Are you dealing with foot pain? Today we’re going to talk about how to start the rebuilding process out of pain and back to normal life again!
This is part 6 of a series titled “Foot Pain (How To Fix ‘Plantar Fasciitis’ and Other Common Foot Problems)”
Part 1: Introduction
Part 3: How Shoes Change Your Foot
Part 4: What Causes Plantar Fasciitis?
Part 5: How To Screen Your Foot Pain
Part 6: Foot Pain – The Rebuilding Process
Part 7: Foot Pain – Should You Wear Orthotics?
Part 8: Foot Pain – What About Steroid Shots? – Coming Soon…
Dr. McClanahan (a podiatrist specializes in using non-invasive treatments to help strengthen, align and restore foot health) teaches that the first and most important treatment for almost any type of foot pain is not a “corrective exercise.” It’s not a stretch, an expensive orthotic or a pain numbing medication. It is simply to get into a shoe that allows your foot to assume its “natural” position. By addressing the cause of many common foot problems, we are able to take the first steps towards a real and lasting resolution for your symptoms.
The first thing you need to do is find a shoe that is completely flat (no heel or toe spring) and wide enough at the toe box to allow your toes to sufficiently spread out. As podiatrist William Rossi wrote, “the less a shoe does TO a foot, the better FOR the foot.”1
When the foot is unobstructed from the confines of a modern “normal” shoe, a number of small changes begin to occur. The first is that the toes begin to leave their molded cramped position and spread out. There is research that dates back to the mid-1900’s that shows changing into a wider toe box can reshape your feet and allow your great toe to straighten back out into its “natural” position!2 The is direct evidence that many foot “abnormalities” such as bunions are not hereditary and can often be greatly modified by choosing better shoes!
This improved toe splay can be very helpful for many dealing with “plantar fasciosis.” Spreading the first toe from the other toes decreases the strangulation hold of the posterior tibial artery by the abductor hallucis muscle thus allowing blood flow to be restored to the bottom of your foot!
As you continue to walk and move throughout your day in “natural” shoes the muscles of your foot also become stronger! In fact, there are multiple scientific studies that show significant improvements in foot strength after switching to a “natural” shoe.3,4
At first many will be hesitant to change their shoes. The most common complaint I hear is the desire to continue wearing fashionable brands like Nike, Adidas or ASICS. My answer to this protest is always the same: if you tell me that you truly value the function of your body and want to keep it running/performing optimally for as long as you live, then you must value function over fashion. This means choosing shoes that are best for your feet and not based on the logo they come with. Fortunately, there are new brands emerging every day that are working to blend function with fashion in a way that preserves the natural foot shape (such as Bearfoot Athletics, Xero, Feelgrounds, Lems and Vivobearfoot).
So, let’s talk about how to actually make this transition if you’re one of the many that have worn brand name shoes your entire life.
Ask yourself this question, “How often are you barefoot throughout the day?” If the answer is almost never, your feet are probably not ready to make a quick transition into a “natural” or barefoot style shoe. Jumping from supportive shoes to natural shoes can lead to injuries if you make the transition too quickly.
This is why there was such a backlash against the original Vibram “FiveFinger” shoes back in the mid-2000’s. Vibram was one of the first shoe companies touting the benefits of returning to a more minimalist shoe for running. Unfortunately, many runners transitioned too quickly from a cushioned shoe to Vibrams and subsequently developed injuries. Nowadays we know there is plenty of science to support the use of “natural” shoes…it just comes down to how you transition into them.
Think about it like this, you wouldn’t throw a child into the deep end of the pool and tell them to swim if they have only ever experienced the shallow end with inflatable “floaties” on their arms to keep them from sinking. Of course not! You first teach the child how to swim before transitioning into the deep end of the pool. In the same way, you need to slowly build capacity and strength of your foot. Remember, the less support from the shoe means your foot needs to do more (but this is a good thing).
I recommend starting slower than you think. Walk 100 yards and/or wear a pair of “natural” shoes for one hour the first day and see how your body responds. Simply increasing this amount of time each day (by as little as 20-30 minutes) can help your foot adapt optimally to the increased stress. Move too quickly and your foot will be unable to adapt and build sufficient capacity. A small amount of soreness in the muscles of the of the foot can be a normal part of the process, pain is not.
You will also find that wearing a “natural” shoe requires a slightly different walking/running technique (called your “gait” pattern). Conventional shoes with a semi-rigid sole, high heel and toe spring lead most people to “heel strike” as their foot hits the ground. However, jam your heel hard into the ground each step without this cushioned pad to absorb the force and your body won’t like it.
