TO WEAR SHOES OR NOT TO WEAR SHOES
By Mark Salamon, August 1, 2017
Have you seen these things called “toe shoes”? They are shoes that show each individual toe, like a pair of gloves for your feet. They were invented in order to make your feet look even more hideous than they already look in their natural state, and to allow your feet to work in a more natural way. There is also a whole line of “minimalist” shoes out there that do basically the same thing without making you look like a swamp creature. They are all the rage. The kids are all wearing them. It’s tempting to see this as another marketing ploy that will go the way of the rocker-bottom. But there is actually a large body of research that has been examining the effects of this type of shoe, as well as barefoot walking and running, for many years. It is a controversial topic among podiatrists, many of whom still strongly advocate for shoes with tons of support and cushioning, especially where rehabilitating injuries are concerned.
Early studies focused on comparing large populations in countries where supportive shoes are worn routinely with countries where most people wear no shoes. Many of these studies showed surprisingly little difference in overall foot problems, leading many to wonder why we place such a strong emphasis on protective footwear. (1)
More recent studies have looked closely at bio mechanics of walking and running with and without shoes, and have shown remarkable differences that suggest that going without shoes creates a more natural gait pattern which places much less stress on the ankles, knees, hips, and back. (2) (3) This is because with bare feet, we naturally tend to land more on a flat foot, which decreased the impact force in three ways. First, it forces us to fire the small muscles in the feet, which absorb much of the force of impact. Second, it increases the size of the impact area, which mechanically spreads out the force. And third, it allows the knee to be bent more during foot strike, causing it to absorb more shock.
Shoes with tons of lateral support and big, cushiony heels have made us lazy and allowed us to strike the heel first. Even though this feel fine in the short term, it still causes wear and tear in the long term and keeps my clinic full of patients with horrendous heel pain. It also causes the knee to be straighter at impact, which increases the force not only on the knees, but on the hips and back as well. And the small muscles in the feet don’t have to do any work with these shoes, so they get weak and atrophy.
So what’s the solution? In my opinion, it’s not as simple as just recommending that everyone go barefoot or wear minimalist shoes. If you have been wearing supportive shoes your whole life, your feet are not ready for this. They are weak. And your ankles, knees, hips, and back are not used to the flat-foot walking pattern, so an abrupt change could cause real problems. These problems can be magnified with age, because young bodies are more flexible and adaptable to change, as well as an injury or chronic problems such as bunions, hammertoes, or collapsed arches. If you are in this category, supportive shoes may be necessary, and I recommend following your doctor’s advice.
If you are not in this category and are interested in progressing to minimalist shoes or barefoot walking or running, I recommend going very gradually. Start with ten minutes, and add a minute each day. Some soreness is normal, but stop if you have sharp or severe pain. And don’t forget to watch for blisters, especially with running barefoot on sand. In my opinion, if you are a good candidate and acclimate the right way, this more natural way of walking and running can prevent a lot of problems down the line.
By Mark Salamon, July 1, 2017
When my kids were just babies, everyone would say to me, “Hey Mark, how are those little girls? Mark? Are you ok? Mark, wake up, Mark, Mark, (violent shaking) DOES ANYONE KNOW CPR!”
My girls kept me up for fourteen months straight. I shouldn’t say that. I took a twenty minute nap every day at around three in the morning. That’s pretty much all I remember. So I have experienced firsthand the effects of sleep deprivation. (I also took naps sitting at red lights. I wouldn’t recommend this.) It wasn’t a particularly healthy lifestyle. Sleep is essential for repair of all tissues in the body, and many of you already know what it’s like to walk around all day with a body full of unrepaired tissues.
During this time I became a big fan of the power nap. Actually, I had already perfected the technique in college. I didn’t even need to lay down. I could sit in a lecture hall with my head perfectly balanced over my shoulders and fall sound asleep without moving. Other less experienced nappers would jerk themselves awake and fall into the isles, but not me. I can sleep anywhere. If I get tired driving, I pull over and close my eyes for exactly ten minutes (no alarm needed), and wake up completely refreshed. I once took a nap standing up on a bus.
So I was thrilled to see that new research is validating my long held belief in the benefits of this technique. Short bursts of sleep during the day have been shown to clear the brain of adenosine, which is a molecule that is a “byproduct of wakefulness and activity” according to Allen Towfigh, MD, medical director of New York Neurology and Sleep Medicine. High levels of adenosine have been shown to cause fatigue. In fact, about 85% of all mammals sleep for short bursts throughout a 24 hour day, and some sleep experts believe that this may actually be more natural for humans.
