The use of ice for treating medical injuries originated in the 1960s when it was used to preserve the tissue of a severed limb. A remarkable medical breakthrough occurred when a 12-year-old boy became the first person to have a major limb (arm) successfully reattached to his body. The news of this successful procedure quickly spread around the world, capturing public attention. However, as the story was retold by those not directly involved in the surgery, some details were altered and complex medical concepts were simplified for the general public. Over time, one documented case of successfully using ice for tissue preservation prior to limb reattachment surgery was mistakenly generalized to applying ice to all types of injuries to facilitate healing. This belief continues to be widespread even today.

Inflammation, Swelling, and Repair

The RICE protocol aims to combat or stop inflammation and swelling. Many people perceive inflammation as a harmful process that needs to be stopped as soon as possible. However, inflammation is actually a necessary and crucial part of the body’s initial response to injury. It helps control the injury at a cellular level and prepares the tissues for the next phase of healing. Inflammation is followed by a repair phase which is then followed by a remodeling phase, and each phase must come to completion before the next phase can begin. Inflammatory cells trigger blood vessels to open and increase their permeability, which allows healing cells to access the injury and start the repair process. Attempting to limit or suppress inflammation can interfere with this process and result in chronic inflammation.

As the inflammatory phase comes to a close, excess fluid waste (swelling) is cleared through a series of channels throughout the body called the lymphatic system. Lymph vessels rely on movement from nearby skeletal muscle contractions to propel fluid along their pathways. Therefore, muscle contractions are necessary to facilitate the reduction of swelling. Immobilizing the injured area prevents movement and muscle contraction, hindering the lymphatic system’s ability to reduce swelling, which in turn delays tissue repair and increases the risk of chronic inflammation. 

The main issue with inflammation is not necessarily its intensity but rather the interruption or delay of the process and inadequate clearance of inflammatory fluid. In many cases, inflammation does not need to be suppressed, reduced, or delayed, especially in acute situations. Instead, it should be encouraged to run its course efficiently. Optimal inflammation is a swift and strong response that sets the stage for tissue repair. Once the excess fluid is cleared, the repair phase begins by forming new healthy tissue and establishing new blood vessels to deliver oxygen and nutrients to the area. This is followed by the remodeling phase, which relies on adequate blood supply to develop and strengthen the newly formed healthy tissue.

Ice and Immobilization Interrupt Inflammation and Delay Healing

Applying ice to an injury causes the local blood vessels to narrow, reducing blood flow and limiting the movement of inflammatory cells and their signals. This vasoconstriction can persist even after the ice is removed, leading to a low-oxygen environment that hampers healing. Furthermore, ice suppresses the release of IGF-1, a hormone that plays a crucial role in the healing and regeneration of muscles and other injured tissues. Considering these effects, it becomes clear that cold application slows down the healing process.

Resting, particularly by avoiding putting weight on the injured area, can be necessary to prevent further damage. However, it does not actually enhance or accelerate the recovery process. As mentioned before, the lymphatic system relies on muscle contractions to remove waste products from the injured area. Immobilizing the injured area can result in congestion and stagnation, impeding the drainage of excess fluid. This prevents the completion of the inflammatory phase, which in turn hinders the progression to the repair and remodeling phases of healing.

Elevation & Compression

There isn’t strong evidence specifically analyzing the effectiveness of elevation as a post-injury measure. However, it can be beneficial for some individuals. If elevating an injury feels good—go for it, but there’s no need to force it if it doesn’t provide relief. The main purpose of both compression and elevation is to reduce swelling, which can be appropriate in certain situations but should not be the sole focus. Non-rigid braces and compression sleeves can temporarily reduce swelling by physically compressing the affected area. This can alleviate pressure on nearby nerves, reduce pain signals, and improve joint mobility and range of motion. Compression is particularly useful during the rehabilitation and strengthening phases of post-injury recovery, facilitating a smoother transition back to activity. Compression sleeves work great for the ankle, calf, and knee.

Anti-Inflammatory Medications

In addition to the RICE protocol, anti-inflammatory medications such as NSAIDs (e.g., Ibuprofen, Motrin) are commonly recommended for managing musculoskeletal injuries. It’s important to understand how these medications work so that you can align their use with your healing goals. NSAIDs function by blocking the production of prostaglandins, which are responsible for initiating inflammation. Consequently, they can temporarily reduce inflammation, as well as alleviate pain and swelling. However, as we’ve discussed earlier, inflammation plays a vital role in the healing process. NSAIDs can interfere with fracture healing and impede proper tendon healing following tears. Acetaminophen (Tylenol) works differently from NSAIDs. It primarily helps to reduce pain and fever without significantly affecting the inflammatory process.

However, it’s essential to recognize that masking pain signals can have its drawbacks. Pain serves as a valuable warning sign, alerting us when we may be damaging or injuring ourselves. By suppressing pain, we lose this awareness and run the risk of further injury. Moreover, like many other medications, NSAIDs can have various side effects, but discussing them in detail goes beyond the scope of this article.

HEAT, PEACE & LOVE

We love our acronyms, and if RICE won’t cut it, you can consider alternative approaches like “HEAT” or “PEACE and LOVE.” HEAT stands for Heat, Exercise, Analgesics, and Topicals. Ice can be useful immediately following an injury to help temporarily numb the pain and slow down any potential excess bleeding into the surrounding tissues, but for many injuries, the actual bleeding stops within minutes to hours after the initial injury. Starting within 24-48 hours after most injuries, heat alone or intermittent cold alternating with heat applications (5-10 minutes at a time) can be used to help reduce the potential for stagnation and congestion while encouraging adequate healthy blood flow. Good circulation is crucial for healing, especially in less vascularized areas like ligaments, tendons, joints, and fascia. Heat can also temporarily relieve pain for some individuals.

