Your SHOES Are Probably Part Of The Problem (+10 Steps To Fix Your Feet)

BORN WITHOUT SHOES; ORIGINALLY DESIGNED WITHOUT SHOES

No child is born wearing Oxfords or high heels. The original design (ala Genesis chapters 1-3) had man and woman operating in a lush and vibrant garden, totally naked, sans shoes. Am I advocating a return to full-on Garden-of-Eden-living (i.e. veganism, walking around naked, etc.)? Absolutely not. With the world the way it is now that would be quite unwise (plus animal protein is very nutrient dense AND I don't want to see some of you naked). All that said, I do think it’s important to recognize the original design, and the wisdom God used in creating the human body, feet included.

THE AMAZING DESIGN & CAPABILITIES OF THE HUMAN FOOT!

The human foot is an incredibly complex piece of biological machinery, consisting of…

Bones: There are 26 bones in each adult foot- 52 bones in both feet combined. That’s 25% of the bones in the human body!

Joints: There are 33 joints in each foot- 66 joints in both feet combined, which accounts for nearly one-fifth the number of joints in the entire human body!

Ligaments & Muscles: There are 107 ligaments and 19 muscles IN EACH FOOT!


Nerves: Each human foot has nearly 8,000 nerves. The soles of the feet have more sensory nerve endings per centimeter than any other part of the body.

Sweat Glands: And there are an astounding 250,000 sweat glands in a pair of feet. These sweat glands produce as much as 8 ounces of moisture (sweat) EACH DAY! [1-2]


Consider the ball of the foot (or forefoot). It has enough surface area to afford us incredible balance yet is small enough to allow for notable speed and agility. The increased surface area of the forefoot compared to the heel allows for a greater deflection of impact-related force when we walk or run (that is, IF the forefoot is the primary surface area involved in a foot strike... we'll get to that in a minute). The toes, among their many functions, act as outriggers, helping us balance in order to remain upright! And the heel anchors our Achilles tendon and calf muscles which, due to their eccentric and concentric abilities, help propel us when we walk or run or jump.


FEET: THE FOUNDATION OF UPRIGHT MOVEMENT

Dr. Andrew Weil notes that “our feet are our body’s connection to the earth.” I like to say that our feet are “the foundation of upright movement.” And for those of us who are blessed to have two biological feet (an estimated 1.5 million Americans don't), our feet play the central role in our ability to… [3-4]

Stand upright without falling over. That means supporting and balancing a body that is, on average, 170lbs for an American woman (up from 140lbs in the 1960s) and 200lbs for an American man (up from 165lbs in the 1960s) and... [5]


Walk, jog, run and jump! This is really saying something, in light of the “impact force” that is experienced by the foot during common physical activities. The foot typically experiences an impact force of 1-1.5 times a person’s bodyweight while walking. That ratchets up to 3-4 times a person’s bodyweight when running on a level surface, and up to 10-18 times a person’s bodyweight when jumping and landing. For example, I’m 6’5” and around 210lbs. That means that my foot is handling 600-800lbs of impact force per foot strike when I’m running, and as much as 2,000lbs (or more) if I’m jumping and landing. This is one of the reasons why I encourage most people to limit their time running on asphalt or concrete! [6]



And it’s not just the feet that feel the impact. Walking on a level surface exerts an impact force on the knee that’s 2 to 3.5 times a person’s bodyweight. The hips experience a similar impact force- 2.1 to 4.3 times a person’s bodyweight when walking on level surfaces. It’s important to note that walking or running uphill exerts significantly less impact force, while walking or running downhill can exert significantly more. [7]

“HOUSTON, WE HAVE A [FOOT-RELATED] PROBLEM”…

As amazing as the human foot is, a large percentage of the American adult population struggle with foot, ankle and lower limb pain and/or dysfunction, which can even result in chronic disability. For example…

  • 75-80% of Americans will experience foot problems in their lives

  • 60% of all foot and ankle injures for U.S. adults are ankle sprains and strains

  • 25% of the U.S. population has flat feet

  • Over 2 million Americans seek treatment for plantar fasciitis each year

  • American women have 4 TIMES as many foot problems as men (a habit of wearing high heels is often the culprit; for instance, a 2.5” high heel can increase load on the forefoot by 75%)

  • 9 out of 10 American women wear shoes too small for their feet

  • More than half of U.S. women have bunions, a common foot deformity where the joint that connects the big toe to the foot gets enlarged and juts out

  • Only a small percentage of people are born with foot problems. They tend to develop primarily because of… (drumroll please)… IMPROPER SHOES! [1-2]

GOING BAREFOOT VS WEARING SHOES

There is a fair amount of research in the peer-reviewed literature examining the biomechanical efficiencies of barefoot movement versus “shod” movement (or moving while wearing shoes). The winner? Barefoot movement, over and over again. Below are 9 examples for the skeptics and nerds out there (of which I am both), all published from 1995-2018 and listed in chronological order (most recent first)…

  • April 2018, Frontiers in Pediatrics. “Motor Skills of Children and Adolescents Are Influenced by Growing up Barefoot or Shod.” Author(s): A. Zech, et al. [8]

  • March 2018, Royal Society Open Science. “Heel Impact Forces During Barefoot Versus Minimally Shoe Walking Among Tarahumara Subsistence Farmers and Urban Americans.” Author(s): Wallace, et al. [9]

  • Sept. 2015, Gait & Posture. “Barefoot vs Common Footwear: A Systematic Review of the Kinematic, Kinetic and Muscle Activity Differences During Walking.” Author(s): S. Franklin, et al. [10]

  • Jan. 2010, Nature. “Foot Strike Patterns and Collision Forces in Habitually Barefoot Versus Shod Runners.” Author(s): D.E. Lieberman, et al. [11]

  • Jan. 2008, Gait & Posture. “Foot Motion in Children Shoes: A Comparison of Barefoot Walking with Shod Walking in Conventional and Flexible Shoes.” Author(s): S. Wolf, et al. [12]

  • Sept. 2006, Arthritis & Rheumatism. “Walking Barefoot Decreases Loading on the Lower Extremity Joints in Knee Osteoarthritis.” Author(s): N. Shakoor, JA Block [13]

  • Oct. 2002, Podiatry Management. “Children’s Footwear: Launching Site for Adult Foot Ills.” Author(s): W. Rossi [14]

  • March 1999, Podiatry Management. “Why Shoes Make ‘Normal’ Gait Impossible.” Author(s): W. Rossi [15]

  • March 1995, Journal of Bone & Joint Surgery- British Volume. “The Influence of Footwear on the Prevalence of Flat Foot. A Survey of 1846 Skeletally Mature Persons.” Author(s): V. Sachithanandam, B. Joseph [16]

My current favorite research piece on this topic is titled “Conclusions Drawn From a Comparative Study of the Feet of Barefooted and Shoe-Wearing Peoples” and comes from the American Journal of Orthopedic Surgery from waaaaay back in October 1905! It’s a great read and contains some fascinating pictures. The author, Dr. Phil Hoffmann M.D., reached some of the same conclusions that the authors above reached- that barefoot movers avoid the vast majority of foot-related ills (including bunions/hallux valgus, plantar fasciitis, flat feet, Morton’s neuroma, hammer toes, corns and athlete’s foot) that plague many shoe-wearers, and that upright movements performed barefoot are more efficient than those performed with shoes on. [17]

So what’s the answer? Going barefoot all the time? The answer depends on who you ask. While I recognize the many benefits of going barefoot, there are a number of activities where the risk of injury (or inability to perform at a high level) would prevent me from going without shoes. Despite that, there are a number of adults in the U.S. (and around the world) who do choose to go barefoot all the time. There are even advocacy groups for going barefoot, such as the Society for Barefoot Living (www.barefooters.org).

