Hi there
My name is Nick. I'm the Chief Education Officer at Sole Freedom and the guy who writes our blog posts. Since founding The Foot Collective in 2015, I've been on a journey to better understand feet and how to help people take better care of their bodies starting at the foundation. This foot health protocol is the summation of my research and my effort to share the insights I've picked up along the way. My hope is to help raise the bar in how we prevent and resolve foot dysfunction as a community of health professionals.
[A protocol is a standardized procedure to follow. This whitepaper is an in-depth proposal for a foot health protocol which can be applied by individuals and professionals to prevent and resolve foot dysfunction]
This is a work in progress. My goal is to have a v1.0 draft completed by 4.20.24 which can then be made available for public review and scrutiny. My hope is that hundreds of peers will eventually review, contribute thoughts, and endorse this evolving protocol so we can collectively establish a consensus gold standard for how we approach the prevention and resolution of foot dysfunction.
[last edited: 3.18.24]
Abstract
95% of shoed humans currently wear shoes that literally deform, disable, and damage their feet. Simply look around and you can confirm this to be true. With that fact considered, it’s unsurprising that roughly 75% of people develop foot problems at some point in their lives. This paper seeks to upgrade our collective understanding of human feet and presents a radical approach to preventing and resolving foot dysfunction. The framework is grounded in first principles and serves as an effective alternative to the current status quo which treats symptoms of dysfunction without addressing the root cause. A paradigm shift is currently underway in how we think of health broadly and foot health specifically. Instead of simply diagnosing problems and treating symptoms (disease care), professionals are beginning to help their patients and clients take better care of themselves (health care). This shift is a much needed change to help us move towards better health. Optimal health is the output of exposing our bodies to natural behaviors that align with our biology. Within the domain of foot health, it is the duty of care and responsibility of health professionals to protect those they serve from the harmful effects of unnatural footwear. By increasing awareness, respecting first principles, focusing on the essentials and designing aligned incentives, we have an opportunity to prevent and resolve the vast majority of foot dysfunction.
The word radical comes from the Latin word radicalis which means, "of or relating to a root". In our context, radical signifies a reversion back to first principles and focusing on the root cause of foot issues we face today. The term also makes reference to the fact that a simple, first principles approach is a radical shift from our current paradigm of complex, ineffective treatments that offer short term benefits while ignoring long term unintended negative consequences. Treating symptoms of disease while ignoring the root cause is no longer meeting a reasonable standard of care.
Our feet abide by the same first principles of physiology as any other body part yet they are currently treated in a fundamentally different way. If the natural default state of the human body is to be free of dysfunction and longstanding pain, why then do 75%+ of shod people develop foot pain over the course of their life? If the body is self healing and self organizing, the only answer to this problem is that unnatural inputs are disrupting the healthy biology we are each given at birth. Armed with a basic understanding of foot function, and the observation that 99% of modern humans are wearing unnatural footwear, it becomes painfully obvious why so many people develop issues with their feet. As a community of health professionals, it's our duty to do better and to protect our patients from the harmful effects of unnatural footwear instead of simply treating the symptoms created by shoes that disrespect our biology.
“out of sight, out of mind”
It’s easy to forget about something or stop taking care of it when it isn’t visible. If we wear shoes all the time, it’s easy to forget we even have feet let alone care for them. Feet are crucially important sensor for efficient locomotion and are grossly misunderstood by individuals and health professionals alike. Each foot contains 26 bones, 33 joints each with 6 degrees of freedom and in the arch of the foot alone, there are 10 muscles and 4 layers of tissue. As Leonardo da Vinci once said, “the human foot is a masterpiece of engineering and a work of art”. Nature doesn’t make mistakes. The level of complexity tells us that our feet are designed to be dynamic and capable of highly complex patterns of motion. In order to remain mobile, the articulations must articulate and in order to remain strong, the muscles must be loaded.