The “E” in HEAT stands for Exercise. It involves starting with gentle movements and general exercises aimed toward improving the range of motion, gradually progressing to dynamic movements and strengthening exercises as the injury heals. Strengthening the muscles around the injured area supports full functionality and reduces the risk of future injuries.

Analgesics and Topicals are methods to alleviate pain. If optimal tissue healing is your goal, it’s often best to avoid NSAIDs if possible. Sometimes natural supplements like turmeric can help to modulate inflammation. Topical treatments containing menthol, camphor, and capsaicin can effectively reduce pain and encourage exercise. Topicals are particularly suitable for foot and ankle injuries, as the affected structures are often close to the skin surface. One example of a topical treatment is Sombra, used at Northwest Foot & Ankle.

PEACE is a thoughtful approach for immediately following an acute injury and stands for Protect, Elevate, Avoid anti-inflammatory modalities, Compress, and Educate. Patient education is crucial for long-term success. On the other hand, LOVE guides the rehabilitative aspect of recovery, standing for Load, Optimism, Vascularization, and Exercise. When resuming activity, it’s important to manage the load and avoid overexertion to prevent re-injury. Optimism, along with education, plays a significant role in successful treatment outcomes. It’s essential to recognize that we are our own best healers, and rather than impeding or suppressing our natural healing processes, we should learn to support and facilitate them. For more information about how to help heal your specific injury, please consult with your holistically-minded physician or reach out to us at Northwest Foot & Ankle.

Sources

1. 1. Scialoia, D. The R.I.C.E Protocol is a MYTH: A Review and Recommendations. The Sport Journal. 2020. Vol. 22.
2. 2. Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22-28. doi:10.1179/106698110X12595770849524
3. 3. Su B, O’Connor JP. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol (1985). 2013;115(6):892-899. doi:10.1152/japplphysiol.00053.2013
4. 4. Weerasekara RMIM, Tennakoon SUB, Suraweera HJ. Contrast Therapy and Heat Therapy in Subacute Stage of Grade I and II Lateral Ankle Sprains. Foot & Ankle Specialist. 2016;9(4):307-323. doi:10.1177/1938640016640885

Written by: Dr. Andrew Wojciechowski, ND

If you’re seeking more individualized foot health care and would like to work with Dr. Andrew directly, you can schedule at Northwest Foot and Ankle.

Schedule a virtual remote consultation with Dr. Andrew Wojciechowksi, ND.

Schedule an in-person appointment with Dr. Andrew Wojciechowski, ND at Northwest Foot & Ankle in Portland, OR.

In the late 2000s, a barefoot running renaissance emerged, capturing the attention of runners and fitness enthusiasts alike. Vibram FiveFinger “toe shoes” and Christopher McDougall’s bestselling book, Born to Run, fueled the belief that running barefoot or in barefoot-mimicking shoes could enhance foot and leg strength, reduce injuries, and improve overall resilience. Who wouldn’t want stronger, more resilient feet?

Transitioning to Barefoot Shoes

The transition from conventional running shoes to minimal footwear proved to be more challenging than anticipated. Many individuals excitedly discarded their bulky, motion-controlling shoes and jumped straight into training barefoot or with minimalist footwear like Vibrams. 

While liberating, running barefoot requires a different level of skill, strength, and awareness compared to traditional running. Surprisingly, even accomplished runners found the gap between their ability to run barefoot or in minimalist shoes and their performance in modern maximalist shoes to be substantial. Without a gradual and thoughtful transition, the risk of injury loomed large.

Unfortunately, society’s obsession with immediate results often overlooked the importance of gradually strengthening and mobilizing the feet to handle increased workloads. This became evident when Vibram faced a class-action lawsuit, with plaintiffs accusing the company of making false health claims regarding their FiveFinger toe shoes. Although subsequent studies demonstrated that training in Vibram FiveFingers did indeed strengthen intrinsic foot muscles, there were no available studies at the time of the lawsuit.

The majority of conventional footwear, including running shoes, features design elements like tapered toe boxes, toe springs, and heel elevations. While intended to correct foot stability, these features inadvertently interfere with the foot’s natural function, hindering the big toe’s ability to push off and leading to an overpronated posture and flattened arches. 

In response, shoes are now equipped with built-up arch supports and motion-controlling features. However, the more external support shoes provide, the less opportunity there is for the feet to develop internal strength and stability. Feet that rely excessively on support can become dependent on shoes with stabilizing features, ultimately weakening and deforming due to the footwear’s design and technology.

The Impact of Wearing Conventionally-shaped Shoes

Over time, wearing conventionally-shaped shoes can result in muscle imbalances and foot deformations. A tapered toe box squeezes the toes together, weakening the muscles on the sides of the foot while tightening those in the middle. This imbalance can lead to the development of bunions and hammertoes. 

Similarly, heel elevation and toe spring lengthen and weaken the muscles on the bottom of the foot while shortening and tightening the extensor muscles on the top. Consequently, many people live with feet shaped by their footwear—restricting their ability to move effectively without external assistance.

Consider this thought experiment: imagine a boxer who keeps their hands constantly wrapped in boxing gloves. Although protected from injuries, their finger strength and coordination may not be sufficient to perform delicate tasks like playing the piano or using chopsticks. 

