I figured I would kick of May’s blog posts with a bang and discuss one of the most common pathologies we treat in podiatry. Heel pain. More specifically plantar fasciitis. Each day I encounter numerous patients suffering from this in either a chronic or acute form. Why is it so prevalent in our society? I’ll give it my best to try to explain why it is so common.
To begin with, we live in a society that thinks we need “good shoes” for our feet because we need to “support” our arches. How do we define “good shoes” and “support”. It’s obviously very subjective, but the ultimate answer is our feet aren’t looking for shoes or support. Remember the days of being a kid and running outside barefoot? Still today as you watch any young child they can’t wait to kick their shoes off and run barefoot. I bet most of you reading this article who are on your feet all day can not wait to get home and take off your shoes. Why? Our feet were meant to work without shoes. Consider, it’s the only part of our body that we “support” or wear something on that we feel is “needed” to function. But do we need shoes? If you examine the history of shoe gear, you will see that it has evolved over time from being an item that simply protected the soles of our feet from the environment, to a rigid device with a heel and tons of cushion and support. We really have no scientific reason for this. In fact, a lot of it has come at the the discretion of the shoe industry and fashion world. How many men really want to be in a stiff soled dress shoe with a 3/4 inch block for a heel? Probably zero. Even the ladies who LOVE their high heel shoes can’t wait to take them off come the end of the night. I’m sure you’ve seen, or even experienced, someone taking off their high heels at a wedding because their feet were killing them. I had a friend reach out to me last week about having his plantar fasciitis “flare up” again because he is standing in the OR all day in dress shoes. He wanted to solve the problem by getting some “inserts”. Inserts may help. The key word is “may”. Scientific studies do show improvement to some of those wearing the inserts, but we still don’t know why or what it is actually doing. The support or change in position they are providing can be achieved naturally by strengthening the foot and improving our postural musculature to reduce abnormal pressure to our feet and arches. The means for prescribing and fitting orthotics, although taught to follow a systematic implementation, often becomes very a haphazardness approach differing from one practitioner to the next. Even the lab that is performing the minute measurements and creating the device often produce something different then what was intended by the clinician due to the human error involved given the difficulty level measuring the joint’s angles and range of motion. What advice should I give my friend? I told him I would certainly get him into orthotics if he wants, but for starters, “you need to get out of those dress shoes!!!”. Strengthen the feet a bit by walking naturally without supportive shoes and see what happens. It’s not that he needs an arch support, he needs to learn how to stand and walk again. Maybe a consultation with a 5 year old child would help!!
Continuing on with the discussion of “do we need shoes?”. I would think so. But not shoes as most of our society tends to think of them. Let’s try to simplify this:
Men’s and Women’s dress shoes: These are status and image needs. Our society has created this. The shoe is in no way protecting our feet, nor is it providing support. It’s basically creating injury. If you weren’t expected to wear them, most likely you wouldn’t.
Industrial Shoegear: Many occupations require steel toe boots, or stiff soled boots for protecting the feet from hard objects etc. This is probably needed to protect the foot from becoming damaged due to trauma. The real challenge lies in allowing the foot to function naturally, yet protecting it from the environment.
Athletic Shoes: This can be an extremely controversial topic. What is best for the foot during the challenge of an athletic event? Most athletes have developed some sort of strength for their feet throughout life so the shoe at this point it is necessary to allow them to participate at a higher level. This of course does not account for all athletes and there are still situations where many athletes, even runners, develop plantar fasciitis.
Everyday shoes: That’s sort of a misnomer. In the US, shoes are a fashion statement. Period. I’m sure many of you at one point have heard someone say, “Those are cool shoes! Where did you get those?”. Point being – are they needed?
So where am I going with all of this? Our society, in one way or another, has influenced our selection of what we place on our feet for more reasons other then to protect them from the environment. Over time this leads to standing, walking, running, and functioning in a manner that is not normal for the body. Our body responds by compensating, not using the postural muscles to keep us standing and eventually the joints become stressed given the unnatural movement and lack of musculature control. Eventually the muscles become so fatigued in the foot that overuse injuries occur leading to the catch all term plantar fasciitis. What do most individuals do at this point? They go out and look for a “good shoe” and the circular process continues.
It would be very interesting to see what would happen in our society if would could crack the code on shoe gear and move from what is expected to be on our feet to what should be on out feet. We’ve seen a complete industry shake up in the running shoe world as a market of minimalist shoes have come into existence. Some may argue that they have existed for years known as racing flats. This is very true, however, they were not worn by the masses. Running is one of the only sports where you train in a shoe that is completely different from that of which you compete in. Does it make sense to wear a supportive shoe for the majority of your training which weakens your foot to then go and compete in a racing flat which is going to make your foot work harder to stabilize itself and absorb the impact at foot strike? Podiatrist Kevin Kirby, an advocator of using orthotics for running injuries both for treatment and prevention, advocates running barefoot as a training tool to increase strength to the foot. He also has called minimalist shoes a fad advocating runners to adhere to the unproven paradigm of stability and motion control shoes that are prescribed according to foot type. This approach does not make sense in accordance to the sport specific model of training. It’s difficult for me to understand how we can advocate so many different approaches to the foot for running (orthotics, stability control shoes, racing flats, and barefoot) when they are all very different. Why would you want to immobilize the foot and not strengthen it during training by using orthotics and motion control shoes. It would be like telling a baseball pitcher to wear a sling all week while practicing to protect the arm, then on game day go out and through as hard as you can. I’m not sure that’s being done in the major leagues.
In conclusion, plantar fasciitis is a lot like many of the illnesses our society continues to see by lack of prevention. Using orthotics and rigid shoes to treat it, is not much different then masking high blood pressure by taking medication instead of exercise and diet. You may be able to control it, but the causes are still there. Hopefully we will see a change in the paradigm used to treat this condition which will end the frustration of many patients who are not responding to the current model. Studies are being conducted by myself as well as others in the field that have been showing promise to the new proposed treatment. Paradigm changes take time and obviously one of this magnitude will take even longer.