Everything begins with awareness. Before we can begin exploring a topic, we must first 1) be aware of the topic, and 2) view the topic as relevant or important enough to deserve our time and energy. Our cultural blind spot around feet becomes glaringly obvious when we observe that 95% of shod people are wearing shoes that damage their feet and 75% of people develop foot issues over the course of a lifetime. It’s time to bring our understanding of feet into the 21st century. As the physical foundation for our bodies and our primary tactile sensor for the world we move upon, feet are a crucially important structure of the human form. Neglecting our feet is akin to neglecting the foundation of a skyscraper - a sure path to disaster. Ask anyone who has suffered from debilitating foot pain how important feet are and they will tell you that it’s easy to ignore feet until they stop working and we have our primary means of transportation and movement independence taken from us. Beyond expanding awareness that feet are important, its time to acknowledge that we currently have a disease care system that is being mislabeled as healthcare. Diagnosing disease and treating symptoms without addressing the root cause has nothing to do with health and is not healthcare. It’s time to do better. It’s time for individuals to expect better from those who serve them.
Awareness that the footwear we choose to wear is the primary determinant of our foot health is essential. Without understanding the impact our footwear choices have on our foot health, it’s impossible for us to make wise choices and take care of our feet.
Efficiency means doing things right. Effectiveness means doing the right things. Many people are investing time, money and energy into improving their foot health but few people are being effective. Over my past 8 years of research, I’ve come to understand that effectiveness in preventing and resolving foot dysfunction comes from consistently applying 7 essential behaviours. By consistently applying these 7 fundamental behaviours, our lower body receives correct inputs that facilitate a restoration of natural health and function. By understanding and applying these 7 essential elements, we become empowered to prevent and resolve 99% of foot problems. By adopting a long term mindset, protecting ourselves from harmful footwear and implementing a consistent daily practice that includes foot reconditioning, balance training, squat restoration and time on the floor, we gain the ability to respond to any foot challenges we may encounter. We become empowered to take responsibility for our foot health.
Helping people understand and apply these 7 simple and applicable behaviours is the work of the effective healthcare professional. Through this paper we seek to present this education framework as a new gold standard in foot health education and a template that can be adopted by health professionals in all domains to help those they serve achieve a stronger, more resilient foundation for whole body health.
A paradigm shift refers to a fundamental change in prevailing viewpoints or practices. It's the result of a complete transformation in the underlying assumptions, theories and methodology that guide a field of work. By challenging outdated frameworks and ineffective treatment methods, we’re invited to explore new ways of thinking and novel ways of approaching problems.
Firstly, It's important to acknowledge that the predominant system that exists today is disease care. This system revolves around the diagnosis of disease and treatment of symptoms. Even with good people and good intentions, this system is disempowering, myopically focused on short term suppression of symptoms, and built on a framework of financial incentives that reward intervention instead of positive long term health outcomes. While many professionals working in disease care view themselves as healthcare professionals, the truth is that disease care has nothing to do with health and disease care professionals are in fact not trained to address root causes while being financially dis-incentivized to help patients heal.
In economics, time preference is a term used to describe the relative value we place on the present moment versus the future. Someone with a high time preference cares more about the present than the future and someone with a low time preference cares more about the future than the present moment. For example, when offered a drug that will reduce pain in the short term but will create more problems in the long term, someone with high time preference will choose to feel better right now regardless of the long term consequences whereas someone with a low time preference will accept feeling less comfortable in the present moment in order to have a better long term outcome. Disease care has a high time preference bias. Disease care offers interventions that manage symptoms in the short term while creating unintended negative consequences in the long term. A blind spot about long term consequences is created because research measures short term effects while rarely (if ever) measuring long term issues that are created.
Improving one's health is a long term endeavour that requires a low time preference. Being healthy requires us to forfeit the donut today in order to have better health tomorrow. It requires us to forfeit the pain medication today so we can continue receiving the crucial feedback loop of pain and engage with the process of rebuilding capacity. The paradigm shift from disease care to health care is fundamentally a return to low time preference thinking and the adoption of a long term mindset. In contrast to disease care, health care revolves around education and empowering individuals to take better care of themselves. By helping people understand the root cause of problems and offering effective guidance, healthcare empowers individuals to reclaim responsibility for their well being by enabling them to make lifestyle choices that support better health. Healthcare places primary responsibility back on the patient/client, who are the only ones capable of making better daily decisions.
