Toss the Orthotics: Why Your Feet Don’t Need Support

“…most people wearing extra support on their feet shouldn’t be.”

If I told you to go buy a good running shoe, you’d probably look for something like the shoe pictured above. Cushy, breathable, with arch support and more cushion under the heel than under the toe. Lots of therapists would recommend just that, plus a pair of orthotics to round out the package. If you have flat feet, collapsed arches, shin splints, or plantar fasciitis, the chance of being prescribed foot support gets a whole lot higher.

Realistically though, you shouldn’t have to “support” your feet. There are some people who really do need structural foot reinforcement, due to significant foot deformity or long-term dysfunction. That said, most people wearing extra support on their feet shouldn’t be.

But Don’t Feet Need Support?

Not necessarily. There are muscles in your feet that do the supporting for you. While many people are concerned with their arch collapsing, there are actually muscles in your foot that hold the arch up. The posterior tibialis and fibularis longus muscles wrap around the bottom of your foot like those old 80’s stirrup leggings. Why don’t they always do their job? If you provide external (shoe) support to your feet the most of the time, the muscles don’t have to be that strong. Your arch may roll in since the muscles are weaker. When you start to use those muscles more–like starting a new running routine or walking without support–you definitely feel it.

When babies start walking, they all have flat feet. The weight they put on their feet is important in developing the bones, as well as the ligaments and muscles connecting the bones.¹ The longer babies are on their feet, the stronger the muscles get. Feet muscles play an important role in absorbing ground forces, transferring them through the leg, and transforming them into forward motion.

The flip side of this is that most kids are wearing chunky supportive shoes as soon as they’re on their feet. Some folks argue that these supportive shoes help arches develop. While research does show that shoes can change the speed with which arches form, they don’t actually change whether or not the arch develops.¹ On the other hand, deformities like bunions, flat feet and hallux rigidus (a stiff first toe) are less common in people who are regularly barefoot.^2,3 The pliability of regularly shoe-less feet is greater, the arch is higher, and the toes are able to spread better.³ In contrast, injuries in the metatarsals (the bones in your toes and end foot) are more common in people consistently wearing shoes.⁴ 

When comparing different shoes, shoes that don’t take into account the natural shape and function of the foot actually change the foot structure and biomechanics.² So footwear designed to account for your natural foot shape and function leads to less foot issues and builds the support muscles.

So why do I have pain if I don’t have cushion or lose orthotics?

Patients are forever telling me that they have back pain, knee pain or foot pain when they walk for a while that gets worse if they don’t wear supportive shoes. There’s two main reasons why supportive shoes will make it near impossible to walk without them.

1. Cushioned shoes change the forces that are absorbed into your feet and legs.

Your feet have receptors in them to feel how hard you’re hitting the ground. If there’s significant cushion between these receptors and the ground, you land harder. So while it seems like these shoes would decrease the force you absorb, they actually increase the forces transferred up your knee and hip. They especially increases the load on the medial knee (the inside part of your knee), which is the most common place to get arthritis in the knee.⁵ Turns out the cushion supposed to protect can actually increase wear and tear on your feet, knees and hips.

2. Cushioned shoes also change where and how you land.

This applies especially to runners. Runners without cushioned shoes tend to land on their forefoot. Forefoot landings mean less loads absorbed to the foot, and the loads go through the toes and lower legs rather than the heels and up through the leg.⁶ Landing on your heels results in three times as many injuries like hip pain, knee pain, low back pain, plantar fasciitis, tibial stress injuries and stress fractures.⁷

And “supportive” shoes don’t just change where you land–they also change what your foot does as it lands. Most shoes don’t flex around the arch area. The extra stiffness means the muscles responsible for holding up your arch don’t have to do as much. Your body is great at building muscle for what you do regularly, and also getting rid of muscle when you don’t need it. So wearing shoes that don’t make you use your foot muscle can result in feet that don’t work well without support. On the other hand, a few months of incorporating barefoot walking can shorten the arch, meaning it doesn’t collapse so much as you’re walking.⁷ Removing shoe support strengthens the feet muscles. Stronger feet are healthier feet!

So is this something I should look into?

Depends on who you are and how much you care. I’m all about prevention and doing things the way your body was designed to do them. Some people just want to live life without thinking until their body stops them. After all, everyone values their health differently. If you have foot pain and you want the easiest option, go ahead and consider orthotics. If that’s you, just know that that’s a choice you’re making. For the prevention-type folks, especially those with bad balance, think about spending some time barefoot, switching to minimalist shoes, or doing some foot exercises. Take a look at the resources listed below and start to challenge your feet.

