More weird podiatrist stuff

Over at Jason Robillard’s Barefoot Running University blog, he takes podiatrist Catherine “Cat” McCarthy to task for more of the usual crap about how only elite, Olympic-class athlete’s should even consider running barefoot. You’ll want to go read that. He debunks her points:

• that only world-class athletes can be barefoot runners;
• that our present environment is not barefoot-friendly, yet out ancestor’s environment was; and
• that the foot needs support.

But he did not link to her blog entry, so I went looking for it to read it myself. The entry is here, or I should say, it was there, because if you click on that link, you find that link does not exist.

However, you can can find the entry in the Google cache, here.

I wonder why it was removed? I know, if I had written it, I would have been ashamed enough to remove it.

Let’s see what she says. Here’s how she starts out:

If you are a world class athlete under the supervision of a team of professional trainers – please disregard my diatribe. Barefoot running shoes may be appropriate for you as you train for your future Olympiad event – best wishes and I sincerely hope you win!

If you are like me and the other 99.999999% of the world’s population – this review is for you.

She later goes on to say:

I cannot help but have an emotional reaction to people arguing for barefoot running and perhaps that is my own personal downfall but I have spent my career trying to heal people’s foot and ankle injuries caused by one false move in a bad shoe that did not protect their foot and led to injury and pain.

Well, there’s your problem: “one false move in a bad shoe”. Ya think it might be the shoe?

In her defense (slightly), she is mainly gigging on “barefoot shoes”, which are not barefoot, and because the soles of those things prevent proper feedback they might
cause more problems. However, there is still no evidence that shoes are better than bare feet when it comes to running injuries (though, of course, all too many podiatrists say that backwards — no evidence that bare feet are better than shoes). But, for non-running situations, we know that bare feet do not cause bunions, corns, or even fallen arches the way shoes (oh, yeah, those are “bad shoes”) do.

HuffPo? HuffGo!

OK, after trashing The Huffington Post for this article with ridiculous statements about barefoot running, I have to do the opposite for the article they published today: Barefoot Shoes? The Primal Reason You Want to Take Off Your Shoes.

The article is by Mark Sisson, described as “former elite marathoner and triathlete, author of the best-selling health and fitness book, The Primal Blueprint.”

He notes how we evolved (and did just fine doing so) with bare feet, and goes on to note:

We’ve still got those same feet, but we don’t use them anymore. Instead, we cover them up. We wear shoes that alter the structure and function of our feet, and that weaken the myriad tendons, muscles, and ligaments through disuse. We strap on rubber soles that sever our proprioceptive connection with the ground and restrict our nervous system’s ability to subconsciously respond to changing environments and protect us from tripping or turning an ankle.

He also describes our favorite Philip Hoffman study, “Conclusions Drawn From a Comparative Study of the Feet of Barefooted and Shoe-Wearing People”.

His call? “Go barefoot as often as possible. It’s as simple as that.”

Here, here.

And for some of us, that is all the time. Admittedly, everybody cannot do that, and Sisson also acknowledges that. I’d add that one reason everybody cannot do that is nothing more than cultural expectations, and one of the things that the Society for Barefoot Living is doing is trying to change those expectations and make going barefoot more acceptable. Sixty years ago jeans were restricted to farmers, and then hippies or college students. But today jeans can be worn nearly everywhere. There is no reason the perception of bare feet cannot change the same way.

Sisson also includes a reasonable caveat:

As with any muscle you haven’t been using for an extended period of time, your feet are probably weak, and rushing into mile runs or two hours hikes in unprepared bare feet will be painful and potentially dangerous. Ease your way into it, especially if you’re habitually shod.

Good advice.

It is nice to see many of the arguments we have made over the years make it into more mainstream media, and that the barefooting movement is not just us barefooters talking amongst ourselves.

