Over the past couple of weeks, I talked about What is Posture – the fundamental need for stabilization to provide healthy movement; and You Cannot Control Your Posture – postural control does not come from conscious thought. This brings up an obvious question. How do you train postural control? The answer is by integrating a full body, holistic approach to health and fitness. The program I use with my clients involves deep tissue massage therapy with a focus on the fascial system, self-massage using a foam roller, flexibility training, corrective exercise, functional strength training, and barefoot or minimalist walking and running. In today’s post, I will take you through the first steps (pun intended) of this process.

It Starts With the Feet

The feet are your connection to the Earth.  They are the foundation of your posture and the platform from which you move. In Architecture, the foundation of a building provides a base of stabilization that supports the entire structure. A weak foundation leads to collapse. The same is true for your feet, with a very significant difference… you move! Your feet have the challenging responsibility of providing strength and stability while maintaining flexibility and mobility to aid in the movement of the entire body structure. Not a simple task!

The Feet are your Foundation

With a strong healthy posture, the body aligns over the feet.  This is what provides the incredible stability from which healthy movement is derived. Just like the foundation of a building must be stable to support walls and a roof, the feet must be stable to support the legs, torso, spine and head. If your feet are weak, they are unstable. This is equivalent to building a house upon a bed of sand. The feet become misaligned and the ankles, knees, hips, back, and shoulders follow. Misalignment creates dysfunctional movement which causes pain and injury. A healthy foot is fundamental to good posture.

How Do We Get There?

What should you do if your goal is healthy feet and good posture? Focus on developing strength, stability and mobility while staying grounded and connected to the Earth. A great way to do this is to take your shoes off. You can read more on why I am an advocate of making the transition to barefoot or minimalist footwear in Free Your Feet, and how shoes affect running and walking gait patterns. But before you toss your shoes and fully convert to a barefoot lifestyle there is an important step you must take. It is vital that you rebuild the strength and stabilization of the muscles of your lower leg and feet – they are likely weak from decades of neglect.

Remember: the feet you walk on are the very foundation of your posture. The healthier your foot care is the better your body will move and feel. Below are exercises to build strength, balance and stability in your feet and lower legs.

The following exercises will help strengthen the intrinsic muscles of your foot and leg, challenge postural muscles, and train your foot and lower leg to stabilize providing healthy movement for your entire body. I recommend doing these exercises two to three times a week for eight to twelve weeks. As your foot gets stronger you can continue to perform these exercises for maintenance on a weekly basis.

Self-Myofascial Release using Foam Roller Therapy

By performing self-myofascial release techniques using a foam roller or ball, you can reduce trigger points, decrease tissue tension, and break down scar tissue adhesions in injured myofascial tissue (muscle and fascia) formed by a combination of acute trauma, poor posture, repetitive movement, over-training, or inadequate sleep. The goal of self-myofascial release is to speed up the healing and recovery process, reduce pain, improve joint range of motion, balance the body, and prevent injury.

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Last week I defined posture, not as an ideal position, but as the necessary stabilty from which all healthy movement is derived. Today I am talking about the first step in re-engaging postural control.How did we get here?
The human body is awe-inspiring. It is capable of moving with speed, power, agility, stamina, and grace — in an amazingly wide range of motions. It is also capable of adapting to the demands that are placed upon it. Unfortunately, most of us no longer move the way our body was designed to move.  We weren’t trained to.  The training grounds that once shaped The Human Body no longer exist. What we have instead are cars, couches, computers and ergonomic chairs. These are the new “training grounds” and our body has adapted to them well.  For many, it has adapted too well.
In this training we sit for long hours each day. We do not utilize movement that engages our postural system the way it was designed to be engaged. Over time, these muscles become weak. They atrophy. They fall asleep and quit functioning. They no longer provide the essential stabilization that is so important to movement. In time, our body adapts to this new environment and develops bad habits.  The most prominent example is the recruitment of mobile muscles to provide stability. Let’s revisit the analogy of driving your car with the brakes and the gas pedals pressed down at the same time. How well would your car move? Not well at all.  Driving like this is extremely damaging to the car.  The same is true for your body.  The pain you feel in your body is the indicator light telling you “stop driving and visit a mechanic.” A mechanic in this sense would be a “body” mechanic, a deep tissue massage therapist, postural movement coach, or physical therapist. I recommend somebody with advanced knowledge and experience with the fascial system and how it relates to pain.

