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

Hey everyone. Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness and we've established a great team of analysts to make this happen. It is extremely important important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com subscribe my guest this week is Courtney Connolly. Courtney is an internationally renowned foot and gait specialist who teaches globally on topics related to foot function, gait mechanics and strategies to combat foot and ankle pain. She is the founder of Gait Happens, a group of clinicians providing high quality online cutting edge foot education. She is also the owner and operator of Total Health Solutions Clinic and Gym in Golden, Colorado where she heads patient care with a focus on restoring gait mechanics and helping people resolve their foot problems. She holds a BA in Kinesiology and a BA in Human Biology and a doctorate in Chiropractic Medicine. In this episode we speak about all things related to the foot. We talk in great detail about the anatomy and complexity of the foot and unfortunately you do need to understand this if you want to understand why things go wrong in the foot as they so often do. Now, I should mention at this point that I know many of you listen to this podcast in audio only and that's fine. This again might be one of those episodes that is worth watching on video, and the reason for that is that Courtney uses a model of the foot quite a bit when we're talking about anatomy and even when we come back to some of the pathology of the foot because it's just easier to actually see, for example, why you end up getting a bunion if you understand the biomechanics and anatomy of the foot. So with that said, we speak about loading, balance, falls, control, range of motion, posture. We talk about the common injuries again, including what I just mentioned, bunions, tendon issues, toe weakness, Achilles injuries, hammertoes, plantar fasciitis, and much more. Through this conversation we do a deep dive into all the various shoes that people should be looking at not only as adults, but potentially as children. In addition to this interview that you're about to hear, we also recorded a video in the gym to better explain a number of the concepts that we spoke about. So in this video, we break it down into diagnostic tests that are used to determine mobility, strength, etc. And then we cover the exercises that you should do to improve the outcomes based on the diagnostics. So this interview will be available to everyone. The videos from the gym will only be available to our paid subscribers and they can be found on the show notes page. So without further delay, please enjoy my conversation with Courtney Conley. Courtney, awesome to see you. Thank you for making the trip to Austin. It's much better to be doing this in person, I think, than by video, given all the content we're going to cover.

Thank you so much. I'm very excited.

So, before we kind of get into the foot, help me understand your personal obsession with this part of the body. Where did that begin?

I grew up as a ballet dancer, and pretty much all through grade school and high school, I spent a lot of time on my feet, a lot of time in ballet pointe shoes, which, as you know, are very rigid, stiff, you're up on your toes. And I kind of always battled foot pain. And then when I decided to choose this as a career, I was my self exploration. I thought I was going to learn all of this stuff about the foot, and that just didn't happen. Really didn't get a lot of education in regards to how the foot actually functions.

Because you're a chiropractor by training, why did you choose that over, say, podiatry or something that was purely focused on the foot?

My father and I have had this conversation so many times. I first was going to go down the physical therapy route, and then I was like, I want to create my own treatment protocols. And my dad has always been a big fan of chiropractic. So we just had a lot of conversations and that's where it went. I've always been interested in exercise and movement. It just seemed like a good fit.

So as you said, you go to school and you're probably not spending that much time on the foot.

I think we had like half a semester and I was that much right.

That's actually a lot. I would have guessed less, but okay.

I just became fascinated by it because it just always intrigued me. It's a very complex part of the body, and I think with our education, it was always viewed as if something hurts in the foot. Were either going to put an orthotic under it or refer them for some type of surgery. And I was blessed enough to have some really good mentors around me that increased my appetite for learning about that. And that's kind of how it started. I ended up graduating from school and working in a couple of orthotic labs.

I see. So you went straight from school directly into specializing effectively in the foot.

Yeah, it's changed a lot.

Yeah. So orthotic labs. So this is presumably a place where people come and have custom orthotics made.

Yes. So I would work in the front of these offices, and there'd be grinders in the back, and they'd be making the orthotics. And so I was just constantly surrounded by all of that. And that's what we knew is we'd see patients, they'd have foot pain, and we would cast them for orthotics and.

Make the orthotics interesting. So even when you came out of school, your knowledge and your practice was largely still based on the conventional way of putting support under the foot, hoping for the best?

Yes. All right.

So with that background, we can evolve to where you are today, which is obviously leaps and bounds ahead of that. But let's give folks a bit of a sense of the complexity of the foot. I think most people look at their hands, and because of our dexterity, I think people understand the intricacies of the hand. I know once in a while when I'm trying to communicate that to a patient, I'll even show them a picture of the homunculus, which is the image of the. I know you know what this is, but just for the listener, the image of the cerebral cortex, where it graphically represents the size of the anatomic features in proportion to how much motor and sensory control they have. And one of our superpowers as a species is what we can do with these things. It differentiates us from all other species. So how does the complexity of the foot fit into the equation of the human body?

Well, I think another one of our superpowers, actually, is that we're a bipedal. So we have so many cutaneous receptors, muscle spindles, joint proprioceptors on and in our feet that communicate with our vestibular system so we can become upright and bipedal. When you take away those functions, it really alters how you're moving, how you're interacting with your environment. I mean, it's always so wild to me because when we think about it from a rehabilitation perspective, we Are very good at rehabbing the low backs. We do a lot of core strength, we do a lot of glute strength, we do a lot of hip strength. But you don't hear many people saying, I'm doing a lot of foot strength. And it's literally our first interface with the ground. It's how we contact the ground. That's how everything starts. So when we take that away, you're really making it much more challenging for yourself. And I think it really can alter our survival as well as decrease our quality of life.