In fact, the first time you put on a pair of “natural” shoes you will feel like you’re clomping around like a monster. This is because you will still be moving with the same walking pattern you have grown accustom to over the years of hard heel strike. Eventually you’ll learn to use a smoother gliding gait (making much less noise) as your body adapts to a less forceful gait pattern. Research demonstrates that this is due to the ability to distribute the pressures of walking more evenly across the entire foot.5 This progression can take weeks or even months but is a necessary part of learning to move outside of the constraints of a “normal” shoe.
After modifying your shoes to address the cause of your foot pain, we can now add some rehabilitation exercises that will address the negative adaptations your foot has undergone due to your previous footwear. This means performing specific stretches to short/stiff muscles and strengthening muscles that have become weak.
Toe Extensor Stretch
Commonly physical therapists and other medical practitioners will prescribe stretches to the plantar fascia (some even prescribe boots/socks that maintain your foot in a stretch throughout the night). This recommendation is based on the idea that the plantar fascia is tight/short. However, this is incorrect. Modern footwear lengthens this tissue by raising your heel and toes from the ground. So rather than trying to stretch something that is already overly lengthened we will focus our attention on the opposite side of the foot!
Start with a stretch to the toe extensors (these muscles are often short/stiff when the toes are constantly elevated off the ground in shoes with toe spring). In a seated position, pull one or both feet behind you and position the top of the foot on the ground. Next, pull your heel back and towards the ground. This action should bend or flex your toes underneath the foot and bring out a good stretch to the top of your foot. Hold this position for 10-30 seconds before relaxing. It is common at times to have the arch of your foot cramp during the first few stretches. Just know this is normal and will get better with time.
You can also perform this manually with one foot at a time. Position your thumb at the ball of your foot (directly in the center) with your fingers wrapped over the top. Simultaneously push your thumb into the foot while pulling the toes into a flexed position. Doing so should bring out a good stretch to the top of the foot. Again, hold for 10-30 seconds.
Soft Tissue Mobilization
If you were to Google “How to fix plantar fasciitis” you would likely come across a recommendation for rolling a small ball on the bottom of your foot. While I often discourage generic treatment recommendations found on the internet, this is one that actually works well for many people.6 When deep pressure massage is applied to the plantar fascia, blood flow is stimulated (which can accelerate healing) and pain is often temporarily decreased.7-9.
Find a small ball (golf ball, tennis ball, dog toy, etc.) and roll it slowly on the bottom of your foot. If you come to a spot that is painful, stop and hold this pressure for 10-20 seconds before moving off the tender area. After 4-5 minutes of rolling, stand up and see if your symptoms are any better than before. If so, this can be performed a few times a day as a helpful way to manage your pain.
I would recommend avoiding this particular mobilization if you’re dealing with a neuroma of the forefoot. Placing excessive stress onto an irritated nerve can often lead to an increase in symptoms.
Bunion “Tack & Stretch”
For those who have develop a painful bunion, many medical doctors will sometimes recommend a bunionectomy (a surgery that removes bone, cuts muscles and repositions your big toe back into an aligned position using pins and screws). Rather than go under the knife and risk a costly surgery, many can make significant progress in realigning their foot with a more natural and less-costly approach! The first step is to treat the cause (tapering toebox). You can then perform soft tissue work to parts of the foot to help enhance the big toe realignment process.
Start by pulling your big toe out to the side away from your other toes (an abducted position). Next, you’re going to take your thumb and slowly push into the area between your first and second metatarsals. You’ll likely find a small tender area (this is the adductor hallucis muscle that adaptively shortens over time when the big toe is held an angled position).
Put pressure into this tender spot as you pull the big toe out to the side and hold the stretch for 10-30 seconds. This “tack and stretch” method is similar to an active release technique some rehabilitation practitioners will use with patients to improve flexibility and mobility of restricted joints.
If you found restricted ankle mobility with the prior testing, stretching and soft tissue work for the calf muscles and/or banded joint mobilizations should be a part of your rehab plan.6,10,11
During the ankle mobility screen, a “pinching” or “blocked” sensation felt in the front of the ankle indicates a probable joint impingement. This restriction will not resolve itself with stretching and foam rolling and should therefore always be the first area to address.
One of the most efficient ways to address a joint restriction on your own is to use a band mobilization. This exercise assists with the way our bones glide over each other. If we look at the ankle, the talus bone of the foot moves backwards as the shin moves forward into dorsiflexion. This motion is needed in order for us to walk normally, lunge or perform a squat.
In order to help improve this movement to increase mobility, the band must help push the talus bone backwards.45,46 These types of mobilizations (simply termed mobilizations with movement) have been used for years by physical therapists and was something I first learned from Dr. Kelly Starrett with his “MobilityWOD” videos in the mid 2000’s. Try 10-15 reps before retesting your ankle mobility to see if the exercise was able to bring out any significant changes.
