Image by Mitch Mandel (September 2010 Runners World)

Exercising while barefoot is a good way to work on your balance, proprioception (joint position sense) and lower leg strength. Runners World has a fine short article on Barefoot Exercise written by Adam Bean (which I was interviewed for) in the September, 2010 issue and online.

Several Videos of an agile athlete demonstrating the exercises are online and on the iPad app.

The wobble board exercise is particularly good for many ankle injuries as part of a recovery plan. The toe curls and toe pickups can be helpful in conjunction with an overall plan for plantar fasciitis. Overall the series of exercises was set up for a healthy runner. In you have an injury, check with your sports doc or PT for advice specific to your injury.

Toe Curls

Toe Pickups

Wobble Board

One-leg Hops

One Leg Squats

Best quote of the day was by Chris Mcdougall in the New York Times:

“You know any sport has gone off the rails when you have to remove body parts to do it,” said Christopher McDougall, the author of a recent book about ultrarunning called “Born to Run.”

With it’s motto of “all the news that’s fit to print” the Times seems to have not had room to fit the rest of what I’m sure Chris said. First, “Born To Run” is about a quest to run, and Chris’s quest was answered by running barefoot or in minimalist shoes. What I’m sure Chris said was that it might be easier to remove your shoes than have your toenails removed at their roots.

The article highlighted ultramarathoners who had elected to have all of their toenails removed rather than suffer thick nails, ingrown toenails, and bleeding underneath the nails. This is not something that would be done often or by many. It is not something that should really be necessary to do. Many runners, tennis players, and other athletes have problems with “black toe” or bleeding underneath a toenail or two. The first thing to do is make sure there is enough room at the front of the shoe. Be certain you have a fingers width in front of the longest toe. Make sure your socks fit well and don’t pinch your toes. Your socks should be made of a wickable material. Cut your toes just at the end of your toes, not too long, and not too short.

If you’ve developed bleeding under your toenail and it has turned black, don’t panic. If you have Diabetes, or any other medical problem that could cause foot insensitivity or a neuropathy, get to your doctor or some place to be checked fairly quickly. If it hurts see your podiatrist for evaluation and advice. You may gradually have the nail fall off, but the new nail will reattach properly over 90% of the time. With repeated injury the toenail will usually thicken and in some cases it may not attach quite as well.

For toes that repeatedly grow in at the corners, having a portion of the ingrown part permanently removed might be the best option and a wise choice. For a toenail that has fallen off after bleeding underneath, and has a new toenail growing,  the new nail will usually reach the end with no problem. It moves forward slowly like a glacier and pushes the skin down in front of it. On occasion a corner won’t grow out and it will have to be removed. Only rarely does the entire front edge dig in and require removal of the whole nail. But, removing 10 toenails permanently? Sorry, I don’t expect to be doing that any time soon. I’d rather have you toss your shoes, and find a better fit. And Chris would get you out for a barefoot run.

Can Shoes Be “Tiny Coffins”. Yes, they can.

(Please read comment section below. Author Chris McDougall has posted an informative comment and added to the quotes seen in Born To Run.  I’ll extract from the quotes, but be sure to read the comment. (If it says “comments closed”, which the blog does automatically at a set time interval, please click on the blog title which will open this entry in full, with the comments visible.) The thrust of this blog entry will remain the same. For me the deadly shoes I’m speaking of point to the neuropathic foot which was a large part of Paul Brand’s professional life work. )

Paul Brand, M.D. (1914 – 2003) was quoted by Chris McDougall in Born To Run as essentially saying that if everyone stopped wearing shoes, his office would be less busy and most foot problems would disappear in a generation.