Yeah, it's funny, you can probably tell looking around how obsessed I am with race cars. And I've made this analogy before, but basically there were four things that determine the speed of a car. Obvious things. The engine, the chassis, the aerodynamics, the stiffness, the driver's capabilities, what they can do in the car. But of course, the tires. And the analogy here, of course, is clearly that the tires are the feet. And you can have the greatest car in the world, the most powerful engine, the most remarkable chassis, and the best driver. If the tires are shot, none of it matters. You simply can't get the power to the ground and back. So I think there's a lot to be said for how it is imperative. In fact, I would even go one step further. I think feet are even a more important part of the human body than tires are to the car. And here's the reason why. As we'll discuss, the feet play a role in the suspension more than the tires play a role in the suspension of a car. So when you now talk about force absorption, the feet are even more of a priority. And if you can't absorb force in the feet, I think we're going to hear that. We're going to translate that inability to translate force all the way through the body.

Yeah. A good friend of mine, Jay deceri, he always says that you can't build a jet engine on a paper airplane. And I just love that we're building all of the strength and we're focusing on everything above the knee, when in reality, so much of this force, I mean, gait, is shock absorption, it's stanceability, it's propulsion, and all of those things enable us to become efficient with movement.

Now, we'll talk about a lot of this stuff when we get into the gym later today and go through some of these things. But on a personal level, my interest in this probably didn't start until a couple of years ago, when I began to, for the very first time in my life, experience pain in My feet, that wasn't just fleeting, obviously. Like every other knucklehead, I had the odd bout of plantar fasciitis in my youth that got better with traditional means, but it was really only when my volume of rucking started to get really high and the poundage started to get really high that I was starting to experience pains in my feet that I now believe could be attributed to weakness. So, Courtney, I think it would be much easier for everyone to kind of understand the complexity of the foot if we had a better understanding of the anatomy, myself included. So I noticed you brought your friend here. What's his name again?

Eddie. Named after Eddie Vedder. Pearl Jam is one of my favorites.

As we have both been to the same concert recently. Okay, so walk us through the anatomy of the foot.

So very important, I think, especially when it comes to understanding how we're treating the foot and foot pain, to understand the anatomy of the foot. So there's basically three parts to the foot. You have a rear foot, a midfoot, and a forefoot.

How many bones here?

26 bones, 33 joints. It's a complex part of our bodies, and I think that's why a lot of rehab treatments and protocols have veered away from really understanding what's happening here. So starting in the rear foot, the calcaneus, it's one of my favorite bones. And here's a fun fact. A 100 pound female actually has a larger calcaneus than a 350 pound gorilla.

Wow.

Fun fact. Some other fun facts about this. The actual bone itself, there's two layers to the bone. So there's a thin cortical layer, outer layer, and then there's a spongy inner layer. So the way the calcaneus is actually designed, think of like a rubber ball bouncing. It was designed to absorb shock. The other thing about the calcaneus is there's a fat pad that sits outside the calcaneus, also two chambers. So there's a thin micro chamber that is not easily deformable because when we walk, most of us, as in a walking gait, we graze the heel. So that outer chamber is not designed to deform, but there's a macro chamber on the inside of the fat pad that is highly deformable. So again, we have a fat pad and we have the way the bone has been designed to absorb shock. That fat pad, by the way, is two times a better shock absorber than Sorbothane. It's a material. It's a synthetic material, like a rubber that a lot of performance. Orthotics, for example, are made of. Designed to dampen vibration and absorb shock. And so when I'm talking to my patients, I'm like, we have a beautifully designed calcaneus that was designed to handle all of this shock, to handle what happens when our heel strikes the ground when we walk. So very important structure there.

Now, the calcaneus looks like it interacts with another major bone there that sits right under the fibula and the tibia.

The talus.

Yeah, one of the few I remember.

Yes. And fun fact about the talus, there is zero muscle attachment to that bone.

It's all ligaments.

So there was a study, Ben o', Nig, who's done a lot of research in our work, they looked at sectioning the anterior talofibular ligament. So that's also a very common ligament when we sprain our ankle. If those ligaments on the outside of the ankle get completely torn, you now have this talus that has nothing attached to it. So what can happen is the talus can migrate, it can adduct. So the tibia will internally rotate, the talus adducts, and then what happens is it kind of bangs into the medial malleolus there. So patients will often present with pain along the inside of their ankle, and it will be diagnosed as, say, a tendon dysfunction, posterior tibialis, when it is an instability at the rear foot because that talus is shifting.

And would that patient have necessarily suffered something traumatic to have torn the AF ligament?

I mean, typically when you look at ankle sprains, for example, mild ankle sprains, over and over again actually pose more of a problem from a gait perspective or a rehab perspective, because people will typically sprain their ankle, shake it off, and then continue to walk or play on it.

And in that situation, the ligament is just getting longer and longer and looser and looser.

And when you have these continuous sprains, you have changes to the ligament. But here's the cool part. The ligament actually heals. More of what the issue is is that the superficial peroneal nerve, so the nerve on the outside of the foot.

Show where that would be.

So that would come on the outside of the ankle. Those nerves get stretched. Sometimes those nerves get torn. And once you start changing the neurological input, that's the issue. The ligament will heal. It's when you lose.

It's when you lose the sensory input.