I especially emphasize the benefits of foot strength with patients with bad balance. Falls cause injury and loss of independence, and they’re more likely the older you get. One third of older adults fall every year, and one fall makes you twice as likely to fall again.⁸ Working on balance before you fall can significantly change your health outcomes in old age.

Balance exercises can be as easy (or hard) as standing on one foot or walking heel-to-toe on a wooden 2×4. Doing these in bare feet or minimal shoes is recommended, since stability is better in bare feet or thin-soled shoes (especially for older people).^7,9

If I’m a runner, do you still think this is a good idea?

Yep. Most running shoes have a “drop,” meaning toes are lower than the heel. A drop usually causes you to land more on your heel and shortens your achilles tendon over time. Additionally, the toe on most shoes curls up so that it rolls your foot forward, since the shoe stiffness limits your foot’s flexibility. So running in these type of shoes means you log a lot of miles with different mechanics than your body was designed for.

Removing some of the cushion from your heel makes you more aware of how hard you’re actually landing. As mentioned, most runners will naturally shift toward landing more on their forefoot. The force from landing on the ground, rather than going up through your heel and leg, gets absorbed by the springier tissues of your foot and calves (the plantar aponeurosis, gastrocnemius and soleus). This usually results in getting more forward movement with less effort, and less energy gets wasted with up and down movement. So yes, this can be a really good idea for runners.

That said, transitioning from a traditional shoe should be slow. Because the fascia along the back of your leg and bottom of your foot aren’t used to absorbing forces if your shoes have been doing it for them, they need to be built up before they can absorb your body weight all the time.

OR if you don’t want to transition, at least work on barefoot walking or grab a pair of minimalist shoes for around town. Even wearing minimal shoes around town can increase the strength in your foot muscles, which is good for both runners and non-runners.¹⁰ 

Uh, where do I start?

So, if you’re wondering how exactly you go about building up your feet, here’s my recommendation:

• Start slow. The ability to walk barefoot or wear minimalist shoes takes some intentionality. If you’ve had foot support for the last 30 years, your feet muscles have gotten very used to not having to work much. It’s like going to the gym and powerlifting as much as you can after years of not working out–a surefire way to get yourself in trouble. It can take some people months to transition themselves safely and without injury. Rather than jumping straight into a pair of minimalist shoes, start with foot strength and flexibility exercises. That keeps you from injuring yourself as your feet transition to higher demands being placed on them. Katy Bowman’s Whole Body Barefoot book has a whole range of exercises to work through.
• Massage your calf muscles frequently to help them adapt to the increased load placed on them.
• Work on balance to increase foot and ankle strength. You can progress by standing on one leg, toe-to-heel walking, or using movement systems like yoga or MovNat. Even something like standing on one leg when you’re brushing your teeth is going to help balance and foot strength.
• Working on unweighted squats, eventually working your way toward a deep squat, will help increase mobility through the knees and calves.

The Harvard Skeletal Biology and Biomechanics Lab recommendations are useful for switching if you aren’t sure how fast to go:

• Start with walking around the house without shoes. This doesn’t mean sitting on the couch without shoes on, it means walking around the house while doing chores, cooking, cleaning, etc.
• From there, try heading outside. Being barefoot outside can be hard if you’re not used to it because your skin is thinner and can’t protect from twigs and pebbles. 
• Once you’re able to manage that, walk no more than ¼-1 mile every other day or a week. Then increase your distance by no more than 10% per week. If you are still sore the following day at the end of a week of that distance, don’t increase. Take another day off and stay at that distance for another week.
• Be patient and build gradually. This transition can take months for some people.
• If you experience pain, not soreness, stop and give yourself a chance to heal or get help from a manual therapist.
• Be aware of your gait. If your arches, the top of your feet, or anything else is hurting, be mindful of how you are landing. Foot or arch pain can happen if you land with your foot too far in front of your hips, land with a rigid foot, land too hard on your heel, of, if your toes are pointed too much (a habit that can carry over from shoes with a toe drop).
• If you are running long miles, you don’t need to drop your miles a bunch. Add in forefoot or midfoot striking progressively to your usual stride and gradually increase the proportion of forefoot striking in comparison to your old gait over a few months. Use the 10% increase per week guideline the best you can.