HuffPo HuffPoo

The Huffington Post has a bit of a reputation among real scientists for promoting quackery, or at least promoting “medicine” that is not backed up by science. See, e.g., The Huffington Post’s war on medical science is noticed, Why is there so much medical misinformation in The Huffington Post?, and A science section for the Huffington Post? More like a pseudoscience section! (2010 edition). Now they have an article on barefoot running from Dr. Robert Kornfield, an “alternative medicine” advocate: Barefoot Running Shoes: How Effective Are They?. Dr. Kornfield is a DPM (Doctor of Podiatric Medicine), and I’m afraid his article reads much the same as others we hear from a lot of other podiatrists who are unfamiliar with barefoot or minimalist running.

As far as he is concerned, barefoot running (or, in this case, running in minimalist shoes) is a fad.

Barefoot running shoes are designed to re-create a “natural,” barefoot running dynamic on “unnatural” surfaces like concrete, asphalt, red top, black top, etc. How can we have a barefoot running shoe? Doesn’t barefoot denote without shoes?

Choosing to run on non-yielding surfaces without the protection afforded by proper running shoes can be harmful to the foot and ankle and cause even more problems downstream from compensation patterns. So what really are these pedal marvels and why is everyone running to take their shoes off?

Hey, at least he recognizes that a “barefoot running shoe” is not “barefoot.” But he also starts off with misconception number 1, that there is something different about “unnatural” surfaces. He goes on to say

Barefoot running shoe manufacturers believe that the human foot, unimpeded by synthetic surfaces and restrictive running shoes, should function at its best. That is a correct assumption, save for the fact that the human foot was designed long before the paving of roads. In fact, uneven, grassy surfaces are the most natural surface for the human foot because it helps the body navigate and respond to uneven terrain, while at the same time absorbs shock, stabilizes weight and propels the body forward. In order for this to occur successfully, most of us are born with a flexible forefoot and a rigid or stable rearfoot. In other words, at heel strike — when your heel hits the ground — your leg from the hip down is aligned for optimal function and is stabilized during normal walking.

OK, stop right there. He somehow seems to think that the human foot evolved in some sort of grassy park. Has he never gone hiking? You know, out in nature? There are all sorts of surfaces, from mud to sand to grass to rocks to hard pan. Those latter two are not all that different than asphalt or concrete. They also tend to occur a lot in the parts of Africa we all came from.

And then he talks about heel strike. I guess he just hasn’t heard about the research from Dr. Lieberman at Harvard. Barefoot runners who have been doing it any length of time don’t heel strike. What he does is introduce some sort of false dichotomy about heel strike: that is has something to do with whether you run on a natural or unnatural surface:

The lack of heel strike on unnatural surfaces is not mimicking the way the foot would perform barefoot on natural surfaces. For this very reason, these shoes will eventually come up short, as the foot requires either cushioned heel strike on an unnatural surface or minimal heel strike on natural surfaces.

No. When you run barefooted you simply do not heel strike, regardless of the surface (and if you do heel strike, you are doing it wrong, keeping the lousy habits you picked up from wearing shoes, in which the elevated heel guarantees a heel strike).

He then tries to give us a demonstration of this at work, and tells us that this decreases the propulsion of the big toe:

Try this. Hold your first metatarsal and pull it up as hard as you can, then with your other hand try to pull your big toe upward toward your ankle. You will find the joint will jam up and feel restricted. Now, hold your first metatarsal and apply pressure down toward the floor, then with your other hand, pull your big toe up toward your ankle. You will find a dramatic increase in the upward range of motion of the big toe — this is normalized function.

Huh? Ok, you can test this. The first metatarsal is the long bone just behind the toe bones. It runs from around the ball of your foot back to near the ankle bone (and of course, you have one for each toe). The one he is talking about is for the big toe, which does most of the work, which means its the one at the highest part of your arch.

So, go ahead, do what he says. Just inside your arch, pull up as hard as you can, then see if you can pull you big toe up. It’s really hard, isn’t he. So he is right about that. And if you let go of that first metatarsal, it’s really easy.

But what does this have to do with hard surfaces versus soft surfaces? Absolutely nothing. You see, under your first metatarsal there is a tendon (the one for pulling your toe down and applying force when you are running). When you press the tendon against the metatarsal, that prevents it from moving (you can feel it trying to work as you hold it down). So of course that prevents the big toe from moving against it. Duh.

