296 ‒ Foot health: preventing common injuries, enhancing strength and mobility, & picking footwear

1. 0:00 – 1:11

   Intro

   1. PAPeter Attia0:00

      So let's now go from toe strength back to falls, since you said that the measurement of toe strength is one of the greatest predictors of fall risk. Um, it's a huge problem.

   2. CCCourtney Conley0:12

      Yes.

   3. PAPeter Attia0:12

      The mortality is enormous once you reach the age of about 65. Um, so w- what do you think are the most important things that we need to be training to minimize the risk of a fall?

   4. CCCourtney Conley0:30

      First and foremost, toe strength. That is the single biggest predictor of falls in the elderly, is a weakness-

   5. PAPeter Attia0:36

      Amazing

   6. CCCourtney Conley0:37

      ... in toe strength. It really is.

   7. PAPeter Attia0:38

      I would not have guessed that.

   8. CCCourtney Conley0:39

      And when we get in and start doing these exercises, I mean, I think it is an imperative. You know how kids get scoliosis checks? I mean, we should be checking kids' feet. That- that's when we need to start paying attention to this stuff. Because if we start training these things, once we get to this age where toe strength is a massive deficit, we'll be ready for it. [upbeat music]

   9. PAPeter Attia1:01

      Hey, everyone, welcome to the Drive Podcast. I'm your host, Peter Attia. Courtney, awesome to see

2. 1:11 – 4:12

   Why Courtney chose to specialize in the foot

   1. PAPeter Attia1:11

      you. Thank you for making the trip to Austin. It's much better to be doing this in person, I think, than by video, given all the content we're gonna cover.

   2. CCCourtney Conley1:18

      Thank you so much. I'm very excited.

   3. PAPeter Attia1:20

      So I don't know, l- before we kinda get into the foot, help me understand your personal obsession with-

   4. CCCourtney Conley1:26

      [laughs]

   5. PAPeter Attia1:26

      ... this part of the body. Um, y- wh- yeah, where, where did that begin?

   6. CCCourtney Conley1:30

      I, um, I grew up as a ballet dancer, and pretty much all through grade school and high school, I spent a lot of time on my feet, a lot of time in ballet pointe shoes, which as you know, are very rigid, stiff, you're up on your toes. Um, and I kind of always battled foot pain. And then when I decided to choose this as a career, I was, you know, my self-exploration, I thought I was gonna learn all of this stuff about the foot, um, and that just didn't happen. Uh, we really didn't get a lot of education in regards to how the foot actually functions.

   7. PAPeter Attia2:05

      Because you're a chiropractor by training.

   8. CCCourtney Conley2:07

      Yes.

   9. PAPeter Attia2:07

      And so you... Why did you choose that over, say, podiatry or something that was purely focused on the foot?

   10. CCCourtney Conley2:11

       You know, my father and I have had this conversation so many times. I first was gonna go down the physical therapy route, and then I was like, I wanted to create my own treatment protocols, and my dad has always been a big fan of chiropractic, so we just had a lot of conversations, and that's kind of where it went. I was always been interested in exercise and movement, um, and it just seemed like a good fit.

   11. PAPeter Attia2:32

       So as you said, you go to school, and you're probably not spending that much time on the foot, correct?

   12. CCCourtney Conley2:36

       I think we had, like, half a semester, and I was fascinated.

   13. PAPeter Attia2:39

       That much?

   14. CCCourtney Conley2:39

       [laughs] Right?

   15. PAPeter Attia2:40

       That's actually a lot. I would have guessed less, but okay.

   16. CCCourtney Conley2:43

       Um, and I just became fascinated by it because it just always intrigued me. It's a very complex part of the body, and I think with our education, it was always viewed as if something hurts in the foot, we're either going to put an orthotic under it, um, or refer them t- for some type of surgery. And I was blessed enough to have some really good mentors around me that kind of really in, you know, increased my appetite for learning about that, and that's kind of how it started. I ended up graduating from school and working in a couple of orthotic labs.

   17. PAPeter Attia3:17

       I see. So you went straight from school directly into specializing effectively in the foot.

   18. CCCourtney Conley3:23

       Yeah.

   19. PAPeter Attia3:24

       And so it's interesting-

   20. CCCourtney Conley3:24

       It's changed a lot.

   21. PAPeter Attia3:25

       Yeah, so orthotic labs, so, um, this is presumably a place where people come and have custom orthotics made?

   22. CCCourtney Conley3:32

       Yes. So I would work in the front of these offices, and there'd be grinders in the back, and they'd be making the orthotics, and so I was just constantly surrounded by, by all of that. And that's what we knew, is we'd see patients, they'd have foot pain, and we would cast them for orthotics and make the orthotics.

   23. PAPeter Attia3:50

       Interesting. So even when you came out of school, your knowledge was still, and your practice was largely still based on the, you know, conventional way of putting support under the foot, hoping for the best.

   24. CCCourtney Conley4:02

       Yes.

   25. PAPeter Attia4:03

       All right. So with that background-

   26. CCCourtney Conley4:05

       Mm-hmm

   27. PAPeter Attia4:05

       ... [laughs] we can evolve to where you are today, which is obviously leaps and bounds ahead of that. Um, but let's kinda

3. 4:12 – 8:25

   The vital role of foot strength, function, and health in human movement and well-being

   1. PAPeter Attia4:12

      give folks a bit of a sense of the complexity of the foot.

   2. CCCourtney Conley4:14

      Yeah.

   3. PAPeter Attia4:14

      I think most people look at their hands, and because of our dexterity, um, I think people understand the intricacies of the hand. I, I know once in a while when I'm trying to communicate that to a patient, I'll even show them a picture of the homunculus-

   4. CCCourtney Conley4:29

      Mm-hmm

   5. PAPeter Attia4:29

      ... which is the image of the... Yeah, I know you know what this is, but just for the listener, the image of the cerebral cortex where it, it, it graphically represents the size of the anatomic features in proportion to how much motor and sensory-

   6. CCCourtney Conley4:42

      Yes

   7. PAPeter Attia4:42

      ... control they have. And, and obviously one of our, one of our superpowers as a species is what we can do with these things. It differentiates us from all other species. Um, so how, how does the complexity of the foot fit into the equation of the human body?

   8. CCCourtney Conley4:59

      Well, I think another one of our, um, superpowers actually is that we're a biped.

   9. PAPeter Attia5:03

      Yep.

   10. CCCourtney Conley5:04

       Right? So we have so many cutaneous receptors, muscle spindles, joint proprioceptors on and in our feet that communicate with our vestibular system so we can become upright and bipedal. Um, when you take away those functions, it really alters how you're moving, how you're interacting with your environment. I mean, it's always so wild to me because when we think about it from a rehabilitation perspective, we are very good at rehabbing the low backs. We do a lot of core strength. We do a lot of glute strength. We do a lot of hip strength. But you don't hear many people saying, "I'm doing a lot of foot strength," and it's literally our first interface with the ground. It's how we contact the ground. It's how the whole... It h- it's how everything starts. So when we take that away, you're really making it much more challenging for yourself, and I think it really can alter our survival as well as decrease our quality of life.

   11. PAPeter Attia6:01

       Yeah. I mean, I, it's funny, you can probably tell looking around how obsessed I am with race cars, and, um, I've made this analogy before, but basically there are four things that determine the speed of a car, right? So it's the, you know, obvious things, the engine, um, but the chassis, the aerodynamics-

   12. CCCourtney Conley6:17

       Mm-hmm

   13. PAPeter Attia6:17

       ... the stiffness, uh, the driver's capabilities to what they can do in the car, but of course, the tires. And if, the analogy here of course, is clearly that the tires are the feet, and you can have the greatest car in the world, the most powerful engine, the most remarkable chassis, and the best driver. If the tires are shot, none of it matters. You simply can't get the power to, to the ground and back. So I think there's a lot to be said for, um, how it is imperative that the... And, and in fact, I would even go one step further. I think feet are even a more important part of the human body than tires are to the car, and here's the reason why. As we'll discuss, the feet play a role in the suspension more-

   14. CCCourtney Conley7:00

       Mm-hmm

   15. PAPeter Attia7:00

       ... than the tires play a role in the suspension of a car. So when you now talk about force absorption, the feet are even more, you know, of a, of a priority, and if you can't absorb force in the feet, I think we're gonna hear that we're, we're gonna translate that inability to translate force all the way through the body.

   16. CCCourtney Conley7:16

       Yeah. A good friend of mine, Jay Dicharry, he always says that you can't build a jet engine on a paper airplane.

   17. PAPeter Attia7:22

       Yeah.