10 “STEPS” TO FIX YOUR FEET & IMPROVE LOWER BODY MOVEMENT

In light of all this data, how do we improve and optimize foot, ankle and lower body health and functioning? I've listed 10 ways below…


STEP 1: ADDRESS THOSE CALLUSES & CORNS

Corns and calluses are thick, hardened layers of skin that are generally caused by friction and pressure. Corns are smaller than calluses and usually have a hard center surrounded by inflamed skin. Both corns and calluses are caused by things like faulty footwear (poorly fitting shoes), poor foot mechanics and/or high levels of physical activity. [18]



I'll talk more about the footwear piece below, but from my personal experience, having some self-care tools to address calluses and/or corns is also important, so that these often painful nuisances don't continue to exacerbate poor movement patterns. My current favorite tool here is the Ped Egg, which is a cool little foot filer that I've found most effective for removing excess skin (more effective than other products like the Amope Electronic foot file or classic pumice stone).


STEP 2: DO EXERCISES FOR YOUR TOES, FEET, ANKLES & CALVES

I often categorize exercises by their "component of fitness", which at a basic level includes self massage, mobility (which includes stretching and range of motion), balance/stability and strengthening.


Dozens of scientific studies have shown that self massage, mobility, balance and strengthening exercises for the toes, feet, ankles and calves have positive effects on a host of lower limb-related maladies, including chronic foot and ankle pain, poor gait patterns, plantar fasciitis, ankle sprains, ankle instability, Achilles tendinitis, turf toe and even circulatory problems and diabetic neuropathy. [19-24]


I suggest that many people start with self massage techniques. Massage can help improve blood flow and circulation, soften fascia and connective tissue, reduce scar tissue, and address causes of pain and dysfunction such as knots, trigger points and adhesions. A number of self-massage options are available, including…

  • Manual myofascial release (massage) using your hands

  • Myofascial release using a tennis ball, racquet ball, lacrosse ball, foot roller, etc.

  • Electronic shiatsu massagers (usually $50-$250 or more)

Standing on a tennis or lacrosse ball and gently massaging the plantar area is one technique, as is using a massage balm (ex. Tiger Balm, Biofreeze, Icy Hot, Bengay, etc.) and your hands to massage problematic tissues and joints. For plantar, Achilles and calf issues I've also found gua sha scraping tools to be effective in some cases.



For mobility work I often suggest starting with stretching before doing ankle range of motion movements. Stretch the toes (through flexion and extension) and gently stretch the Achilles and calves (back of lower leg) and shin extensors and Tibialis muscles (front of lower leg) the same way (through foot flexion and extension). One way of stretching the Achilles and calves involves simply standing on a step with the balls of your feet while letting your heel slowly drop. Adjustable wooden incline slant boards are another tool you can use to stretch the Achilles and calves (see image below). Next, you can try ankle range of motion exercises by gently creating air circles with the toes, both clockwise and counterclockwise.



Strengthening exercises for the toes, feet and calves include flexing and extending the toes (or making "fists" with your toes) and various types of calf raises.


STEP 3: WALK AROUND YOUR HOUSE BAREFOOT

We've already established that going without shoes carries several health benefits. Of course most of us have stubbed our toe or stepped on something painful at home while going barefoot, so we know that walking around the house barefoot isn't totally risk free. Still, home is generally more of a controlled environment, and many of us have carpeted (and clean) floors that make walking around barefoot pretty darn comfortable! If you have pressure points or "hot spots" on your feet, are dealing with excess weight, or have other foot, ankle or lower limb issues that make prolonged barefoot activity difficult, don't distress- you may just need to do your at-home "barefoot therapy" in smaller doses.


STEP 4: TAKE UP A BAREFOOT FITNESS ACTIVITY

What are some relatively safe barefoot fitness activities that will help increase the functional mobility and strength of our feet, ankles and lower body? Some options include water-based activities (swimming, water aerobics, surfing, stand up paddle boarding, etc.), yoga, Pilates, tai chi, certain types of martial arts, gymnastics and beach/sand volleyball.



Some of you may be aware that the Pilates method was founded and formulated by Joseph Pilates, a German physical trainer (1883-1967). If you've ever done Pilates you may also be familiar with some of the equipment, such as the Reformer (pictured above) and the Cadillac. While there are several other pieces of Pilates equipment, two lesser known items are the Foot Corrector and the Toe Tensometer, which, as you can probably tell from the name, were designed to help correct and strengthen toe, foot and ankle-related problems. [25]


If you’re considering barefoot jogging or running, I recommend doing so on an artificial turf surface (ideally), although a sandy beach or a well-maintained grass surface area (like a football field) may also work.

One risk that may not be obvious to those considering barefoot running or hiking is hookworm infestation. Going barefoot on surfaces where mud and animal feces may be prevalent can carry an increased risk of contracting hookworms (although hookworms can penetrate the fabric of many types of shoes as well). I advise taking extra precautions if doing a barefoot activity in this kind of environment, or simply find another more hygienic barefoot activity to engage in. [26-27]

STEP 5: USE MAGNESIUM

(EX. EPSOM SALT SOAK, TOPICAL SUPPLEMENT, ORAL SUPPLEMENT)

An estimated 48-75% of Americans don't get enough magnesium in their diet. Among its many roles in the body, magnesium exerts a relaxing effect on soft tissue. When magnesium levels are low, the muscles and fascia are often overly tense and tight. This phenomenon is often exacerbated by high levels of calcium in the soft tissue. [28-30]



When it comes to addressing lower limb issues, there are generally 3 options with magnesium: Epsom salt soaks (magnesium sulfate), topical or transdermal magnesium oil or lotion (usually magnesium chloride) or oral magnesium supplementation (typically magnesium citrate or mag glycinate).