Yes. So you're walking down a curb, you lose sensory input, and you say, oh. And there's no cue saying, don't do that anymore. And then you keep doing it over and over again. I had a patient this week that had had multiple ankle sprains when he was a kid. And the last couple sprains that he had, he couldn't feel anything. And that's when they were like, okay, we need to take care of this, because he lost all sensory input.

I kind of wonder how much of that I have going on from all my frequent ankle sprains growing up. But we'll probably figure that out when we do some of the interesting diagnostic stuff. So what is that bone that the talus and the calcaneus look like they're both touching? Is that the navicular?

This is the navicular right on the inside. So this is the highest point of the medial arch and also an important bone here, posterior tibialis. So a very important inverter of the foot. So it inverts the foot, it helps stabilizes the arch, comes down, wraps around the navicular, and inserts on the bottom of the navicular. It also has eight plus insertion points in the bottom of the foot. I'm sure you've seen people that have an accessory navicular. So it's almost an extra bone that sticks off that navicular. And you can see it when you're looking at someone, it looks like they have a protrusion because the posterior tib has to come down and wrap around the navicular. If you have an extra bone there, the vector of force is longer. So the way I'll describe this to my patients is if you were doing a chest press, for example, and you starting here, imagine having to start all the way back here. It'd be more difficult. So that's where with those patients, when you see that or you see that they have an arch that doesn't want to recoil or function, you have to consider, hey, we really need to go after strengthening posterior tibialis and. Or some of these patients, if there's too much of a structural variant, that's when you implement things like an orthotic, for example.

So is the navicular considered then, part of the mid foot?

Midfoot.

Is the calcaneus the only thing that makes up the posterior foot?

The rear foot.

The rear foot. And those distinctions. I'll let you finish talking about the forefoot. But presumably those distinctions are based on not just their location, but do they have some functional significance?

Yeah, I think when you look at the gait cycle. So when we talk about the gait cycle, we look at different rockers of the foot. So when we're initially walking and our heel strikes the ground, that rear foot, the calcaneus starts or initiates pronation. So then we go into eversion, and then you have the mid foot that unlocks.

And because we're going to use these words so much today, let's make sure people understand. Eversion, pronation, supination of the foot.

Absolutely.

Yeah. Just show us maybe with your hands.

So inversion would be going out. That's also a supination. Pronation is an unlocking of the foot. So this is where the foot flattens and widens. And I think we've kind of demonized pronation.

Definitely. And we'll talk. I know we're going to go through a couple of drills today that you've had me doing to really work on relaxing the foot and letting it pronate without tensing up.

Eversion, same. So the calcaneus, when you evert, it's basically allowing that pronation to begin.

And is that movement, all of those movements, are they facilitated by muscles or are the ligaments themselves actually deforming?

I think it's everything. When your heel hits the ground, you have body weight, then you're dealing with ground reaction force. I think the beautiful thing about gait is that we need to have adequate range of motion, but you also have to be able to control that range of motion. And that's when things get sticky, is when we see people speeding through the gait cycle, or they're speeding through pronation and they can't control it. Then you have the system going slow down.

And presumably that comes back to eccentric weakness.

I mean, certainly if you look at. I'm sure we'll get into specific muscle talk, but there's a lot of eccentric control that's required when our foot hits the ground.

All right, so three massive bones there. We've covered massive. Certainly on the scale of the foot. Let's keep going down the path. There's.

I just want to talk about one more quick thing that I think is really cool. This sustentaculum tali, it's a medial lip off the calcaneus. It's fully ossified by the time we're seven years old. There was a research study. Raoul and Joseph looked at 2,300 children, and they looked at static footprints and how footwear affected the development of their medial architecture, which I thought that's a pretty large cohort for a study. So what they found is by the age of 13, these were kids, 4 to 13. By the age of 13, those who did not wear shoes, less than 3 of them presented with what they considered flat feet. The ones that wore shoes, 9% were considered having flat feet.

Sorry, 3% or 3 in total?

3%.

Okay, 3%.

So the ones that wore shoes, they also noticed the type of shoe. So the ones that wore closed toe box shoes had a higher prevalence for. I always say with research, let it guide you, not shackle you. So I thought it was interesting. So with a closed toe shoe, there was more of a prevalence than even the kids that wore sandals. So why is that? You know, did they kick their shoes off and run around barefoot? Did they have more toe splay? Was the foot able to function in a better position? What the conclusion of the study was, the researchers said that this sensory information that was gained by their feet somehow gave them a protective tone, an increase in protective muscular tone that was enabling their arch to elevate.

Now, how is that accomplished? Because I know that there's going to be many people listening to this who are going to immediately want to think about their kids. The reality of it is most of our kids are in school from a pretty young age, and therefore they have to kind of be in shoes. You live in Colorado. It's not like you're gonna send your kid to school in sandals in the middle of the winter. So do you get a sense of the time requirement being out of shoes? If indeed there's causality between time away from shoes and improved foot health at a young age?

I think we have the opportunity with the kids. I mean, when they're at home, just take their shoes off. Different sand grass. I mean, this doesn't have to be all the time, but even just a little bit. I mean, every kid on the planet, the first thing they do is take their shoes and socks off because they're wanting to gain that sensory input. So I think even a little bit can go a very long way. And then we'll get into footwear, because that's a big one for the kids.

Yep, we definitely want to talk about that for both kids and adults.