   18. CCCourtney Conley7:22

       And I just love that because it's, we're, we're building, we're building all of the strengths, and we're focusing on everything above the knee, when in reality, so much of this force, I mean, gait is shock absorption, it's stance ability, it's propulsion, and all of those things, um, enable us to become efficient with movement.

   19. PAPeter Attia7:41

       We'll talk about a lot of this stuff when we get into the gym later today and go through some of these things, but on a personal level, my interest in this probably didn't start until a couple of years ago when I began to, for the very first time in my life, experience pain in my feet that wasn't just fleeting. Obviously, like every other knucklehead, I had the odd bout of plantar fasciitis in my youth that got better with sort of traditional means. But it was really only when my volume of rucking started to get really high and the poundage started to get really high that I was starting to experience pains in my feet that I now believe could be attributed to weakness.

4. 8:25 – 19:10

   Anatomy of the rear foot and midfoot

   1. CCCourtney Conley8:25

      Mm-hmm.

   2. PAPeter Attia8:25

      Um, so let's maybe talk a little bit about the anatomy of the foot. It is truly one of those things that despite not only having gone to medical school, but even having been a surgeon, meaning I'm relatively familiar with anatomy-

   3. CCCourtney Conley8:40

      Yeah

   4. PAPeter Attia8:40

      ... it's a freaking black box to me.

   5. CCCourtney Conley8:42

      [laughs]

   6. PAPeter Attia8:42

      Like, I, you know, if you told me, like, show me the navicular bone versus the-

   7. CCCourtney Conley8:47

      Yeah

   8. PAPeter Attia8:47

      ... talus, I'd have a hard time until I started having to go back and relearn this. So the fact that I once knew this 26 years ago or whatever is amazing to me. Um, and I suspect many people listening will be completely unfamiliar with this. So, um, understanding that-

   9. CCCourtney Conley9:03

      We'll take it slow

   10. PAPeter Attia9:04

       ... yeah, understanding that some people are gonna be listening to this only in audio, this'll be a great time for people to tune in on video. But, but for certainly, let's assume that most people are watching us, and, and then l- let's show them the model here. So I noticed you brought your friend here. What's his name again?

   11. CCCourtney Conley9:17

       Eddie. His name is-

   12. PAPeter Attia9:19

       Named after, uh-

   13. CCCourtney Conley9:20

       Eddie Vedder

   14. PAPeter Attia9:20

       ... Vedder

   15. CCCourtney Conley9:20

       ... Pro Jam is, um, one of my favorites.

   16. PAPeter Attia9:23

       As, as we have-

   17. CCCourtney Conley9:24

       Yes

   18. PAPeter Attia9:24

       ... both been to the same concert recently. Um, okay. So walk us through-

   19. CCCourtney Conley9:28

       Yes

   20. PAPeter Attia9:28

       ... the anatomy of the foot.

   21. CCCourtney Conley9:30

       So, um, very important, I think especially when it comes to understanding how we're treating the foot and foot pain to understand the anatomy of the foot. So there's basically three parts to the foot. You have a rearfoot, a midfoot, and a forefoot.

   22. PAPeter Attia9:44

       How many bones here?

   23. CCCourtney Conley9:45

       26 bones, 33 joints.

   24. PAPeter Attia9:48

       Yeah.

   25. CCCourtney Conley9:48

       So it's, it's a complex part of our bodies, and I think that's why, um, a lot of rehab treatments and protocols have veered away from really understanding what's happening here. So starting in the rearfoot, the calcaneus, it's one of my favorite bones, and here's a fun fact: a 100-pound female actually has a larger calcaneus than a 350-pound gorilla.

   26. PAPeter Attia10:12

       Wow.

   27. CCCourtney Conley10:13

       Fun fact. But some other fun facts about this, the actual bone itself, there's two layers to the bone. So there's a thin cortical layer, outer layer, and then there's a spongy inner layer. So the way the calcaneus is actually designed, think of like a rubber ball bouncing. It was designed to absorb shock. The other thing about the calcaneus is there's a fat pad that sits outside the calcaneus. Also, two chambers. So there's a thin microchamber that is not easily deformable because when we walk, most of us, as in a walking gait, we graze the heel. So that outer chamber is not designed to deform. But there's a macrochamber on the inside of the fat pad that is highly deformable. So again, we have a fat pad, and we have the way the bone has been designed to absorb shock. That fat pad, by the way, is two times a better shock absorber than Sorbothane. So-

   28. PAPeter Attia11:22

       Sorbothane

   29. CCCourtney Conley11:23

       ... it's a material, it's a synthetic material-

   30. PAPeter Attia11:25

       Like a rubber?
5. 19:10 – 23:20

   The development of flat feet, the impact of footwear, and the benefits of going barefoot

   1. CCCourtney Conley19:10

      when our foot hits the ground.

   2. PAPeter Attia19:12

      All right, so three massive bones there we've covered.

   3. CCCourtney Conley19:15

      Mm-hmm.

   4. PAPeter Attia19:15

      Massive certainly on the scale of the foot. Then what... G- Let's keep going down the, down, yeah, down the path there.

   5. CCCourtney Conley19:22

      I just want to talk about one more quick thing-

   6. PAPeter Attia19:23

      Yeah, yeah. Of course

   7. CCCourtney Conley19:24

      ... that I think is really cool. This sustentaculum tali that lives kind of, it's the, it's a medial lip off the calcaneus.

   8. PAPeter Attia19:33

      Okay.

   9. CCCourtney Conley19:35

      It was, it's fully ossified by the time we're seven years old. So they looked at... There was a research study, Raan Joseph looked at 2,300 children, and they looked at static footprints and how footwear affected the development of their medial arch, which I thought that's a pretty large cohort for a study, right? So what they found is by the age of 13, these were kids four to 13, by the age of 13, those who did not wear shoes, less than three of them presented with what they considered flat feet. The ones that wore shoes, 9% were considered having flat feet, and-

   10. PAPeter Attia20:20

       Sorry, 3% or three in total?

   11. CCCourtney Conley20:23

       3%.

   12. PAPeter Attia20:24

       Okay, 3%, yeah.

   13. CCCourtney Conley20:24

       Right? So the ones that wore shoes, they also noticed the type of shoes. So the ones that wore closed toe box shoes had a higher prevalence for... You know, and I always say with research, let it guide you, not shackle you. So I thought it was interesting. So with the closed toe shoe, there was more of a prevalence than even the kids that wore sandals.

   14. PAPeter Attia20:45

       Mm-hmm.

   15. CCCourtney Conley20:46

       So why is that? You know, did they kick their shoes off and run around barefoot? Did they have more toe splay? Was the foot able to function in a better position? But what the conclusion of the study was the researcher said that this sensory information that was gained by their feet somehow gave them a, a protective tone, an increase in protective muscular tone that was enabling their arch to elevate.

   16. PAPeter Attia21:14

       Now how is that accomplished? 'Cause I know that there's gonna be many people listening to this who are gonna immediately wanna think about their kids.

   17. CCCourtney Conley21:20

       Yeah.

   18. PAPeter Attia21:21

       And y- you know, the, the reality of it is most of our kids are in school-

   19. CCCourtney Conley21:26

       Yes

   20. PAPeter Attia21:26

       ... from a pretty young age, and therefore they have to kind of be in shoes. It's kind of, you know, especially like you live in Colorado.

   21. CCCourtney Conley21:32

       Yeah.

   22. PAPeter Attia21:32

       It's not like you're gonna send your kid to school in sandals-

   23. CCCourtney Conley21:34

       No

   24. PAPeter Attia21:34

       ... in the middle of the winter.

   25. CCCourtney Conley21:35

       [laughs]

   26. PAPeter Attia21:35

       So do you get a sense of the, the, the time requirement being out of shoes, if indeed there's causality between time away from shoes and improved foot health at a young age?

   27. CCCourtney Conley21:49

       I think we have the opportunity with the kids. I mean, when they're at home, they're, just take their shoes off. Different, um, sand, grass. I mean, this doesn't have to be all the time, but even just a little bit. I mean, every kid on the planet, the first thing they do is take their shoes and socks off because they're wanting to gain that sensory input.

   28. PAPeter Attia22:09

       Yeah.

   29. CCCourtney Conley22:10

       So I think even a little bit can go a very long way, and then we'll get into footwear 'cause that's a big one for the kids.

   30. PAPeter Attia22:15

       Yep. Yeah. We, we definitely wanna talk about that for both kids and adults.
6. 23:20 – 31:00

   Anatomy of the forefoot, common injuries, and why most injuries occur in the forefoot

   1. PAPeter Attia23:20

      Okay.

   2. CCCourtney Conley23:20

      Midfoot, if you will. Moving into the forefoot. The forefoot is where we will see most of our injuries because when we're walking, there's eight times our body weight that go through the forefoot with propulsion.

   3. PAPeter Attia23:35

      Why, why, that is so hard to fathom.