What is next?
Before you can sit up straight or intentionally hold your body “in good posture,” you must re-teach your body to stabilize, but how is this accomplished?

You have heard the phrase, “stand up straight and pull your shoulders back.” For most of us this is our cue to establish “good” posture. There is something inherently wrong with this method and it lies in a concept that we have conscious control over our posture, when in fact we do not.

Pain
If you are currently suffering from acute or chronic pain, the first step is to treat the pain. Pain prevents or changes movement. There is no such thing as healthy movement with pain. Pain is the signal that something is wrong and you need to see that mechanic.What does this mean?
It means you have to stop thinking and move. Your body needs to be retrained to move healthy. It means, on a regular basis, moving your body the way it is designed to move, every muscle, every joint, with full range of motion, in every direction, at all speeds, performed with agility, power and grace. You don’t want movement where you have to think about your posture. You must challenge and train your body to once again think for itself.

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In these difficult financial times, when stress levels are high and every dollar counts, massage is more necessary than ever. I am frequently asked if I can bill insurance for the services I provide. Many people don’t understand why it is not covered in most instances, considering other treatments like acupuncture and chiropractic often are. My best answer is to suggest they look into flexible spending accounts, or FSA’s, as a reasonable alternative.

FSA’s are available through many health plans, most large employers, and any company that offers benefits under a “cafeteria plan”. Once the account is set up, the employee determines a set amount to be set aside pre-tax from their regular paycheck. These accounts are typically used to cover qualified medical related costs not covered by insurance. The primary advantage of a FSA is that the money goes in before payroll taxes, which means roughly 30% more value on every dollar.

Because expenses covered have to be “qualified”, it means your doctor has to prescribe massage for a specific health issue. The commonly accepted definition of what is qualified is as follows:
Section 213(d) of the Federal tax code stipulates that a qualified expense must be “to alleviate or prevent a physical or mental defect or illness.”
Since therapeutic massage is frequently used for stress related issues, like high blood pressure and anxiety, as well as chronic pain and musculo-skeletal issues, a physician would most likely write a prescription for these types of conditions.

A recent study, published July 5, 2011 (article) has shown that massage is clearly effective in reducing low back pain. This is a huge step forward in establishing the therapeutic value of massage in a resistant medical culture. Citing studies of this nature can be helpful in persuading a doctor who might be hesitant to prescribe.

The two common methods of using the FSA account are with a debit card and with reimbursement. Many companies are using the debit card option, as it cuts down on processing and paperwork. Otherwise, the client pays for the session, gets a receipt from the therapist, and submits that receipt for reimbursement. Receipts need to include the medical reason for the visit in order for the FSA to process it. Not all therapists are able to accept debit cards, so the reimbursement method may be the only option.

One thing to be aware of with the Flexible Spending Account is that it is “use it or lose it”. These plans are annually renewed, typically at the beginning of the year, which means the full benefit is available January 1. However, anything left in the account after December 31 gets absorbed, leaving the employee with a loss.

Many therapists offer bulk purchase discounts, allowing additional savings. When purchasing these bulk plans early in the year, the employee can potentially get a discounted rate for the package prior to actually paying for it, on top of the 30% pre-tax savings! A little advance planning is a worthwhile thing.

While most people believe in the therapeutic benefit of massage, the financial concern is the most often sited reason for visiting less frequently. With the Flexible Spending Account, you can think of your massage visit as being automatically discounted 30%. A conversation with your HR person or health insurance provider is strongly recommended to find out the specifics about the plan you have access to.