Similarly, expecting dysfunctional and dependent feet to handle the rigors of barefoot running or minimalist shoes immediately is unrealistic. Regaining foot function requires more than just switching to naturally-shaped footwear; it often necessitates reversing damage and retraining the foot.

Toe Correcting Solution

This is where Correct Toes comes into play. Similar to braces for teeth, Correct Toes gradually guide micro-changes toward optimal toe alignment. By splaying the toes back into their natural wide position, Correct Toes help reverse muscle imbalances caused by narrow toe boxes. 

Proper toe alignment provides natural support for foot arches, improves balance, eliminates overpronation, optimizes weight distribution, and promotes optimal circulation, among other benefits. The alignment of the big toe is particularly crucial for walking and running, as it bears a significant amount of weight and plays a key role in pushing off the ground for the next step. When the big toe is misaligned, as often seen in bunions or tapered toe boxes, its ability to effectively extend and push off becomes compromised, leading to compensatory patterns and reduced functionality.

While wearing Correct Toes during activities helps train the toes and foot muscles to operate in healthy alignment, complementing their effects with targeted exercises and manual therapies is highly beneficial. The bunion stretch and soft tissue release, for example, helps realign the big toe by loosening tender spots between the foot bones and releasing tight muscles. 

Similarly, the toe extensor stretch lengthens the tendons on the top of the foot, which are often tightened by shoes with toe spring and heel elevation. By addressing these issues, it becomes possible to effectively strengthen the weak muscles on the bottom of the foot. Additionally, using a lacrosse ball or massage ball to encourage plantarflexion can help bring the toes back to a flat position.

The foot is an elegantly designed structure, capable of supporting and moving our body weight for a lifetime. Its three arches provide strength and adaptability, allowing us to navigate various surfaces. However, when one end of an arch is displaced, instability arises, and the foot struggles to maintain its integrity. These arches must be both strong and flexible to function optimally, efficiently transferring energy.

Barefoot Shoes and Toe Spacers for Optimal Foot Health

To experience the full benefits of being barefoot or wearing minimalist shoes, the foot must be in a position and posture that can naturally support itself—flat with toes splayed in alignment. Simply switching to footwear shaped like feet is a significant first step, but for those who have worn conventional footwear for an extended period, addressing muscle imbalances and retraining the foot is often necessary. 

Correct Toes, combined with targeted exercises and manual therapies, helps encourage a healthy foot posture and facilitates a smoother transition to barefoot shoes, enabling you to achieve optimal foot health and continue moving forward with confidence.Unlock the potential of your feet and embrace the strength and functionality they are meant to possess. Transitioning to barefoot shoes is a transformative journey that requires patience, dedication, and the right tools. 

By incorporating Correct Toes and holistic foot care practices, you can embark on a path toward healthy, resilient feet that will support you for years to come. Get ready to experience the joy of movement and discover the true potential of your remarkable feet.

Written by: Dr. Andrew Wojciechowski, ND

If you’re seeking more individualized foot health care and would like to work with Dr. Andrew directly, you can schedule at Northwest Foot and Ankle.

Schedule a virtual remote consultation with Dr. Andrew Wojciechowksi, ND.

Schedule an in-person appointment with Dr. Andrew Wojciechowski, ND at Northwest Foot & Ankle in Portland, OR.

Many athletic shoes have a rigid toe spring and narrow toe box that tapers to a point in the middle of the foot. This obviously lifts and pinches the toes together—a subfunctional foot/toe position that is unstable—which increases the risk of injury and hinders performance potential. An aligned big toe is absolutely critical to maintaining a healthy and functional arch—so it makes no sense to push the big toe towards the foot’s midline and lift it above the ground surface. Many more athletic shoes will pair this type of negligent toe box with an elevated heel that further compromises the positioning of the foot and ankle. As one can imagine, this combination creates an even more chaotic and dysfunctional environment for the foot to try to navigate. A foot forced to operate from this positioning really can’t help but overpronate. Dr. Ray McClanahan demonstrates this vividly in his Pronation vs. Overpronation YouTube video. The athletic shoe attempted solution for this self-created instability and overpronation is a built-up “arch support” on a stiff sole that forcefully resists overpronation. It’s a clever band-aid for a self-created problem, but these “arch supports” also prevent natural and normal pronation from happening—a literal bump in the road to a healthy gait.

It’s true that tight footwear is necessary for certain sports, which is why it’s so important to take extra care of the feet when they don’t have to be in that type of restrictive footwear. Within tight, stiff, supportive footwear, the many small bones and joints of the foot become essentially immobilized into a compromised foot posture, and the foot muscles’ ability to appropriately engage, strengthen, and adapt to the varying ground surfaces greatly diminishes. The small intrinsic foot muscles are critical for balance, explosiveness, and injury prevention, but are often underdeveloped due to chronic over-use of ill-fitting footwear and naivety surrounding natural foot health. An obvious strategy to address foot weakness is more external structure and support using taping, compression, braces, etc. There is certainly a time and place for extra support when injured and when performing—but typically while training and in everyday life, the feet should be generally uninhibited and left to support and move you as they were designed to do.

Dangle one foot in the air and observe the shape and width of that foot while non-weight-bearing. Now stand one-legged on that same foot alone. There should be a noticeable difference, especially in width. In many tight athletic shoes, this spreading of the foot while weight-bearing is significantly restricted. Over time, this can create a lot of pressure, tension, and friction within the foot.