   4. CCCourtney Conley23:38

      Well, how about some other numbers here? Your Achilles tendon is about four times your body weight when you walk.

   5. PAPeter Attia23:45

      Meaning it experiences four times your body weight with each step?

   6. CCCourtney Conley23:49

      With force, yes.

   7. PAPeter Attia23:51

      And the Achilles is the tendon of only the gastroc or the gastroc and the soleus?

   8. CCCourtney Conley23:58

      Gastroc and soleus.

   9. PAPeter Attia24:00

      Okay.

   10. CCCourtney Conley24:01

       In fact, when we s-

   11. PAPeter Attia24:01

       We should just also clarify, I, I'm sure many people know this, but when we are referring to tendons, we're talking about the attachments of muscles to bones. Earlier, we referred to ligaments, which are the attachments between bones.

   12. CCCourtney Conley24:14

       Correct.

   13. PAPeter Attia24:15

       So folks understand that. And the Achilles tendon, which everybody is familiar with-

   14. CCCourtney Conley24:18

       Yes

   15. PAPeter Attia24:19

       ... um, is obviously an massive tendon. I mean, I've seen the size of these things when they're injured, when they're severed.

   16. CCCourtney Conley24:25

       Mm-hmm.

   17. PAPeter Attia24:26

       I mean It's, I don't know where it ranks in tendon size for the body, but it is certainly one of the largest, I would have to believe

   18. CCCourtney Conley24:33

       I love talking about the Achilles tendon. It's just, it's beautiful. I mean, you have the gastroc and the soleus that they twist on each other, so it, it's be- can become a very robust tendon, and the soleus actually makes up larger fibers of the Achilles tendon, um, than the gastroc. The soleus is a powerhouse.

   19. PAPeter Attia24:51

       Mm-hmm.

   20. CCCourtney Conley24:52

       Um, but getting back to that load, when we're walking, four times. When you start running, those numbers double. So the inside of the arch, so the calcaneonavicular area, experiences loads of up to 11 times your body weight when you're running. I mean, it's massive, but here's the very cool thing, is our foot was designed to handle it. I mean, we have all bone structure, muscle, tendon that was designed to handle that load. The problem is, is if you don't use it, you will lose it.

   21. PAPeter Attia25:25

       Yeah. So it's interesting you said that the majority of foot injuries are gonna occur in the forefoot. Now, by my math, there's about, what, 15, 18... No, let me think. How many bones there? 15 in the forefoot?

   22. CCCourtney Conley25:40

       Lots of bones in the forefoot.

   23. PAPeter Attia25:41

       Yeah.

   24. CCCourtney Conley25:42

       Metatarsals, phalanx, distal phalanx, proximal phalanx.

   25. PAPeter Attia25:46

       Ah, distal and proximal there. Yeah.

   26. CCCourtney Conley25:48

       I-

   27. PAPeter Attia25:48

       Okay

   28. CCCourtney Conley25:48

       ... except for the big toe.

   29. PAPeter Attia25:49

       Yeah. Okay.

   30. CCCourtney Conley25:50

       Um, eight times our body weight at propulsion. The forefoot has to be incredibly stable at push off because it handles so much load.
7. 31:00 – 41:00

   Foot musculature and its role in maintaining foot stability and preventing deformities like bunions and hammer toes

   1. PAPeter Attia31:00

      Got it.

   2. CCCourtney Conley31:01

      Right?

   3. PAPeter Attia31:02

      Let's talk a little bit about the muscles in the foot as well, because it is a very muscular structure. We don't think of it that way 'cause we look at it and we can sort of see the bones through the skin, but especially on the bottom, the musculature is incredibly complicated, and it is really related to what's happening in the lower leg as well.

   4. CCCourtney Conley31:25

      Oh, yeah. Um, well, I think when we talk about muscles of the foot, we can talk about intrinsic muscles versus extrinsic. So intrinsic muscles, they live in the foot. They start and they end in the foot. We have four layers of muscles there.

   5. PAPeter Attia31:39

      Which is just unbelievable.

   6. CCCourtney Conley31:41

      It is. And the, I think the beautiful thing about the foot is you can look at the foot. It's the only place in the body where you can look at it and say, "Something is going awry here," because you'll form things like bunions and hammer toes and tailor's bunions, and you'll be able to look at your foot and go, "This isn't the way it's supposed to look. Maybe I should pay attention to it." You can't do that in a knee or hip unless you take an x-ray. And when you can get your hands on a foot where you start to see these deformities and they're flexible, you really think about it from a muscular imbalance.

   7. PAPeter Attia32:19

      Hmm.

   8. CCCourtney Conley32:20

      So if we wanted to look at some of the intrinsic muscles of the foot, so if we were to start with the big one, abductor hallucis, so he sits on the, along the big toe, and he's responsible for straightening the big toe.

   9. PAPeter Attia32:35

      And I think the other thing that will be helpful when we go through this is, y- you know, every medical student and whatnot has to learn what an adductor versus an abductor is, and since they're always embedded within the names of the muscles, we always remembered this as abductors abduct. They take things away. Like, a person's being abducted, they pull away from the body, basically.

   10. CCCourtney Conley32:54

       Yes.

   11. PAPeter Attia32:55

       An adductor pulls back towards the body. So with that said, hopefully people will have an easier time-

   12. CCCourtney Conley33:01

       Yes

   13. PAPeter Attia33:01

       ... remembering some of these terms.

   14. CCCourtney Conley33:03

       So we have, um, our forefoot here. Here's the big toe. So abductor hallucis is going to straighten the big toe. There's also a muscle-

   15. PAPeter Attia33:15

       Pulls it to the middle

   16. CCCourtney Conley33:16

       ... pulls it towards the middle

   17. PAPeter Attia33:17

       To the midline, yep.

   18. CCCourtney Conley33:19

       There's an adductor hallucis. It's kind of like a backwards seven.

   19. PAPeter Attia33:23

       Mm.

   20. CCCourtney Conley33:25

       So when these guys get out of balance, for example, if I'm in a shoe, which we'll talk about later, that's going to squeeze my toes together-

   21. PAPeter Attia33:36

       Such as your ballet shoes.

   22. CCCourtney Conley33:38

       Yes

   23. PAPeter Attia33:39

       Or most dress shoes, yep.

   24. CCCourtney Conley33:41

       I have adductor now that's shortened.

   25. PAPeter Attia33:44

       Mm-hmm.

   26. CCCourtney Conley33:44

       And I have abductor-

   27. PAPeter Attia33:46

       It's lengthened

   28. CCCourtney Conley33:47

       ... is lengthened. So you start to get this imbalance at the foot, and then you start to see changes in the foot. I mean, bunions are a result of an instability in the foot.

   29. PAPeter Attia34:01

       Yeah. What exactly is a bunion? Everybody's heard of them.

   30. CCCourtney Conley34:04

       So, and a lot of people have them.
8. 41:00 – 54:41

   The intrinsic musculature of the foot, plantar fasciitis, footwear, & more

   1. CCCourtney Conley41:00

      There's a couple key muscles, you know, I, I think they're all key, but we don't have time to go into all of them, but that are responsible for a lot of our foot function. So for example, flexor digitorum brevis is one of my favorites. So this guy runs from the heel and inserts up into the phalanx, so into the toes. He is responsible, he runs-

   2. PAPeter Attia41:27

      So he's a big muscle

   3. CCCourtney Conley41:28

      It's a big muscle. He runs parallel to the plantar fascia.

   4. PAPeter Attia41:31

      Yeah.

   5. CCCourtney Conley41:33

      He's responsible for decelerating toe extension when we walk. Remember, it's all about slowing things down. We wanna control it. If I don't have good strength of that muscle, he shares, um, load, if you will, with the plantar fascia. So one of the biggest predictors for patients that have plantar fasciitis, so this would be an acute plantar fascial pain, is a weakness of flexor digitorum brevis. When you look at treatment protocols on how to get people better with plantar fasciitis, it's like stretching their calves, and I'm not saying that's bad, but you also have to look at the strength and the stability at the foot, and he is a ex- a very big player.

   6. PAPeter Attia42:18

      Hmm.

   7. CCCourtney Conley42:18

      Very big player in the stability of the foot in decelerating pronation.

   8. PAPeter Attia42:24

      You just referred to plantar fasciitis. We talked about it a second ago. It's clearly something many people listening will understand. They will also probably have a ballpark sense of what it feels like and how there's a real tenderness in the arch. But can you explain the anatomic structures that make up the plantar fascia?