I hope this information is helpful to those who are hesitant to visit their massage therapist because of the expense. I’d love to hear feedback from people who have used, or are currently using a FSA for massage. Have your experiences been positive, negative or neutral?

Q: In the transition to minimalist footwear, am I going to get hurt? And how long does this transition take?

The Emotional Effects Of Carpal Tunnel Syndrome Can Be More Harmful!

Carpal Tunnel Syndrome is a condition caused by compression of a key nerve in the wrist. It is an especially painful condition that affects approximately three percent of all adults in the United States.

People who work with their hands are the most at risk of developing Carpal Tunnel Syndrome. This includes artists, musicians, some construction workers, and those who use a computer for extended periods of time.

How does Carpal Tunnel Syndrome Affect Someone Emotionally?

Though not part of a normal description of Carpal Tunnel Syndrome, this crippling disorder has many emotional effects as well. Because of this disorder, many strong emotions may come up that one is not prepared to deal with. It is important to familiarize yourself with the common emotional upheavals so you can be prepared to deal with them.

Emotions associated with Carpal Tunnel Syndrome may include:

1. Feelings of uselessness. Carpal Tunnel Syndrome can make it too painful to do anything, including cooking and normal household chores. This leads to feelings of uselessness, and the belief that one cannot make it on their own with Carpal Tunnel Syndrome, especially if they live alone. To overcome this feeling, focus on the many things you still can do and learn to make adaptations to complete normal tasks that are painful.
2. Anxiety and fear of the future. Similar to feelings of uselessness, anxiety stems from not being able to perform everyday tasks. People with Carpal Tunnel Syndrome are worried about the future, and what is going to happen to them if they are unable to take care of themselves. To get over these fears, it is important to stay in the present moment. The anxiety will pass, but it will also never come up if you are not projecting.
3. Loss of enjoyment in fun activities. When you have Carpal Tunnel Syndrome, you may no longer enjoy activities that are fun to you because of your pain. Your future may seem bleak. It is important to concentrate on the fact that you can still have fun and look for activities that will not make your Carpal Tunnel Syndrome worse.
4. Serious depression. Carpal Tunnel Syndrome can be so debilitating that one loses interest in life entirely. It is important to focus on the good things in life. If you are severely depressed, contact a psychiatrist for help.

What are the Symptoms of Carpal Tunnel Syndrome?

Symptoms of Carpal Tunnel Syndrome are varied. They can be felt not only when the hand is in use, but also when it is resting. The pain associated with Carpal Tunnel Syndrome increases gradually over time, and usually must occur for a minimum of 10 weeks. Common symptoms include:

• Pain in the wrist and hand
• Numbness in the fingers
• Tingling of the fingers
• A sense of weakness
• The tendency to drop things
• Loss of feeling coolness or heat in the hand or wrist
• Feeling of swollen hands even though there is no visible swelling

So, as you can see, there are several emotional side effects to this disease. Don’t let it get you down. Get help, and don’t forget that Carpal Tunnel Syndrome doesn’t always last forever. Early recognition and proper treatment is important to treating Carpal Tunnel Syndrome.

With all his books, coaching experience, training methods, racing achievements, and Ironman-like durability with just over a half-century of miles on his legs, Jeff Galloway is a respected fixture in the running community. And along with many other runners, I’m a subscriber to his email newsletter.

But his take on minimalist running shoes in his most recent newsletter is not one that I share. Here’s what he wrote:

“Many runners who own one of the minimal and exotic shoes that have popped up on today’s market will tell you that these shoes have solved their running problems. I hear the other side of this issue, about every day, from those who have been injured (often severely) by using these products or by running barefooted. Many have to stop running for 4 to 6 months. Thousands have reported significant problems.