Disease care creates dependence on "experts" who must intervene with short term measures to ease pain which comes at the expense of long term health. Health care fosters independence by offering individuals an increased ability to respond effectively to the challenges they face. Instead of focusing on pain, the objective is to improve long term function and resilience while understanding that pain is our most powerful guide along the process of healing. In our instant gratification culture, disease care appeases to our desire to take shortcuts and to feel better today regardless of consequences that may come tomorrow. Health care is a return to rational discipline and asks us to prioritize the future over the present moment. Health is a long term endeavor and requires a long term mindset if we are to meaningfully improve our well being. Focusing on eliminating the root cause of problems instead of simply treating the symptoms is a return to effectiveness. Helping people take better care of themselves requires us to educate our patients about eliminating unnatural inputs causing issues and reincorporating natural inputs that nudge our bodies to adapt back to default, healthy settings.
This foot health protocol is grounded in biological axioms that we know with certainty to be true. Just like the laws of physics don’t care about our opinions, the laws of biology also don’t care about our opinions. Fundamental laws impose a non-negotiable reality onto us. Ignoring the laws of biology always comes at a consequences, many of which materialize over longer periods of time and often not in the same region of the body in which the laws were violated. By reasoning from indisputable first principles we know to be true, we honour the natural laws of biology. By understanding how the human body adapts to the inputs it receives, we become empowered to live in alignment with our biology and optimize our health.
Our guiding axioms in human physiology are the assumptions that the human body is self healing, self organizing and adapts specifically to the demands we place upon it. In engineering terms, we are an adaptive system that optimizes for efficiency. This axiom applies globally to all body systems, including human feet. For muscles to get stronger, they must be exposed to load. For joints to remain mobile, they must be exposed to motion. For our balance to improve, it must be challenged. We aren’t designed to wear shoes that compromise function and damage our feet. Remove the problem and things begin getting better. Change the inputs and our biology will adapt accordingly. If our desired outcome is natural foot function (defined as strong, stable, mobile, resilient feet that are free of longstanding pain), we must expose our bodies to natural inputs.
The output of wearing shoes that are stiff, supportive and pointed is a foot that is stiff, weak and deformed. The output of wearing shoes that are flexible, flat and foot shaped is a foot that is mobile, strong and naturally shaped. Thinking from first principles allows us to consider long term unintended consequences that result from the disease care approach of optimizing solely around pain reduction.
Returning to first principles enables a return to effectiveness. If we want to restore natural foot function, we must eliminate unnatural inputs and allow our bodies to adapt accordingly. By using this axiom as a lens through which to view foot health, we are able to orient our efforts around the elimination of unnatural inputs and the addition of natural inputs in order to restore the body back to it's natural, healthy settings.
“we are how we move”
The health and function of our bodies is a direct reflection of how we use our biology. According to our first principles, if expose the body to natural inputs, the result is natural outputs. If we expose our bodies to unnatural inputs, the result is unnatural outputs. Health and resilience are natural outputs. Sustained pain and disease are unnatural outputs.
In the context of feet, the two primary natural inputs required for foot health are varied movement and load. Our primitive biology is optimized for a world where humans are barefoot, walk extended distances each day on foot and are consistently exposed to a wide variety of surfaces. These behaviours naturally create varied loads and movement positions which serve as inputs for our system. The mismatch between our world today and the world in which our biology has been adapted to is what creates problems. Our bodies adapt impartially and unapologetically to the inputs we provide it and doesn’t care if that results in pain and dysfunction. Human feet require movement and load to remain mobile and strong. Unnatural shoes and excessive chair sitting disrupt our exposure to varied movement and loading that are required for healthy feet. Remove the unnatural inputs and our biology immediately begins adapting back to default settings.
Systems thinking allows us to make sense of complex human biology by looking at it through a holistic frame of reference and considering relationships rather than oversimplifying into isolated parts. Understanding the human foot requires us to consider the entire lower body (navel and below) as an integrated system consisting of multiple interdependent subsystems.
Instead of thinking about what things can be done to a specific body part, we must consider the broader set of factors and interactions contributing to a certain outcome. This perspective is well articulated through the musculoskeletal concept of regional interdependence which states that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with a primary complaint.
The function of our lower body system is a product of the interactions of different parts, not simply the sum of its parts. For example, attempting to modify the arch of our feet without considering the impact that our hip has on foot position is naive and far too simplistic to achieve meaningful long term results. Systems thinking invites us to understand the interconnectedness of subsystems and feedback loops that govern how our bodies adapt based on the inputs we provide it.