Totally. And then getting back to the development of this guy, the susuntaculum taliyah. So if we know that it ossifies by age 7, and we have this window where we know that between these ages 3, 4, 5, 6, that the arch is developing and we can start to allow sensory input and start to begin muscle strength. The way he develops. There's a little lip. You see how it lips up so it positions the talus almost with a lateral tilt. So it's very important, from a bony architecture perspective on how stable that foot is. There are cases where this will develop in a downward slope, and then you predispose. You could predispose for some type of flat foot deformity in the future.

Okay, carry on.

So that's the rear foot, midfoot, if you will, moving into the forefoot. The forefoot is where we will see most of our injuries, because when we're walking, there's eight times our body weight that go through the forefoot with propulsion.

That is so hard to fathom.

Well, how about some other numbers here? Your Achilles tendon is about four times your body weight when you walk, meaning.

It experiences four times your body weight with each step with force.

Yes.

And the Achilles is the tendon of only the gastrocs or the gastroc and the soleus.

Gastroc and soleus.

Okay, we should just also clarify. I'm sure many people know this, but when we are referring to tendons, we're talking about the attachments of muscles to bones. Earlier, we referred to ligaments, which are the attachments between bones. So folks understand that. And the Achilles tendon, which everybody is familiar with, is obviously a massive tendon. I mean, I've seen the size of these things when they're injured, when they're severed. I don't know where it ranks in tendon size for the body, but it is certainly one of the largest, I would have to believe.

I love talking about the Achilles tendon. It's beautiful. I mean, you have the gastroc and the soleus. They twist on each other. It can become a very robust tendon. And the soleus actually makes up larger fibers of the Achilles tendon than the gastroc. The soleus is a powerhouse. But getting back to that load, when we're walking four times, when you start running, those numbers double. So the inside of the arch, so the calcaneo navicular area experiences loads of up to 11 times your body weight when you're running. I mean, it's massive. But here's the very cool thing, is our foot was designed to handle it. I mean, we have all bone structure, muscle, tendon that was designed to handle that load. The problem is, if you don't use it, you will lose it.

It's interesting. You said that the majority of foot injuries are going to occur in the forefoot. Now, by my math, there's about 15 in the forefoot.

Lots of bones in the forefoot. Metatarsals, phalanx, distal phalanx, proximal Phalanx, distal and proximal.

There.

Yeah.

Okay.

Except for the big toe.

Yeah. Okay.

Eight times our body weight at propulsion. The forefoot has to be incredibly stable at push off because it handles so much load. So when we're walking, for example, one of the most common injuries at the forefoot will be a generic diagnosis of metatarsalgia, or stress fractures. So two and three typically will be your metatarsalgia area, and one being the big toe.

One is the big toe being the pinky toe.

Yeah, we'll get to that favorite guy right there. 3 and 4, typically where you'll see a lot of stress fractures.

Tell people what a stress fracture is.

A stress fracture basically can be caused by two different things. Tensile strain or compressive loading. It's when you have force going through the bone, and the system just can't handle it, so it starts to irritate the tissue, if you will. When you look at the foot, and I think this is important from a rehab perspective, is depending upon where the fracture is, you'll know what type of stress fracture it is. So, for example, if you have patients that are hitting their heel very hot and heavy, so they might have a rigid foot, they might have one that doesn't have good mobility, and they hit the heel heavy, they can get a stress fracture in the calcaneus, the fifth metatarsal. Also very common location for these compressive loading stress fractures, because they can't handle that compression. But on the other side of the foot, remember we talked about the navicular? That 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 to 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 navicular stress reaction, leading to stress fracture.

So interesting. We think about bones as having this great capacity for contractile force, right? So axial loading, we 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. Medial 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 navicular stress fractures, the metatarsal stress fractures, the sesamoid 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, it's because they couldn't control their motion. That's why people with sesamoid injuries, for example. So the sesamoids are the two little bones under the big toe. They're similar to the patella.

Sesamoid refers to, if I recall, a bone that is completely surrounded by tendon.

Yes. It's like a little joint capsule.

Yep. Nothing is exposed of the bone. It's completely embedded within the tendons, Correct?

Yes.

Yep.

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 and they'll say, okay, the bone's 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.

Oh, yeah. Well, I think when 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 awry here, because you'll form things like bunions and hammer toes and tailor's bunions, and you'll be able to look at your foot and go, this isn't the way it's supposed to look. Maybe I should pay attention to it. You can't do that at 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 hallucis. 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 whatnot has to learn what an adductor versus an abductor is. And since they're always embedded within the names of muscles, we always remembered this as abductors abduct. They take things away, like a person's being abducted. They pull away from the body. Basically, yes. 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 hallucis is going to straighten. It's a big toe. There's also a muscle.

Pulls it to the middle.

Pulls it towards the middle.

Yep.

There's an adductor. Hall says it's kind of like a backwards seven. So when these guys get out of balance, for example, if I'm in a shoe, which we'll talk about later, that's going to squeeze my toes together.

Such as your ballet shoes.

Yes.

Or most dress shoes. Yep.

I have adductor now that's shortened. And I have abductor.

It's lengthened.

Is 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 metatarsal medial cuneiform. When someone can't control motion at the.

Foot sort of the junction between the midfoot 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 out pouching 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. What 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.

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 splay. 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. Here'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. It 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 pointe 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 it's a different ball game.

And what's a hammertoe? While we're at the topic of common pathology.

Yes. So bunion, very common. Hammertoes 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 2 through 5. 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. And 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 hammertoe 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. So on the bottom of the foot, it's the exact opposite. I have my short flexors that aren't doing anything and my long flexors, who are. So hammertoes 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 are pushing the big toe in, what is the environmental trigger that is most commonly driving a hammertoe?