However, there is a situation in which pressure is regularly applied to the bottom of your arch there (and which would then lead to decreased propulsion). That’s right: when you are wearing a shoe with arch supports, which nearly all running shoes do. The embedded arch presses the tendon against the metatarsal, reducing its range of motion. I have rather flat feet, and back when I wore shoes, those embedded arches always gave me a lot of discomfort as they severely restricted decent (and natural) motion.

And then he finishes with our favorite shibboleth: that only “special” people with “special” feet can get away with running barefoot. Because everybody else evolved with the shoes they came out of the womb with. Right. Oh, and for all those non-special people?

you can safely wear conventional running shoes manufactured by companies who have spent years on research and technology with the addition of a proper running orthotic.

(Emphasis added.)

Yup. Prescribing more orthotics to try to fix the problems that the shoes themselves cause. I’ve said it before and I’ll say it again: these podiatrists have never seen feet that have not been damaged (and had that damage perpetuated) by shoes. They have no idea what a strong foot looks like, or what a strong foot can do.

Da Nile

It’s more than just a river in Egypt.

A week ago there was an article in The Detroit News entitled Barefoot craze hits everyday footwear. It’s mainly just a plug for a shoe made by Sanuk that they call a “Sidewalk Sandal”. It is yet another minimal support shoe (though, of course, it is not barefoot). I suppose if you have to wear something on your feet for your job, it’s better than nothing. (Huh? What am I saying? Of course, nothing is better. Let me try again: if you have to wear something on your feet for your job, it is probably among the least burdensome. How’s that? But I digress.)

But then the article makes the mistake of talking to the usual coterie of barefoot-ignorant and barefoot-hostile podiatrists:

Podiatrists aren’t thrilled with this celebration of shoelessness. People wear shoes, they say, because in modern society they need them.

Really? Why? Any support for this? Of course not.

Few people have an ideal foot type that doesn’t require support, said Brett Sachs, a Wheat Ridge, Colo., podiatrist. “Most people I see are ones who have flat feet or high arches or are getting other types of symptoms related to the fact they don’t have the support their feet should provide them and stress is getting redistributed to other parts of the body.”

Now this is just crap. How the heck did our remote ancestors ever manage to survive? Practically everybody has an ideal foot type that doesn’t require support. That’s the way evolution works. That’s what was found in the Hoffman study I often cite. This guy, in his daily practice, sees nothing but feet that have problems because they spend all their time in stiff-soled shoes that make them dependent upon getting support. And then he thinks that feet are naturally that way.

I’m reminded of how, for the longest time, it was thought that back belts were the way to go to prevent job-related back injuries. Everybody knew it. Until an actual study was done. A Prospective Study of Back Belts for Prevention of Back Pain and Injury, by James T. Wassell, et al. in The Journal of the American Medical Associationa, December 6, 2000, Vol. 284, No. 21, p. 2727, found no effect at all.

Barefoot advocates say going shoeless makes them feel more powerful, but Clinton Holland, an Englewood, Colo., podiatrist, doesn’t buy it.

“The whole idea of strengthening your feet by not wearing shoes, there’s nothing that backs that up,” he said. But he’s not opposed to shrinking from support.

“I tell patients, if it helps you, do it,” he says. “If it feels better, then knock yourself out.”

OK, I’ve read few things quite as moronical. He is basically saying that exercising a body part will not strengthen it. Really? But it is so nice (and condescending) of him to let us know that he will deign to let us go barefoot. It would be nice, though, if he recognized the limits of his practice.

I’ve mentioned before that podiatrists rarely see people who go barefoot all the time, so they just don’t have experience in the area. When they were in medical school, the learned tons of information, but all that information had been distilled for them (that’s what medical school does—distills and presents the information they need in their practice), and that information had been based on studying a shod population. And when it comes to barefooting, they are operating outside of their field of expertise and often don’t even know it.

It is kind of like examples we see on Monsters Inside Me in which somebody picks up some tropical parasite, and that person has to go through a whole slew of doctors before they find one who actually knows what is going on.