By applying systems thinking to foot health, we consider the lower body as an integrated system whereby no singular element of the system can be meaningfully optimized in isolation of other elements. Our feet, ankles, knees, hips and pelvic control are a tightly interlinked network of subsystems that must be considered together in order to effectively resolve dysfunction at the feet. A foot conversation must always be a lower body conversation. Isolating the foot is ineffective and futile.
“a problem well-defined is a problem half-solved”
By understanding that unnatural footwear is the primary cause of foot dysfunction, we empower ourselves to implement an immediate solution. When we eliminate the source of damage, our biology immediately begins to recalibrate and heal.
Footwear is clothing humans initially wore on their feet to protect them from potential environmental dangers like sharp objects or temperature extremes. Today, footwear has become largely a fashion consideration and the unnatural shoes that 95% of people wear are disabling, deforming and damaging their feet. In contrast to these unnatural shoes, natural footwear respects the shape and function of our feet and should be recommended as the primary tool to prevent and resolve foot dysfunction. Simply put, wearing unnatural footwear weakens, deforms and disables our feet. Wearing natural footwear protects our feet while respecting our biology. Human feet are naturally widest at the toes, mobile and loaded with sensory nerves which exist to perceive the ground below us. Natural footwear protects our feet while honouring their shape and function. Our heuristic for identifying natural footwear is the five F’s: Foot shaped, flexible, flat, feel (thin sole), and fixed (ie not flip flops). In contrast, unnatural footwear is pointed, rigid, ramped, has a thick sole and may not be fixed to our foot.
The shoes we choose to wear have profound impacts on our foot health, movement patterns and the function of our entire lower body system. Until we view the foot as an important and adaptable structure, we have little reason to pay attention to them or to consider the effects that our footwear might be having on the health and function of our feet. If we aspire to prevent and resolve foot problems, we need to begin using our feet as they are adapted to be used. Eliminating unnatural footwear and choosing to wear natural footwear that respects the function of our biology is the first step to restoring strong, healthy feet.
Responsibility can be defined as our ability to respond. The ability to effectively respond to a problem first requires an understanding of the problem. In order to do better as a community of professionals, we must first unlearn information that no longer aligns with healthcare, and update our understanding so we can build our ability to effectively guide those we serve towards better health. Within the context of foot health, we must understand the effects of our footwear choices on foot health and advocate wearing footwear that supports a healthy foundation. As individuals, our health is fundamentally our responsibility. As health professionals, our responsibility to those we serve is to offer truthful, helpful, applicable education that empowers them to make wise lifestyle choices.
Health professional is defined as any individual who earns the majority of their income from helping others improve their health. It is the responsibility of these individuals to be informed, and to offer guidance that helps those they serve make better decisions in their day to day lives. Based on that definition, health professionals include movement coaches, yoga instructors, physicians, physiotherapists, chiropractors, massage therapists, podiatrists and many more professions who aspire to empower those they serve with information that guides healthy behaviour change.
In order to be effective and preserve a reputation of competence, disease care professionals will be required to shift their approach to align with the health care paradigm that has begun to emerge. As health professionals we must elevate our understanding of feet and the effects of footwear choices so we can help our patients effectively respond to the challenge of foot dysfunction.
As health professionals, it's our duty to protect our patients and clients from behaviours that harm their health. By providing truthful, applicable education, we enable them to make wise choices and take better care of their bodies. Within the context of foot health, our primary duty is to protect them from the dangers of unnatural footwear that disables, deforms and damages their feet. Failing to advocate natural footwear is a failure in upholding our duty of care.When we learn better, we do better. Regardless of our current perspective when it comes to feet, we owe it to those we serve and are duty bound to constantly upgrade our understanding and to base our guidance on the most truthful protocol that respects fundamental laws of biology.
Best practices are a standard or a set of guidelines that are known to produce good outcomes if followed. Assessing our patients barefoot, educating them about natural footwear and warning them about the dangers of unnatural footwear are the simple yet effective best practices that enable us to achieve good outcomes. It’s no longer acceptable to ignore foot health. A simple 60 second conversation can dramatically change a persons understanding of how to care for their feet and empower them to protect themselves from potentially debilitating foot problems in future.