The toes, feet, and ankles have become (in my humble opinion) untrusted and untrained in athletics NOT because feet are incapable of performing to our desire, but because they are continually asked to perform from a less-than-optimal (and often harmful) position. This blindspot becomes predictably exacerbated when we also chronically train, and live our day-to-day lives, with our feet in similar positioning. Like water in a vessel, our feet eventually conform to the shape of our shoes over time. Time moves faster for athletic feet and feet that take more steps, but the endpoint is the same—feet shaped like shoes. The less often we’re barefoot, the further we stray from true natural foot health.

It was Leonardo Da Vinci who famously said, “the foot is a masterpiece of engineering and a work of art.” And it is truly remarkable to see the structural similarities between the skeletal arches of the foot and the strongest manmade arches. 

Ideally, foot-shaped, zero-drop, barefoot-mimicking footwear would be accessible for all types of sporting occasions. The reality is, we’re not there yet—so for now, we must meet people where they’re at. If you’re an athlete that can’t currently escape your performance footwear, there’s still plenty of ways to incorporate natural foot health into your training, recovery, and everyday lifestyle. 

1. BAREFOOT TRAINING

Training in conventional athletic footwear that has arch support, extra stabilization features, and lots of cushioning significantly limits the foot’s ability to function and efficiently absorb impact. Instead (often unknowingly), these impact forces are transmitted up the skeletal system to the shins, knees, hips, and lower back. When training barefoot, you quickly realize that without lots of cushioning or super-soft ground, the heel bone is NOT great at absorbing impact. It takes time and patience to adjust as responsibility for stability and shock absorption shifts to the muscles of the feet and ankles. This will feel unfamiliar and often overwhelming to feet that have spent significant time inside unhealthy footwear. However, the truth is: the foot is capable of all this and more—so long as it’s positioned as nature intended with strong and limber muscles.

Our feet were designed to move and support us for a lifetime, and they will if we take care of them. And by “take care of them” I mean appropriately loading and challenging the feet and ankles and using them to their fullest extent. NOT forever immobilizing, excessively supporting, and pampering the feet always. Barefoot training engages and strengthens smaller intrinsic foot musculature that gets neglected within stiff and ill-fitting conventional athletic shoes.

Beyond any potential athletic performance enhancement that comes with having stronger and better-controlled muscles, the intrinsics are also important for balance by helping your feet to adjust and adapt to the surfaces you’re standing on. And perhaps just as importantly, strong intrinsic foot muscles also help protect the foot from common nagging injuries like plantar fasciitis/fasciosis, stress fractures, shin splints, bunions, bunionettes, hammertoes, and many more. 

Another benefit of training barefoot is sensory feedback and proprioception—your awareness of your body in space. A lifetime of wearing cushioned rubber under the soles of our feet has left most feet predictably hypersensitive to even the most mildly textured surfaces. If feet are always wrapped in a fluffy cushion and aren’t regularly exposed to varying hardness and textures—carpet, wood, grass, cement, rocks, sand, etc.—they will inevitably become hypersensitive to touch. For an analogy: imagine wearing earplugs all day every day since the age of two. Then as an adult, the first time those earplugs are removed, everything in the world would seem screamingly loud. The sense of hearing had been excessively sheltered and deprived for so long and is now starved for stimulation to the point that faint whispers register as fire alarms. Similarly, attempting barefoot training without properly transitioning from years (possibly a lifetime) of cushioned, supportive shoes is like being in the front row at a rock concert after wearing earplugs your entire life: too much, too soon. Yet regulating this sensory feedback system is paramount for your nervous system health. With as many as 200,000 nerve endings per sole, the bottoms of the feet absolutely crave attention, texture, and mobility. Establishing good nerve health and sensory feedback from the feet is not only beneficial for an athlete today, but is also important for foot health and balance longevity.

Training barefoot is truly the best way to engage, strengthen, and ultimately protect your feet. However, if you’ve only ever trained with shoes on and/or you’re not barefoot very often, then your feet might not be quite ready to train barefoot just yet. If this is the case, you can start “transitioning” simply by being barefoot at home more often and getting a pair of zero-drop, wide-toe box shoes to allow your feet some time to adjust in. See our blog post on transitioning here. Also check out our YouTube page for mobilizing, stretching, and strengthening exercises that can help smooth your transition.

CORRECT TOES

Individual professional athletes and strength & conditioning staffs from the top professional sports leagues worldwide use Correct Toes to help reverse the damaging effects of narrow, tapered toe boxes. This medical-grade silicone toe spacer helps to position the toes into optimal anatomical alignment and can be customized to fit your unique foot. Correct Toes were designed to be worn while active and exercising so that foot muscles can engage and strengthen into a healthy alignment. Correct Toes can be worn barefoot or within shoes that feature a toe box wide enough to comfortably fit them. We have a list of Correct Toes Approved footwear here. For further reading about some of the specific benefits of Correct Toes for athletes, check out our Correct Toes for Basketball Players post from 2 years ago.