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. And if you were to walk around with your hands in 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. So 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 function. So, for example, flexor digitorum brevis is one of my favorites. So this guy runs from the heel and inserts up into the phalanx, so into the toes. It's a big muscle. It runs parallel to the plantar fascia. He's responsible for decelerating toe extension. When we walk, remember, it's all about slowing things down. We 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 digitorum brevis. 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 the stability at the foot. And he is a very big player, very big player in the stability of the foot in decelerating pronation.

You just referred to plantar fasciitis. 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 Plantar fascia.

So the plantar fascia is going to start at the calcaneus and it's going to insert into the deep transverse metatarsal ligament up at the forefoot. The plantar fascia has a very key role, by the way, in stability of the foot. I'm going to explain something called a tie bar mechanism. So the tie bar mechanism of the foot is this I like to call free, because we need to take advantage of it, where we have a ligament that runs across the metatarsals 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 and widen, when the forefoot splays, it triggers receptors in that deep transverse metatarsal ligament. The plantar fascia inserts into that ligament. So it's kind of like this T. So when the foot splays, 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.

It's like a fan. So that's the beautiful thing about forefoot splay 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. Gets me excited. You take that away, you take away forefoot splay. You can forget about the receptors talking to you because you're not getting the tug on them from the deep transverse metatarsal ligament 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 splaying to activate the plantar fascia.

In that regard, there's numbers out there. You say 3 to 5 millimeters. You know, I don't expect people to get out and start measuring this. But a good way to look at this, 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, it's too 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 rucking or doing something under load. I 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 wear Nikes. 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?

No, 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 age?

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 wide toe box, a flexible, thin sole, because we want your child's foot to do what it was designed to do. And 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 splay, they will always say, it feels more comfortable. Think 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 plantar fasciitis itis, of course, refers to inflammation of the plantar fascia. What 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 Baxter's neuropathy. So people will have Googled and they'll just immediately say, I have plantar fasciitis. So 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. 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 an itis 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, because 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 plantar fascia. Is that why?

Yeah. And when you talk about what exactly an orthotic does, the jury's still out on that, but 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. You have to be strengthening Things like flexor digitorum brevis 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 deload 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.

I'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 in 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 calcaneus, 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.

And 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 tendinopathy, 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 tendinopathy, 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 going to be right back where they started from. So when we talk about loading the tendons, it's a mechanotransduction. So when I load a tendon, there's a fascial 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. Yeah, 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 and tensile. And the mechanoreceptors in the bones, which sense the deformation, use estrogen as the chemical signal to signal bone building. It's, of course, why estrogen is arguably the most important hormone here. So it's the same thing. It sounds like in tendons, presumably different chemical transduction systems. But it's mechanical deformation signals a chemical to build.

Yeah, there's the tenocytes 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. What 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 churn.

So when they come in, I'll always. I have a toe dynamometer. So it's this little device.

Did you bring it today?

I did.

Okay, good. Wanted to try one of these.

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, and 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 hallucis longus. When you put the card underneath 2 through 5, you should be able to produce about 7 to 8% of your body weight. When they're pressing their toes down, there's a couple rules. They can't lift up their heel and they can't hammer the toes. Remember we talked about that hammering. 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. It'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 hallucis longus, are toes 2 through 5, do they need to be off the ground or are they on the ground, just not hammered?

On the ground.

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 diamonds.

You can buy them. I think the other thing that's also easy to measure first, if someone's going to do it at home, is I have a little laser scanning device. I also brought this today where you would stand close to a wall and you'd measure from your umbilicus 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.

Oh, boy.

But it's really fascinating, right? Toe 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 at the initiation of gait. So if I don't have that anterior falling delobe, 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, and is research by Karen Merkel one of the single best predictors of falling, which is, I mean, massive.

Yeah, 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. What drives you towards temporary orthotic versus no orthotic and just get right to work. So when I've had plantar fasciitis, 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, medial gastroc, the way the medial gastroc inserts into the Achilles tendon. So 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 dorsiflexion.

Tell people what dorsiflexion is.

So ankle dorsiflexion is basically this motion.

When I am walking, pulling the toes back. Basically pulling the foot back.

Yes.

Yeah. And plantar flexion, just for. Point the toes the other way. Yep.

Point the toes, extend the foot. That ankle dorsiflexion in a walking gait cycle, we need about 10 to 15 degrees. You'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. It'd 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. 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? How well can my glute max, for example, control the rotation, control my pronation? So that is that having 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 plantar 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 plantar fascia is pretty long. Is it typically more posterior and close to the Heel.

Most of the fibers that were more commonly irritated are that medial. There's 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. 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, allow the foot and the toes to splay and do a couple foot strengthening exercises. And it doesn't have to be difficult.

Yeah. And we're gonna 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. 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.

Right. Gastroc soleus communicating through the Achilles tendon down around the calcaneus and attaching right through the plantar fascia to the forehead foot.

Yes. Very big guys. Here. The soleus 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 soleus has more type 1 fibers than the gastroc.

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 gastroc, but far more endurance.

It's the powerhouse of the lower leg. It does create a lot of force at the forefoot. It'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, biceps femoris, all medial hamstrings. Strengthen, strengthen, strengthening. But the research we'll look at has shown that it's the strength of the soleus 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 soleus, there are numbers out there that in a seated calf raise. So when you're seated, the gastroc is not your big body immobilized.