Another great trick is to drink coffee just before your power nap. As strange as this sounds, it works because caffeine takes about ten to twenty minutes to kick in, which is just about the time you wake up. And caffeine is also an adenosine blocker, which adds to the effect.
Having said all this, there are still people out there who have real sleep disorders that will not respond to tips from me or anyone else. If you think you are in this category, you should see a doctor to be evaluated. Highly trained physicians often know the instant they walk into the room that a patient has a medical sleep disorder by the way they are still awake after waiting seven hours. It is very important to get treatment if you need it. Sleep is even more important than we previously thought, and it affects literally everything we do, both mentally and physically.
And if you are able to master the power nap, remember, just don’t do it at red lights.
By Mark Salamon, June 1, 2017
A good friend of mine emailed me recently with a question about an injury she was almost embarrassed to tell me about. She was in a hotel where the nightstand next to the bed was a little lower than the one she had at home. When she reached over to put her phone down, she felt a little pop in her shoulder with a very minor pain, but ever since then it has gotten tighter and tighter and more and more painful.
She had just had her 50th birthday, so I immediately launched into a lecture on the fact that we’re not 18 years old any more and it might be time to start thinking about cutting back on some of these high risk activities like reaching over to the night stand. I then explained to her that she is not alone. What she has is called adhesive capsulitis, or a “frozen shoulder”, which many people develop even without doing anything crazy like putting your phone down. In fact, most people I see with this condition don’t remember anything happening. The pain and tightness just come out of nowhere.
A frozen shoulder is caused by inflammation of the joint capsule, which is a balloon-like sheath made of thick, tough ligamentous material which surrounds every joint in your body. “Itis” means inflammation, so capsulitis is inflammation of the capsule. Inflammation causes soft tissue to tighten down, resulting in the progressive loss of range of motion. It also causes the layers of tissue that normally glide on each other to stick together, or “adhere”, thus the name “adhesive capsulitis”. Pain occurs for two reasons. First, inflammation causes pain, and second, the tighter the joint gets, the less room there is for the soft tissue to move, which causes more friction and pressure. This in turn causes more inflammation. It is a vicious cycle that will make you realize how debilitating inflammation can be.
So what causes the inflammation in the first place? Inflammation is a built in protective mechanism. It is a biochemical, cellular response to trauma that your body uses to protect itself while an injury is healing. The problem is that it can be triggered by something so minor that you don’t even remember it. Even rolling the wrong way in your sleep can trigger inflammation, and the pain caused by this inflammation can be much worse than the original injury that triggered it.
Acute inflammation is good. It protects injured tissues during healing and subsides within a few days or weeks. Chronic inflammation is bad. It continues long after it has done its job, like a switch that won’t turn off. Over time it can cause the layers that have adhered together to grow into a thick solid mass, making it almost impossible to stretch out, and surgery is often needed to cut the adhesions and separate out the layers. But this does not always work because surgery itself is a trauma that causes inflammation, and this can put you right back where you started.
So it is very important to start treating a frozen shoulder as quickly as possible, and the only way to do this is with stretching. When soft tissue tightens down, the only way to restore its normal flexibility is to stretch it. But you have to do it the right way. If you stretch too aggressively, you can irritate the tissue and cause it to become more inflamed. And if you stretch it in a direction that causes sharp, pinching pain, you are not really stretching, you are just jamming the soft tissue together and irritating it more. Every shoulder is different, so it is important to see a doctor first to rule out a tear or other pathology, and then a physical therapist who can evaluate which motions are tight, determine which stretches are appropriate, and make sure you are feeling the stretches in the right places.
You may run across some articles that say that a frozen shoulder will “thaw out” and get better on its own with no treatment in about 12-18 months. In my opinion, this is old, outdated hogwash. I have talked to many orthopedic surgeons about this, and I have yet to meet one who has seen a frozen shoulder resolve on its own. And even if it were true, who can wait around for 18 months with severe pain?
Don’t wait 18 months. Don’t even wait 18 days. Get this thing checked out now.