Immune System

Over at the Facebook page for The Barefoot Book, author Daniel Howell asks:

Is there a connection between shoes & immunity? Many long-time barefooters report stronger immune systems.

I answered:

I’d be very careful generalizing. This is one area in which confirmation bias could be very, very strong, and an area in which one should be suspicious of anecdotes. I think a careful study with decent controls would really be needed to tease out any effect.

Let me go into more detail here.

First of all, what is confirmation bias? It is the tendency for humans to remember things that agree with what they already think and to forget those that disagree. This effect has been well-demonstrated in many cognitive studies. So, what we need to do is conduct well-designed studies that remove such bias.

Quite a few barefooters report fewer colds since they started going barefoot. Could that be from a barefoot-induced improved immune system? Well, I suppose it’s possible, but I personally tend to doubt it.

I’ve noticed that I tend to get fewer colds since going barefoot. But let me note how confirmation bias and other confounding factors could work into that. First, I have not kept careful track of my colds over the past years, so I really don’t know if I am getting fewer of them now. It may seem that way to me, but without accurate records, that could just be confirmation bias. Second, my kids are older now and have (mostly) left the house. When they were really little, it seems they were always bringing a cold home, and of course I’d catch it. As they grew older, they didn’t need such close care, and were much more careful about covering their noses when they sneezed, so transmission vectors were reduced. And now with them mostly out of the house, the opportunity for catching something from them is really, really reduced.

Now, that period coincides with my taking up barefooting. Without decent controls, it would be easy to attribute fewer colds to barefooting instead of what is the more likely explanation: fewer chances to get a cold.

There is also the question of mechanism. How might going barefooting increase the efficacy of the immune system when it comes to colds? Without at least a scientifically plausible mechanism, it all seems unlikely. I can think of two possible mechanisms, both fairly weak. First, we’ve noted that going barefoot can improve circulation. Maybe that does something, but the circulation is really only in the feet, and I don’t see how a cold virus would notice that, or how that would effectively raise the immune system. Second, and this one is more plausible, stress has been shown to depress the immune system. So if going barefoot gives you a better feeling of contentment and reduces stress, then it could improve your immune system. I’m not sure this is a really strong effect, though.

So, this is why I say it would really take a decent study to figure it all out.

So far I’ve focused only on colds. There are other areas in which I think barefooting might have a larger impact on the immune system. One reason may be the Hygiene Hypothesis, which suggests that an overly clean environment, one that our ancestors did not have, might insufficiently stimulate the immune system and lead to allergies. Of course, if you go barefoot, your body is physically exposed to a lot of dirt, so it could help with allergies.

In addition, there is the famous anecdote of the guy who cured himself of a severe allergy by infecting himself with hookworm. There has also been a study backing that up.

I can see another way the immune system could be strengthened. For all the hiking I do, I do occasionally get small dings on my foot, and those dings come into direct contact with the soil and soil micro-organisms. Of course, my immune system has to react to that. What I seem to have noticed is that (look out for confirmation bias!) while originally I would get some redness as my immune system had to develop new antibodies, the more I barefooted, the less redness would result, presumably because my body could call upon my pre-existing antibodies against those soil bacteria. That could come in handy if my body gets exposed to such bacteria in other contexts, and might give me an immunological advantage over a person who had not had such previous exposure.

Bottom line: there is some possible anecdotal evidence, but it needs to be backed up with carefully designed studies.

Flat Feet versus Fallen Arches

A couple of weeks ago, over at America’s Podiatrist, Dr. Nirenberg asked, “Can Barefoot Running & Walking Fix Flat Feet?” He references a study, The Influence of Footwear on the Prevalence of Flat Foot: A Survey of 2300 Children, by Udaya Bhaskara Rao and Benjamin Joseph (The Journal of Bone and Joint Surgery, Vol. 74-B, No. 4, July 1992, p. 525. The study was conducted on children in India.

Below is the criteria they used for grading an arch as high, normal, or flat:

Definitions of arch types

What they found was that while 2.8% of the children who went barefoot all the time had “flat” feet, 8.6% of those who wore footwear had “flat” feet. They also found that the more shoe-like the footwear, the more of the children had “flat” feet.