   9. CCCourtney Conley42:40

      So the plantar fascia is going to start at the calcaneus, and it's going to insert into the deep transverse metatarsal ligament up at the forefoot. The plantar fascia has a, a very key role, by the way, in stability of the foot. Okay, so I'm gonna explain something called a tie bar mechanism. So the tie bar mechanism of the foot is this, um, I like to call free because w- we need to take advantage of it, where we have a m- a ligament that runs across the metatarsals. When our foot, when we're walking and we go into midfoot loading, so when all the pressure comes and our arch starts to flatten and widen, when the forefoot splays, it triggers receptors in that deep transverse metatarsal ligament.

   10. PAPeter Attia43:37

       Okay.

   11. CCCourtney Conley43:38

       The plantar fascia inserts into that ligament, so it's kind of like this T. So when the foot splays, it triggers this mechanism of horizontal stability as well as vertical stability.

   12. PAPeter Attia43:57

       Because the plantar fascia, like a triangle at the forefoot now begins to spread under tension while it's also being elongated vertically.

   13. CCCourtney Conley44:06

       Yes. It's like a fan.

   14. PAPeter Attia44:07

       Yeah.

   15. CCCourtney Conley44:08

       So that's the beautiful thing about forefoot splay, is it's this free mechanism that's basically telling our brains, "Hey, you're about to push off. You better get real strong and you better get real stable because we're about to take on eight times your body weight." Gets me excited, right? You take that away, you take away forefoot splay, you can forget about the receptors talking to you because you're not getting the tug on them from the deep transverse metatarsal ligament, the splay, and you're also not signaling the plantar fascia.

   16. PAPeter Attia44:41

       What would oppose that? How narrow does... Or how much compression needs to be on the foot, presumably in the form of a narrow shoe, that would prevent sufficient splaying to activate the plantar fascia in that regard?

   17. CCCourtney Conley44:55

       You know, there's numbers out there. You say three to five millimeters. You know, I don't expect people to get out and start measuring this, but a good way to look at this is if you were to take out the factory insert of your shoe-

   18. PAPeter Attia45:06

       Mm-hmm

   19. CCCourtney Conley45:07

       ... and you place your foot on it, and then stand on top of the factory insert. If your forefoot expands over-

   20. PAPeter Attia45:16

       Wider than the insert

   21. CCCourtney Conley45:18

       ... wider than the insert-

   22. PAPeter Attia45:19

       It's too narrow

   23. CCCourtney Conley45:19

       ... you can be pretty certain that those toes are getting squeezed. And, you know, shoe com-

   24. PAPeter Attia45:25

       That's a great rule of thumb. I would bet that many of my shoes-

   25. CCCourtney Conley45:31

       Mm-hmm

   26. PAPeter Attia45:31

       ... don't pass that test. And, and is it safe to say that it might be tolerable if it's a fashion shoe you're wearing, but you certainly wouldn't want that in an athletic shoe where you're running or rucking or doing something under load?

   27. CCCourtney Conley45:47

       I mean-

   28. PAPeter Attia45:47

       You, you would argue never be in a shoe of that nature, but, but-

   29. CCCourtney Conley45:50

       [laughs] Right. I mean, I-

   30. PAPeter Attia45:52

       Yeah
9. 54:41 – 1:03:45

   Plantar fasciitis: diagnosis, causes, and treatment

   1. PAPeter Attia54:41

      So let's go back to the g- the, the person who shows up. So you've l- you've excluded other things. You've diagnosed them with indeed plantar fasciitis. W- what are the most typical reasons for that presentation in, um, let's start within a young person, a young active person?

   2. CCCourtney Conley54:59

      Weakness to the foot for certain.

   3. PAPeter Attia55:01

      And when you say weakness, specifically within which muscles? Which, which are the prime examples of the muscular sure that-

   4. CCCourtney Conley55:08

      So when they come in, I'll always... I have a toe dynamometer, so it's this little device-

   5. PAPeter Attia55:12

      Did you bring it today?

   6. CCCourtney Conley55:13

      I did.

   7. PAPeter Attia55:14

      Okay, good.

   8. CCCourtney Conley55:14

      I-

   9. PAPeter Attia55:14

      I've always wanted to try one of these.

   10. CCCourtney Conley55:15

       Yes. Um-

   11. PAPeter Attia55:16

       I'm embarrassed to find out where I stack up-

   12. CCCourtney Conley55:18

       [laughs]

   13. PAPeter Attia55:18

       ... but we'll see.

   14. CCCourtney Conley55:19

       It tests the strength of your toes. So it's a little device. You put a, like a card underneath your big toe, and I'll have the patient press the, their big toe into the card.

   15. PAPeter Attia55:31

       Yep.

   16. CCCourtney Conley55:32

       Um, you should be able to produce 10% of your body weight through your big toe.

   17. PAPeter Attia55:40

       Okay.

   18. CCCourtney Conley55:43

       That's flexor hallucis longus. When you put the card underneath two through five, you should be able to produce about 7 to 8% of your body weight. When they're pressing their toes down, there's a couple rules. They can't lift up their heel, and they can't hammer the toes. Remember we talked about-

   19. PAPeter Attia56:13

       Yes

   20. CCCourtney Conley56:13

       ... that hammering?

   21. PAPeter Attia56:14

       Yep.

   22. CCCourtney Conley56:14

       That's when you'll see people who love to hammer their toes because it's a compensation for weakness in the foot. So that's how they walk. It's like I'm clawing my way forward.

   23. PAPeter Attia56:26

       Hmm.

   24. CCCourtney Conley56:28

       So when they do that, they have to press their toes down.

   25. PAPeter Attia56:33

       When they, when you do the big toe-

   26. CCCourtney Conley56:36

       Mm-hmm

   27. PAPeter Attia56:36

       ... the extensor hallucis longus, are the, are two, are toes two through five, do they need to be off the ground, or are they on the ground just not hammered?

   28. CCCourtney Conley56:44

       On the to- on the ground not hammered.

   29. PAPeter Attia56:44

       On the ground not hammered, but you're pressing down 10% of body weight. I mean, these se- I lo- you know, you know me, Courtney.

   30. CCCourtney Conley56:50

       Yeah. [laughs]
10. 1:03:45 – 1:09:27

    Posterior leg muscles: strength assessment methods, role in ACL injuries, & more

    1. PAPeter Attia1:03:45

       Let's talk a little bit about the extrinsic stabilizers of the foot. Obviously, as their name implies, these are muscles that originate out of the foot, but presumably have tendinous attachments within the foot.

    2. CCCourtney Conley1:03:57

       Yes. So we have on the, you know, you have the medial aspect and you have the lateral aspect, and then you have the posterior aspect. So if we were to start with posterior, and we've talked about that a little bit already.

    3. PAPeter Attia1:04:09

       Right. Gastroc, soleus communicating through the Achilles tendon down around the calcaneus and attaching right through the plantar fascia to the forefoot.

    4. CCCourtney Conley1:04:18

       Yes. Um, very big guys here. The soleus is the largest muscle of the lower leg. He is the one that produces a lot of that force at the forefoot when we walk.

    5. PAPeter Attia1:04:33

       And if I'm not mistaken, the soleus has more type one fibers than the gastroc.

    6. CCCourtney Conley1:04:38

       Slow twitch.

    7. PAPeter Attia1:04:39

       Yeah. So it's really the workhorse that can keep going and going and going. Maybe not generate as much force as the gastroc, but far more endurance.

    8. CCCourtney Conley1:04:48

       It is, it is the, uh... It's the powerhouse of the lower leg. Um, it does create a lot of force at the forefoot. It's also very important in the prevention of ACL injuries, which I think is-

    9. PAPeter Attia1:05:03

       Counterintuitive-

    10. CCCourtney Conley1:05:04

        ... A, right

    11. PAPeter Attia1:05:04

        ... given that it's below the knee.

    12. CCCourtney Conley1:05:06

        I mean, when you look at any ACL, um, protocol, it's always hamstrings, right? So biceps femoris, all medial hamstrings, strengthen, strengthen, strengthen. But the research we'll look at has, has shown that it's the strength of the soleus that prevents tibial progression.

    13. PAPeter Attia1:05:27

        I see. And if you have... If you can resist the tibial moving for- the tibia moving forward, you prevent the-

    14. CCCourtney Conley1:05:36

        Yeah

    15. PAPeter Attia1:05:36

        ... stretch on the ACL in that hit. Interesting.

    16. CCCourtney Conley1:05:41

        Mm-hmm.

    17. PAPeter Attia1:05:41

        Never thought of that.

    18. CCCourtney Conley1:05:43

        It's fascinating.

    19. PAPeter Attia1:05:44

        Yeah.

    20. CCCourtney Conley1:05:44

        And I know you and I have talked about this before, but if we look at capacity of, of the soleus, you know, there are numbers out there that in a seated calf raise... So when you're seated, the gastroc is, is not your big player.

    21. PAPeter Attia1:06:01

        Immobilized. Yep.