2. CROSS-TRAINING WITH NATURAL FOOTWEAR

Even if you have to wear cleats or specialty footwear during athletic performance, typically other training environments will allow for more flexibility when it comes to footwear. Fortunately, there are several good footwear options to choose from when it comes to zero-drop, wide-toe box running and hiking shoes (some companies are starting to make cross-trainer gym shoes too). Altra, Topo Athletic, Vivobarefoot, Xero, Joe Nimble, and Bearfoot are all examples of shoe companies that make varying styles of athletic shoes shaped like healthy feet that will mostly accommodate Correct Toes. If you are able to wear general athletic and running shoes during certain parts of training, consider using shoes from these brands (Altra typically has the most cushion so they are recommended for people who are used to more supportive and cushioned shoes). The overarching benefit of training in a zero-drop, wide toe shoe is that it gives the foot an opportunity to support itself naturally and operate from more ideal positioning, while still offering significant protection (and sometimes cushion). Similar to training barefoot, these barefoot-style style shoes encourage natural mobility and intrinsic muscle strengthening to help better prepare your foot for when it has to be back inside of a conventional athletic shoe. For Basketball-specific footwear, check out our post from 2 years ago, Basketball and Natural Footwear Options.

3. MODIFYING FOOTWEAR TO FIT YOUR FEET

Since there aren’t any foot-shaped cleats (or basketball shoes, etc.) yet, shoe modifications are a simple strategy to help you change your footwear to fit your feet better. The most egregious problem with athletic shoes is usually a narrow, tapered toe box. The first and easiest way to tackle this is by simply removing the removable insole from the shoe if the shoe has one. Another strategy is to re-lace the shoe so the lacing starts 1-2 eyelets back from the toe box. This gives the upper more ability to expand around the toes. Additionally, a wooden shoe stretcher or ball-and-ring stretcher can help to expand the toe box upper material; but if the upper won’t stretch, small incisions can be made in the toe box upper to allow the toes a little more room. Of course, it also helps if you have a wider shoe model to start with in the first place.

Another potential solution found while researching was a company called Custom Cleats that transplants cleats onto sneakers and other types of shoes. It’s unclear how this process would work on a minimalist shoe, but it might be a viable solution for foot-shaped shoes that have a thicker stack height. A similar clever solution for golfers comes from the company Golfkicks, which sells individual golf spikes that can be screwed into the bottom of sneakers with thick enough stack heights (1/3 inch).

RECOVERY

Correct Toes toe spacer is a fantastic tool for training, encouraging the development of natural stability and strength. But Correct Toes is also a great recovery tool too! Anyone who’s been a part of grueling sporting matches with their toes crammed into tight athletic shoes knows what a relief it is to take those shoes off post-game and let your feet breathe and toes splay out wide. Correct Toes can help to make sure that a healthy splay—anatomically appropriate for your foot—is maintained during the recovery period. Having the toes properly aligned not only solidifies inherent foot stability, but also positions the nerves, vasculature, and other soft tissues into their optimal alignment. For context, when the big toe gets pushed over as seen within a narrow toe box, blood flow to the foot can decrease by 20% (Jacobs, et al. 2019)!! Conversely, when the toes are aligned with the foot bones, the foot vasculature becomes optimally positioned for robust blood circulation and healing response. The feet are furthest from the heart and injuries commonly happen to poorly vascularized structures, so maintaining optimal blood flow is critical for healing chronic foot injuries. These circulatory benefits, in conjunction with the natural stability that comes from the foot posture facilitated by Correct Toes, go a long way towards keeping minor injuries from lingering and preventing injuries altogether.

If you’re someone who is often active in shoes that aren’t flat and foot-shaped, it’s only a matter of time before your feet start to become shaped by the shoes they reside in. And until more foot-healthy specialty athletic footwear exists, harm reduction is our best strategy at improving this type of athlete’s foot health. I hope this article helps to increase awareness of some of the problems in athletic footwear and the potential consquences, as well as provide some useful strategies for navigating natural foot health in a world full of unnatural footwear.

Addendum: There is a new, rising startup shoe company called CODE Footwear that makes sneakers and cleats custom-built for your specific feet based on a volumetric 3D foot scan. They are currently taking pre-orders for both footwear options with an anticipated launch date of Spring 2022. Cleats are estimated retail price of $695 and the sneakers are $595, and I don’t think that covers the cost of a foot scan. This could be the future of footwear moving forward, folks!

*** This post is for educational purposes only and is not medical advice. Please consult with your holistically-minded health provider before initiating any treatment strategies.

Written by: Dr. Andrew Wojciechowski, ND

If you’re seeking more individualized foot health care and would like to work with Dr. Andrew directly, you can schedule at Northwest Foot and Ankle.

Schedule a virtual remote consultation with Dr. Andrew Wojciechowksi, ND.

Schedule an in-person appointment with Dr. Andrew Wojciechowski, ND at Northwest Foot & Ankle in Portland, OR.

Shin splints, sometimes called medial tibial stress syndrome (MTSS) or tibial periostitis/fasciitis, are one of the most common lower leg injuries seen in athletics. Shin splint pain typically radiates along the medial and posterior edges of the shin bone (tibia) and is often associated with a sudden significant increase in activity, such as initiating a new training regimen or playing a new sport. Often the pain is first felt during the beginning of the activity and then subsides as the activity progresses, only to return hours to days later with a vengeance. Shin splints are reported most often by those who experienced chronic repetitive stresses to the lower legs, such as runners, dancers, soccer players, military, etc. Similarly to many pains of the foot and lower leg, the cause of shin splint pain is multifaceted but mostly the result of biomechanical issues and muscle imbalances that stem from a general lack of use. Additionally, most shoes have become so supportive and protective to the point that our feet have become weakened and hyper-sensitive as a result. Inflammation to the periosteum—a vascularized, innervated tissue that covers bones and joints—arises from friction, rotation and torque along this membrane during activity. Shin splints, however, are still more a symptom of an underlying musculoskeletal or movement problem, rather than a true medical condition in and of itself.

