Dooley Noted: 4/7/2016
As a former employee of the New York College of Podiatric Medicine, I know the DPM students learn their anatomy – as well as their gait cycles.
So, I know they know that three of the four phases of gait involve the calcaneus (heel) moving inwards in the coronal plane.
This is a position often deemed as rear foot supination, which drives the talus bone into external rotation and shoves weight more to the outside of the foot.
But – in order to be fully powerful in any movement, one must be stretched in the opposite direction first.
It’s the length-tension curve principle of biophysics.
Want to launch a rubber band across the room? Pull it back first.
So, the four phases of gait do just that for supination power.
This gait phase involves foot pronation, seen in the suspension phase (front leg planted, bearing much of your weight).
I’m not sure what many podiatrists or running stores have against pronation.
From orthotics to shoes with excessive posterior buildup, people are encouraged to support their arches at all times.
There’s just two major problems with this:
1. If something is supporting you, your muscles get the cue that they don’t need to do it for you.
2. If your foot is stuck in an arch, you never get a chance to properly enter a healthy pronation of the foot. Pronation allows the healthy lengthening of the plantar fascia, relative to the bones to which it connects.
So, why do people get plantar fasciitis or Achilles tendinitis – both problems with proper access to pronation and supination?
Are they overpronating?
They are often told to wear everything from insoles, to orthotics, to Croc shoes and shoes with heels. These interfere with the pronation and encourage foot supination.
In my 9 years as a chiropractic rehabilitation specialist, I’ve yet to meet one person with plantar fasciitis nor Achilles tendinitis that could pronate well.
Achilles tendinitis and plantar fasciitis have a major anatomical connection: the calcaneus.
Both the Achilles’ tendon and plantar fascia are anchored to the calcaneus.
And the calcaneus must evert (move outward in the coronal plane) in order to take tension off the Achilles’ tendon AND the plantar fascia.
These are the consistent findings I observe with these conditions:
1. A foot stuck between pronation and supination, with a lack of calcaneal eversion or lack of ability to move from inversion Ito eversion
2. On palpation, a painful, tight arch, as well as painful, tight tibialis posterior muscular attachments to the tibia
3. Hyperostosis (extra bony formation) at the site of the medial and intermediate cuneiforms (midfoot bones on the top of the foot)
4. In suspension, a lack of proper femoral internal rotation at the hip, with excessive medial knee movement to compensate
5. Callus/corn formation and/or excessive wear pattern on the lateral side of the foot and footwear
While these five factors absolutely support the idea that the patient does not properly pronate through the rear foot, the same patients have always been suggested by antiquated therapists to do the following:
1. Wear orthotics that anchor the foot in supination.
2. Wear heels to prevent pronation.
3. Wear Crocs or shoes full of cushion material to pamper the foot.
4. Avoid being barefoot, which encouraged pronation.
5. Avoid flat footwear, which encourages pronation.
Regarding each of these five recommendations, I’d like to offer my educated two-cents to counter their suggestions.
1. Regarding orthotics: Telling a painful heel or arch to never pronate will absolutely rob you farther up in the kinetic chain.
If you never allow the foot to pronate, you can never load the gluteals to full eccentric positioning.
If you can’t load it, you can’t explode it.
That’s why we don’t do glute bridges to get a butt to strengthen.
A single-leg deadlift gets the glutes abduction power, because it loads you first in pronation and drives you then towards midstance by approaching supination.
This pelvic control is crucial for the mobility, stability, and strength to maintain gait.
2. Regarding heels: Heels encourage weight to shift into the forefoot, which will encourage you to activate the anterior hip chain and encourage anterior pelvic tilting.
Shift the weight more forward, and you increase into the knee and low back.
For people with tendencies toward low back/knee pain or current anterior pelvic tilting, prepare for these situations to worsen.
3. Regarding comfy shoes: Your feet were not designed to walk on cushions.
The vast majority of the foot’s dorsal and plantar surfaces are innervated by sciatic nerve’s branches.