Paul Brand 2002

While many may think Paul Brand had an ordinary waiting room, he did not. Brand did not specialize in treating the usual foot problems. He was a brilliant innovator on the special problem of diseases which cause loss of pain sensation via neuropathy.  He worked for many years at the National Hansen’s Disease Center at Carville in Louisiana. He specialized in  the orthopedic treatment of Hansen’s Disease (leprosy). Among other innovations, his work led to contact casting to help heal ulcers in feet with neuropathy, such as diabetics and those with Hansen’s Disease.  He contributed a good deal to knowledge about the significance of neuropathy in the creation of ulcers and to the care of insensitive feet. (Brand also worked extensively on hands with problems related to neuorpathy and insensitivity.) These neuopathies also affected strength rations of opposing muscle groups which often led to significant foot problems including hammer toes and bunions. Insensitivity combined with altered biomechanics, physical deformity, create special problems in walking and wearing shoes, particularly ones that are not fit well and do not serve to balance areas that are overloaded by pressure (pressure points on toes, hallux valgus, or on the plantar surface (metatarsal area or any other part of the bottom of the foot).

Brand worked with patients whose shoes often did create significant and even life threatening problems. Lacking sensation, because of neuropathy, they couldn’t feel the blisters, ulcerations, and infections developing. Another one of his sayings was “Pain is god’s greatest gift”. A shocking statement, but he said that because those lacking normal sensation did terrible damage to themselves.

As tiny coffins in this case, the shoes which caused the problem could lead to an amputation of a foot or leg in a diabetic which would lead to a second amputation more than 50% of the time within 2 years. Amputation in diabetics also is known to have a high mortality rate over 5 years (up to 74%, note that bypass operations may help). Slow healing ulcers have a death from all causes mortality of up to 50% within 5 years. This is worse than many forms of cancer.

Chris McDougall has provided some direct quotes, ( I believe from one of Brand’s biographical works – which will is now added to my reading list.) I’ll add some of those here. For the remainder, please be sure to read the comment section.

“A high proportion of the world’s population walks barefoot most of the time, and the average person who walks barefoot has much healthier feet than the average person who wears shoes.”, said Dr. Brand. Speaking of his own personal experience he said that “The barefoot walker receives a continuous stream of information about the ground and about his own relationship to it, while a shod foot sleeps inside an unchanging environment. Sensations that are not used or listened to become decayed and atrophy. There is a sense of aliveness and joy which I experience walking barefoot that I never get in shoes.”

Chris reports that Dr. Brand said this of normal people in normal shoes. And adds that Dr. Brand was a proponent of barefoot walking and sports. We will accept that as Dr. Brand’s opinion and statement and warn people who do suffer from pain insensitivity to not take this as advice directed at them. They are usually given special advice to not go barefoot, and in many cases to have carefully designed shoes, often custom, with special insoles or diabetic orthotics designed to decrease pressure, and to lessen excessive pressures over areas at risk. In spite of this care problems may still develop and this is only a cursory and incomplete look at these problems and their causes.  Patients with pain insensitivity must perform a self-inspection daily.

I was lucky to meet Dr. Brand in 2002 at the American Podiatric Medical Association meeting in Seattle, Washington. Dr. Brand opened a special section on insensitive feet which included presentations by his former prodigies on their current work. While I spend more time working with athletes, all knowledge is helpful, and Dr. Brand was a true icon.

While I scoffed the other day at  the quote in the New York Times about shoes as tiny coffins that halted evolution, in cases like these they truly are tiny coffins. They could cause your loss of limb and ultimately put you at a much higher than normal risk of death. Seeing the New York Times quote calling them “tiny coffins” did immediately make me think of the neuropathic foot. We’ve previously discussed the cost of amputation. We also see that diabetic ulcers and amputation are also deadly problems.

Preventative care, helpful? Yes, of course.  Make sure it gets properly included in any health care reform. Medicare ( a government run system) includes special shoes, non-custom inserts, yearly foot checks, and some  insurance carriers include this also. Some policies cover custom orthotics for diabetics, but not for runners. The policies and medicare aren’t quite up to speed but they are improving. Make sure that encouraging healthy life habits and preventative care is incorporated in some fashion and included as a core feature in future health policy to assist in decreasing the overall cost of care and in particular the cost of chronic illness. If you are diabetic, get your feet checked regularly, check them yourself, and learn how to both check and care for them. Exercise as recommended by your physician, and make sure you eat correctly, and monitor and control your blood sugar appropriately. Follow advice from your podiatrist on what foot wear  and socks are best for you.