RECENT RESEARCH

A recent study published by Mattock, et al. in the Journal of Foot and Ankle Research just last month (July 2021) observed that people experiencing shin splints were found to have both structural and functional changes to several muscles of the lower leg when compared to their asymptomatic counterparts. According to this study, those with shin splint pains were found to have significantly smaller flexor hallucis longus and smaller soleus muscles, but a larger lateral gastrocnemius. Additionally, symptomatic individuals also displayed statistically significant deficits in strength (measured by dynamometer) of the flexor hallucis longus, soleus, tibialis anterior and peroneal muscles, as well as a reduced ankle plantar flexor endurance capacity (a single leg heel raise protocol with participants attempting to perform as many single leg heel raises as possible). Of course, this study only highlights correlation, not causation; but it is another important piece to the puzzle.

WHAT CAUSES SHIN SPLINTS?

Generally speaking, there are two simplified ways in which muscles become deconditioned from lack of use. If a muscle is chronically held in a contracted position, that muscle will likely become short, tight and knotty. If a muscle is chronically held in a lengthened position, that muscle becomes elongated, lax and ropey. In both cases the muscles become weakened and are unable to provide the natural support and flexibility necessary to function at a high level, pain free.

We’re already aware of how fashion footwear can affect the shape and strength of certain muscles and tendons. Injurious footwear featuring a rigid toe spring, tapered toe box, and an elevated heel will hold the toes and forefoot in an extended elevated position. This position both overstretches and inhibits the flexor muscles on the bottom of the foot from functioning properly, causing the flexor hallucis longus and flexor digitorum longus muscles (which attach at the mid-tibia and -fibula down to the tips of the toes, running deep to the gastrocnemius and soleus) to become long and weak—a finding similarly reported in the research done by Mattock, et al.

Chronically wearing and exercising in footwear featuring a heel elevation also has the unfavorable consequence of shortening and stiffening the calf and Achilles tendon. The gastrocnemius and soleus muscles together form the bulk of the calf muscle, combining (also with the plantaris muscle) to attach on the calcaneus (heel bone) forming the Achilles tendon. The gastrocnemius is the most superficial calf muscle and crosses both the ankle and knee joints. It’s a powerful muscle that does a fine job of grossly plantarflexing the ankle and flexing the knee, as well as encompassing the rest of the posterior leg compartment under its sheath-like hood—but it is the soleus that more so exudes the finer motor control portion of plantarflexing the ankle; including stabilizing the ankle and appropriately receiving the ground when in motion, especially when forefoot striking. The soleus is also more prominently used to stabilize the lower leg when standing. However, footwear with built-in support “technologies” like artificial arch support, a wide-flaring outsole and rigid heel counter can over-stabilize the ankle to the point that other important stabilizing muscles like the soleus become neglected and ultimately weaken. When the soleus weakens, we commonly see the lower leg compensate by relying more on the gastrocnemius. This scenario is also reflected in the research by Mattock, et al., where we see a significant decrease in both size and strength of the soleus paired with an increase in gastrocnemius size.

“The human foot is a masterpiece of engineering and work of art.” – Leonardo Da Vinci

ARCHES, CUSHIONING & IMPACT FORCES

The three main arches of the foot are magnificently designed, take it from Da Vinci. These strong yet mobile arches can bear immense weight and withstand substantial impact forces when they’re appropriately utilized. Arch mobility and strength also help us balance by allowing the feet to make a plethora of tiny adjustments at any moment to match any terrain.

Footwear which artificially props up and “supports” the medial longitudinal arch actually prevents the arch from doing its job: receiving the ground as the foot pronates and transferring that energy into the next step. Instead, overly supportive footwear with thick cushioned outsoles mask the foot’s initial impact forces—bypassing the foot’s arches—but still allowing those forces to travel upstream into the shins, eventually to the knees, hips and low back. Additionally, many cushioned running shoes with elevated heels make heel striking comfortable by slowing the rate of loading, but this does not eliminate the impact forces. On the contrary, studies show that heel striking while running produces forces up to 3 times your bodyweight (7 times more impact force than experienced by forefoot strikers). For most people this can mean anywhere from 450-650 lbs. of force every single step! These impacts add up, since you strike the ground almost 1000 times per mile! When your foot and ankle are unable to adequately absorb and dissipate these forces they travel next through the tibia and fibula. Daniel Leiberman of Harvard Barefoot Running describes this heel-striking transfer of energy with an analogy of dropping a metal rod vertically on its end—the rod comes to a sudden, loud and jarring stop. It may seem counterintuitive to suggest less cushioning when considering forces of this magnitude; however, what happens with less cushioning is humans tend to naturally shift their running form towards biomechanically protecting their heel with more of a forefoot and/or midfoot strike. This running style is also commonly seen in cultures that are habitually unshod or typically wear only thin sandals as footwear, which highlights, perhaps, an ancient natural wisdom.

TREATMENT APPROACHES

While shin splints are more often experienced as a nagging pain, if left untreated they can progress towards debilitating pains and even stress fractures of the tibia. The first—and most obvious—approach to shin splints is to simply rest. Time heals and most cases of shin splint pain will resolve within hours to days after the triggering event. Ice and anti-inflammatories can help with immediate pain, but can carry a steep cost by reducing and delaying any healing response—which is what the inflammatory process actually is. Certain medical websites and running advice resources will suggest targeting the inflammatory response instead of targeting what is triggering the inflammatory response (tight muscles pulling on the periosteum and weak muscles unable to support the bone and joints), which is a very short-sighted way to approach chronic pain problems. We suggest briefly using ice for short bouts of acute inflammation following activity (only when needed), and utilizing heat to stimulate blood flow and a healing response during asymptomatic periods for a more nuanced long-term approach to chronic recurring shin splint pain.

