Paul Mumford, an internationally respected Personal Fitness Trainer, interviewed me for his article in Ultra-Fit Magazine June 2014 from which he used excerpts from our interview. You can read Paul’s article on his own blog here: “Time To Get Naked”
Below is our interview in full.
1. Firstly, how would you like to be described?
I’m a Musculoskeletal Podiatrist.
My focus is on natural barefoot gait as the basis for optimal foot & lower-limb health and movement. Understanding more about how the natural human foot functions barefoot on natural surfaces, informs & modifies my treatment choices as I consider the effects of all the unnatural influences exerted on the foot by footwear and man made surfaces which modify human gait.
I’ve been nicknamed by others as “The Barefoot Podiatrist” due to my practice of being unshod for 95% of the time.
2. Your approach to podiatry has radically changed over the last few years. Can you explain what brought about this change and how this has altered the way you treat your patients?
I’ve been qualified for 26 years this Summer & in the profession for 29 years. From about 14 years ago I became involved in the design of a very successful range of foot orthoses for the correction of gait abnormalities with a company called Healthy Step.
At that time, & up till about 4 years ago, I believed, like many podiatrists, that approximately 80% of the World’s population would be helped by wearing functional foot orthoses.
The prevailing belief is that human beings function best when shod in protective & supportive footwear for almost all activities. Wearing shoes is seen by most in my profession as the norm. Not once did I consider that human beings could safely live a barefoot lifestyle.
In fact, as I stated above, not only did I believe that humans need footwear for optimal gait, but that approximately 80% of people also need foot orthoses to avoid injuries to their lower-limbs & backs.
I not only believed in prescribing foot orthoses for patients with musculoskeletal lower-limb injuries and pathology, but also using them for preventing problems from occurring.
Then, just over 4 years ago, I read an article in The Telegraph newspaper “Why expensive trainers could be worse than useless” about Chris McDougal and his experience learning to run barefoot with the Tarahumara Indians in Northern Mexico. I was totally surprised to discover that this indigenous American tribe could run long distances with little or nothing on their feet for protection or support. I was so intrigued by this incredible feat of human achievement that I became obsessed with researching more about them, as well as other habitually unshod races around the world. I spent four months reading everything I could find about barefoot gait in the orthopaedic and podiatric literature.
It became apparent that some medical researchers have known for well over one hundred years that footwear always interferes with natural gait creating mechanical dysfunction, and eventually compensatory adaptions in almost everybody who wear them for prolonged periods of time.
It is also very well understood that footwear dramatically increases the risk of developing foot deformities like bunions and hammer toes.
After giving this new information serious consideration I realised I needed to revaluate how I practised as a clinician.
I changed my practise philosophy from emphasising longterm support of the foot and leg with corrective orthoses and stabilising footwear, to one where I promote rehabilitation and prevention.
I now advise exercises and lifestyle changes, including going barefoot more often, particularly on uneven surfaces.
I believe, just like the rest of our bodies, our feet are more healthy if given plenty of fresh air, exercise and sunshine.
I encourage my patients to strengthen & mobilise the joints and muscles of their feet with spiky massage balls daily, as well as to walk or run barefoot on natural uneven surfaces as often as possible.
Foot orthoses are still very useful, but should be seen more often as a short-term tool to support an injury whilst the patient rehabilitates than as a permanent necessity.
Many foot and lower-limb problems can be more appropriately and effectively addressed by rehabilitative muscle exercises, mobilisations, massage and lifestyle changes.
I give many patients a choice between rehabilitation with and without orthoses, or treatment just with orthoses. Realising that orthotic supports have been shown to create dependency, I try my best to help my patients avoid the problem of relying on foot orthoses as a panacea, rather than properly rehabilitating.
3. What are the most common problems people come to you with and how do you treat them?
I’ll briefly discuss three of the most common injuries presenting in my clinic. Plantar fasciitis, metatarsalgias and shin splints.
The most common problem I see in my clinic is plantar fasciitis (fasciosis), followed by various types of metatarsalgias. I also see quite a few cases of anterior knee pain and shin splints of various types.