Resources:

This can be a harder change to make for most people because it involves not just more movement, but also a change in footwear. There’s also that issue of shoes being normal social behavior. I don’t walk through stores barefoot because…people. But I also don’t want to have to compensate for shoes that don’t let my feet work like they should.

My answer to this is minimal shoes. This term can mean different things to different people, but it usually means:

• No extra cushioning under the heel. Your toes are level with your heel.
• A flexible sole without arch support. If you can’t easily twist and bend the sole of the shoe, then it’s probably too stiff.
• Less sole. If you’re new to these kind of shoes, you may not be ready for the 4mm sole of some minimalist shoes, so start with the first two points listed.

If you’re looking for minimalist shoes, check out:

So if you want shoes to help you, look at Vivobarefoot, Lems, Tune loafers (men), UnShoes (women), Xero, Sanuk, Merrell Vapor Gloves, Earth Runners, Luna, Wildling, Shamma Sandals, certain Minnetonka or Otz shoes, Camper Peus, Tieks ($! and not super wide), Fit In Clouds (like Tieks but way cheaper), or Happy Little Soles (kids). I get my nicer shoes from VivoBarefoot or off of Etsy (especially the Drifter Leather) because most minimalist shoes at this point are more athletic-looking, and I’m a little vain. I’ll also get wide, flexible, flat shoes at normal retail stores so long as my feet can move. This can be cheaper, but also the shoe construction tends to be cheaper (duh). The 1/4″ heel on some shoes isn’t too hard to pry off either. 

Justin Owings at Birthday Shoes has a lot of reviews available on minimalist shoes if you obsessively research before a purchase (like I do). For more reading about mechanics, look up Stephen Gangemi (The Sock Doc) or the Natural Running Center by Dr. Mark Cuccazella. Dr. Cuccazella has free online training modules for how to transition to a natural gait, and both Docs have videos available on youtube. Dr. Cuccazella focuses more on running training form and Dr. Gangemi focusing on injury prevention. Katy Bowman is a biomechanist who published a book called Whole Body Barefoot: Transitioning Well to Minimal Footwear. It’s way more in-depth than this article and gives you all the things you need to know for transitioning. Research junkies can check out the Harvard University Skeletal Biology and Biomechanics Lab website or this video by the Lab’s leading doctor, or any of the cited resources.

 

 

 

 

 

Sources:

1. Fritz, B., & Mauch, M. (2013). Foot development in childhood and adolescence. In Handbook of Footwear Design and Manufacture (pp. 49-71).
2. D’AoÛt, K., Pataky, T., De Clercq, D., & Aerts, P. (2009). The effects of habitual footwear use: foot shape and function in native barefoot walkers. Footwear Science, 1(2), 81-94.
3. Hollander, K., Heidt, C., Van der Zwaard, B., Braumann, K., & Zech, A. (2017). Long-term effects of habitual barefoot running and walking: a systematic review. Medicine & Science in Sports & Exercise, 49(4), 752-762.
4. Zipfel, B., & Berger, L. (2007). Shod versus unshod: The emergence of forefoot pathology in modern humans?. The Foot, 17(4), 205-213.
5. Shakoor, N., & Block, J. (2006). Walking barefoot decreases loading on the lower extremity joints in knee osteoarthritis. Arthritis & Rheumatism, 54(9), 2923-2927.
6. Lieberman, D., Venkadesan, M., Werbel, W., Daoud, A., D’andrea, S., Davis, I., … & Pitsiladis, Y. (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 463(7280), 531.
7. Altman, A., & Davis, I. (2012). Barefoot running: biomechanics and implications for running injuries. Current sports medicine reports, 11(5), 244-250.
8. Ambrose, A., Paul, G., & Hausdorff, J. (2013). Risk factors for falls among older adults: a review of the literature. Maturitas, 75(1), 51-61.
9. Robbins, S., Waked, E., Allard, P., McClaran, J., & Krouglicof, N. (1997). Foot position awareness in younger and older men: the influence of footwear sole properties. Journal of the American Geriatrics Society, 45(1), 61-66.
10. Bruggemann, G., Potthast, W., Braunstein, B., & Niehoff, A. (2005, July). Effect of increased mechanical stimuli on foot muscles functional capacity. In Proceedings of the ISB XXth Congress-ASB 29th Annual Meeting: 31 July-5 August 2005; Cleveland (Vol. 553).

On September 28, 2018   /   Aches, Pains, and Mechanical Problems, Uncategorized   /   1 Comment