    22. CCCourtney Conley1:06:02

        So you're focusing on soleus. Um, those numbers, 1.5 times your body weight.

    23. PAPeter Attia1:06:08

        For a single leg calf raise. You realize I still haven't been able to do this.

    24. CCCourtney Conley1:06:13

        I know.

    25. PAPeter Attia1:06:13

        I, I want people to understand how difficult that is.

    26. CCCourtney Conley1:06:15

        Yeah.

    27. PAPeter Attia1:06:15

        'Cause when you told me that, I was like, "That is insane." And then I found my way... You, you need a Smith machine to do the test. I don't have a Smith machine.

    28. CCCourtney Conley1:06:23

        Yeah.

    29. PAPeter Attia1:06:23

        So I was at a friend's house who had a Smith machine, and I set up the apparatus. I actually had to download... I was luckily, I had my phone. I was able to download the paper you sent that walked-

    30. CCCourtney Conley1:06:32

        Yeah
11. 1:09:27 – 1:13:56

    Lateral and medial muscles: ankle stability, arch support, big toe stabilization, and exercises to strengthen and prevent injuries

    1. PAPeter Attia1:09:27

       You mentioned now a lateral and a medial set of muscles. What are those large muscles as well? They, they seem to cause a lot of pain. [laughs]

    2. CCCourtney Conley1:09:33

       Yes. Um, let's talk about lateral ankle stability, okay? So you have your peroneals are the, are the big boys on the outside. So peroneus brevis is going to insert on the fifth metatarsal, okay? Powerful everter of the foot.

    3. PAPeter Attia1:09:48

       Okay.

    4. CCCourtney Conley1:09:48

       Okay? So that's gonna take us from this position towards the big toe.

    5. PAPeter Attia1:09:52

       Okay.

    6. CCCourtney Conley1:09:53

       Peroneus longus, also on the outside, wraps underneath the foot and inserts on the medial s- aspect of the foot.

    7. PAPeter Attia1:10:05

       Okay. So down on the outside of the foot, around and under to the medial so-

    8. CCCourtney Conley1:10:10

       To the big toe.

    9. PAPeter Attia1:10:11

       Yeah. So when it contracts, it flattens the arch.

    10. CCCourtney Conley1:10:15

        When peroneus longus contracts, this is when-

    11. PAPeter Attia1:10:17

        It pronates.

    12. CCCourtney Conley1:10:18

        Mm-hmm.

    13. PAPeter Attia1:10:18

        Yep.

    14. CCCourtney Conley1:10:19

        What he does is he's going to evert the foot, and most importantly, this is why the, the peroneals are a very big stabilizer of your big toe.

    15. PAPeter Attia1:10:31

        Which is counterintuitive 'cause they're on the opposite side of the foot.

    16. CCCourtney Conley1:10:34

        Yes. So when peroneus longus, this is the one that goes underneath the foot, when he's doing his job, he dro- we call it dropping the head of the first metatarsal. So basically what that means is it takes that bone, the metatarsal, and it anchors him to the floor so that we have a stable position at push off.

    17. PAPeter Attia1:10:57

        Yeah, so one of my favorite exercises is putting a band, uh, like an elastic, you know, under huge tension on the floor, pulling medially such that... And the only part of the, the myself I let contact the floor is the base of the big toe.

    18. CCCourtney Conley1:11:14

        Yes.

    19. PAPeter Attia1:11:15

        And then doing single leg balance drills. So that's actually strengthening outer leg.

    20. CCCourtney Conley1:11:20

        Yes. Very important. When patients have ankle sprains, for example, remember we're losing sensation, right? We have a, a sensory loss, if you will. You can have dysfunction of your peroneals. When I'm walking, because peroneus longus drops that first metatarsal down, he's anchoring my big toe to the ground. If he's not doing his job, this guy will stay elevated, so he'll stay lifted a little bit. So now when I'm walking, I don't have this stability at my first ray, and so I'm either gonna go to my outside again, which means there's my another ankle sprain, or people will complain of a pinching on the top of the big toe. So there's a difference between a bunion, so this is when it goes into the, this direction-

    21. PAPeter Attia1:12:20

        Comes out, yeah

    22. CCCourtney Conley1:12:21

        ... comes out, versus people will see a bump on the top of the toe. Those are two different animals. So if I'm walking and I don't have that first metatarsal dropping, when my big toe tries to extend, it doesn't have this nice, like, roll and glide. It kinda jams first, and then you get this-

    23. PAPeter Attia1:12:47

        Hmm

    24. CCCourtney Conley1:12:47

        ... irritation on the dorsum aspect of the toe, and it'll get red, and it'll get irritated, and it's what we would term a functional hallux limitus, so a restriction of motion at the big toe.

    25. PAPeter Attia1:13:01

        And it all stems because there is not enough muscular force from the lateral musculature of the foot, the peroneals, to bring the toe down, the base of the toe down.

    26. CCCourtney Conley1:13:16

        I mean, in my opinion, unless there's been trauma, like you've dropped a weight on your toe or you've had turf toe or things like that where there's been an accelerated inflammatory response-

    27. PAPeter Attia1:13:25

        Mm-hmm

    28. CCCourtney Conley1:13:25

        ... then yes, it is a dysfunction at that first ray. Which is often caused by a weak foot, there's this common theme here, instability of the outside of the ankle, ankle sprains, and if those movement patterns are not, um, restored and regained, then you start to have this arthritic change at the big toe, and that is not fun for anybody. It will alter gait. It will alter movement.

    29. PAPeter Attia1:13:55

        So

12. 1:13:56 – 1:19:21

    Importance of strength of lower leg muscles for gait and preventing shin splints, stress injuries, & more

    1. PAPeter Attia1:13:56

       the big meaty muscle on the outer part of your shin is the tibialis anterior?

    2. CCCourtney Conley1:14:03

       Correct.

    3. PAPeter Attia1:14:04

       And does it attach... It must go down around the lateral malleolus as well? It's on the front of the lateral malleolus, correct?

    4. CCCourtney Conley1:14:11

       Tib anterior comes down and then tib anterior tendon-

    5. PAPeter Attia1:14:15

       Mm-hmm

    6. CCCourtney Conley1:14:15

       ... is kind of, you'll see it more on the medial aspect of the foot. It's a dorsiflexor of the foot.

    7. PAPeter Attia1:14:21

       Biggest dorsiflexor, right? So the... Yeah. Okay.

    8. CCCourtney Conley1:14:25

       So now we're ta- so we were just talking lateral compartment.

    9. PAPeter Attia1:14:28

       Mm-hmm.

    10. CCCourtney Conley1:14:28

        We've now shifted. You were going around the house.

    11. PAPeter Attia1:14:31

        Yep.

    12. CCCourtney Conley1:14:31

        So now we're in the front of the lower leg.

    13. PAPeter Attia1:14:33

        Yep.

    14. CCCourtney Conley1:14:33

        So this is where tibialis anterior and all of your extensors live, so they extend the toes.

    15. PAPeter Attia1:14:40

        Mm.

    16. CCCourtney Conley1:14:41

        There's a couple reasons-

    17. PAPeter Attia1:14:42

        Interesting. Is- sorry to interrupt, and maybe you were just about to address this. Why do we have toe extensors out of the foot?

    18. CCCourtney Conley1:14:52

        When you're walking, we always talk about with gait what's happening in stance phase. So there's stance phase when the foot is on the ground, and then swing phase when the foot's in the air. And the reason why a lot of us give so much attention to stance phase is because that's where all the magic happens, right? The, all the load.

    19. PAPeter Attia1:15:09

        Mm.

    20. CCCourtney Conley1:15:10

        But swing phase, when we're walking, you have to clear the ground. So when I'm assessing gait, I will often close my eyes and listen because you'll hear the scuff-

    21. PAPeter Attia1:15:26

        Mm

    22. CCCourtney Conley1:15:26

        ... as I like to call it, where they can't clear the ground. These will be your runners that come in and tell you, "Ah, I keep tripping over... When I'm running, I keep tripping over rocks." I'm like, "Are you really tripping over rocks, or what's happening here?" Because if those tissues can't extend the toes and extend the foot when they're running or walking, they'll scuff the ground and you can hear it. So they're responsible for a clearance in swing phase, but then also at heel strike, here's that eccentric component. When my heel strikes the ground, here's my extensors.

    23. PAPeter Attia1:16:05

        Yep.

    24. CCCourtney Conley1:16:06

        They have to be very strong eccentrically because they're going to decelerate my foot hitting the ground. So again, I'll close my eyes and I'll listen, 'cause if they don't have good control of those pre-tibial muscles, tibialis anterior and your extensors, it's like an elephant's walking down the hallway-

    25. PAPeter Attia1:16:30

        Hmm

    26. CCCourtney Conley1:16:30

        ... 'cause it's foot slap after foot slap. These patients will tell you they have shin splints. They have medial tibial stress syndrome because they just can't handle the repetitive motion of their foot slapping the ground without control of those muscles.