DON’T RUN ON A PAINFUL FOOT
By Mark Salamon, May 1, 2017
If you have ever had unexplained pain in the bottom of the foot or heel, listen up. This is called plantar fasciitis, and it is caused by inflammation of the plantar fascia, which is a thick, tough ligament that runs the length of the foot from the ball to the heel. As a student in physical therapy school, I learned how important it is for patients with plantar fasciitis not to run, because the pounding of running can irritate the inflammation that causes the pain. So this is my tip this month: If you have pain in the bottom of the foot or heel, don’t run on it.
If this seems obvious, let me tell you why I feel like I need to mention it. After several years of practicing as a physical therapist, I myself had an onset of unexplained sharp, severe pain in my heel. So naturally I did what any good therapist would do. I went out for a run.
Wait! Before you click back over to facebook, let me explain. I am not an idiot. Well, not about this. I am just like every other health care professional with an interest in research and an obsessive, compulsive urge to prove that everything we ever learned in school was actually wrong. Testing conventional wisdom is what propels science and medicine forward. Many things in medicine are done out of sheer habit, while no one really stops to realize that it was never really proven to work. So I decided to put the no-running rule to the test. For six months. This was precisely the length of time it took me to conclude that running was indeed bad for plantar fasciitis. To be sure, I repeated the experiment a couple of years later, and obtained the same result.
Since this tip is geared towards runners, I don’t feel too embarrassed sharing this story with you, because I know that you runners out there don’t see anything particularly idiotic about what I did. That is because runners are mental. As a runner, I am allowed to say that. And in our defense, plantar fasciitis pain is usually worse when first getting up from sitting or sleeping. Once you are warmed up, running often is not painful at all. So it is logical to think that you are doing no damage. But here is the thing I want to get across. Inflammation is a biochemical process. It is one of the many protective mechanisms your body has to defend itself and heal injuries. Acute inflammation, or the short duration inflammation that occurs after an injury, is good. Chronic inflammation, or the long lasting inflammation that continues for months or years because of repeated trauma, is bad and can lead to permanent damage.
The right type of exercise will promote better healing by increasing blood flow and restoring normal strength, flexibility, and movement patterns. The wrong type of exercise will continue to irritate the inflamed tissues and may turn the good, acute inflammation into the bad, chronic inflammation. And the wrong type of exercise includes anything fast, ballistic, or pounding. This applies to all injuries, not just plantar fasciitis. Slow, controlled movements and gentle stretching are what is needed to increase blood flow and promote healing.
So as painful as it is, put those running shoes away for a while. You may want to bury them in a lock-box in the back yard so you are not tempted. And wait until you have no pain for about a month before easing back into running. Twenty years from now, your feet will thank you.
By Mark Salamon, April 1, 2017
Milk has been a staple of a healthy American diet ever since the 1950’s when impartial government scientists funded by lobbyists from the meat and dairy industries came out with the four food groups. Since then we have worked steadily to earn the coveted title as the country who spends the most on health care and simultaneously has the worst health. But we have not rested on our laurels and become complacent with this reputation. Scientists are still hard at work trying to improve our health even further, and many studies done by scientists not funded by the meat and dairy lobby are showing some startling results.
So my tip this month is that if you want to decrease your chances of osteoporosis, cancer, obesity, heart disease, and high blood pressure, one of the best ways to do this is to cut way back or eliminate dairy products from your diet.
Since everyone associates milk with strong bones, let me tackle this subject first. Many recent (and not so recent) studies have shown conclusively that consumption of dairy products does not decrease your risk for osteoporosis and fractures (1,2), and may even increase that risk because protein from animal products has been shown to increase bone loss (3). I know this flies in the face of what we were all taught from the time we were in grade school, not to mention TV commercials. But the evidence is plain, and is also supported by the fact that people who live in countries with the lowest consumption of dairy have the lowest rates of osteoporosis and fractures. (4)
And what about cancer? We get so bombarded with news reports every day of something else that causes cancer that most Americans tune it out and decide to just eat what they want and enjoy life. And who can blame them? We end up accepting the risk, and our medical system does not help. Our doctors, who are good, caring, smart people, are trained in how to administer medications and perform surgery. And then they are thrown into practices where they are forced to see a new patient every ten minutes. I have had several doctors tell me that if I live long enough I will most likely get prostate cancer, but it is treatable with surgery and medication and I will probably die of old age before the cancer kills me. I have never had a doctor tell me that in countries where they eat almost no dairy, almost no one gets prostate cancer (5). The simple fact is that there is a mountain of evidence that dairy consumption is associated with a significantly higher risk of prostate (6,7), breast (8), ovarian (9), and testicular (10) cancers.