I’ve seen this fad come and go 5 times during my 52 years of running. Something will come out in the media about minimal support/barefooted running, and thousands will try it. About a third of those who try it run for short distances and like the tingle of the feet so they run more. Without support, the distance or the surface of the run will often cause an injury–including a number of serious ones such as stress fractures. Each fad cycle ends when those injured tell other runners about their experience–so that very few want to put themselves at risk.

Minimal shoe/barefooted running has its place if the foot can handle it: Short runs when running on a safe surface can give the foot a bit more strength and develop a lighter touch. Unfortunately, there are lots of risks on most running surfaces: pieces of glass, medal or rock–hidden below even the most groomed grass surfaces. There are also lots of surface irregularities that can produce serious trauma injuries in one step.

Today’s shoes have decades of orthopedic research behind them and can protect the foot from most of the problems due to running surface. Go to a store with trained and experienced staff members, like my Phidippides stores in Atlanta, and get the best advice.”

Here’s my reply to Jeff:

I am curious about the runners who are showing up everyday claiming to have been injured as a result of minimalist shoes. Over a year ago in Shepherdstown, West Virginia, I opened the first footwear store in the nation purely devoted to minimalism and sold no shoes with traditional elevated heels. Two Rivers Treadswas only the first store of its kind. There are now six new stores in the country who have embraced minimalism – and all are partners with the Natural Running Center (http://naturalrunningcenter.com/), where I am also its executive director. All of these stores are completely aligned with the education message of teaching good form, prescribing more functional footwear, and the progressive adaptation to more natural running.

At Two Rivers Treads, we just don’t sell shoes; we have a discussion with each and every customer regarding their running, injuries, goals, and some simple and clear instruction on how to reduce impact loads on their joints. We have sold over 3,000 pairs of shoes in a year and only five customers at most have returned with an injury and blamed the shoe. This is far less than Galloway’s daily experience. Are the injured runners just going to the doctor instead of back to us? I doubt it as we would be the first place they would return to if they felt it were the shoes. Do I have scientific data for all this….no, we are a small business.

Maybe we are doing something different when we sell minimal shoes. So just what are we doing? The following educational information is included on our store walls and handouts.

Let’s first define how we interpret minimalism, a minimalist shoe, the risks, and the gradual progress.

What is Minimalism?

— Free the foot to develop naturally

— Look for the least amount of shoe you can safely wear now

— Work toward reducing the amount of shoe necessary through strengthening the foot and improving your stride

— Running is a natural movement of the body, rather than an unnatural act that requires artificial support to perform safely

— Embraces the notion that the beefier the shoe, the more a runner’s natural stride is inhibited

What is a Minimalist Shoe?

— Complements natural foot function

— Heel to toe drop is very low

— Material under the foot is thin….allowing maximum ground feel

— Upper is Soft and Flexible

— Light Weight and Flexible

Effects of a Modern Running Shoe?

— Impairs your natural bounce

— Promotes heel striking

— Alters your natural lever (heel lift)

— Creates unstable base

— Causes loss of sensory input

— Causes skin atrophy

— Creates unhelpful movement memory

What are the Risks of Minimalism?

— Foot is NOT guided into running stride

— Feet need to do some of the work and need to get strong

— If form is incorrect and you are not strong in the right places you may develop soreness….so listen to your body and progress gradually

How to go Minimal?

— Take it slow at first

— Add distance gradually

— The more minimal the shoe the more adaptation it will take

— Progress through the stages of Shoes from Neutral/Transition to Minimalist to Barefoot Style

— Do some barefoot running and walking

For early adapters who are weak in their foot and hip stabilizers a minimal shoe may be what we call a “neutral –transition shoe”, such as a Newton Isaac or Altra Intuition.