For the runners, I expect you should shortly find here some blogs on what bad can come to you from your shoe, and what steps to take.

References:

Diabetic foot ulcers: prevention, diagnosis and classification.
Armstrong DG, Lavery LA. Am Fam Physician. 1998 Mar 15;57(6):1325-32, 1337-8.

Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial. D. G. Armstrong, L. A. Lavery, S. Wu, and A. J.M. Boulton. Diabetes Care, March 1, 2005; 28(3): 551 – 554.

Revisiting the Total Contact Cast. Maximizing off-loading by wound isolation. Petre, M, Tokar, P, et. al. Diabetes Care  April 2005   vol. 28  no. 4  929-930

The total contact cast. A therapy for plantar ulceration on insensitive feet
WC Coleman, PW Brand, and JA Birke. J Am Podiatr Med Assoc, Vol. 74, Issue 11, 548-552, November 1, 1984

Mortality rates and diabetic foot ulcers. Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. J Am Podiatr Med Assoc. 2008 Nov-Dec;98(6):489-93.

What is the most effective way to reduce incidence of amputation in the diabetic foot? Apelqvist J, Larsson J. Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S75-83.

Diabetes Res Clin Pract. 1997 Jul;37(1):41-7. Mortality following lower extremity amputation in minorities with diabetes mellitus. Lavery LA, van Houtum WH, Armstrong DG, Harkless LB, Ashry HR, Walker SC.

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Moulik PK, Mtonga R, Gill GV. Diabetes Care. 2003 Feb;26(2):491-4.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Faglia E, Favales F, Morabito A. Diabetes Care. 2001 Jan;24(1):78-83.

Sense and Sensibility

Note: There are several comments, but the interface on word press blogs will only show them if you click on the title and view only this blog entry.

The media seems to have decided that barefoot running is the trend that can’t be stopped, and should perhaps be encouraged. “Throw away your shoes” seems to be the dominant theme, if not the only thing we hear. And no one wants to stand against the tide and seek balance.  I’ve run barefoot on the beach for miles, and enjoyed it. And I’ve done that for years starting in middle school. During high school, I enjoyed barefoot running along the beach during the run up to soccer season. And, even at that time professional football teams were said to do the same. But the current persistent hyping of barefoot is as balanced as are the discussions on health care reform. Some years back, HMOs were touted as the solution to all of our health care needs. But, they aren’t singing that tune any more.

Now we are told that we evolved to run barefoot. Shoes are tiny coffins for feet and have stopped evolution. Tiny coffins that stopped evolution? Really? Evolved to run barefoot? Well, yes we did evolve to run barefoot. But we’ve had 30,000 years to develop body coverings and improved aids to motion, comfort and speed. We’ve made shoes – one shoe fits either foot, domesticated horses (and even tamed elephants) to catch  a ride, added lifts to our sandals to move faster in battle (Caesar), made steam and coal powered engines for trains, boats, sailboats, steam boats, shoes – designed for right or left foot, made cars, bicycles, airplanes and rocket ships that have carried us to the moon.

We’ve gone from eating nuts and greens to meat and back to nuts and greens. We’ve made other aids like glasses, robot flown drones, satellites to explore the rest of the solar system. But wait, did we evolve for this? Or is it wrong? Should we be barefoot and living in trees or in caves? Could we run faster without shoes?

It is said that shoes don’t help prevent injuries. But does running barefoot? Does wearing “unbalanced” shoes help? Do those shoes help you burn more calories? One person’s opinion quoted in the NY Times was that they did, they made her legs sore, so they must burn more calories. To me, that just shows that she overdid it and was a victim of the “terrible too’s” – too far, too fast, too soon, (too often and too little rest).

Could we run faster without shoes? Since 1960, only at the Mexico City Olympics,  has the Olympic marathon been won as slowly as Abebe Bikila ran it while winning in Rome in what was a world record time in 1960 (2:15:16, an impressive time). In 1964, Bikila wore (Puma running) shoes in Tokyo, ran faster, and set another world record. He took 3 minutes off of his previous world record, running 2:12:11. The current world record of 2:03:59 is held by Haile Gebrselassie, who does wear shoes while racing. Of course the shoes the elite runners wear during races are usually racing flats. During training, there will be some variety, and some elite runners incorporate barefoot drills into their regimen.