Yep.

So you're focusing on soleus. 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 lucky. 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, obviously 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 the 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 their body weight? And 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. 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 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. So 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 superhuman things, but when you isolate the soleus, 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 gotta give. And whether that's gonna be today with the athlete or it's gonna be 10 years down the road when you are not using your plantar flexors, and I'm talking in a walking gait cycle, when that strength capacity isn't there, it's going to rear its head at some point. And you might be a fast runner. But imagine if you started to actually strengthen 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 gastroc and soleus that 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 we'll 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? They seem to cause a lot of pain.

Yes. Let's talk about lateral ankle stability. Peroneals are the big boys on the outside. So peroneus brevis is going to insert on the fifth metatarsal. Okay. Powerful everter of the foot. Foot. So that's going to take us from this position towards the big toe. Peroneus longus, also on the outside, wraps underneath the foot and inserts on the medial aspect of the foot.

Okay. So down on the outside of the foot, around and under to the medial.

To the big toe.

Yeah. So when it contracts, it flattens the arch.

When peroneus longus contracts, it pronates.

Yep.

What he does is he's going to evert the foot. And most importantly, this is why the peroneals 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 peroneus longus, 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.

Yeah. So one of my favorite exercises is putting a band like an elastic under huge tension on the floor, pulling medially such that the only part of myself I let contact the floor is the base of the big toe, and 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 peroneals when I'm walking, because peroneus longus drops that first metatarsal down. He's anchoring my big toe to the ground. If he's not doing his job, this guy 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 I'm either gonna go to my outside again, which means there's my another ankle sprain, or 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 direction, comes out, 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, like, 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 hallux limitus. So a restriction of motion at the.

Big toe, and it all stems because there is not enough muscular force from the lateral musculature of the foot, the peroneals, 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 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. It will alter gait, 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 on the medial aspect of the foot. It's a dorsiflexor of the foot.

Biggest dorsiflexor, 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 tibialis anterior and all of your extensors live. So 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 gait, 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 phase is because that's where all the magic happens, Right? All the load. But swing phase, when we're walking, you have to clear the ground. So when I'm assessing gait, I will often close my eyes and listen, because you'll hear the scuff, as I like to call it, where they can't clear the ground. These 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 eccentrically, because they're going to decelerate my foot hitting the ground. So again, I'll close my eyes and I'll listen. Because if they don't have good control of those pre tibial muscles, tibialis anterior and 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 tibial stress syndrome, because they just can't handle the repetitive motion of their foot slapping the ground without control of those muscles.

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. So 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. Let's go back to that from the big boy on. The medial aspect is where you'll see a lot of injuries as posterior tibialisation. So posterior tibialis, 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? They 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 medial aspect of the foot. That's post tib.

Yeah. And that's the one that when we get into the gym, we're gonna work on that exercise of relaxing the post tib while we allow the arch to descend.

Yeah, I mean, posterior tibialis 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 posterior tib, you will see activation from that guy from the second the foot's on the ground until propulsion. He'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 Tibetan, very, very important for free energy and propulsion. And because of how it attaches, it has to be trained in those planes, in rotational 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. So plantar fasciopathy, lots of tendinopathies. So your Achilles tendinopathies and your posterior tibialis tendinopathies. 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 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 peroneal. I mean, many people have peroneal tendonitis as well.

Interesting. Is that predisposed by lots of ankle sprains, or 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 and the peroneus longus is 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? Do you tend to rely mostly on the clinical history, the physical exam? What fraction of the time do you rely on imaging?

I think the biggest time and the most important time at the foot, especially with imaging, is ruling 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 tendinopathies in Achilles, it really doesn't give you all that much information that's valuable because you can see a tendon on an image and it'll be like, wow, what's going on here? And it doesn't correlate with subjective or even.

So it's not that different from the back 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 the 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. I 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 tendinopathy 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? Clearly, there's a load component to this, right? There has to be some insult.

Well, first, let me say, consider yourself lucky. It's three months. These tendinopathies 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 their Achilles tendon. So a lot of my work in talking to patients with Achilles tendinopathy 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. There's less of a chance of you rupturing it, but you have to be aware 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 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 five out of ten. But I'm a guy who's lived at a zero out of ten in his Achilles. I've had a lot of pain in a lot of other parts of my body, but to wake up and every day be at a 5 out of 10, we're just walking to the bathroom. I'm like, good Lord.

Yeah.

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 tendinopathy 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 tendinopathy, 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. Then you have an insertional Achilles tendinopathy 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 as 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 tendinopathy occurs.

And sorry, in that case, you would really minimize any dorsiflexion mild. 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 midfoot 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. Midfoot stability. We've talked about what the midfoot is anatomically. Now explain in 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. What 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, 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 are they potentially also extrinsic?

It could be A bunch of things.

Right 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, gait, 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.

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. So we have to be able to give people movement options. I have assessments that we'll 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.

Right. There's like utilities and it goes to measure. And I'll measure their dorsiflexion. 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. And 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 8 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 hyperextend their knee. So it's called a varus thrust gait. So because they can't dorsiflex, the knee goes, well, let me help you. Let me hyperextend to propel you forward. So these patients will come in and tell you, my knee feels 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 that. Hyperextension 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?

I've been teaching these courses now for a while, and I think a lot of the referrals now are coming from other physicians, other pts, 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 gait. 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.

Got it. Okay. So we were back to the compensations for weak dorsiflexion.