Epsom salts have been used since at least the 1600s, and Epsom salt foot and ankle soaks have a well-established history as a folk remedy for sore and achy muscles and joints. The clinical research, however, is quite limited. [31-33]


There is a little more scientific research available on topical or transdermal magnesium. A 2015 study involving 24 patients with fibromyalgia (chronic muscle pain) found that "transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia." [34]


A 2017 study of 25 participants found that supplementing with a low dose (56mg/day) of topical magnesium improved blood magnesium levels by 8-9%. [35]


If you decide to try a topical magnesium oil or lotion, I'd suggest considering the products made by Ancient Minerals. If you have sensitive skin, use caution, as topical magnesium products are known to cause rashes in certain people.


With oral magnesium I generally recommend a mag citrate or glycinate product (not mag oxide). Most of my clients use anywhere from 150mg up to 1000mg a day (500mg is about the highest single dose I'd recommend though).


STEP 6: PICK UP SOME TOE SPACERS

For those who have mangled, deformed or otherwise misshapen toes due to years of wearing traditional shoes (like me), you may want to consider purchasing a pair of toe separators (i.e. toe spacers, spreaders, straighteners, etc.) to help correct and align your phalanges (toes) for less pain and better movement.



I was a little surprised to find a decent bit of clinical research on toe spacers (perhaps I shouldn't be- as of 2021 there are approximately 20,000 practicing podiatrists in the U.S.). [36]


At first glance the research seems to be split. A March 2008 study in Prosthetics and Orthotics International found that an insole with toe separator did significantly decrease pain in 30 female hallux valgus (bunion) patients but didn't improve toe angles. [37]


Bunions are actually the most common foot deformity in the U.S. (>60 million Americans are affected) and involve a bony and often inflamed bump that forms on the joint at the base of the big toe. The angles of the toes are also commonly misaligned with hallux valgus, with the big toe pushing over against the second toe. Tight and poor fitting shoes are the most common cause of bunions (surprise!) and conditions like arthritis and gout also tend to increase the likelihood of bunions developing. [38]



Unlike the 2008 study above, other studies looking at the effects of toe spacers have found them effective for both bunion pain and deformity when they're customized.


A 2018 study of 79 patients with bunions found that a customized toe spacer was effective for reducing both pain and toe deformity associated with hallux valgus. Another 2018 study found similar results using custom spacers made from a 3D printer. [39-41]


With generic/ready-made toe spacers, a variety of options are commercially available, with prices generally ranging from $10 to $70. For these kinds of products I'd recommend checking out Correct Toes.


For custom toe spacers it gets a little trickier. You might find a local podiatrist who makes custom spacers for his/her patients, but if you want to try to DIY, you can pick up a jar of PediFix PediPlast moldable footcare compound. There are a few YouTube videos that can show you how it's done.

STEP 7: PICK UP SOME TOE SOCKS

Ok, you might laugh at me for this one, and I haven't found any scientific articles that examine the potential benefits of toe socks (at least, not yet!), but I do think toe socks are worth consideration. Why? I'll give you 3 possible benefits...


  • Blister & Hot Spot Prevention: With each toe covered in fabric, skin-on-skin friction is eliminated.

  • Encourages Toe Separation & "Splay": Toe splay (which happens more naturally when barefoot) helps with balance and proper lower limb biomechanics.

  • Moisture Management: With each toe wrapped in sweat-wicking material, the foot remains drier, more comfortable, and less prone to athlete's foot.


The most well-known toe sock company is Injinji, but several others are also available.


STEP 8: BUY SOME ERGONOMIC SHOES (AND DITCH THE OTHERS)

American adults average between 5,000-6,000 steps a day. Adults in western Australian average around 9,700 steps a day, and Amish men and women average between 14,000 and 18,000 steps a day! I even knew one girl who regularly registered more than 30,000 steps over the course of her workday! [42-44]


Spread out over the course of a year, those 5,000 to 18,000 steps a day become 1.8 to 6.5 MILLION steps. The type of shoe your foot is in during each of those foot strikes will play a major role in the health and function of your feet (which in turn heavily impact the knees, which impact the hips, which impact the lower back, and on up the kinetic chain).



Regularly wearing shoes that encourage more natural foot and ankle functioning is an important step (pun intended) in alleviating lower body pain and dysfunction and helps to ensure that lower body pain and dysfunction related to poor foot biomechanics won’t occur in the future. So what makes for a good shoe? I recommend looking at 8 criteria…

FOOT SHAPED DESIGN

We buy gloves shaped like hands, so how much sense does it make to buy shoes that aren’t generally shaped like our feet?! A foot-shaped design generally has a significantly wider toe box (among other distinctives) when compared to traditional shoes.



"ZERO DROP"

The “drop” of a shoe is the difference in sole thickness between the heel compared to the forefoot (where the ball of the foot will be). A "zero drop" (0mm drop) encourages a more natural foot strike, whereas an elevated heel tends to encourage a more prominent heel strike, which can decondition the muscles, tendons and ligaments of the foot while also increasing the amount of shock and impact force travelling through the foot, ankle and lower extremities.

FLAT SOLE

You might think that a “zero drop” shoe would, by nature, have a flat sole, but you’d be wrong (I’ve made the same mistake myself, which is why I mention it here). The flat sole mimics a flat ground surface, encouraging a more natural foot strike.

APPROPRIATE "STACK HEIGHT" (SOLE THICKNESS)

Stack height is the sole height- basically the distance from the bottom of your foot to the floor. If the stack height is too low and you're walking (or running) on hard surfaces (concrete, asphalt, etc.) for significant lengths of time (or if you’re significantly overweight), your foot will likely ache from the effect of repeated impact (I speak in part from personal experience). If the stack height is too high, you may feel unbalanced, which can increase the risk of falling (or rolling/twisting your ankle). For me, the “sweet spot” stack height (not too low, not too high) for a general training, work or recreational shoe is usually somewhere between 15-25mm.

OTHER SHOE QUALITIES TO CONSIDER

Lightweight: Think about the average number of daily steps again (5,000-18,000). Every additional ounce a shoe weighs works against a natural movement pattern in the foot and lower leg. A lightweight shoe with a decent stack height will likely be in the 5-7oz range (larger sizes will obviously weigh more, and smaller will weigh less).

Good Fit: While I believe the 5 factors above are central in choosing a health-promoting shoe, there are other design factors that will play into how the shoe feels on your foot. These factors add to the overall feel and fit of the shoe. What we’re aiming for here is a fit that’s not too tight/constrictive (which may adversely affect toe splay and the natural functioning of the foot and ankle) but that comfortably secures the foot (so the foot doesn’t slip/slide when performing physical activity). Consistency in sizing should also be considered.

Good Traction: What you want here will depend on the types of activities you're doing and surfaces you're doing them on. For me personally, I usually prefer a shoe with a lug (or lugged) sole. A lug sole includes moderate to deep indentations and/or grooves which provide added grip and traction. One of my life goals is to avoid slipping or falling down as much as possible, and the lug sole helps with that.