My treatment for plantar fasciitis has changed dramatically due to my new philosophy. I now emphasise strengthening exercises and massage as the primary aspect of curative treatment, with some patients also using foot orthoses in the short term to give quick pain reduction, almost as a first aid measure. For most of my more able-bodied patients I also recommend barefoot beach walking using a short stride with forefoot strike (followed by gentle heel placement) onto the soft-sand for 10-20 minutes 3-5 times a week. The main aim of this rehabilitative approach is to stimulate an increase in foot & ankle muscle strength as well as to improve the hysterisis (elasticity) of the plantar fascia. Footwear advice is given to my patients because I believe the evidence is clearly showing that stiff, supportive shoes, acting like braces, cause muscle weakness & atrophy, along with joint stiffness. The evidence is showing that the plantar fascia & arch muscles need to be used in a repetitive stretch/shortening cycle in order to keep them strong & pliable. In essence, to keep the foot healthy it needs to function in the way it was evolved to function – naturally! Stiff supportive footwear don’t allow this.
As far as metatarsalgias are concerned, apart from some rather uncommon problems with fat pad atrophy, most pathologies in the ball of the foot are caused directly by wearing shoes over prolonged periods of time, leading to disruption in the normal plantarflexion of the toes causing a muscle imbalance between the long extensors & flexors of the toes, as well as between the extrinsic foot muscles & the intrinsic muscles of the foot. In the case of many forms of metatarsalgia there is also the pathological effect of lateral compression of the forefoot causing a disruption in the relative positions of the metatarsals & also the plantar digital nerves, making Morton’s neuroma very common, along with capsulitis of the metatarso-phalangeal joints.
( A brilliant explanation of the causes of metatarsalgias is found here, written by my good friend & co-designer Andy Horwood: Mechanically Caused Metatarsalgias )
My treatment is always aimed primarily at trying to restore natural position & function, wherever possible. So plantarflexion exercises to mobilise the joints & stretch contracted soft-tissues are used. Plus I use strengthening exercises for the intrinsic foot muscles. Osteopathic mobilisation techniques of the foot, including the cuboid, are also very helpful. Orthotic foot supports are frequently used in my clinic to off-load the pressure areas & reduce the inflammation in the soft-tissues. Sometimes orthoses are used short-term, but quite often long-term because many patients end up with permanent adaptive deformities associated with the long-term over-use of shoes.
When it comes to treating shin splints my treatment philosophy has changed completely. It seems to me that most types of shin splints, but particularly medial tibial stress syndrome and anterior compartment syndrome, are associated with poor running technique. Over the years of treating runners with these all too common running injuries, the single most successful treatment approach has been to get patients to change their foot plant from a rearfoot to a forefoot strike. So I also teach barefoot/natural gait running technique & drills which incorporate a gentle forefoot strike, along with advising on going barefoot or using minimalist shoes.
4. Can everyone be ‘fixed’ by simply taking off their shoes?
The short answer is sadly NO!
Mainly because some patients’ problems have been left till its too late. In some cases barefoot walking or running is no longer possible comfortably.
UnfortunateIy, some people I see cannot fully rehabilitate. This is due to irreversible arthritic changes to the joints, or permanent adaption of the soft-tissues.
Also, the simple act of “taking off their shoes” is not enough for most people any way. The adverse effects of prolonged footwear use creates physical dependency on them. Most people have to be gently and slowly weaned off their supportive and protective footwear.
And tragically for many people the physical adaptive changes to the foot, and the whole lower-limb can be irreversible. These people would probably benefit from going barefoot more often, or wearing minimalist shoes, but they won’t receive the full benefits because of the irreversible anatomical changes.
In some few cases, those changes to the physical anatomy of the body are so widespread and so well established, that changing their gait to a more natural style is not an option which would be beneficial at all, but would actually cause more problems. Fortunately, I believe this to be true only for the minority of shoe wearers.
There is possibly only one medical condition which could preclude someone from barefoot gait. This is sensory neuropathy. If you cannot sense the ground with your feet then you are in danger of traumatic injury. (I would now add some others: see future blog post for update)
The biggest problem though is the psychological/socio-emotional dependency. Most people just cannot imagine ever walking or running barefoot. And certainly not in public. This is treatable with the introduction of new information which can change our attitudinal paradigms to feet and their use.
I consider my clinic to be almost like an addiction recovery clinic. Only, the drug is shoes.