Conventional podiatrists might also suggest stiff orthotics or other supportive cushioned inserts to help remedy shin splints. These devices might help with pain and comfort in the immediate short-term, but will ultimately weaken the muscles of the foot and lower leg, eventually leading to worsening symptoms.

The natural approach to rehabbing shin splints includes an active recovery and should be approached slowly, thoughtfully, and progressively. Once pain has subsided, stay active by cross-training and doing low-impact activities like cycling and swimming, while also regularly doing exercises (examples below) that target muscles in the foot and lower leg. These exercises are designed to mobilize and strengthen the muscles associated with shin splint pain:

1. 1. Lengthen the top of the foot and front of the leg → unlocks/releases extensor dominance and allows flexors begin shortening and strengthening.
   1. –Toe extensor stretch.
   2. – Advanced: kneeling tibialis anterior stretch.
   3. – Also try rolling bottom of foot on lacrosse ball and/or using a metatarsal pad
2. 2. Shorten and strengthen flexor muscles in bottom of foot and lower leg.
   1. – Toe yoga – for toe mobilization and dexterity.
   2. – Toe presses – strengthens flexors.
   3. – Toe curls – strengthens flexors.
   4. – Short foot – strengthens arch muscles.
3. 3. Lengthen and strengthen soleus muscles. The gastrocnemius crosses both the ankle and the knee joints, while the soleus only crosses the ankle joint. So to engage more of the soleus and less of the gastrocnemius, soleus exercises are performed with the knees bent.
   1. a. Soleus stretch. Simply only wearing zero-drop shoes or barefoot will help reset your calf muscle length, but stretching can help accelerate the process.
   2. b. Soleus strengthening.
      1. – Bent knee calf raises.
      2. – Seated weighted heel raises.
      3. – Tip toe walk.
4. 4. Strengthen peroneal muscles.
   1. – Calf raises that supinate/invert the ankle and roll onto outside of foot
5. 5. Barefoot walking is a total foot workout that engages all of the muscles of the lower limb; however, it’s important to start low and go slow. Weak muscles and hyper-sensitive feet can overwhelm inexperienced barefoot walkers shockingly quickly.
   1. – Advanced: barefoot running.

Walking Barefoot While Carrying Running Shoes

Once running, hiking, and moving again, it is generally wise to increase mileage and intensity by about 10% per week. If shin pain returns, take a couple days to rest, then mobilize and strengthen again before continuing on your path. If shin pain persists, contact a medical professional. The information contained in the post is for educational purposes only. If you are experiencing shin splints or similar pain, please seek medical advice before initiating any treatment regimens.

Written by: Dr. Andrew Wojciechowski, ND

If you’re seeking more individualized foot health care and would like to work with Dr. Andrew directly, you can schedule at Northwest Foot and Ankle.

Schedule a virtual remote consultation with Dr. Andrew Wojciechowksi, ND.

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Correct Toes Approved

What it means to be Correct Toes Approved

Correct Toes are the only toe spacers designed to be worn with shoes. Not all footwear will accommodate your foot while wearing Correct Toes. The reason for this is that conventional footwear does not allow for natural toe splay or natural foot function whether you’re wearing Correct Toes or not. Correct Toes can only be worn inside of natural footwear or naturally shaped shoes.

The goal of natural footwear is to mimic the barefoot experience as closely as possible.

Shoes with minimal added features allow for natural foot function and optimized foot health.

Correct Toes Approved footwear generally meets the following criteria:

• Widest at the tips of toes
• Zero-Drop construction
• Completely flexible allowing for full-foot flexibility
• Absence of a toe spring
• The shoes should pass The Shoe Liner Test while wearing Correct Toes

Widest at the Tips of the Toes

Choose foot shaped shoes! Your shoes should be widest at the tips of the toes. Tapered toe boxes are responsible for several common foot conditions, including bunions, overlapping toes, and Plantar Fasciosis. Not only are narrow shoes extremely uncomfortable, but they can also cause long-term damage to our feet. Tapered toe boxes restrict blood flow, contort our feet into unnatural positions, and hinder natural biomechanics.

Wide toe box shoes mimic our natural barefoot shape to promote blood flow, stability, and natural foot strengthening.

Note that a “wide” shoe does not mean that the shoe has a wide toe box. Most people use the Brannock Device to measure shoe size. This device is found in most shoe stores and is used to take three measurements of the foot. The Brannock device measures the overall length of your foot, the length of your arch, and the width of your foot. This width measurement is reflected in the A-EEE scale. Measuring the foot’s width is extremely important. However, the Brannock Device measures the foot width at the ball of the foot instead of at the tips of the toes. The result is that “wide” shoe lasts are made to be widest at the ball of the foot and still have narrow, tapered toe boxes that cram our toes and do not give our feet enough room to splay naturally. “Wide” shoes will often have the same narrow toe box as its “medium” size. Always look for shoes that are widest at the tips of the toes. The image above depicts the difference between a shoe with a narrow toe box (left foot) and a shoe that is widest at the tips of the toes (right foot).