Running barefoot should strengthen the intrinsic muscles of the foot. Those are the muscles that start in the foot and end in the foot. It could also have a strengthening effect on muscles in the leg. And for those who do need more support, it could have these muscles working harder than they should and not feel very good. Running barefoot or with minimalist shoes helps balance and joint position sense. Over cushioned shoes are distinctly bad for joint position sense (proprioception).  So yes, running shoes can cause many problems through bad fit, bad design, mismatch of foot to shoe, and in many other ways. That has been the subject of many lectures and articles. Unfortunately, there no longer seems to be a balance in approach to shoes versus barefoot, when it should be shoes and barefoot.

Looking at 30,000 (ya) year old to 2 (mya) million year old bones will tell you where we’ve been, but won’t tell you where we are as a species now. Wired magazine had a recent article quoting a renowned anthropologist who felt that running barefoot was the way to go, and that evolution would have taken care of plantar fasciitis and runner’s knee. Unfortunately, that may be a nice hypothesis, but we are all built differently and have different needs. Some are knock kneed, some are bow legged, some legs are just right. Some people have high arches, some have low, and some are just right. Some of us have 20/15 vision and can fly jets, others could run barefoot and naked in the sun without sunscreen and never get a melanoma, but that is not wise for most of us. Some can run a marathon in 2:05, others in 3:05 or 5:05, but there are vast differences between them.

In evolution there are many expressions of genes called “phenotypes”. There is no one size fits all. Regarding melanoma, skin color and vitamin D, an excellent example of evolution is apparent. With Africa the presumed origin of the genus homo, migration from Africa led to genetic (genotype) changes in the genes that affected melanin. Putting it simply, the northerners had a mutation that led to less melanin in the skin and a lighter mutation. This allowed for better absorption of UV and production of Vitamin D in the northern climes (less light, less intense solar impact). It is another example of differences through evolution and adaptation to the environment with survival of those best suited to the environment.

While some wonder if human evolution has stopped, many believe it continues in many ways. Social relations, altruism, tribalism, and many things have deep roots, but also morph and change. There are differences between us and among us. We all aren’t prepared to comfortably run barefoot. But some of us are. Those who are and those who want to should start slowly with a few minutes and gradually build on that. Don’t look at it as necessarily a cure all for everything. It will feel great for some, and not so great for others. It may solve some problems in some, it may create problems or not solve problems in others. So, no, I am not claiming that barefoot is all good, all the time, for everyone. And I’m not claiming that barefoot is awful,  bad for everyone, something for everyone to avoid, always. (There is no simple answer, there are few informative studies. But, to quote Leigh Peele with her classic and often used statement “it depends“).

On the subject of barefoot running, my views have evolved. My first interview on this topic was with a journalist who wanted everything black and white and refused to accept the possibility that in my opinion some may have a foot better designed for barefoot running than others. There was a refusal to accept that while I didn’t think barefoot was all good, I didn’t think it was all bad. The quotes used in that article didn’t reflect a nuanced approach but were couched as a warning not to run barefoot. This was not what I felt was correct for all. Not long after that another journalist got it right. I pointed the second journalist to the same barefoot subject pictured in the first article. The runner was shown with beautiful “C” shaped, mud covered feet after completing his first marathon barefoot. She wrote about it in the Orlando Sentinel, along with suggestions on how to start barefoot running. (The Philadelphia Inquirer and Washington Post within the past few months had recent quotes on starting barefoot running slow and easy and a little at a time in the context of a review of “Born To Run”.)

But, as we look at the one size fits all solution, we see a trend in approaches to a variety of injuries. While many years ago, people were told to stop running, they then were told that almost all injuries came from foot problems. Now it is core weakness. No one solution fits all problems. Each problem is really solved only by a “total approach” that looks at the injury in a multi-faceted way, and looks for what changes can be made in training, equipment, muscle imbalances, stretching and strengthening. One “fix” is not enough to get it right.