5. Why is it so important to feel the ground beneath your feet? (could you explain a little about proprioception here?)
One of the most important functions of our feet is to sense the surface on which they are placed. The many thousands of highly specialised sensory nerve endings in the skin of our feet have evolved to expect intimate skin contact with the ground. There are touch, pressure and vibration mechano-receptors which function to give vital information to our brains so our brains know precisely what we are standing on and how are feet are interacting with that surface. The sensory information is necessary for optimal muscle function and postural alignment. The better the quality of that information, the more effectively our muscles can work to enable us to walk and run as efficiently as possible, thus reducing the risk of musculoskeletal injury.
The big problem with footwear of any type is they interfere with that sensory perception of the ground. Muffling and distorting the image our brains receive of our interaction with the ground.
Minimalist footwear designs go some way to improving the amount of proprioceptive feedback, but with evolution only giving us just enough sensory nerve endings for optimal proprioception, nothing is as good as totally barefoot.
Some minimalist footwear are better than others for various reasons. The main criteria I think are important are the thickness of the material under the sole of the foot, combined with how pliable that material is. The other is: does the footwear allow natural foot movements, with individual toe function very high on the list.
6. Let’s talk about toes. Is it OK to bunch them all together in socks and shoes or is there a real benefit in allowing them to move independently and spread? Why is it so important to have strong toes?
Though the scientific research hasn’t proven this conclusively yet, I believe that it makes sense from an evolutionary & a biomechanical perspective to maximise the number of bones & joints moving, as well as muscles contracting & relaxing for the best proprioceptive feedback. From experience in my clinic over the last four years I’ve found people who wear Vibram FiveFingers seem to have less foot injuries than those wearing minimalist shoes with toes all bunched together.
There is evidence that separating the toes increases the intrinsic muscle activity in the ball of the foot. Having strong muscles in the forefoot helps to protect against injury.
7. Finally, what do you think needs to be done in order to change the way we treat our feet? Why have we got it so wrong for so long?
I’m convinced their needs to be a paradigm shift in thinking about our feet. In fact, we just need to think about our feet. Most people are completely oblivious to how their feet work, or don’t work. They just stick them into shoes without any thought about what the shoes are doing to the function of their feet. It’s a bit like everyone habitually sticking their hands into boxing gloves and then ignoring them day in, and day out. Eventually there would be repercussions.
The biggest challenge, I think, is that the overuse of shoes in our society has become so normal, so expected by social convention that people don’t consider that shoes could actually be causing their foot, ankle, knee, hip or back problems. It’s because wearing shoes is the norm, & has been for many years, that very few people consider the risks. Children grow up without a choice of whether or not to wear shoes when they go outside. No-one makes a choice, they just do what society has programmed them to do – wear shoes!
The problem with the over-use of shoes is not normal for all societies, mainly Western European & American. Australians & New Zealanders are much more relaxed & comfortable about going barefoot outside & in public.
The main reason for obsessive shoe use in Europe is believed by historians to be related to the class system going back to the Renaissance when the aristocracy wore shoes to set them apart from the peasantry. When you wore shoes you were “well-heeled!”
After that the lower classes aspired to become like the upper and middle classes, and wearing shoes was part of the image they desired.
Since then, wearing shoes just became a tradition. Most people don’t consider why they wear shoes, they just do.
However, just like in other fields of medicine, where once a cause for pathology is discovered lots of effort is put into educating the population about healthier lifestyle choices, the same is true for feet.
In dentistry, once sugary foods in our diets were discovered to be a major cause of took decay, the dental profession gave advice about better diets.
Once doctors discovered that smoking causes lung cancer, health promotion campaigns encouraged people to give up the dangerous habit.
Now that we know that sedentary lifestyles increase our risk of developing diabetes & heart disease, exercise for health is encouraged.
In a similar way, now we know footwear can be harmful to our bodies, we should inform & educate the population about the risks of shoe wearing & encourage people to make healthier lifestyle choices. At the very least we can teach people that they have a choice.
The biggest hurdle is challenging social convention. The general population need to become more accepting of seeing a bare human foot in public.
Just as a bare hand is normal for human beings, so should a bare human foot be!
Please visit my podiatry clinic website for more information: StepFree.co.uk