    27. PAPeter Attia1:16:49

        Very interesting. Okay, so we've got these three pockets of extrins- extrinsic st- um, st- stabilizers, the intrinsics. Let's talk a little bit more about the common pathology that you see. So we've talked about-

    28. CCCourtney Conley1:17:06

        Yeah

    29. PAPeter Attia1:17:06

        ... a handful of them already. What are the most common pathologies you see due to the anterior and lateral compartment?

    30. CCCourtney Conley1:17:14

        Yeah, and we missed the, uh, medial aspect too, because-
13. 1:19:21 – 1:26:55

    Tendinopathies and other common pathologies related to the anterior and lateral compartments of the foot

    1. PAPeter Attia1:19:21

       let's go back to pathology there.

    2. CCCourtney Conley1:19:22

       Yeah.

    3. PAPeter Attia1:19:23

       What else do you see?

    4. CCCourtney Conley1:19:24

       So I think probably the most common diagnoses that we will see, we've discussed one of them already, is heel pain, so plantar fasciopathy. Um- Lots of tendinopathies, so your Achilles tendinopathies and your posterior tibialis tendinopathies. Um, we know that these tissues need movement. We know that these tissues need load. And I think it's important to understand it's not that we want necessarily, you know, yes, we want strong calves, but from a tendon perspective, we want a tendon that is healthy, which means you have to load it, and that goes for both the Achilles as well as post tib, as well as your peroneal. I mean, many people have peroneal tendonitis as well.

    5. PAPeter Attia1:20:10

       Interesting. Is that predisposed by lots of ankle sprains?

    6. CCCourtney Conley1:20:13

       It can be

    7. PAPeter Attia1:20:13

       ... or is that more a function of just weakness in the musculature?

    8. CCCourtney Conley1:20:17

       Um, I think there's a lot of factors you have to look at. You know, do they have the integrity of the musculature? Um, have they had a history of ankle sprains that have just never been re- rehabilitated appropriately? But think of, you know, the post tib and the peroneus longus as like a sling. It's this beautiful sling that stabilizes the foot, and they work together. And when you have one side that's not helping out the other side, you can start to have these changes within the foot.

    9. PAPeter Attia1:20:49

       You alluded to imaging earlier. How often does imaging play a role in your diagnoses? Do you tend to rely mostly on the clinical history, the physical exam, and then ima- like yeah, what, what fraction of the time do you re- rely on imaging?

    10. CCCourtney Conley1:21:07

        I think the biggest time and the most important time at the foot, especially with imaging, is ruling out stress fractures.

    11. PAPeter Attia1:21:14

        Mm.

    12. CCCourtney Conley1:21:14

        Especially when you're dealing with, uh, runners and things like that. Um, but as far as everything else, I mean, if you look at research on doing MRIs, for example, for tendinopathies in Achilles, it really doesn't give you all that much information that's valuable. Because you can see a tendon on an image and it'll be like, "Wow, what's going on here?" And it doesn't correlate with subjective or even-

    13. PAPeter Attia1:21:39

        So it's not that different from the back-

    14. CCCourtney Conley1:21:41

        Yes

    15. PAPeter Attia1:21:41

        ... where the MRI, you know, you're gonna, you, you image a lot of people that feel nothing, and you'll see horrible looking backs. You image a lot of people who feel fine, and you could, you know-

    16. CCCourtney Conley1:21:51

        Yeah

    17. PAPeter Attia1:21:51

        ... the reverse. So, um, stress fractures make sense. MRI probably better, or CT. What, what, what's the diagnostic, uh, test of choice for a stress fracture?

    18. CCCourtney Conley1:22:02

        I mean, I like diagnostic ultrasound.

    19. PAPeter Attia1:22:05

        Really?

    20. CCCourtney Conley1:22:06

        Mm-hmm. I think it can be more, um, accurate. Um, but yeah, the MRI, I just, I rarely will order that just because it doesn't really give me the information that I'm looking for.

    21. PAPeter Attia1:22:17

        Interesting. Um, let's go back to the Achilles. I, I, I don't know what it is in my old age that has made me so paranoid of an Achilles injury.

    22. CCCourtney Conley1:22:28

        Mm-hmm.

    23. PAPeter Attia1:22:28

        I've had one bout of, you know, tendinopathy there that took, God, probably, like, three months to really resolve. Now, in that three months, I didn't really have to do anything different. I mean, I just did a lot of training.

    24. CCCourtney Conley1:22:44

        Mm-hmm.

    25. PAPeter Attia1:22:44

        But I would wake up every day in quite a bit of pain. It got better as the day went on, but it, you know, it w- it was, it was, it was uncomfortable, but I had this huge panic that at some point I was gonna tear it, you know, doing some of the jumping exercises I do and things like that. And, um, y- you know, how much of that is, um... I d- I never wanna say the inevitability of age, but how much of that is due to tissue pliability of aging as a, as an additional predisposing factor?

    26. CCCourtney Conley1:23:16

        Yeah. Well-

    27. PAPeter Attia1:23:17

        I mean, clearly there's a load component to this, right?

    28. CCCourtney Conley1:23:19

        Yes.

    29. PAPeter Attia1:23:19

        There has to be some insult.

    30. CCCourtney Conley1:23:22

        Um, well, first let me say consider yourself lucky it's three months.
14. 1:26:55 – 1:34:57

    The importance of midfoot integrity and ankle dorsiflexion and a discussion of gait alterations

    1. PAPeter Attia1:26:55

       And let's again, because I, I, I, I wanna come back to reinforce these terms, midfoot stability. We've talked about what the midfoot at, uh, midfoot is anatomically. Now explain in exactly that setting, 'cause that's a very common movement, right? Which is, "Hey, I wanna do a negative when I'm doing a toe press of some sort." What needs to be true of the midfoot for a person to be able to do that, going back to the anatomic structures we've already discussed?

    2. CCCourtney Conley1:27:21

       When you are looking at someone from the back, okay, and if I was looking at them with their heels off the back of a step-

    3. PAPeter Attia1:27:28

       Mm

    4. CCCourtney Conley1:27:28

       ... as they go into that negative, if they can maintain the integrity of their foot, so in other words, when they drop the heel down, I don't wanna see this collapse or this excessive medial drive, right? Where the whole foot just looks like it can't, it's, can't even hold itself up.

    5. PAPeter Attia1:27:50

       Mm. And which, presumably those are more intrinsic failures, or are they potentially also extrinsic?

    6. CCCourtney Conley1:27:58

       It could be a bunch of things, right?

    7. PAPeter Attia1:27:59

       Could be everything down to the ligaments.

    8. CCCourtney Conley1:28:01

       If they have poor ankle dorsiflexion mobility, so if they can't dorsiflex here, they're going to steal it.

    9. PAPeter Attia1:28:11

       Mm-hmm.

    10. CCCourtney Conley1:28:12

        So-

    11. PAPeter Attia1:28:12

        What's the minimum angle of dorsiflexion you need to be a functional human who can walk?

    12. CCCourtney Conley1:28:17

        Walking gait, we need about 10 degrees.

    13. PAPeter Attia1:28:21

        Running?

    14. CCCourtney Conley1:28:22

        Running you need a little bit more. But if you think about when I'm training someone, I don't wanna train minimum degrees.

    15. PAPeter Attia1:28:31

        No, of course not. No.

    16. CCCourtney Conley1:28:31

        Right? So I wanna give people movement variability. The more movement variability someone has, the less, um, [lips smack] I won't swear, the less, uh, oh no moments we have.

    17. PAPeter Attia1:28:44

        [laughs]

    18. CCCourtney Conley1:28:44

        Right? [laughs] So we have to be able to give people movement options. So when P- I have assessments that we'll do, and I'll say, "Okay, we're at 10 degrees," and it's actually really cool. You can just use your, um, iPhone, right? There's a-

    19. PAPeter Attia1:29:00

        'Cause it has a built-in little cup, yeah

    20. CCCourtney Conley1:29:01

        ... right, there's like utilities, and then it goes to measure, and I'll measure their dorsiflexion. I like to see about 35 degrees.

    21. PAPeter Attia1:29:07

        Wow.

    22. CCCourtney Conley1:29:09

        You'd be shocked at what people give you. And they'll say, "Well, I only need 10 degrees in order to walk." "Well, do you sit in a chair? Do you walk up and down a stair?" Because if you do any of those other motions, you have to be able to have ankle dorsiflexion, and ankle dorsiflexion is a huge lack of range in the foot, and there's three big compensations that you will see for people that don't do that. The first is when they're walking, they'll lift their heel up early. So it's an early heel rise.