Insulin is a nice medicine. We don’t all need to inject it though. L-Dopa is good for Parkinsons, but we all don’t need to take it as a supplement.  Prozac is helpful for many, running does it for others. One size doesn’t fit all, nor does one solution.

NY Times Article

Best quote:

“In 95 percent of the population or higher, running barefoot will land you in my office,” said Dr. Lewis G. Maharam, medical director for the New York Road Runners, the group that organizes the New York City Marathon. “A very small number of people are biomechanically perfect,” he said, so most need some sort of supportive or corrective footwear.”

Pithy quote:

“The shoe arguably got in the way of evolution,” said Galahad Clark, a seventh-generation shoemaker and chief executive of the shoemaker Terra Plana, based in London. “They’re like little foot coffins that stopped the foot from working the way it’s supposed to work.”

Related Posts:

Comments on Chris McDougall’s fine book at http://www.drpribut.com/blog/?p=325

Bipedal Beginnings: http://www.drpribut.com/blog/?p=331

Evolution and Exercise: What Made the Brain Get Bigger: http://www.drpribut.com/blog/?p=368

Walk This Way: Oldest Bare Footprints – 1.5+ Million Years Old: http://www.drpribut.com/blog/?p=215

For more information and to visit a community forum I recommend the Runner’s World Barefoot Runners Forum with links and discussions on all things barefoot.

Music: Barefoot by Ray Collins Hot Club

To view comments please click on the title of this entry. There are several comments, but we are currently having some interface issues. For more discussion visit the active Runner’s World Forum linked to above.

Chris McDougall’s book “Born To Run” is probably the most fun and enjoyable book I’ve seen written about running. The prose is wonderful. The story telling is rich. And Chris develops both his characters and presents his thoughts on the evolution of running in a careful and thorough manner.  While I would disagree with the apparent conclusion that Chris and some others have reached that we have all evolved so well that barefoot running is right for everyone, I found so much else in this book that I recommend it whole heartedly. Chris covers diverse people and topics ranging from Barefoot Ted to Professors Bramble and Lieberman. I’ve read and thought about much of the scientific literature that Chris mentions in his book.  And I have a take on it that is much the same.  I will try to detail my take on some of the issues, but will not be casting any polemics towards this thoroughly enjoyable book. The science is only a small part of the book. The story is the thing. But the science is still worth thinking about.

This year is the 200th anniversary of the birth not only of Abraham Lincoln but also that of Charles Darwin. Darwin’s “Origin of Species” was published 150 years ago.  It is worth a look at how we got here, where we are, and how we fit into society and the world. We should look at why many of us like to run. Why is movement good for us and is life enhancing in many ways, and even life extending.

We’ll try to take a look at how we evolved to stand upright and run. We’ll look at what are the purposes, benefits and drawbacks of shoes in society and sport. What aspects of barefoot running are good and is barefoot the way to go for all of us? And up front, I’ll admit to having spent significant time running barefoot myself. Hopefully over the next few months we’ll have posts up detailing this and more.  With a long and ever changing list of topics to write on blog about, I’ll do my best to keep this at the forefront of my “to blog” list.

But I’ll again recommend reading “Born To Run”. It will make for enjoyable and thought provoking summer reading and you won’t have to wait for serial publication of the next chapter. You’ll just want to keep reading to find out what happens next. And after I finish the last 20 pages, Born To Run will sit in an honored place on my bookshelf. Right next to George Sheehan’s “Running And Being” and “This Running Live” and next to Amby Burfoot’s “The Runner’s Guide To the Meaning Of Life”. Murakami’s “What I Talk About When I Talk About Running”  is there too, along with many others, but a bit further over on the shelf.

If you’d like to see some of the details on hominid development of endurance running, see Bramble and Lieberman’s article from Nature (2004).

On the npr website is a spot by reporter Allison Aubrey on this topic. Allison came by earlier this week and interviewed me on foot problems and footgear, along with west coast podiatrist/pilates instructor Colleen Schwartz, DPM. Allison did a great job on putting this story together, is very nice, and has much high quality health information available at the npr site.

NPR Spot on Barefoot, Flipflops & Plantar Fasciitis