Durable: How long the shoe maintains its integrity (i.e. durability) should also be considered. One of the more common criticisms I've seen with shoe companies that are relatively small in size (as is the case with many of the companies that produce the kinds of shoes we’re discussing here) is that the durability of their product is sometimes lacking when compared to shoes produced by larger manufacturers (ex. Nike, Adidas, etc.).

A common question that pops up when discussing shoe durability is “How often should I replace my running or athletic shoes?” The specific answer depends on several factors, but the general advice is to replace every 300-600 miles, or 3-6 months. [45]


Reasonably Priced: Since my introduction to “foot-shaped, zero-drop, moderate-stack-height” shoes in early 2012, I’ve seen discounted pairs for as low as $50, while other models go for as high as $200. A median price point seems to be around $100 a pair.


Positive User Reviews: If you're anything like me, you probably find value in reading the reviews of others before purchasing a product. While amazon.com is an option, with shoes I find that runrepeat.com gives me insights that Amazon doesn't.


Reputable (and Fast) Vendor: While I order a lot of things from Amazon, with shoes I've also had good experiences ordering from Zappos.com, Backcountry.com, Runningwarehouse.com and REI.com, among others.

TWO TYPES OF ZERO DROP, FOOT SHAPED SHOES:

MINIMALIST & NON-MINIMALIST

Minimalist shoes that are also zero drop and foot shaped tend to be very lightweight and have very low stack heights (sole thickness). In my experience, these kinds of shoes are good for weight training and walking/jogging/running on soft forgiving surfaces (ex. grass fields, certain trails, softer sand). Spending long periods of time or doing high impact activities on hard surfaces in these kinds of shoes tends to cause foot pain for many people. Companies that produce these kinds of shoes include Vibram, Xero and vivobarefoot.


Non-minimalist shoes that are also zero drop and foot shaped may be relatively lightweight or moderate weight or even relatively heavy, and tend to have moderate to high stack heights. These kinds of shoes (depending on specs) tend to be good for cross training and walking/jogging/running on harder and less forgiving surfaces (ex. track surfaces, treadmills, roads, sidewalks, wooden floors, etc.). Because of the built up sole on these types of shoes (>15mm thick), the ball of the foot and the heel are more protected from the impact of the foot strike. However, some stability, balance and proprioception may be loss because of it. Companies that produce these kinds of shoes include Altra and Topo Athletic.


Lems is another company that makes zero drop, foot shaped shoes, and they tend to offer both minimalist and non-minimalist models.


"IS THERE SCIENCE ON THESE KINDS OF SHOES?...

...IF SO, WHAT'S IT SAY?"

Since 2010 there's been a notable increase in the number of published peer reviewed studies looking at the effects of "minimalist shoes." One of the problems I see when glancing at the scientific literature is that most of the authors fail to distinguish between the minimalist shoes I just described above (ex. Vibrams, Xeros, etc.) and the non-minimalist-but-still-zero-drop-and-foot-shaped shoes we just talked about (ex. Altras, Topos). Most of the studies I've looked at so far are comparing the biomechanics of barefoot movement to minimalist shoe movement to conventional shoe movement.


Another problem seems to be ignoring the type of surface the activity is performed upon. Running on hard surfaces like concrete, asphalt or even a track or treadmill in a conventional shoe with 30mm of cushioning will have very different effects on impact forces and the plantar (bottom) area of the foot than will running on these surfaces in a minimalist shoe with a 5mm sole.


Those two important issues aside, what's the data say?


A 2012 article from the U.S. Army Medical Department Journal looked at self reported survey data from more than 2500 adult runners and found that those who wore traditional shoes were 3.4 TIMES more likely to report injuries than experienced runners wearing minimalist footwear (the article also outlines the limitations of self reported survey data). [46]



Another 2012 study, this one of 52 runners, found that "74% of runners experienced a moderate or severe injury each year, but those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike." [47]


A January 2013 study published in the British Journal of Sports Medicine found that running efficiency was superior in barefoot running when compared to running in minimalist shoes. [46]


A May 2015 study in the journal Sports Health found that "both barefoot running and minimalist running shoes produce greater running efficiency... with a greater tendency toward a midfoot or forefoot strike and a shorter ground contact time." [47]


A 2015 study of 35 distance runners found that the rate of rear foot striking (where the heel impacts the ground instead of the midfoot or forefoot) was lowest during barefoot running (59%) followed by non-cushioned minimalist shoes (63%) followed by cushioned minimalist shoes (87%) followed by standard shoes (94%). [48]



A 2017 BMJ study of 35 runners found that "the use of minimalist footwear leads to increased cadence and reduced stride length during treadmill running (when compared to standard running shoes)." [49]


A 2017 review of 20 studies in the journal Sports Medicine- Open found that minimal footwear provided limited benefits for running economy and muscle development. The review also noted the risk of injury during the initial transition period (from conventional to minimalist shoes) due to higher loading rates and plantar pressures, however, the overall injury incidence when wearing minimalist shoes versus conventional shoes was similar. [50]


A 2018 study in the journal Scientific Reports found that those wearing minimalist shoes had higher and stiffer longitudinal arches and larger abductor hallucis and abductor digiti minimi muscles when compared to those wearing conventional shoes. In other words, wearing conventional shoes is associated with weaker foot muscles and may increase the risk of developing flat feet. [51]


A January 2019 study headed by Dr. Sarah T. Ridge found that "Minimalist shoe walking is as effective as foot strengthening exercises in increasing foot muscle size and strength." [52]


A 2020 review of 63 studies found that "Minimalist shoes can improve running economy... but also induce greater loading of the ankle and metatarsophalangeal (big toe) joint." [53]


Some of the main takeaways of this research center around the relative superiority of minimalist shoes versus conventional shoes when it comes to...

  • running economy and efficiency (cadence, stride length, etc.)

  • lower leg muscle activation and strengthening

  • reduced chance of developing flat feet

  • reduced chance of rearfoot/heel striking and

  • reduced risk of injury.


CONSIDER THE SURFACE TYPE TOO!

On that last point (risk of injury), I think it's very important to consider the type of surface the running or physical activity is being performed on. For instance, an inexperienced runner sliding on a pair of minimalist Vibram's and going for an 8 mile jog on concrete is likely a recipe for injury.



I even thought of adding "Consider Activities On A More Forgiving Surface" as another step to fixing your feet, but realized that topics like the type of shoe and type of surface (and the kind of physical activity) are usually wrapped up in each other.


As far as studies that compare the effects of running on different types of surfaces go, I didn't find as much research as I did comparing shoe types, but there are some studies.