This protocol consists of 3 simple elements. The first element is to adopt a long term mindset, focus on inputs and trust the process of adaptation. The second element is to eliminate unnatural footwear and choose to wear natural footwear when we want to protect our feet. The third element is to adopt a daily practice of at least 10 minutes which includes elements of reconditioning, balance training, squat restoration and time on the ground. This simple protocol ensures a robust array of natural inputs that will recalibrate the lower body over time and facilitate the prevention and resolution of foot dysfunction.
"Show me the incentive and I'll show you the outcome"
The quote above is by Charlie Munger and serves as a great reminder that when trying to make sense of people's actions, understanding incentives can offer great clarity. Incentives are the hidden forces that govern human behaviour. Whether obvious or hidden, they are always present and their impacts are significant.
“It’s difficult to get a man to understand something, when his salary depends on his not understanding it”
The above quote by Upton Sinclair illustrates an important point. In the legacy paradigm of disease care, professionals are financially incentivized to treat symptoms of disease with complex, expensive interventions that are often ineffective or worse when long term consequences are honestly considered. The incentive to treat without regard for effectiveness or long term results is a perverse incentive causing wasted resources, and an implicit dis-incentive to help people understand and resolve issues by addressing the root cause. Until we acknowledge that current reality, we won't be able to move beyond it.
Incentives are about more than money but monetary incentives are important because health professionals must generate income in order to pay their bills, feed their families and run viable business ventures. The desire to help others, to do what's right and to be effective is strong, but when placed in opposition to financial incentives, professionals often default to doing what makes them money regardless of their desire to help people improve their health.
Designing aligned incentives within foot health is actually very simple. If the footwear we wear is the largest determinant of our foot health and everyone wears shoes, it makes sense for health professionals to be financially rewarded for recommending natural footwear. This framework is ethical, effective and aligns the interests of all parties involved (patient, provider, footwear seller). It's a win-win-win situation.
The uncomfortable truth is that many disease care professionals specialized in treating foot problems are incentivized to remain ignorant. If we want to change how disease care professionals understand foot health, we must first help them change how their salaries are earned. Humans are naturally dis-incentivized from believing anything that is in opposition to their current beliefs, especially if a lot of time, energy and money was spent acquiring those beliefs. Disease care degrees creates a false sense of confidence and a blind spot for many professionals. The sunken costs of acquiring those degrees also creates strong friction to dropping knowledge learned that may no longer be useful.
Adopting an effective foot health protocol allows us to create new economic incentives around footwear and imposes new social and moral incentives that affect our reputation. The practice of healthcare offers us new psychological incentives contributing to increased satisfaction and meaning in our work because we are helping people improve their health instead of simply treating symptoms without addressing the issue. Misaligned incentives are no longer acceptable.
Footwear recommendations are the domain of modern day health professionals and footwear retailers and manufacturers would be wise to partner with professionals and compensate them for recommending footwear that aligns with foot health. Footwear commissions can become a significant revenue stream for health professionals. Getting paid to recommend natural footwear is ethical, upholds our duty of care and aligns with better foot health. It's time to create financial incentives that reward professional effectiveness and serve to replace existing incentives that reward ineffective, expensive, complex treatments that fail to address the root cause of foot problems.
We have proposed a simple, effective foot health protocol grounded in fundamental laws of biology. By improving public and professional awareness of the importance of feet, the impacts of footwear, viewing the lower body as an integrated system, focusing on natural inputs and designing aligned incentives, we hope to expand cultural understanding of foot health and establish a consensus of best practices for the professional community.
While the application of this foot health protocol will vary widely among individuals and professionals, the core fundamentals remain constant and must be respected. Long term mindset, natural footwear and a daily practice that includes a robust array of natural inputs for the lower body are the path to a more functional, resilient, strong and stable lower body. A natural by-product of a healthy lower body is the prevention and resolution of foot dysfunction.
If we want better foot health outcomes we must create financial incentives that reward effectiveness. Natural footwear offers a new opportunity for aligned incentives that generate income for professionals who protect their patients and clients from the damaging effects of unnatural footwear.
Our hope as a collective of co-authors is for this protocol to be reviewed, scrutinized and endorsed by peers so it may evolve and create a new consensus standard for health professionals. If you wish to contribute to this paper, formally endorse this work or contribute funding to help further protocol evolution and development, please contact nick@thefootcollective.com.
