet toes, spurs or other bone problems, you do not have to live with them.

The best treatment for corns is to pad them with moleskin, wear loose fitting shoes and have a good podiatrist examine your foot. The podiatrist will take an x-ray and you will immediately see how the bone is causing the painful corn or corns. From there, the doctor will explain the treatment options for the corn.

Additional Information:

Wikipedia

Mayo Clinic

Photos

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Can Correct Toes Help You?

Invented by podiatrist Ray McClanahan, Correct Toes realigns your toes to their natural position to achieve optimal foot health, and in doing so, claims to prevent and cure foot problems (such as hammertoes and bunions).  

Correct Toes is a sturdy toe-spacer made of medical grade silicon that gently, painlessly positions your toes in a more natural, more correct position.

McClanahan states that he has before and after photos showing the success of Correct Toes and clinical proof, but did not provide that for this review. He also states he is in the process of doing a clinical study to prove Correct Toes effectiveness.

Lack of clinical data does not mean a product does not work; in fact, when it comes to foot products such as arch supports, most companies’ claim their supports are beneficial but rarely provide any proof. One would think with all the money Dr. Scholl’s has, it is about time they provided some proof of the benefits of Gellin.

Unlike other toe-spacing products such as Yoga Toes, Correct Toes doesn’t just stretch your toes apart but puts them in their normal, physiologic position. Correct Toes is also compact enough that you can wear it in shoes—albeit you will need a shoe with a large, wide toe box. Lastly, Correct Toes is less expensive than Yoga Toes.  

When I asked McClanahan’s associate, Dr. Robyn R. Friedman how Correct Toes work, this was her reply:

Dr. McClanahan’s treatment approach is based largely on his experiences in west Africa, where there are some of the world’s greatest runners.  Being a competitive runner himself, Dr. McClanahan was interested in their training methods.  He was amazed to note that these top-notch runners train predominantly barefoot or in minimal footwear, and also they experience  a very low rate of injury, estimated to be about 3% (versus 65-75% of runners in the US.)  This low rate of foot (and knee, hip, lower back) ailments is seen elsewhere in the world where people are predominantly unshod or use predominantly flip-flops or sandals. 

Among the many conclusions that Dr. M drew from his experiences, one of them was that have strong, spaced toes is essential to proper foot health and maximally efficient gait, and most Americans, who have spent a lifetime in footwear that has elevated heels and tapered toe boxes, have lost this essential structural integrity that we were born with. 

The goal of Correct Toes is to return the toes to their appropriate and correct positioning, which would be the very shape of the foot we were born with – widest at the ends of the toes, with the toes spaced, straight, and strong.

So the mechanism of action: Correct Toes work in a similar way to how braces work for the teeth.  They place the toes into alignment and slowly and progressively allow the muscles and other tissues to adapt and strengthen accordingly.  But unlike with orthodontia, we’re simply trying to return the feet the their natural shape, the shape that had at birth, and the shape that would have remained if we had spent a lifetime either barefoot or in shoes that were sufficiently wide (in the toe box) and flat.

How long does it take to see results?  This varies, depending on many factors, such as the patient’s age, tissue elasticity, extent of the deformity, level of compliance (with using Correct Toes, wearing only wide & flat footwear, doing extensor stretches and other relevant stretches), how often the product is used in weight-bearing activity, and so on. 

Patients usually report feeling different/better/slightly sore right away or within a few days.  To actually see physical changes (the angle of the hallux valgus improving, or hammertoes starting to straighten), may take 3-6 months, with continuously progressive change over a year or two.  I like to remind patients that it took many, many years of wearing footwear with tapered toe boxes and heel elevation for our foot architecture to change from the strong, spread toes we were born with to the current architecture, and as such, positive changes will also require some time.  But it’s worth it, because the approach has a life-time of positive implications.

Intuitively, I agree with much of McClanahan’s theory. Certainly, just forcing people to wear shoes with a wide, non-constrictive toe box is going to help let the toes spread out. Further, for most people, their foot problems are likely due to wearing ill-fitting shoes.

I found Correct Toes comfortable, but using them for a few days did not yield any significant, measurable results. But, I did not really expect to see changes in such a short time. Correct Toes is a long term, conservative, natural method of addressing foot pain and deformities of the toes.

Oddly, few clinical studies exist on using spacers, splints or splinting to affect change in adult feet and toes. In one study of a toe splint, after 3 months, pain decreased but there was no improvement in digital alignment.

McClanahan claims structural change can occur in 3 to 6 months of use. I am not sure if the analogy to our teeth is correct. Our toes and feet are composed of bones, ligaments, capsular tissues, and muscle. Teeth only have to contend with the gums to hold their position. Further, given that dental braces are worn for anywhere from one and half to three years, I suspect Correct Toes would probably need to be worn for much longer six months to see structural changes—though McClanahan does allude (above) to the fact that changes occur for one or two years.

Certainly, Correct Toes, in theory, can gently stretch tight ligaments and muscles, pushing them toward their more correct positions. Again, I would love to see a clinical study on Correct Toes—just to gain some insight into how long this process would take.

I do find the idea of repositioning the toes, non-surgically, fascinating, and I see nothing wrong with wearing Correct Toes for six months or even a year or more to avoid surgery. (McClanahan did not say if he expects people to wear Correct Toes when asleep.)

Final Thoughts on Correct Toes

Most people want instant gratification and sadly, will not put a spacer on their foot for 3 months, let alone a year or more. However, for those who are willing to persist with wearing Correct Toes, it may be a great, simple, non-surgical solution to their foot pain, problems, and deformities.

To learn more about Correct Toes visit NW Foot & Ankle.

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