A 2010 study of 44 runners in the Journal of Science & Medicine in Sport (JSAMS) found that peak foot pressures were higher in all areas of the foot measured (central, lateral rearfoot, lateral forefoot) when running on asphalt versus natural grass. In other words, running on grass provokes lighter loads on the rearfoot and forefoot when compared to asphalt. [54]


A 2012 study in the Journal of Sports Sciences looked at impact forces when running on asphalt, concrete, rubber and natural grass. Running on grass produced peak pressures 5-17% lower than running on other surfaces. The study authors concluded that "running on grass may reduce the total stress on the musculoskeletal system compared with... running on more rigid surfaces." [55]


Another 2012 study, this one from Research in Sports Medicine, found that "running on natural grass showed a lower magnitude of maximum plantar pressure at the total foot, lateral midfoot, central forefoot and lateral forefoot" when compared to running on either rubber (a track) or concrete. [56]


While the above 3 studies look at 4 surface types (grass, rubber track, asphalt and concrete), there are several other surface types that are commonly run on, including artificial turf, sand (ex. beach running, beach/sand volleyball), dirt or woodchip trails, clay (ex. some tennis courts), hardwood floors (ex. basketball, indoor volleyball), treadmills and tennis hardcourts.


BAREFEET VS MINIMALIST VS MODERATE STACK VS MAXIMALIST

My general rule of thumb is, the more forgiving the surface, the less sole thickness you're going to need.


So for barefoot movement, I'm normally comfortable running/moving on artificial turf and some softer sand surfaces. I mentioned the risk of hookworm infection when doing barefoot activities on grass, so I'd probably be a little more leery of that.


For slightly less forgiving surfaces such as hard sand, dirt or woodchip trails and most track surfaces (which tend to be synthetic rubber), I'd probably be comfortable in a minimalist shoe like Vibrams or another zero drop, foot shaped shoe with a stack height under 15mm.


For harder surfaces like hardwood floors, treadmills and tennis hardcourts I'd want a shoe with moderate stack height (ex. 15-30mm). As an aside, these are the kinds of shoes I also prefer as my "daily wear" shoes. Altra's Lone Peak, Superior and Escalante models are some of my favorites.


And for the hardest surfaces (ex. asphalt, concrete) I might even want a "maximalist" shoe with a stack height over 30mm, especially if A) I'm carrying more body weight and/or B) I'm doing longer distances. For zero drop and foot shaped options here, Altra's Olympus 4 has a stack height in the mid 30s (while they're not zero drop or foot shaped, the Hoka brand also makes several models in the 30-40mm stack height range).

STEP 9: GET A FOOT & LOWER LEG MASSAGE

And then there's the option of receiving a foot and lower leg massage from a trained health professional (typically from a massage therapist, but some physical therapists, chiropractors and sports medicine specialists also provide myofascial work). The peer-reviewed literature is rife with the positive benefits of foot, ankle and lower leg massage (including reflexology). I’ve included 9 such studies below, all published from 2010-2018…

  • Aug. 2018, Psychology & Aging. “Massage Can (Re)Activate the Lower Limb Sensorimotor Representation of Older Adult Inpatients.” Author(s): T. Rulleau, L. Toussaint [57]

  • May 2018, Complimentary Therapies in Clinical Practice. “The Effects of Reflexology on Pain and Sleep Deprivation in Patients with Rheumatoid Arthritis: A Randomized Controlled Trial.” Author(s): E. Bakir, et al. [58]

  • March, 2018, Foot (Scotland). “Manual Therapy for Plantar Heel Pain.” Author(s): Y. Pollack, et al. [59]

  • Nov. 2017, BMC Research Notes. “A Foot-Care Program to Facilitate Self-Care by the Elderly: A Non-Randomized Intervention Study.” Author(s): S. Omote, et al. [60]

  • May 2017, Journal of Physical Therapy Science. “Application of Massage for Ankle Joint Flexibility and Balance.” Author(s): J. Park, et al. [61]

  • Feb. 2017, Physiotherapy Theory & Practice. “The Effect of Foot Plantar Massage on Balance and Functional Reach in Patients with Type II Diabetes.” Author(s): E. Tutun Yumin, et al. [62]

  • July-Aug. 2015, Latin American Journal of Nursing. “Foot Reflexology in Feet Impairment of People with Type 2 Diabetes Mellitus: Randomized Trial.” Author(s): NC da Silva, et al. [63]

  • April 2015, Medical Science Monitor Basic Research. “Effects of Thai Foot Massage on Balance Performance in Diabetic Patients with Peripheral Neuropathy: A Randomized Parallel-Controlled Trial.” Author(s): U. Chatchawan, et al. [64]

  • Sept. 2010, International Journal of Nursing Practice. “Effect of Foot Massage to Decrease Physiological Lower Leg Edema in Late Pregnancy: A Randomized Controlled Trial in Turkey.” Author(s): A. Coban, A. Sirin [65]



STEP 10: ADDRESS OTHER ISSUES CAUSING DAMAGE

TO YOUR FEET & ANKLES

While the above steps and strategies are more lower leg specific, it's also important to address systemic issues that may be adversely affecting your feet and lower legs. This includes obesity and excess weight as well as diabetes, cardiovascular disease and edema (swelling due to fluid retention).


OBESITY INCREASES RISK OF LOWER LEG PROBLEMS...

Roughly 40% of U.S. adults are obese. That's nearly 100 million people. With obesity, there's a good bit of clinical data highlighting the link between obesity and risk of foot problems. For instance, a 2007 study of more than 1400 adults found that being "overweight or obese significantly increased the chances of having tendinitis." [66]


A 2015 RCT of 41 obese adults found that "even a modest weight loss significantly reduced the dynamic plantar (bottom of the foot) loading in obese adults." [67]


A 2016 study of more than 7500 children ages 1 to 12 found that extra body mass led to higher overall loading in the midfoot and foot arch. [68]


A 2019 study of 52 young adults found that those who were obese had more abnormalities in the medial arch, were more prone to plantar fasciitis, had more plantar pressure and had more ankle weakness and balance problems than those in the normal weight group. [69]


Other studies have shown that excess body weight can increase the risk of bone fractures, flat feet and heel pain, and according to the American College of Foot & Ankle Surgeons, being just 1 pound above your ideal weight can increase pressure on your ankles and feet by as much as 8 pounds! [70]


Effective strategies for losing excess weight include...

  • staying hydrated

  • addressing gut issues, thyroid/hormone issues and nutrient imbalances with diet and high quality supplementation

  • carbohydrate restriction

  • intermittent fasting

  • portion control

  • a consistent exercise habit (usually a mix of cardio and strength training)

  • a healthy amount of daily physical activity (i.e. non intentional exercise)

  • proper sleep (generally 7-9 hours/night) and

  • examining if any medications are contributing to weight gain


DIABETES INCREASES RISK OF LOWER LEG PROBLEMS...

An increasing number of Americans are dealing with either diabetes (>34 million as of 2020) or prediabetes (88 million as of 2020). Diabetes greatly increases the risk of lower leg problems, particularly diabetic foot ulcers. Consider the following statistics...