    23. PAPeter Attia1:29:48

        Mm-hmm.

    24. CCCourtney Conley1:29:48

        Now, remember we talked about with eight times your body weight going through your forefoot, do I wanna increase that load? No. Do I wanna speed it up? No. So problem number one there. Next what people will do is they'll hyperextend their knee.

    25. PAPeter Attia1:30:06

        Mm.

    26. CCCourtney Conley1:30:07

        So it's called a varus thrust gait. So because they can't dorsiflex, the knee goes, "Well, let me help you. Let me hyperextend to propel you forward." So these patients will come in and tell you, um, "My knee feels a little wonky. The back of my knee feels unstable," and you have to look at the ankle because it could be feeding why they're doing... That hyperextension at their knee could be the reason-

    27. PAPeter Attia1:30:36

        Now, how do these people find you?

    28. CCCourtney Conley1:30:37

        [laughs]

    29. PAPeter Attia1:30:38

        Because y- you're, you're, you know, y- you're, you're, you're famous through treating the foot. Are they finding their way to you because they're hearing you on a podcast talking about just that, or are there other practitioners that are aware enough to recognize knee pain and say, "Actually, your knee pain is a compensation for your gait"?

    30. CCCourtney Conley1:30:58

        Yeah, I mean, uh, I've been teaching these courses now for a while, and I think a lot of, um, the referrals now are coming from other physicians, other PTs, other doctors. Um, I work with, uh, a couple clinics in Colorado, so... And it's really, it's been really awesome to see the medical community really starting... I mean, we've had patients who, um, you know, have hip replacements, and the feedback on the other end of this sometimes is, "You don't need to retrain your gait." And now we're getting a lot of these referrals and going, "Yes, you do." Like, these are all things you need to pay attention to. So the word is spreading about the importance of what happens at the foot and how that can affect above the- But pretty much everything else
15. 1:34:57 – 1:41:23

    Proximal stability and its implications for posture and movement patterns

    1. CCCourtney Conley1:34:57

       down to proximal stability. How do we create stability? How do we create a safe environment for their brain and their body so that they want to go into a deep squat 'cause they need to go into a deep squat?

    2. PAPeter Attia1:35:09

       Yeah. I, I mean, I, I, I've shared this story before, and, um, it's, it's worth sharing again, which is that, um, when a person is under anesthesia, they can be stretched into positions that they would never imagine if they're not under anesthesia. And you might say, "Well, okay, so what? But they're probably gonna get hurt." But they don't, right? Like you can take-

    3. CCCourtney Conley1:35:32

       Yeah

    4. PAPeter Attia1:35:32

       ... a person who can't touch their toes, and again, when they're under anesthesia, you could almost fold them in half, right? You could get their palms past their toes, and when they wake up from anesthesia, they will not have torn a hamstring.

    5. CCCourtney Conley1:35:44

       Yep.

    6. PAPeter Attia1:35:44

       And you ask the question, how is that possible? And it's possible because neurologically they are being inhibited from doing that because the body says, "You are not stable in that position." To me, and, and, and I'll give you an example one more time. I, I had a guy that once, when I first was learning this, I was in a lot of back pain, and I was so stiff I couldn't touch my toes, and he walked... He, he took me through a 30-minute exercise of increasing intra-abdominal pressure.

    7. CCCourtney Conley1:36:11

       Mm-hmm.

    8. PAPeter Attia1:36:12

       And within 30 minutes, my palms, my, you know, the, the... my entire palm was past my toes. I mean, again-

    9. CCCourtney Conley1:36:20

       [laughs]

    10. PAPeter Attia1:36:20

        ... did I, did I get more flexible in 30 minutes? Of course not. But by generating high degrees of intra-abdominal pressure, my back relaxed enough that it allowed my body to move to that spot. Um, this to me is one of the most difficult things to both identify, but more importantly, to be able to train. Because in a way, it is a light switch, right? But then it ha- the, the, the circuit has to be grooved a lot to, for that to become the new default. So how do you go about doing that given A, its ubiquity, uh, and B, its complexity?

    11. CCCourtney Conley1:36:58

        I think that assessing patients for proximal stability is mandatory. It's absolutely mandatory. And I'm a foot person, so I'm... if I'm far away from where we consider proximal stability and creating intra-abdominal pressure. But if you were to, um, look at someone, and I'm, I'm always gonna take this down to the foot. There's something called a, you know, my pe- if you think of your pelvis as like a bowl of water.

    12. PAPeter Attia1:37:26

        Yeah.

    13. CCCourtney Conley1:37:27

        Right? If I were to stand and dump out all the water, right, you have a forward tilt to the pelvis. That also can happen when the, the rib cage would flare, okay? And we call it an open scissor posture. So when I'm assessing these patients, I'm looking at can they stack their rib cage over their pelvis? Do they have good breathing patterns? Can they breathe 360 degrees around their belly? Can they expand their ribcage? Because if they cannot do those things and they stay in this posture, if you were to stand up and dump all the water out, tell me what would happen to your feet, 'cause I'll tell you. You will feel all of this medial pressure along your big toes. You'll feel your arches kind of collapse, if you will.

    14. PAPeter Attia1:38:27

        And this is where pronation gets a bad name.

    15. CCCourtney Conley1:38:30

        Yes. You know, and, and genu valgum, right? Everybody's saying, "Don't let your knees knock." I- I'm like, "Tell that to a hockey goalie [laughs] who stands there for three periods in a valgus position at the knee." I, I don't believe there's any bad posture positions. It's only bad if you can't control it and you can't get out of it. You have to be able to do these things. I have to be able to protract my shoulder. I have to be able to arch my back. You just better control it and be able to get in and out of it.

    16. PAPeter Attia1:39:01

        Yeah, I think this is worth maybe double-clicking on a bit, Courtney, because, A, it's not a conventional view. It's not a mainstream PT view, and I'm not throwing PT under the bus.

    17. CCCourtney Conley1:39:10

        Yeah.

    18. PAPeter Attia1:39:10

        It's not a mainstream anybody view, and yet I've heard it enough from the people who I think are hands down the best at movement that we should reiterate the point. There isn't a bad posture per se, but control is what matters, and you could argue that the best movers on the planet frequently engage in what would be viewed as, quote-unquote, "bad posture."

    19. CCCourtney Conley1:39:39

        Yes. Yes. I mean, [sighs] I don't think we were all designed to look like these robots and be in these, like, perfect postural positions. It's just not realistic, you know? I think some of, um... I'm just thinking of golf. My father's a big golfer, and we used to watch, um, Arnold Palmer swing a lot, and if you've ever watched Arnold Palmer swing, you'd be like, "How is this guy so good?" You know? Um, but being able to create this stability to your system and to be able to control these different postural positions is key. It's key to be able to get in and out of. And if you think about that at the foot, it's not that pronation is bad. We have to do it. It's our first opportunity for shock absorption when we walk. We have to be able to then get out of it.

    20. PAPeter Attia1:40:32

        Yeah, and the person most commonly who is in the open scissor pattern, they're, they're stuck in that position. They, they aren't able to get out of it, and therefore they're equally ineffective at shock absorption.

    21. CCCourtney Conley1:40:46

        Yes, and there's this disconnect, Peter. It's when I have patients stand in front of me, I'll have them tilt their pelvis forward, and I'll ask them, "What do you feel at your feet?" And half the time they're like, "Nothing." There's this disconnect between my pelvic motion and what my foot should be doing. When my pelvis dumps forward, you should feel the feet drop. When you tuck the pelvis back, you should feel the arches lift, and that's this kind of motion-

    22. PAPeter Attia1:41:17

        Hmm

    23. CCCourtney Conley1:41:17

        ... this dynamic motion that the foot is capable of doing.

    24. PAPeter Attia1:41:22

        You said

16. 1:41:23 – 1:45:49

    The age-related decline in foot sensation and strength

    1. PAPeter Attia1:41:23

       something earlier, um, when we were speaking about how our proprioception and sensory, um, appreciation of the universe changes as we age. Um, now that I'm over 50-

    2. CCCourtney Conley1:41:36

       Hmm

    3. PAPeter Attia1:41:36

       ... what, what's, what's changed in my, uh, sensory apparatus-

    4. CCCourtney Conley1:41:40

       Yeah

    5. PAPeter Attia1:41:40

       ... of the foot?

    6. CCCourtney Conley1:41:41

       We talked earlier about, um, how falls are, are prevalent and how there's r- really factors that contribute to these falls. We know, one, we've talked about this, is a weakness in toe strength. That changes, and I think the, the numbers are, like, a 35% decline in strength, right? If-

    7. PAPeter Attia1:42:03

       Over what period of time?