Now how do we define shoes? This too is on our store walls, and the shoes are displayed this way in the Natural Running Center Shoe review sectionhttp://naturalrunningcenter.com/naturalrunningcenter-shoereviews/

Barefoot-Style Shoe

— Your feet “feel” the ground

— Thinnest layer of protection between foot and ground

— Heel and toes are level

— Land on the midfoot/forefoot

— Lightweight

Minimalist Running

— Some cushiony comfort

— Little to no heel-to-toe drop

— Enhanced ground feel

— Soft, flexible shoe moves with feet

— Ideal for all surfaces– road, trail, track

Neutral/Transition

— Similar protection to most running shoes but without elevated heel

— Little to no heel-to-toe area drop

— Foot is in natural position

— Encourages midfoot/forefoot landing

— Ideal “starter” shoe for transitioning runners to minimalist/barefoot-style

The real folks making this happen in a small community such as Shepherdstown are my lead employees, aka the Shoe Guys, Tom Shantz and James Munnis. Tom and James lend some practical and philosophical advice on the topic.

Here’s Tom: “We give verbal warnings to all minimalist shoe buyers. I have been adapting for a little over a year now. It’s a slow process. What I have found that works best is to have two pair of shoes. One that is ‘flat’, zero drop, and one that has a drop of 5mm. One should transition into the 5mm shoe first. It should take approximately 2 weeks. The zero-drop shoe should take you approximately three months to transition into. Once you have transitioned into both shoes you should continue to slowly increase your distance in the zero-drop shoe. The 10% week rule is out the window. Try 1% increase in the zero-drop shoe. For a younger runner who has been in racing flats the transition is much shorter.”

Now here’s James: “It’s still funny to me how three million years of evolution is still considered a fad by some folks. Nobody who has ever followed our advice on gradual transition has ever been injured from the act of running completely barefoot, or in minimalist shoes. Many do have the usual fatigue and discomfort over a period of up to a year or so trying to undo the weakness and atrophy of the most excellent foot that has been caused by horrible traditional footwear for everyday wear and for running. Mother Nature has given us a foot that is very endurable and survivable, despite our very recent efforts to screw it up with the many ridiculous features of a traditional running shoe. Would anyone please tell me one single reason to elevate a human heel above the forefoot for anything, or to interfere with our natural suspension system with arch support, and especially for running?”

So there you have it: Two Rivers Treads’ Shoe Guys have spoken. And as their informal comments reflect, it is not about the shoe, but the education. An example of one of the fun educational sessions hosted by our store is the recentNatural Running Roundup with Chris McDougall on the home page of the Natural Running Center.

Here’s to healthier running,

Dr. Mark Cucuzzella

Plantar Fasciitis

Plantar Fasciitis is the common term for what should be more accurately termed Plantar Fasciosis. itits is an acute inflammation caused by a trauma or infection. osis is chronic degenerative condition.

No evidence exists for an ideal treatment of this condition without identifying and treating the causes, which can be many. Since we have no literature to guide us, this advice comes from seeing hundreds of runners and guiding them in self corrections.

What is the Plantar Fascia?

The plantar fascia (PF) is a strong ligament that runs from the heel to the metatarsal heads in the front of your foot. This ligament helps absorb the shock that occurs when your foot contacts the ground. It has function in the windlass mechanism recreating the arch on takeoff.

What is the Cause of Plantar Fasciitis?

The PF is designed to manage a relatively small amount of stress. The intrinsic and extrinsic muscles of the foot are designed to receive signals from the fascia and in turn manage the majority of the load. When those muscles are dysfunctional the load gets transferred to the PF which is unable to handle it hence causing tears or plantar fasciitis. You can repair these tears by using palliative methods but as soon as you hit it again you will have to go through the same process. The only way that you can actually fix plantar fasciitis is to address the root cause… weak foot muscles. (Thank you Lance from Barefoot Science for the insight).

Several Structural Causes can Contribute to the Problem

• Weak intrinsic muscles of the foot
• A misaligned and weak first toe
• Tight shortened calf muscles
• Tight plantar fascia

Other Important Contributors

• Increased mechanical stress from the amount of running or activity
• Obesity
• Adapting too fast from supportive footwear which inhibits intrinsic muscles to flat shoes or barefoot (i.e. summer if going quickly into flip flops or barefoot)
• Poor walking and running mechanics
• Overly supportive footwear leading to instability. This is a paradox as shoes that over support will weaken the foot which in turn leads to the foot’s instability.