* The incidence of diabetic foot disease (including foot ulcers) is still rising and is expected to increase in the future


* Every year, 2.5% to 10% of people with diabetes will develop a foot ulcer


* The lifetime risk of developing a foot ulcer in patients with diabetes is 15-25%



* Diabetic foot ulcers are generally the result of poor glycemic control (often due to excess carbohydrate consumption), underlying neuropathy (nerves often damaged by uncontrolled blood sugar), peripheral vascular disease (PVD), peripheral artery disease (PAD) and/or poor foot care (including improper footwear and hygiene)


* Diabetes is the leading cause of non traumatic amputations in the U.S.


* 85% of amputations related to diabetes start with a foot ulcer


* Foot ulcers, ulcer severity, PAD, PVD, low hemoglobin levels, signs of infection (including leukocytosis [high WBCs], wound infection and osteomyelitis [bone infection]) and old age are risk factors for major amputation


* Between 73,000 and 108,000 U.S. adults have lower extremity amputations related to diabetes EACH YEAR


* The rate of amputations increased by 50% in the U.S. from 2009 to 2015


* Following an amputation, up to 50% of people with diabetes will die within 2 years [71-79]


Many of the same lifestyle strategies mentioned above with obesity will help with diabetes, however, I would place a stronger emphasis here on efforts to control carbohydrate intake. Many of my diabetic clients have had success using a keto or quasi keto diet, where carb intake is strategically spaced throughout the day and daily totals are kept under 75g (net carbs). I'd also emphasis proper foot hygiene and making efforts to address any localized infection (Staph. strains are the most common culprit).


CARDIOVASCULAR DISEASE INCREASES RISK OF LOWER LEG PROBLEMS...

Incredibly, cardiovascular disease (CVD) has been the number 1 killer of American adults each year for the last 100 years! Heart disease and stroke deaths combine to kill more than 750,000 Americans a year.


While much of the attention with CVD is given to the heart and coronary arteries, the legs are also commonly impacted. Peripheral vascular disease (a group of diseases impacting the blood vessels of the lower legs, which includes Chronic Venous Insufficiency) affects some 40 to 45 million Americans. Roughly 30 million Americans deal with varicose veins. These conditions can cause or contribute to lower leg swelling, aches, pains and discoloration, as well as ulcers and the development of blood clots. Speaking of blood clots, around 2 million Americans each year are affected by Deep Vein Thrombosis (DVT), which involves blood clots forming in the veins in the legs. It's estimated that some 60,000 to 100,000 Americans die each year from DVT, often due to blood clots that travel from the leg to the lungs (pulmonary embolism). [80-84]



There's often a lot of cross over when it comes to obesity, diabetes and circulation issues affecting the lower legs. For instance, underlying peripheral artery disease is common in patients with foot ulcers and is associated with poor outcomes. [85]


Smoking is also a major risk factor when it comes to peripheral vascular diseases, and studies have shown that smoking by itself can increase the risk of developing PAD fourfold. [86]


Not surprisingly, other studies have shown that exercise, when combined with comprehensive lifestyle strategies, has notable benefits for patients with PAD, and works to improve the functional capacity of the blood vessels and reduces CV events. [87]


Several nutritional supplements have also been shown to improve cardiovascular health, blood vessel functioning and circulation. These include functional fibers like psyllium, magnesium, taurine (especially helpful for hypertension), potassium, citrulline (increases nitric oxide levels), niacin (specifically, nicotinic acid), vitamin K2 (helps reroute calcium in soft tissue into the bones), several antioxidant supplements (including CoQ10, resveratrol, grapeseed extract and rutin), citrus bioflavonoids (including diosmin and hesperidin), nattokinase (a proteolytic enzyme that can help dissolve blood clots) and several botanicals, including cayenne, hawthorn berry, garlic, horse chestnut and butcher's broom. [88]


"BUT WAIT, YOU DIDN'T MENTION..."

While this isn't a comprehensive discussion of anything and everything foot and ankle related (for that you might wanna check out the 732 page Watkin's Manual of Foot & Ankle Medicine & Surgery), my goal here is to give you some of the essentials when it comes to taking care of your feet and lower legs.


In that there are a few important things I haven't mentioned, such as...


PERIPHERAL NEUROPATHY...

A neuropathy indicates abnormal functioning of the nerves or nervous system. Peripheral means away from the center or on the edges (in the case of the human body this usually means the lower legs and feet as well as the lower arms and hands).


It's estimated that 20-30 million Americans are affected by peripheral neuropathy. Some common symptoms include weakness, numbness and pain (the pain may be a burning or pins-and-needles sensation). Diabetes is a common cause of peripheral neuropathy, as are injuries, infections and exposure to toxins (including chemotherapy drugs and heavy metals).



In addition to the lower leg care strategies already mentioned, with peripheral neuropathy I'd also have a few nutritional supplements on my radar. Alpha lipoic acid (ALA) is a potent antioxidant that also possesses chelating (heavy metal binding/removal) properties. Several B vitamins are also incredibly important when it comes to nervous system health (note that high intakes of vitamin B6 [>200mg/day] can cause neuropathy, so be careful with that one). And essential fatty acids are also crucial when in comes to nervous system functioning, with omega 3s like DHA playing an especially prominent role. [89-90]


LOWER EXTREMITY SWELLING (EDEMA)...

Lower extremity swelling (peripheral edema) is a condition where the feet and/or lower legs retain excessive levels of fluid. This fluid can be blood (which may point to a circulation issue), lymph (may point to an infectious issue), water (may implicate the kidneys) or combination of these. It's estimated that at least 4 million Americans suffer from peripheral edema. [91]



For combating (or preventing) lower body swelling, if the kidneys are suspected, a protocol that includes organic acids (acetic acid from apple cider vinegar and citric acid from lemon juice) and potassium citrate is backed by clinical data. [92]


If infection is suspected, supporting the immune system via supplementation is an important therapeutic step. High dose probiotics, high dose vitamin C, vitamin A (10,000 IU/day or more), vitamin D (5-10,000 IU/day or more) and zinc (75-100mg/day) may be taken orally. Intravenous (IV) vitamin C has also been shown effective for combating several infectious agents. [93-94]


EXCESSIVE SITTING...

Most of us in America know that we, as a culture, don't engage in enough physical activity to maintain health. In 1960 roughly half our jobs were physically active jobs. As of 2019 that number was less than 20%. We simply don't move as much, and we are sitting waaaaaay more. The typical American sits for 10 to 13 hours a day, and dozens of studies have linked excessive sitting with a host of common conditions, including lower leg problems. [95-98]


FOOT HYGIENE...

I almost didn't mention this one because I assumed that most are well aware of the need to do things like periodically wash your feet, trim your toenails and wear clean (and dry) socks and shoes!


COMPRESSION SOCKS/STOCKINGS...

