More than two years ago, I made a shift in my practice. People told me that I would lose patients, that my colleagues would be taking care of all the stress fractures that I would create, and that I should lose my license because I was violating the Hippocratic Oath of doing no harm.
I had made a decision to introduce a philosophy into my practice that was not only against podiatric teachings but also against the norm in the field of podiatry. The decision came after experiencing a life-altering choice to avoid shoe gear as we used to know it. Not only did I abandon my traditional running shoes, I also stopped wearing anything with a heel or any arch support.
The naysayers refer to the minimalist shoe as a fad. Many in the field of podiatry still have a hard time accepting the change but it is happening. We have seen a rise in the number of shoe companies that offer minimalist footwear from only six in 2010 to more than 60 currently.1
In a lecture on barefoot running and minimalist shoes at the APMA annual conference earlier this year, Paul Langer, DPM, noted the positive effects of improving form.2 He notes that discussing running form changes with patients is part of his treatment toolbox that includes shoe gear changes and/or arch supports.
Initially, I saw an influx of patients who wanted verification that they could run with minimalist gear. They inquired about the proper guidelines of transitioning to minimalist footwear. To ensure they were receiving adequate information on proper running form, my practice partnered with the Physical Therapy Center of Akron, Ohio. Here I spent ample hours educating them on this philosophy so everyone was on the same page. Fortunately, they were excited to help runners. They even had a staff member who was an elite runner and already capable of explaining and teaching proper form.
During this initial period, we saw no stress fractures in any of the runners who were transitioning to minimalist footwear. Throughout these two years, we have yet to see a fracture directly related to minimalist shoes or barefoot running. Interestingly enough, I have had three cases of stress fractures in runners who were wearing traditional running shoes.
We tell patients to support the arch, wear thick-cushioned, motion-controlled running shoes and avoid going barefoot. Does it work? Yes, when you add anti-inflammatories, stretching exercises, cortisone injections, night splints, controlled ankle motion walkers, six to 12 months of recovery and more than $1,000 of patient fees.
Instead of asking what is resolving the pain, I like to think of what is actually causing the pain. Studies demonstrated that the tissue we remove during surgery to release the plantar fascia has no inflammatory changes associated with it.3 What may be inflamed are muscular structures — the abductor hallucis, flexor digitorum brevis and abductor digiti minimi. These muscles all originate from the same point on the heel bone as the plantar fascia. They all work in conjunction to help stabilize and support the arch by controlling the flexion capability of the toes. In other words, through the action of flexing or curling the toes against the ground, the arch acquires support or strength in order to function and stabilize the foot during standing, walking and running.
Functioning in rigid or stable shoes lessens the actions of these muscles. This leads to atrophy and the muscles’ job of supporting the arch becomes compromised. With time, the muscles eventually become overused and develop a tendonitis-like situation. Tendonitis usually presents with pain when activity begins. It subsequently improves as the structures warm up only to return later in the day. This explains why patients with plantar fasciitis have pain early in the morning upon rising from bed and immediately upon standing from periods of rest. It is the muscular structures, not the plantar fascia itself, that are inflamed.
Irene Davis, PhD, PT, the Director of the Spaulding National Running Center at the Harvard Medical School, has conducted extensive research on the biomechanics and use of orthotic devices in the lower extremity. She has now changed her mindset on using orthotics as a permanent treatment for overuse lower extremity musculoskeletal injuries.4 This comes after many years of research and significant grant funding.
As Dr. Davis notes, the evolution of her thought process was a culmination of a number of things over several years, including the research she was conducting on the impact forces known as impact transients and an understanding of how these impacts were related to injury. In her research, she noted how forefoot strikers do not have impact transients and how barefoot runners naturally do not typically land on their heels. This led Dr. Davis to believe that barefoot running was a great way to encourage a natural foot strike pattern, promoting strong feet.
Along the same lines, consider flip-flops. Are flip-flops bad for our feet? Not necessarily. What is bad is functioning in them with weak foot and leg musculature. As a person functions all winter in a supportive shoe, albeit with an arch and/or heel, these muscles weaken or atrophy. An abrupt change to a flip-flop then causes these muscles to become rapidly overused. When do people make a gradual adaptation to flip-flops? Rarely. They put them on and typically wear them for a period of hours or sometimes up to an entire day. It would be comparable to not running for six months or more, and then running for several hours straight.
I noticed a common response from runners and even patients with chronic plantar fasciitis when I introduced the minimalist concept.
"Everyone else is telling me I should be wearing arch supports, running shoes, and not to go barefoot!"
My reply: "Is it working?"
Obviously, it was not or they would not have been here for help.
How do I treat these patients with acute plantar fasciitis? I instruct them to rest the foot until the pain becomes tolerable. Then they can begin exercises for strengthening the muscle and realigning the muscle fibers. They can accomplish this by decreasing activity, wearing a cushioned running shoe temporarily and possibly an over-the-counter orthotic if necessary. The key is stressing the word temporary. Obviously, non-steroidal anti-inflammatories (NSAIDs), icing and stretching play a vital role in healing. However, the key is educating patients on what caused the condition and getting them to strengthen their feet.
If the situation is chronic in nature (greater than six months) and patients have failed other treatment with orthotics and motion control shoes, my approach differs. I will make the suggestion to begin going barefoot 20 minutes a day and gradually progressing each week. Of course, patients respond by saying all of the other physicians have advised not going barefoot. My response is to question if wearing shoes and orthotics worked for them. A more regimented program of physical therapy also helps.
There is one caveat to this treatment regimen. For those who are required to be in rigid steel toed work boots for eight to 12 hours a day, sometimes an orthotic is the only option to treat these people as they need external control. They have no ability to function adequately in such a rigid shoe.
Most of my progressive treatment thus far has been on runners. I have stopped implementing foot orthotics in all of my patients who are runners. I encourage transitioning to a midfoot or forefoot strike pattern. Of course, this is not the only solution as we also discuss training patterns and workouts that could lead to overuse. For those who are not suffering from chronic injury, the goal is to teach proper running form and not focus on a change in shoe gear. We do stress the importance of how we are no longer recommending shoes based on foot type and motion control.
As we continue to see more of a shift toward focusing on encouraging natural foot movement and strength as opposed to control, a reduction in plantar fasciitis and other chronic overuse injuries is likely to occur in my opinion.
1. Dicharry J. Anatomy for runners: unlocking your athletic potential for health, speed and injury prevention. Skyhorse Publishing, New York, 2012, p. 135.
2. Langer PR. Barefoot running/minimalist shoes: is there truly a controversy here? National APMA Annual Scientific Meeting, Marriott Wardman Park Hotel, Washington, D.C., August 2012.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(3):234-7.
4. Personal communication with Irene Davis, PhD, PT.