Obesity, heart disease, and high blood pressure are all related, so let me talk about them together. The risks of obesity and heart disease have been shown to correlate with dairy consumption (11,12). Inflammation has been shown to cause high blood pressure (13). And dairy products have been shown to cause inflammation in many people (14). This inflammation stems from the fact that as a species, our bodies were not designed to digest any type of milk after we are weaned, let alone milk from a 2000 pound animal. Dairy contains a sugar called lactose and two proteins called whey and casein (which has a molecular structure very similar to gluten), which are difficult for the human system to digest. Some people get lucky and have no symptoms. Some have vague symptoms that they may not even notice (like low grade high blood pressure). And some have full blown reactions.
There are studies out there that claim that low fat milk actually lowers blood pressure (15). When reading these studies, be alert as to who sponsors them and what websites they are on. The meat and dairy industry has a lot of money, spends a lot of money in Washington, and has a lot to lose.
If you are skeptical of what I am saying, that’s good. You should be skeptical of everything you read, and I encourage you to read more. If you are not sure yet where you stand, my advice to you is this: give it a try. I know this is anecdotal, but I will share with you my experience. I used to consume a ton of dairy, mostly milk and yogurt, every day. So all I did was substitute coconut milk and coconut yogurt. I lost ten pounds without even trying. (I was already thin so the last thing I was trying to do was lose weight.) And for the first time in my life my blood pressure is normal. I’ve had borderline high blood pressure ever since I was a kid, systolic in the 140’s, diastolic in the 90’s. I’ve never taken BP medication, but was always told to keep an eye on it. Now I consistently run systolic right around 120 and diastolic in the 70’s. And cancer, who knows. After fifty years of massive dairy consumption, maybe the damage is done. But maybe not.
by Mark Salamon, March 4, 2017
Ok all you insane workout fanatics and parents of kids who are in sixteen different travel leagues, I’m about to lecture you on one of the most important aspects of training: REST. Professional trainers and athletes know all about this. In fact, any random gym rat could probably educate you properly on the importance of rest, because it is a staple of weight training. But many patients come to me with injuries sustained because they have no concept of the importance of proper rest, so I feel the need to put this out there.
Rest is so important that I once designed an entire training program consisting of only rest days. This didn’t actually work that well, but the point is that rest is much more important than the average person realizes. Training actually breaks down your bodies tissues. This triggers biochemical processes which build those tissues back up later when you are resting. The more aggressive and intense the exercise, the more rest is needed. The most extreme example of this is bodybuilders. They train almost every day, but they work different body parts on different days. High level bodybuilders train each body part for an hour or two in a workout. Imagine working nothing but your chest, for example, for two hours. But they only do each body part once a week. That’s six days of rest for each day of training.
The number of rest days you need depends on several things, including your age, level of fitness, and type of exercise. As a general rule, training that involves many low repetition sets with heavy resistance requires more rest days. As you decrease resistance and increase repetitions, the number of needed rest days decreases. Endurance activities such as running, swimming, or cycling can be considered a low resistance, high repetition exercise and can be done almost every day as long as you build up to this gradually. Stretching can also be done almost every day, but don’t forget to give this a periodic rest as well, because stretching also puts stress on the soft tissues and can cause irritation and inflammation if done too aggressively or too often.
There are many great resources out there to help you design your program, but it can be confusing. No two people are alike, so remember to listen to your body. Pay attention to what causes good soreness or bad pain. If you need help, e-mail me.
And as for kids in sports, I get it. Your kid is talented. They may be able to get a scholarship. If you don’t want to blow their chance, pay attention to what I am about to say. The following applies to all sports, but I’m going to single out baseball pitchers for the sake of example. The last few years have seen the development of strict guidelines on pitch counts for pitchers dependent on age. Yet I still see many patients and their parents ignoring these guidelines and winding up with serious injuries. Kids are pitching in more than one league, so the coaches don’t realize what is going on. And many are pitching year round. If you are the parent of one of these kids, listen carefully. MAJOR LEAGUE PITCHERS DO NOT TOUCH A BASEBALL FOR THREE TO FOUR MONTHS OUT OF EVERY YEAR. If the arm of a full grown athlete at the highest level needs this much rest, what makes you think your child’s growing and developing arm is going to withstand that kind of punishment?