Speaking of socks, medical compression socks (aka stockings) are commonly used in cases of swelling/edema as well as DVT/blood clots, varicose veins and other circulation issues affecting the feet and lower legs. Compression socks are generally given a pressure rating between 8-50mmHg (8-15 mild, 15-20 medium, 20-30 firm, 30-40 extra firm, 40-50 Rx grade). There are pros and cons with compression socks (one of the cons is they can compress the toes too, impairing natural/functional movement) and personally, I'd rather see people dealing with these kinds of lower leg issues implement some (or all) of the above mentioned steps before snagging a pair of these stockings. If you DO decide you want some, I'd check out what Sockwell offers (pressures are 15-30mmHg and usually run $25-30 a pair). [99-100]


THE 3 MOST IMPORTANT STEPS TO FIX YOUR FEET

While each person's health situation is in many ways unique (hence the need for a personalized approach), if I had to prioritize just 3 steps to "fix your feet", I'd generally go with...


  1. Do Exercises For Your Toes, Feet, Ankles & Calves

  2. Buy Some Ergonomic Shoes (And Ditch The Others)

  3. Address Other Issues Causing Damage To Your Feet & Ankles


...OF COURSE THERE'S STILL A PLACE FOR SURGERY

While executing some (or all) of the steps above may fully resolve a number of common foot and lower extremity-related conditions (and prevent others from developing in the first place), some serious conditions may require surgery to correct.

"Make straight paths for your feet, so that what is lame may not be

put out of joint but rather be healed." ~Hebrews 12:13 ESV


ARE YOU READY FOR A HEALTH CHANGE?

If you're ready for a significant, positive health change and want to take a holistic, personalized, evidence-based approach to get there, let me know! I provide health and nutritional consulting as well as personal training services to both local (Charleston, SC area) and remote clients. Email me at drew@agapehealthsolution.com to find out more today.


SOURCES

1 www.ipma.net/page/15 (interesting foot & ankle facts)

2 www.foot.com/foot-facts/ (interesting foot & ankle facts)

3 https://accessprosthetics.com/15-limb-loss-statistics-may-surprise/ (2017 article stating roughly 70% of amputees are lower limb)

4 https://now.aapmr.org/lower-limb-amputations-epidemiology-and-assessment/ (2016 article stating ~65% of amputees are lower limb)

5 www.healthline.com/health/mens-health/average-weight-for-men

6 www.otpbooks.com/emily-splichal-understanding-impact-forces/

7 https://livehealthy.chron.com/much-force-knees-hips-experience-walk-9868.html

8 www.frontiersin.org/articles/10.3389/fped.2018.00115/full (2018 study on motor skills of barefoot individuals versus those wearing conventional shoes)

9 www.ncbi.nlm.nih.gov/pubmed/29657826

10 www.ncbi.nlm.nih.gov/pubmed/26220400

11 www.ncbi.nlm.nih.gov/pubmed/20111000

12 www.ncbi.nlm.nih.gov/pubmed/17353125

13 www.ncbi.nlm.nih.gov/pubmed/16947448

14 https://nwfootankle.com/files/ChildrensFootwear-LaunchingSiteforAdultFootIlls.pdf

15 https://nwfootankle.com/files/rossiWhyShoesMakeNormalGaitImpossible.pdf

16 www.ncbi.nlm.nih.gov/pubmed/7706341 (1995 study on prevalence of flat feet in barefoot versus conventional shoe wearing populations)

17 https://www.tuhykorinek.cz/wp-content/uploads/2016/12/1905hoffman.pdf (1905 study on comparison of barefooted versus conventional shoe wearing populations)

18 https://www.aafp.org/afp/2002/0601/p2277.html (2002)

19 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960082/ (2019; stretching and strengthening program improved pain and gait in patients with plantar fasciitis)

20 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834706/ (2019; 6 week exercise program improved balance in patients with chronic ankle instability)

21 https://pubmed.ncbi.nlm.nih.gov/28478746/ (2018; ankle and toe exercises improve foot circulation markers in patients with blood clots)

22 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031603/ (2014; lower limb strengthening, stretching and functional training program had mildly positive effect on functioning for diabetic neuropathy patients)

23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786815/ (2010; rehab programs that include range of motion, strengthening and coordination exercises are effective for a host of lower limb issues, including ankle sprains, turf toe and Achilles tendinitis)

24 https://pubmed.ncbi.nlm.nih.gov/19888840/ (2009; conventional strength, balance and gait training improve strength and gait markers in older adults)

25 www.ideafit.com/personal-training/two-great-pilates-foot-training-tools/ (2014 article on Pilate's foot corrector and toe tensometer tools)

26 https://www.cdc.gov/parasites/hookworm/index.html

27 https://www.medicalnewstoday.com/articles/313077 (on hookworm infection)

28 https://jaoa.org/article.aspx?articleid=2673882 (2018; citing 2005-06 data found that up to 48% of US population deficient in magnesium)

29 www.thorne.com/take-5-daily/article/who-is-at-risk-for-magnesium-deficiency (2018; 55% below RDA and 20% well below RDA for magnesium)

30 www.aafp.org/afp/2009/0715/p157.html#afp20090715p157-b2 (2009 article citing early 1990s data showing 75% of Americans don’t meet daily intake for magnesium)

31 https://pubmed.ncbi.nlm.nih.gov/6085985/ (history of Epsom salts and Dr. Nehemiah Grew)

32 https://www.healthline.com/health/epsom-salt-bath

33 https://www.medicalnewstoday.com/articles/epsom-salt-foot-soak

34 https://pubmed.ncbi.nlm.nih.gov/26343101/ (2015 study on topical mag and muscle pain)

35 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389641/ (2017 study showing low dose [56mg/day] topical magnesium improved blood levels by 8-9%)

36 https://www.apma.org/index.cfm (American Podiatric Medical Association)

37 https://pubmed.ncbi.nlm.nih.gov/18330806/ (2008 study on using insole and toe spacer to treat hallux valgus)

38 www.jospt.org/doi/10.2519/jospt.2016.0504 (2016 overview of bunion prevalence, and using strengthening exercises to reduce pain and improve mobility)

39 https://pubmed.ncbi.nlm.nih.gov/28318407/ (2018 study on effectiveness of personalized toe spacers on bunion pain and deformity)

40 https://jbeb.avestia.com/2018/001.html (2018 study on custom toe spacers made from 3D printer effective for bunion pain and deformity)

41 https://pubmed.ncbi.nlm.nih.gov/29683337/ (2018 study on effectiveness of toe spacers and exercise in treating pain and dysfunction associated with bunions)

42 www.verywell.com/whats-typical-for-average-daily-steps-3435736

43 www.livescience.com/43956-walking-10000-steps-healthy.html

44 www.businessinsider.com/heres-how-much-the-average-american-walks-every-day-2015-7

45 https://well.blogs.nytimes.com/2013/02/18/when-to-retire-a-running-shoe/

46 https://pubmed.ncbi.nlm.nih.gov/23007933/ (results of 2012 online survey of >2500 adult runners; self reported data indicated traditional shoe wearers were 3.41X more likely to report injuries than experienced minimalist shoe wearers)