What Can You Do to Correct Plantar Fasciitis?

There are a few basic principles but they will vary depending on the cause:

• Any support from an orthotic, arch support, or taping should be a temporary modality while you strengthen and lengthen the tissues. Using one of these forever is akin to breaking your arm and leaving the cast on forever (in one week muscles begin to atrophy from disuse).
• Doing eccentric drop down exercises from a stair can help. Place your foot on stair and drop your heels down. It is OK to have a little pain doing this as long as it is getting progressively better.
• Dorsiflex the big toe to lengthen PF if it is tight
• Get out of heels – gradually – in ALL activities
• Work on foot intrinsics… pick things up with your foot. Walk barefoot.
• Practice a technique of running encouraging more natural form, ligher ground contact and loading rates, and more proprioceptive cueing. For more info, check out Chi Running by Danny Dreyer, Natural Running by Danny Abshire, Evolution Running by Ken Mierke, and the excellent teaching of Lee Saxby of Terra Plana VIVOBAREFOOT (see video).
• Strengthen your big toe by pushing it into the ground as often as you can whenever you are standing throughout the day. This will wake up the foot muscles and help recreate the arch.
• If you first toe is bent in consider a product to straighten it like Correct toes from Dr. Ray McClanahan.
• Use the principle of gradual progression and body sensing when making any changes
• Avoid NSAIDS (Motrin, Ibuprofen, etc). These drugs interfere with natural healthy healing processes.
• See a good health provider who understands natural running and walking

Photo: Markusram

What About Orthotics?

Read this excerpt from Barefoot Science Canada (I am completely aligned with their opinion):

Source: http://www.barefoot-science.ca/plantarfasciitis.html

Custom orthotics and similar products attempt to stabilize the subtalar joint by supporting the arch, claiming to correct the poor biomechanics of the foot. This claim of correction is quite misleading. Orthotics only mask the symptoms by artificially supporting a dysfunctional structure along with its inherent muscle imbalances, while introducing a new angle of ground interface to the foot.

The artificial support provided by orthotics has little or no effect on the alignment or structural integrity of the interlocking bones that are still loose and unstable. The foot remains functionally unstable and will become increasingly weaker and dependent on the support. These bracing and supporting characteristics can actually prevent proper alignment in the foot and ankle as they manage multi-directional activities, contributing to increased stresses at the ankle and knee. And the chance of injury increases when misalignment and increased stress combines with an unlocked structure.

From a biomechanical perspective, by introducing a new angle of ground interface, orthotics cause a shift in the dynamics of the repetitive movement. The symptoms resulting from the old dynamic disappear and the problem seems to be corrected. Unfortunately, over time or with increased activity levels at the new ground interface angle, the repetitive movement often results in new symptoms at different locations. This creates a recurring cycle where new orthotics are prescribed to compensate for the ever-migrating symptoms and pathologies. The current practice is to recommend new orthotics at least every couple of years.

Heel-that-pain has some great exercises and videos including a nice demo on taping. The heel seat can also be a useful non supportive tool to give some short term relief while you strengthen the foot.

And finally do not wear shoes that shorten your PF or place your foot in all-day-dysfunction: wear minimalist footwear!

About the Author

Mark Cucuzella is a Family Physician at Harpers Ferry Family Medicine and Associate Professor at West Virginia University School of Medicine. As a Lieutenant Colonel in the Air Force Reserves, he is coach and captain of their marathon team and designing programs to reduce running injuries in military personnel. His passion for health extends beyond the walls of the clinic into the medical home’s “backyard”- the trails and open space that create the arena for optimum wellness.

You can read more about Mark on his website: http://www.trtreads.org