Don’t destroy your child’s chance for success. Whatever the sport, know the guidelines and follow them. Build in an off season and rest days. Cross train with other sports or activities. If you need help or advice, go to the bottom of this page and e-mail me.
by Mark Salamon, February 2, 2017
While the miracle of modern medical technology has put a halt to many horrendous diseases, those afflicted with these diseases still have to live with many painful and uncomfortable side effects and restrictions. Diabetics who use insulin have to deal with needles, pumps, monitors, and dietary limitations. Cancer drugs cause a host of awful side effects including suppressed immunity and damage to other organs. And men dependent on the life saving medication Viagra have to contend with crippling time management issues as they frantically struggle to complete household projects between erections.
Issues arise even with something as basic as an ice pack. Using ice the wrong way can at best eliminate its positive effects, at worst create real damage, including frostbite. This is especially true with modern ice machines that pump a continuous stream of cold water through a sleeve which uses oscillating pressure to compress the affected body part.
Your basic ice pack has been a staple of injury treatment for decades. In 1978 Dr Gabe Mirkin coined the acronym RICE, which stands for Rest, Ice, Compression, Elevation, and this has been standard treatment for the first few days of an acute injury, especially when there is swelling. The duration and frequency of ice application, however, has been all over the place. I have had patients tell me that they were instructed to ice 10 minutes 2-3 times per day, 20 minutes every hour, 30 minutes every 2 hours, and my personal favorite, "just go home and ice the crap out of it".
If this isn't confusing enough, the last couple of years has seen a surge in research suggesting that ice should actually not be used at all. And from the "DON'T EVER BE AFRAID TO ADMIT YOU WERE WRONG" department, a leading researcher in this movement is, you guessed it, Dr Gabe Mirkin, the guy who made up the RICE acronym in the first place.
Making sense of numerous research studies can be tedious. I have reviewed these studies and I am not yet ready to throw away my ice packs. Let me sum up the basics. First, most studies showing that ice did not help, and sometimes even delayed healing, were done on muscular injuries. Second, ice on joint injuries was sometimes shown to be detrimental when the duration was longer than 20 minutes. Third, ice was often shown to be beneficial when used immediately on joint injuries for no longer than 10 minutes at a time.
So I still recommend using ice for joint injuries, especially for swelling, and especially immediately after the injury. This applies to after surgery as well, because surgery is just an organized traumatic injury. Do not ice for more than 10 minutes at a time, and don't repeat this more often than once an hour. Do not use ice on muscular injuries.
And remember, use a barrier such as a towel or pillowcase between the ice and your skin to prevent harmful side effects such as you taking me to court.
by Mark Salamon, January 15, 2017
Have you ever moved the wrong way and strained your back? Me too, And when this happens, I always thought it my duty as a physical therapist to do something, right away, to fix it. I've seen other therapists do it too. We're all alike. We strain our back and then spend the next half hour running around getting others to stretch, crack, traction, push, pull, bend, twist ice, heat, stim, anthing to "fix" it.
I have made this mistake enough times to know that it doesn't work. The more I do, the more it hurts, and the tighter I get. This is because most of the pain from most neck and back injuries does not come from the injury itself, but from your body's response to the injury, namely muscle spasm. This is a protective reflex that is hard wired into your nervous system. Even a minor injury or wrong move can trigger it, and once triggered, it sends signals to the muscles in the area to reflexively contract to protect and prevent further injury. This reflex does not know what the injury is. There might not even be an injury, just a minor wrong move that triggered the reflex. But the more you run around trying to "fix" it, the stronger it will become as it tries harder and harder to protect you.
So instead of fighting it, try the following technique. You may not find this in any book or study. It's just something I've tried with myself and with patients, and it works. It is also safe.
If you move the wrong way and strain your back or neck, just stop. Don't move. If the position you are in is painful, back out of it a little, just enough to get out of the pain. Now just stay there for a minute or two, take deep breaths, and think about your muscles relaxing. Next, move slowly to a standing position and do the same thing. Just stand for a minute or two. Deep breaths. Relax. Now try to walk around slowly, and when this feels fine you can ease back into your regular routine.
Nine times out of ten this will resolve the situation. The concept is simple. Work with your body. Don't fight it.