Tapered or pointed-toe boxes are purely aesthetic. There is no benefit to wearing narrow shoes. When our feet are shod in a narrow toe box, our big toe (hallux) deviates inward—this consistent deviation is how bunions form. Over time, our feet are forced into an unnatural shape forcing our feet to conform to the shoe’s shape. Shoes should be shaped like our feet – not the other way around!

Tapered toe boxes restrict blood flow in our feet. Shoes with tight toe boxes cramp the toes and cause the big toe (hallux) to deviate inward. This deviation constricts the lateral plantar artery, which negatively affects blood flow. Blood flow is essential to tissue health, injury recovery, wound healing, physical trauma recovery, and more. The image above depicts the difference between foot temperature and blood flow, comparing a foot wearing Correct Toes (right foot) to a foot without Correct Toes (left foot).

Shoes that are widest at the toes allow for natural toe splay. When our toes are splayed instead of cramped, blood circulation is optimized, and our feet can move in a way that will enable them to build strength by moving naturally.

Zero-Drop

What is a “Zero-Drop” shoe? Zero-Drop refers to the height difference between the heel of the foot and the ball of the foot. Zero-Drop design footwear refers to shoes where the heel and the ball of the foot are equal distance from the ground. When a shoe has a 0mm drop, there is no heel elevation or difference in height between the heel and the ball of the foot.

Zero-Drop shoes mimic our natural barefoot stance to promote balance, stability, and resistance to injury. The absence of heel elevation allows the foot to move, bend, and function without having to make unnecessary adjustments in posture, step propulsion, or gait. Lems Primal 2 pictured above.

Elevated heels are not exclusive features found in women’s shoes. Sneakers, loafers, sandals, boots, and athletic shoes for men, women, AND children can have subtle heels that are as tall as one inch in height! Though we do not label these shoes as “high heels,” it is important to note that heel elevation of any height causes our bodies to make adjustments in the feet, ankles, knees, hips, spine, and neck to maintain a standing posture. Left, barefoot, weight shared equally on heel and ball; right, on 3-inch heel weight shared 10% on the heel, 90% on the ball of the foot.

While standing barefoot, body weight is distributed equally between the heel of the foot and the ball of the foot. When elevating the heel, this weight distribution is thrown off dramatically. When shod in a 3-inch heel, 90% of our weight is carried on the ball of the foot and only 10% on the heel. Left, normal state of Achilles tendon and calf muscles barefoot; right, shortening of the tendon and muscles on medium 2-inch heel – and greater still on a 3-inch heel.

The adverse side effects of heeled shoes are not limited to the foot. Regularly wearing heeled shoes can result in the shortening of the Achilles Tendons and Calf muscles. In severe cases seen in habitual high heel wearers, the shortening these muscles and tendons result in the inability to walk comfortably when barefoot. Since both the Achilles Tendon and the calf play an essential role in walking, shortening these muscles and tendons results in altered step propulsion and changes in natural gait.

Many habitual high heel wearers experience pain while barefoot or when wearing shoes without a heel because their Achilles Tendon and Calf muscles have been permanently shortened. Sagittal MRI scan of the plantar flexor muscle-tendon unit (MTU). Images show the MTU while standing on a wooden wedge (left) and on a flat surface (right). Both images were obtained from a non-habitual HH wearer.

Completely Flexible

Conventional shoes have thick, clunky soles consisting of several components (outsole, midsole, sock liner, filler materials, cushioning, etc.). These components result in very stiff soles that do not allow for natural gait. When barefoot, the foot flexes about 55 degrees at the ball of the foot. Shoes with rigid soles flex 30 – 80 percent less than the unshod barefoot flexion—this inability to bend results in resistance and energy strain with every step.

Minimal or barefoot-style shoes have super flexible and thin soles that allow our feet and toes to move and flex naturally. Left, normal 55 degree angle of foot flexed for step push off; right, typical 25 degree flex angle of shoe. Creating flex resistance and energy strain.

Toe Spring is added to shoes with stiff soles to aid in step propulsion.

Wearing shoes that do not allow for natural foot movement can result in weekend foot muscles, shortened tendons, and foot and lower leg pain.

Always choose shoes that allow your foot to move and bend naturally. The healthy foot does not need any added features to aid or improve gait. Vivobarefoot Primus Lite exemplifying a completely flexible sole.

Absence of a Toe Spring

Toe spring refers to the upward angle of the toe box found in most conventional footwear, particularly athletic shoes. The angle between the ball of the foot and the end of the toe box in shoes with this feature can often be 20-25 degrees. This feature is often added to most modern footwear, primarily athletic shoes with the idea that it is helping us roll through our gait pattern and is somehow enhancing our gait. The reality is that toe spring weakens our feet and can lead to several foot conditions such as hammertoes, shortened tendons, foot pain, and limited movement of the toes. Toe Spring, the up tilt of toe end of the shoe; built into the last and transferred to the shoe.

Always choose footwear that mimics natural barefoot stance and avoid any additional features that may interfere with natural biomechanics. The absence of toe spring allows for natural step propulsion which enables our foot to build strength naturally.

Passes the Shoe Liner Test

The Shoe Liner Test determines whether or not your shoe has a wide enough toe box to accommodate your foot while wearing Correct Toes. When considering wearing Correct Toes with shoes, first perform the Shoe Liner Test to determine if your shoes will accommodate Correct Toes.

Passing the shoe liner test means that your shoe is widest at the tips of the toes and that your foot and all of your toes fit on the shoe liner while wearing Correct Toes. If your toes spill off the sides of the shoe liner at all, this indicates that the toe box is not wide enough to accommodate your foot while wearing Correct Toes.