Yeah. So we have early heel rise. We have a hyperextension 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. They'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 into a deep squat, and they'll be like, I just can't go any further. And I'll say, well, why is that? Say, well, it's my hip or my ankle. My ankles just feel 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 mobilizations down at the ankle. Remember the talus, 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, all 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 can. Most people, as soon as they hold onto 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 gonna see anything. Cause that's not what they need, need. And then it comes down to proximal stability. How 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. You could get their palms past their toes. And when they wake up from anesthesia, they will not have torn a hamstring. And 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. 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 abdominal pressure. And within 30 minutes, the entire palm was past my toes. Did I get more flexible in 30 minutes? Of course not. But by generating high degrees of intra abdominal 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, its ubiquity and B, its 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. But 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 bowl of 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. 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 rib cage? 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, Because I'll tell you, you will feel all of this medial pressure along your big toes. You'll feel your arches collapse, if you will.

And this is where pronation gets a bad name.

Yes. In Genuvalgum, everybody's in. Don't let your knees knot. 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.

Yeah, 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. It's just not realistic. I'm just thinking of golf. 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, you'd be like, 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. They 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 arches 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. Now 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 is a weakness in toe strength that changes. And these 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 couple fast adapting and some slow adapting receptors. They'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% decreased 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, increases circulation to the sensory nerves. If we exercise, we're going to 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. 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 like, take an alcohol pad or a cotton swab on the cutaneous branches. And how much of it is much deeper? I 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, too. 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. 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 Hallucis Restrictus? Yeah.

We will see this a lot, and 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 hallux limitus. We need about 40 to 45 degrees of range of motion at the big toe in order to have an efficient walking gait.

Yeah, this is my only superpower. I'm probably like, 90 degrees at my hallux.

Excess range of motion is great, as.

Long as you can control 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.

Yes.

Who gets 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. It'll be red, it'll be swollen, and these patients suffer. I'm on a Facebook group for hallux regidus. 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, like, 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. I 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. So even in those initial stages, we're doing, like, big toe ranges of motion. I always tell 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 hurts? Like, not as bad, but it's amazingly sore 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 and why it's helped with.

The big toe, what we'll have if there's an irritation in the joint, per se.

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. Cause 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.

If 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 isometrics. The reason I call them my pain meds is I will tell my patients, whenever you feel pain, isometrics are safe for you to do. Because what they do is they decrease cortical inhibition. So when we have an injury, think of it. We'll go to a race car. We have a cortical accelerator, so information coming from our brain. And we also have brakes. We want the accelerator and the brake to be in balance of one another. When we have an injury, our brains, our foot's on the brake. So if I'm trying to change my movement or improve my movement pattern, I gotta 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.

Yes. So when you can find these patients that still have. When you're doing a calf raise, 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 peroneus longus 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.

The kinesthetic cueing, 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 rigidus patient? Obviously, isometric's 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 hallux limitus, which means that they can still utilize their big toe based on. If I increase strength of peroneus longus, for example, if we work on range of motion at the big toe, all of those things are key. If you don't do it, then it will progress into hallux rigidus. And I don't consider those the same diagnosis. Hallux rigidus. There's been so much arthritic change to the joint that now you maybe have five degrees. So the toes basically fused almost.

So rigidus, you're associating with the bony arthritic changes, whereas limitus 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 exostosis or like lipping. There is, you know, Wolf's law. They'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, let's fix this thing. Because if not, if that progresses to hallux 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 Hox limitus 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 arthritic change at the toe, they're like, wow, this is hallux rigidus. I'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 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 that path too long, you'll lose the ability forever.

Correct. And you want to talk about what happens up the chain When I see patients walk with hallux rigidus, 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 height with every step.

And it's like, what are you doing? But I always want to instill hope, because there's always hope. You have to do that. And even if patients have effusion in their big toe, even if they have hallux rigidus, 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. Those range of motion, those 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 sequelae 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?

It'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 is more at the midfoot, where they'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 toe yoga, right? So 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 toe 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 digitorum brevis is a big muscle in regards to toe strength. When we do one of the videos, I'll talk about the wink sign. Okay. Cause 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 clamshell 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. I 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 toe strength, you gotta really work on that type of movement in tissue strength.

So let's now go from toe strength back to falls. Since you said that the measurement of toe strength is one of the greatest predictors of fall risk, it's a huge problem. Yes, 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?

First and foremost, toe strength, that is the single biggest predictor of falls in the elderly is a weakness of toe strength. It really is.

I would not have guessed that.

When we get in and start doing these exercises, I mean, I think it is an imperative. You know how kids get scoliosis 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 dynamometer.

Well, 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'll look at more important in the plantar dorsi plane or in the inversion eversion plane?

In both. So when I assess, I have a fall prevention protocol. Dr. Tommy Schaud has put together an excellent fall prevention protocol and him and I have worked a lot together on this. So we'll look at at ankle dorsiflexion. 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. A 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 gait. 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 modulating activity of abductor hallucis. So remember, that's the muscle that straightens the big toe. Abductor hallucis 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 hallucis 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.

And how much of that is the glute Mead versus Max depends on where.

We are in the gait cycle. So when I'm walking at heel strike, that's all glute max.

I think people, as you start to propel, you need the mead to stabilize. And what do you externally, at this point, you need to be able to abduct the hip.

Yeah. So I'm walking, I 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. That's glute mead. 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.