After joint restrictions have been addressed the next step is to perform soft tissue mobilization to the calf muscles with a foam roller. Start by moving slowly up and down the lower leg muscles until you find a tender area. Pause on this area and ‘tack it down’ with your opposite leg for around 10 seconds before moving to find another spot. You can also add in some ankle pumps during this pause to increase the effectiveness. Spend a total of 1-2 minutes on the foam roller if you’ve found these tissues to be particularly tender/sore in order to see significant improvements in flexibility and help with your heel pain.12,13
Once foam rolling is complete, stretching the calf muscles is the next step to addressing soft tissue restrictions. Start with the simple heel drop and box calf stretches to address both the larger gastroc and smaller soleus calf muscles. I recommend starting with 10-30 second stretches for 3-5 repetitions. Again, be sure to retest your ankle mobility after performing to ensure you’re on the right path.
Strengthening The Foot
While limited flexibility has been linked to many foot injuries, reduced strength of the foot can also be a contributing factor. Improving strength of the foot however does not need to be complicated. In fact, the act alone of just switching to a barefoot style shoe is actually just as effective as isolated foot strengthening exercises for increasing foot muscle size and strength!14,15
That being said, for those that do need additional strengthening work for the smaller muscles that support the arch of the foot (called the plantar intrinsic muscles) we can start with a simple exercise is called a “toe scrunch.”
Place a small towel roll on the ground in front of you and position it under your toes. Next, attempt to grasp the towel with your toes and pull it towards your heel. This exercise can also be performed with a small soft ball (such as a “hacky sack”). Make sure your heel does not pop off the ground during this squeeze. Hold for a few seconds before relaxing. Usually, I’ll recommend athletes do 10-20 reps for 2-3 sets at a time.
Next, you can perform a strengthening exercise for the foot but in a weightbearing position called a “short foot” isometric. In a standing position, start by jamming your big toe in the floor before spreading the rest of your toes out as wide as possible as you grasp the ground with the rest of your foot. Then, attempt to grip the ground as hard as possible for a few seconds before relaxing. While the foot itself won’t move, you’ll notice the act of gripping the floor will cause the small muscles that span the arch of the foot to contract. For those who have strong intrinsic foot muscles, you’ll notice the arch of the foot will rise a bit (this is how “natural” arch support is created).
Once you have the ability to easily create this strong foot position and maintain it for a few seconds, we then need to practice how to maintain it under load and under greater balance challenges. For example, I highly recommend training squats and other assistant exercises (such as single leg RDLs) without any shoes. I also recommend performing exercises like the hip airplane for its ability to challenge foot stability within multiple planes of motion. By stimulating the body (with progressive overload and greater balance demands) we can raise the capacity of the foot over time and decrease risk of reinjury.
For those of you with bunions, we can also perform some functional strength training of the lower body but in a way that accentuates realignment of the big toe. All you’ll need for these next few exercises is a small resistance band loop.
Start in a standing position with a resistance band around the toe pulling medially (towards your other foot) to assist in spreading it out as we move into the next part of the exercise. You can anchor this band around your other ankle or a rig.
With the big toe now aligned in a better position, you can then perform heel raises, split squats or even regular squats. The idea is to teach the tip of your big toe to grip the ground while you move but remain in a more ideal position.
Another great exercise to retrain the position of your big toe is to perform some side steps with the same banded set up. As you take a step sideways, the band pulling medially will help ensure your big toe is spread away from the other toes. Plant your foot into the ground and hold for a second or two before coming back to the start position.
That’s it for today’s blog article! Next week we’ll jump into whether or not you should wear orthotics for fixing foot pain!
Until next time,
Dr. Aaron Horschig, PT, DPT, CSCS, USAW
Dr. Kevin Sonthana, PT, DPT, CSCS
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- BARNETT CH. The normal orientation of the human hallux and the effect of footwear. J Anat. 1962;96(Pt 4):489-494.
- Rory Curtis & Kristiaan D’Août (2019) Daily activity in minimal footwear increases foot strength, Footwear Science, 11:sup1, S151-S152
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- Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM; American Physical Therapy Association. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44(11):A1-33.
- Fraser JJ, Corbett R, Donner C, Hertel J. Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. J Man Manip Ther. 2018 May;26(2):55-65.
- Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. Foot Ankle Int. 2002 Jul;23(7):619-24.
- Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernández-de-Las-Peñas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011 Feb;41(2):43-50.
- Vicenzino B, Branjerdporn M, Teys P & Jordan K. Initial changes in posterior talar gide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Manual Therapy. 2004 May; 9(2):77-82
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- Chen TL, Sze LK, Davis IS, Cheung RT. Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume. Clin Biomech (Bristol, Avon). 2016 Jul;36:8-13.