There was a related study done a few years later, “The Influence of Footwear on the Prevalence of Flat Foot: A Survey of 1846 Skeletally Mature Adults“, by V. Sachithanandam and Benjamin Joseph (The Journal of Bone and Joint Surgery, Vol. 77-B, No. 2, March 1995, p. 254. In this one, they compared the prevalence of flat feet based on the reported age at which the adult started wearing shoes. They found a 1.75% rate of flat feet in those who didn’t start wearing shoes until over the age of 16, and about 3.25% for those who started wearing shoes earlier.

It sure looks like wearing shoes contributes to a lower arch.

But what does that have to do with flat feet? Many folks confuse a flat foot (that is, a foot with a low arch) with fallen arches. In fact, Dr. Nirenberg says as much as he starts his blog entry:

Flat feet is a condition where the arch of the feet undergo collapse and flatten: That is why it is often also referred to as fallen arches. Individuals with flat feet can suffer from a variety of foot ailments, pain, and fatigue, which can also extend to the legs and back.

I do not think this correctly describes the situation. To understand what is going on, we have to go way back to a much earlier study, “Conclusions Drawn from a Comparative Study of the Feet of Barefooted and Shoe-wearing Peoples, by Phil. Hoffman, M.D., St. Louis. (The American Journal of Orthopedic Surgery (1905)). Dr. Hoffman had a chance to examine barefoot natives at the Louisiana Purchase Exposition in 1904. He checked their arches and found a fair proportion of them did have low arches. However, and this is important, he did not see any pathologies associated with those “flat” feet. As he put it

If these statistics are a fair index for all feet, the conclusion is justified that weakness of the longitudinal arch rarely results in its depression, and that flat foot as a pathological entity hardly exists.

The height of the arch appeared to bear no relationship to the gait. In shoe-wearers, the affection commonly called flat foot is often associated with more than ordinary eversion of the foot on standing and walking. This eversion is due not to the low arch, but to the associated weakness or stiffness of the joints of the foot and weakness of the muscles controlling them.

In other words, among the barefooted, having a low arch, or “flat” feet, has nothing to do with whether you have a “fallen” or “weak” arch. A weak or fallen arch, a result of wearing shoes and thereby failing to keep those muscles and tendons and ligaments strong (also pointed out by Dr. Nirenberg), is a different condition than merely having a flat foot (or naturally low arch).

So, can walking and running barefoot fix a flat foot? No. But can it fix a fallen arch? Almost assuredly. Will it raise the arch? Maybe.

Obviously, as any physical therapist can tell you, using a previously inactive body part will strengthen it. It will not only strengthen that part, but all the other parts associated with it. Muscles, bones, ligaments, tendons will all respond to the greater use. I can see how it would be possible that toning all those parts could raise the arch as they are all strengthened. Obviously, there is some anecdotal evidence that this is so, but I’ve not seen studies that demonstrate it.

However, as the Hoffman study shows, who cares? It doesn’t matter! It’s not the height of the arch that matters, it is the underlying physiological structure, and you get that from going barefoot whether your arch rises or not.

In my own case, I have no idea if my arches are really raised since I started going barefoot. They do look raised, though. However, much of that just could be the appearance caused by the much thicker pads on my feet now. Since the pads get thicker on the non-arch parts of the foot, that can give the appearance of a higher arch.

One more point: There are reports of over-use injuries in those who just start going barefoot. These are the sorts of people who try to run long distance before all the muscles and bones and stuff have had a chance to properly strengthen (this can take around 6 weeks, and probably it is not fully there until 6 months). Since I also play tennis, I can relate this to tennis. If you never played tennis before and suddenly picked up the sport and starting playing hours on end, hitting as hard as you can, you have a very good chance of picking up tennis elbow. The parts of your arm need strengthening first, and it has to be worked up to (it also helps to work on technique!). Same with any sort of extended or extreme barefooting.

Athlete’s Foot

Those concerned about bare feet always seem to mention athlete’s foot. Here is part of a Question and Answer from Dermatology Insights, Volume 3, Number 1, page 30 (2002). It was published by American Academy of Dermatology. I’ve emphasized some of the text:

Q: Why does athlete’s foot develop?