47 https://pubmed.ncbi.nlm.nih.gov/22217561/ (2012 study of 52 runners found that rearfoot strikers have nearly twice the rate of stress injuries as forefoot strikers)


46 https://bjsm.bmj.com/content/47/6/387.info (2013 study comparing barefoot to minimalist shoe running efficiency)

47 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482302/ (2015 study on barefoot vs minimalist vs conventional shoes)

48 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4444250/ (2015 study of 35 runners comparing heel strike rates among barefoot, minimalist, cushioned minimalist and standard shoes)

49 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530131/ (2017 study showing increased cadence and reduced stride length in minimalist running shoes)

50 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602809/ (2017 review of 20 studies on minimalist footwear)

51 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829167/ (2018 study on minimalist shoes & conventional shoes and effects on intrinsic foot muscles and arches)

52 https://pubmed.ncbi.nlm.nih.gov/30113521/ (2019 study of 57 runners found that minimalist shoe walking is as effective as foot strengthening exercises in increasing foot strength)

53 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039038/ (2020 review of 63 shoe studies)

54 https://www.jsams.org/article/S1440-2440(08)00155-2/fulltext (Jan 2010 study of 44 adult runners found peak foot pressures higher when running on asphalt versus natural grass)

55 https://pubmed.ncbi.nlm.nih.gov/22897427/ (2012 study comparing impact forces when running on asphalt, concrete, rubber and natural grass)

56 https://pubmed.ncbi.nlm.nih.gov/22458825/ (2012 study comparing max plantar pressures when running on concrete, rubber and grass)

57 https://www.ncbi.nlm.nih.gov/pubmed/29963880 (2018 study on benefits of lower limb massage in older adults)

58 https://www.ncbi.nlm.nih.gov/pubmed/29705475

59 https://www.ncbi.nlm.nih.gov/pubmed/29175715

60 https://www.ncbi.nlm.nih.gov/pubmed/29122000

61 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5462673/

62 https://www.ncbi.nlm.nih.gov/pubmed/28095093

63 https://www.ncbi.nlm.nih.gov/pubmed/26444161

64 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416467/

65 https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1440-172X.2010.01869.x (2010 study on foot massage to decrease lower leg edema)

66 https://pubmed.ncbi.nlm.nih.gov/17880874/ (2007 study of >1400 adults looking at obesity and tendinitis)

67 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297201/ (2015 study of 41 obese adults and plantar loading)

68 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767217/ (2016 study of 7500 children showing link between obesity and increased foot loading)

69 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481571/ (2019 study of 52 young adults)

70 https://www.footandanklegroup.com/foot-problems-obesity-how-excessive-weight-can-affect-your-feet-ankles/

71 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275104/ (2011; the annual incidence of ulcers among people with diabetes is 2.5% to 10.7%)

72 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824686/ (2016 study on diabetic foot disease; 15-25% of diabetics will develop foot ulcer at some point)

73 https://www.azuravascularcare.com/infopad/diabetic-foot-amputation-stats/

(2017; facts on diabetic foot ulcers and amputations; 73k lower limb amputations/yr due to diabetes; following an amputation, up to 50% of people with diabetes will die within 2 years)

74 https://pubmed.ncbi.nlm.nih.gov/28465149/ (2017 study of 654 diabetic foot patients in Brazil; In addition to foot ulcer, old age, peripheral arterial disease and low hemoglobin level are risk factor for major amputation)

75 https://www.ajmc.com/view/diabetic-amputations-may-be-rising-in-the-united-states (2018; every day 230 Americans with diabetes will suffer an amputation; 85% of these amputations were the result of a diabetic foot ulcer; in the U.S., rate of amputations increased by 50% between 2009 and 2015)

76 https://www.medicalnewstoday.com/articles/324875 (2019; 108,000 adults had lower extremity amputations related to diabetes in 2014)

77 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570910/ (2019 study of 336 diabetic patients in Nigeria found that risks for lower extremity amputation were peripheral arterial disease, ulcer severity, and signs of infection including leukocytosis (high WBCs), wound infection and osteomyelitis (bone infection))

78 https://www.ncbi.nlm.nih.gov/books/NBK537328/ (2021 overview of foot ulcers and amputations associated with diabetes)

79 https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html (2020; general info on diabetes)

80 https://www.cdc.gov/ncbddd/dvt/data.html (info on DVT)

81 https://www.ncbi.nlm.nih.gov/books/NBK557482/ (2021; overview of peripheral vascular disease)

82 https://www.heart.org/en/news/2018/09/24/being-tall-tied-to-higher-odds-for-varicose-veins (info on varicose veins)

83 https://my.clevelandclinic.org/health/diseases/17357-peripheral-artery-disease-pad

84 https://www.bloodclot.org/

85 https://pubmed.ncbi.nlm.nih.gov/26813616/ (2016 study showing PAD is common in patients with foot ulcers)

86 https://www.ncbi.nlm.nih.gov/books/NBK430745/ (2021; overview of peripheral arterial disease; smoking increases risk 4 fold)

87 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061490/ (2011; benefits of exercise for peripheral artery disease)

88 https://www.drmackay.com/varicose-vein-supplements/

89 https://www.ohsu.edu/brain-institute/peripheral-neuropathy (20-30 million Americans affected by peripheral neuropathy)

90 https://www.peoplespharmacy.com/articles/can-a-supplement-relieve-neuropathy-pain (2020; on ALA, B vitamins and DHA as effective for neuropathy pain)

91 https://www.umms.org/ummc/health-services/heart-vascular/services/vascular-disease/leg-swelling (>4 million Americans affected by peripheral edema/swelling)

92 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265710/ (2014 study on medical & dietary therapies for kidney stones)

93 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161532/ (2020 study on immune system benefits of probiotics, vitamins A, D and zinc)

94 https://www.frontiersin.org/articles/10.3389/fnut.2020.606398/full (2020 study on benefits of zinc, vitamin C & D on immune system functioning)

95 https://getamericastanding.org/ (Americans sit for 10 hrs/day)

96 https://www.forbes.com/sites/nicolefisher/2019/03/06/americans-sit-more-than-anytime-in-history-and-its-literally-killing-us/?sh=3b1e632a779d (in 1960 half of U.S. jobs were physically active; today it's <20%)

97 https://www.prnewswire.com/news-releases/new-survey-to-sit-or-stand-almost-70-of-full-time-american-workers-hate-sitting-but-they-do-it-all-day-every-day-215804771.html (2013 article stating Americans sit 13 hrs a day)

98 https://www.juststand.org/the-facts/ (Americans sit 12 hrs/day)

99 https://www.discountsurgical.com/which-compression-level-is-right-for-you (description of pressure levels for compression socks)

100 https://www.healthline.com/health/can-wearing-compression-socks-be-harmful (2020; pros and cons of compression socks/stockings)

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