He'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. I 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 going to be this big old glute exercise. And as they go to push off, they'll squeeze their butt. And I'm like, it's the wrong spot. You want to squeeze your butt. You want to try to control it. Right. And I really don't ever give people gait 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 gonna do is throw yourself into too much lumbar extension. It'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 gonna 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 who are 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. And 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 feel the ground as 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 word 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 splay. A wide toe box for me is a 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. There's also a very big difference between a wide toe box and a wide shoe. Those are two very different things. A Wide shoe, which most shoe companies have, will give you width here, but it will still taper at the toe and not what we want. Remember the tie bar mechanism? I have to have that forefoot splay to trigger the response of, hey, I better get stable at push off. So that's when I need my toes to be able to splay as well. So a 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. I'm a big fan of these shoes. There are so many companies out there right now. Vivobarefoot toe us. 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.

And I have them listed according to cat category. Right. Like this is a 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. The 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 toes 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 is.

It'll 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.

Interesting. I switched my rucking to a shoe that has an, I think an 8 millimeter drop once. I was having all of that Achilles tendinopathy and I have enjoyed that shoe much more. So I no longer ruck 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 an Achilles. I've never had pain again since doing that. Is that a mistake?

No. And I think it's such a good conversation to have. Think about the whole super shoe, the Nike AlphaFly, 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.

Oh, okay, Right. Oh, is this the super running shoe?

This is the super running shoe.

Oh, yeah, yeah, yeah, I 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. And the research will tell you gives you a 4% advantage. Now, if I'm running in a race 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 and 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. Again, you better be able to handle that. So when you talk about shoes like that, I call them a performance shoe. Fine, but it's a performance. Save that shoe for icing on the cake.

Your speed worker, you have to do the foundational work.

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, 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 tendinopathy, 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. So 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 posterior 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 box is non negotiable. But you will get patients that often. And other doctors have said this to me. Well, we weren't designed to walk on man made surfaces. Okay, fine. Nor were we designed to walk with our toes looking like this. Hence the wide toe box is a non negotiable. But if you are 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, it 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, 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 going to alter the rate of loading. So 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 Stephen Sashen owns 0 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 Steven. Well, I 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. 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? And 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, I'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 in a shoe 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. It'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 5 or 10 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, cushioned shoe, you don't want to take them into something like this too soon. They'll be like, this sucks. And I don't want to do it. And then you lose them right out of the gates.

For a person to run in a shoe like that, must they give up a heel strike?

In running, when 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 striking is bad. Heel striking 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 striding is the enemy. I don't want to have my foot, 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. They just have more knee flexion, 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 forefoot 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?

You 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 because 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 midfoot and forefoot strike when their foot is under, 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 striking.

Correct.

Because it would be very awkward to heel strike at that angle and 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, Achilles tendinopathy, 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. Yeah.

Are 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 splay 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 3 to 5 millimeter heel to toe drop. The Topo Athletic, for example, Altra actually now has a 4 millimeter 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 5. Slowly bring them there. They're going to be like, oh, this feels great. Because they always do. And then we start working on their strength and then we can continue to drop them down into a more functional shoe. But you think about hockey players, rock climbers, where shoes are just what they are. You 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 toe 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 toe spacers in the shoes.

Yes.

I've never seen you not wearing toe spacers. Do you sleep in them?

I don't sleep in them.

You don't? Okay, good to know.

But I do wear them all the time. I wear them when I run as well. I have that history of bunions. The Hallux Valgus 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?

The toe 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 forefoot diagnoses. I 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 toe splay, 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 toe spacer. 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 toe spacers. You're going to walk around barefoot in your house for five minutes. That's it. On their weaker foot, because they don't have toe splay. The toes rub against the toe spacer, and you can get, like, a callus or a corn, and that can be very painful. And they'll 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. Cause they simply can't spread their toes. It's wild. So they start with five minutes a day, then they just slowly increase their time. Then they get a shoe where they can wear the toe spacer in the shoe. Think of it as like just doing an exercise for your foot. Sarah Ridge did a study looking at strength of the foot. And so what she looked at there was a control group, a group that just did foot strengthening exercises and just wore functional footwear. And they looked at four different muscles. So flexor digitorum brevis. The one we talked about that supports the plantar fascia, abductor hallucis. 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. What was the other one? I think it was flexor hallucis 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 shoes.

And the only muscle that didn't get stronger was flexor hallucis 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. Cause you're just saying basically all I have to do is change my shoes and things will get significantly better.

Imagine 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 to. They're 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 where I'm like, start with one, you gotta start with one factor. And if I had to do that, where am I gonna 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 Nikes or I want whatever, the popular shoe of the Day is. And, and I mean, knock on wood, it hasn't happened yet. They love the shoes and that's the end of it.

Like, 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 Nikes and I was like, I will do pretty much anything for you, but I am not buying you a pair of Nikes. But my brother was like, I want to be the good uncle.

A cool uncle, right, the cool uncle.

And I was like, okay, I'm going to 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 ultras on because 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, is when you see bunions and hammertoes, it should be a signal to you going, something is wrong here. Something is wrong. Where is this aberrant load coming from?

Now what do you say to men and women whose, I don't 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. I mean I watch some of the shoes that women wear and I think, God bless you. How, how do you actually wear that shoe? So do you put that in the same category as 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 you have 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 4 inch stiletto, number one, be my guest, have fun with that. Number two, you better do the work on the other end of it or else it's. And I'll tell my patients, you gotta work with me a little bit. You wanna go on a date? You wanna 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 do it yourself process.

Yes, thank you so much.

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