A: Athlete’s foot is a term used to describe a fungus infection of the feet. The correct term for athlete’s foot is tinea pedis. The fungi that cause athlete’s foot grow in moist, damp places. Sweaty feet, not drying feet well after swimming or bathing, tight shoes and socks, and a warm climate all contribute to the development of athlete’s foot. It’s commonly believed that athlete’s foot is highly contagious — that you can easily catch it from walking barefoot in the locker room. This is not true. Experiments to infect healthy skin with athlete’s foot have failed and often one family member may have it without infecting others living in the same house. It’s not clear why some people develop athlete’s foot and others don’t.

. . .

Q: How can you prevent athlete’s foot?

A: Wash your feet daily, and always dry your feet thoroughly, especially in between your toes. Avoid tight footwear, especially in the summer. Sandals are the best warm weather footwear. You should also use an anti-fungal powder on your feet and in your shoes during the summer. Alternate shoes so that they have a chance to dry out at least 24 hours before re-wearing them. Cotton socks (or socks made of a material that takes moisture away from the skin) are best and you should change them if they become damp. Whenever possible, go barefoot at home. Athlete’s foot does not occur among people who traditionally go barefoot. It’s moisture, sweating and lack of proper ventilation of the feet that present the perfect setting for the fungus of athlete’s foot to grow.

I might add that going barefoot all the time, not just at home, is even better.

Also, this is the source of the quote about athlete’s foot on the web page of The Society for Barefoot Living.

Protective Socks?

Yet another fear mongering article has appeared to misinform the uneducated. Dr. Marybeth Crane in Barefoot Passengers in Disgusting Airports describes pathogens found on airport floors. I will ignore Dr. Crane’s exaggerated odds of infection from the pathogens. I will even ignore Dr. Crane’s words “saving your life”.

I will instead focus on one aspect of Dr. Crane’s warning. According to her, all one needs to protect one’s self is a pair of socks. Socks! Really? I did not see Dr. Crane recommending any particular type of sock, such as non-porous latex if such exists. All of the socks I have ever seen are porous, breathable fabric that will certainly allow microscopic pathogens to pass unimpeded. Fungal spores can be airborne, for example, so direct contact with the floor is not even necessary.

How are socks going to stop these deadly pathogens from infecting our feet? Dr. Crane never explains any of this. She simply says socks will protect us. She does not appear to be selling socks. Perhaps it works like the child pulling the covers over their head, so the monster can’t get them.

Only One of my Appendages is Cold

Continuing on with the “coldfooting” theme, today I was doing just a short hike at a local park. I did get the inevitable question, though. Here’s how I answered:

“Only one of my appendages is cold. It’s this hand (my hand that was not holding my hiking stick). You see, my other hand squeezes the stick every time I put it down, and that pushes warm blood into that hand. My cold hand gets none of that.

“My feet get that same push of blood. A foot in a shoe is really quite restricted in its movement, so it’s hard for it to get that blood and therefore gets cold. But my feet don’t have that problem and stay warm.”

They all “got it.”

By the way, once my cold hand gets too cold, I switch my hiking stick to it for a while.

Podiatrists

I came across something at The Barefoot Runners Society that I think is spot on. In one of their forums there is a discussion about podiatrists, and I think “stomper” nails it. He says:

I believe that practically all medical professionals honestly are interested in helping their patients. But my experience suggests that they mostly do so using habits and tradition–i.e. what they’ve been taught to do–and not on the basis of what research does or doesn’t say.

I’m used to reading scientific articles from my work, and occasionally have had to inform my caregivers about things they were doing that were based in tradition and not research. That doesn’t mean they’re especially bad caregivers, just that they’re more concerned with interacting with their patients than understanding the intellectual part of medical practice.

See more here.

By the way, one of the podiatrists who is accepting of the science is Dr. Nirenberg of America’s Podiatrist. Over in the UK, there is also Dr Stephen Bloor at the Runright Stepfree Podiatry and Chiropody Clinic.