Thus, the 10,000+ sensory receptors of the foot provide afference (incoming cues) to the muscles who share their innervation.
In other words, the foot cues the hip.
Also, the bottom of the foot is innervated by mostly L5-S1, the neural drive to the entire posterior chain and lower anterior chain musculature and joints.
Putting on cushy shoes is like trying to do fine details with your gloves on your hands.
(Try commenting to this post with gloves on. I’ll wait.)
If your feet can’t read information from the ground, the majority of the lower extremity goes without cues.
So, while your Crocs are comfy, it is a crock that they truly help plantar fasciitis and other foot ailments.
A comfy foot is a lazy input to the structures higher up in the kinetic chain.
Your foot has 28 bones on average, all designed to read information from the ground to provide proper cues to structures higher up.
Get out of the comfy shoes and learn to be uncomfortable at first in the foot to earn the mobility, stability and strength you earned as a barefoot child.
4. Regarding being barefoot: i have personally suffered from everything from plantar fasciitis, Achilles tendinitis, bursitis, as well as pain in and around the knee, hip, low back, SI joint, shoulders, and neck.
The first step to getting out of chronic pain was to go barefoot at home – and go more barefoot during training.
The ligaments of the foot – including the plantar fascia – are slaves to the muscles controlling joint movements.
After all – joints were made to move, and muscles were made to control movement.
Since the foot’s arches are under muscular control, one must explore the foot’s afference of ground force to properly cue the movement system (as described above).
Was I uncomfortable at first at the foot? Hell yes!
My feet were used to running in cushy Mizunos and Sauconys, making my foot move like a block.
But my feet felt lovely! Instead, I had other pains creep up.
My knees were wobbling medially, causing terrible bursitis that made me fear medial meniscal surgery was eminent.
My hips were constantly tight and locking me into an anterior pelvic tilt, causing gluteal amnesia and low back hyperextension that left my back sore for days.
My pelvic and back positions lead to interrupted timing mechanisms for building intraabdominal pressure, causing me to go vertical with my breathing. This left me with enormous neck tension and shoulder protraction, as well as costochondritis.
Yet my feet, while running, felt great!
When I took my shoes off, though, I would get crippling plantar fasciitis, alternating with Achilles tendinitis.
So, I took Eric Cressey’s advice in 2010 and related all my ailments to my feet.
I transitioned into NB Minimus, then into Merrel’s. Now, I train barefoot as often as possible.
In the past six years, I’ve watched the total disappearance of 99% of my discomfort, with the 1% due to biomechanical mistakes I made without correction.
I’m typing this completely pain free, at 37, and barefoot.
5. Regarding flat shoes: Of course flat shoes will pull on the plantar fascia and/or Achilles’ tendon, if you aren’t used to the shoes!
You can’t expect your locked calcaneus and midfoot bones to suddenly accommodate you. The muscles that are designed to control them have been shut down by your choices and footwear that encourage some midpoint between pronation and supination.
Your body is smart – not a stupid, pain-generating machine. It generates pain in response to perceived threat and tolerance level.
And if your foot cannot learn how to pronate, expect compensation up the kinetic chain.
If your foot has not learned how to properly pronate, don’t expect to learn how to properly supinate, either.
You’ll be stuck somewhere in between the two, with all four of your gait phases compromised.
Pronation needs to become your favorite nation.
Perhaps you need to learn how to do it, and then revisit this nation often.
Feel free to come to Catalyst SPORT, where you will be encouraged to either train barefoot or in shoes that encourage barefoot technology (I.e., encourage a dynamic foot).
Be patient with yourself.
Your foot will have to be uncomfortable before it can get comfortable – as in strong enough – to support the system above.
Don’t give up the first week of transitioning into shoes that help you to pronate more efficiently.
Don’t give up on exercises that encourage pronation, like lunges, the single leg deadlift, and the single leg squat.
Or you can believe the hype, where the doctors and therapists confined you forever to heels and cushiony shoes, telling you you’ll never be able to pronate naturally.
As always, it’s your call.
-Dr. Kathy Dooley