    8. CCCourtney Conley1:42:05

       That's a good question. Um, I'm not sure. Um, when you look at-

    9. PAPeter Attia1:42:10

       But between presumably something young and something old.

    10. CCCourtney Conley1:42:12

        Correct, and especially there's a very big change when you look at the jump from 50 to 80, for example.

    11. PAPeter Attia1:42:20

        Mm-hmm.

    12. CCCourtney Conley1:42:21

        So we're looking at the 35% decline, right, in those ranges. So not only does strength decrease, but we have four different types of receptors, f- couple fast-adapting and some slow-adapting receptors. They're responsible for gaining information so that we can maintain our center of mass, for example. As we get older, so let's start at age 50, you lose 20%. It takes 20% more pressure to stimulate these receptors.

    13. PAPeter Attia1:42:57

        Now versus when I was 20.

    14. CCCourtney Conley1:43:00

        Correct. So as we age, the sensitivity of the receptors decreases. Now, here's where it gets a little scary. When we go from 50 to 85, at 85 we now have 75% decreased sensitivity to these receptors. That's a lot.

    15. PAPeter Attia1:43:20

        What's driving that?

    16. CCCourtney Conley1:43:22

        I think it is a lack of strength at the foot because, here's the good news, exercise we know increases circulation to the sensory nerves. So we, if we exercise, we're gonna have increased circulation to our sensory system. We have increased nerve fiber branching when that happens. With increased nerve fiber branching, we have increased sensation, and that has been found to decrease pain and improve sensation even in patients with peripheral neuropathies. So maintaining strength and function at your foot, I think obviously will decrease the decline of toe strength, but also increase the, um, ability for us to feel the ground, which is imperative from being able to walk upright and being able to prevent us from falling.

    17. PAPeter Attia1:44:19

        And this sensory decline, how much of it is superficial? You know, meaning you can test it and assess it using the standard metrics of, you know, like take an alcohol pad or a cotton swab on the, you know, cutaneous branches, and how much of it is much deeper? I mean, I, I'm guessing more of it is this deep part that is dependent on significant pressure or, uh, but I don't really understand.

    18. CCCourtney Conley1:44:44

        There's a, um... I, I did bring it too. There's a 256, uh, frequency, uh, vibration tool.

    19. PAPeter Attia1:44:51

        Okay.

    20. CCCourtney Conley1:44:52

        And what you can do is you'll have the patient laying down and you take this, uh, 256 tool, and I'll tap it on the ground, right, and I'll put it on the base of their heel.

    21. PAPeter Attia1:45:02

        Mm.

    22. CCCourtney Conley1:45:03

        And you get three chances, right? You're, you're changing what you're doing, and can they pick up the vibration? And it's w- it's actually the, um, accuracy of that test has been shown to be, um, more accurate than the, like the nylon, you know, pricking of the foot.

    23. PAPeter Attia1:45:22

        Interesting.

    24. CCCourtney Conley1:45:23

        And I... It's a, it's an easy assessment that we can do.

    25. PAPeter Attia1:45:25

        So vib- yeah, vibrational sensation is... And, and by the way, that, that's, that makes sense 'cause that strikes me as a more complete form of sensation than... 'Cause the nylon thing is mostly cutaneous.

    26. CCCourtney Conley1:45:39

        Mm.

    27. PAPeter Attia1:45:40

        Yeah. Um, okay. Well, as we talked about a minute ago... Actually, you know what? Let me do something. Before we go to falls, I wanna round out a couple of other injuries.

    28. CCCourtney Conley1:45:48

        [laughs] Okay.

17. 1:45:49 – 1:57:33

    Common toe injuries, treatment, and how to prevent further progression of the injury

    1. PAPeter Attia1:45:49

       There are a couple other toe injuries that are pretty common.

    2. CCCourtney Conley1:45:51

       Yes.

    3. PAPeter Attia1:45:52

       Let's, let's talk about those.

    4. CCCourtney Conley1:45:53

       Okay.

    5. PAPeter Attia1:45:53

       Um, so y-

    6. CCCourtney Conley1:45:55

       Happy to

    7. PAPeter Attia1:45:55

       ... you wanna start with hallux restrictus?

    8. CCCourtney Conley1:45:57

       Yes.

    9. PAPeter Attia1:45:57

       Yeah.

    10. CCCourtney Conley1:45:58

        So, um, we will see this a lot, and I think a lot of it has to do with, um, poor footwear selections, right? We've talked about the chronic ankle sprains and the inability to, you know, allow the first metatarsal to drop. Um, but a functional hallux limitus, we need about 40 to 45 degrees of range of motion at the big toe in order to have an efficient walking gait.

    11. PAPeter Attia1:46:23

        Yeah.

    12. CCCourtney Conley1:46:24

        Okay?

    13. PAPeter Attia1:46:24

        This is, this is my only superpower. I'm, I'm probably like 90 degrees-

    14. CCCourtney Conley1:46:28

        [laughs]

    15. PAPeter Attia1:46:28

        ... at my hallux.

    16. CCCourtney Conley1:46:30

        And, you know, excess range of motion is great as long as you can control it.

    17. PAPeter Attia1:46:34

        Remains to be seen. [laughs]

    18. CCCourtney Conley1:46:36

        So if I wanted to sprint though, I would need 65 degrees, right? 'Cause you're more on your toes.

    19. PAPeter Attia1:46:41

        Yeah. And this is where I've seen a lot of former NFL players-

    20. CCCourtney Conley1:46:46

        Yes

    21. PAPeter Attia1:46:46

        ... who get horrible turf toe that have what literally looks like 10 degrees.

    22. CCCourtney Conley1:46:52

        If you can catch these patients before they've had... So there's stages, right? So the... What will start to happen is you'll get an inflammation on the top of the big toe.

    23. PAPeter Attia1:47:04

        Yeah.

    24. CCCourtney Conley1:47:04

        Okay? Then you-

    25. PAPeter Attia1:47:05

        And the, and the, and the... Is the primary pathology just the repeated jamming-

    26. CCCourtney Conley1:47:09

        Yes

    27. PAPeter Attia1:47:09

        ... of that toe?

    28. CCCourtney Conley1:47:10

        Right, the instability at the, the first ray. And then you, they can't drop the bi- the first met down, so they start to irritate the top of the joint. It'll be red, it'll be swollen, and these patients suffer. Um, I'm on a Facebook group for hallux rigidus. Um, it's a support group, and the reason I'm on it is because I find it f- like, th- there, it's a constant battle for these people for footwear because they just need... They're like, "I need a shoe that's going to eliminate me using my big toe," because it hurts when they try to extend it.

    29. PAPeter Attia1:47:47

        And have these patients all experienced trauma?

    30. CCCourtney Conley1:47:51

        No. If they've had like something fall on their toe, if they've had turf toe, then yes, but a lot of them, this is weakness. This is poor footwear. That's why I think a lot of these diagnoses at the foot can be prevented. This is proactive healthcare.
18. 1:57:33 – 2:06:20

    Preventing falls & managing arthritis with proactive foot care & exercises

    1. PAPeter Attia1:57:33

       are you seeing people that have kind of autoimmune forms of arthritis in the, in the foot and ankle?

    2. CCCourtney Conley1:57:39

       It's a smaller percentage of my patient base, but they do make their way into my office, and a lot of the times where I will see that is more at the midfoot, where they'll have a lot of this arthritic change at the midfoot.

    3. PAPeter Attia1:57:53

       And aside from obviously the medical management of that with, you know, pharmacologic agents, what are the most important things you're doing for those patients to foster midfoot mobility and strength?

    4. CCCourtney Conley1:58:06

       Again, we're meeting patients where they are. You'd be surprised, even patients that have had three and four foot surgeries, 'cause that's typically what I will see, little things like, um, toe yoga, right? So being able to lift the big toe only, lift the four toes, lift all the toes and spread them. All of those little things are sending information to your brain that these people haven't seen in a very long period of time, if ever. So with midfoot, um, issues, isometrics, if I can get a little bit, even a little bit of isometric activity out of them, we're doing it.

    5. PAPeter Attia1:58:41

       We're gonna talk about falls in a second, and that we can use toe strength, which is part of the, you know, the reverse of some of those things you just talked about. Is toe strength mostly a midfoot intrinsic capacity?

    6. CCCourtney Conley1:58:56

       Um, well, flexor digitorum brevis is a big muscle in regards to toe strength.

    7. PAPeter Attia1:59:02

       Okay.

    8. CCCourtney Conley1:59:02

       Um, when we do one of the videos, I'll talk about the wink sign.

    9. PAPeter Attia1:59:05

       Okay.

    10. CCCourtney Conley1:59:06

        Okay? 'Cause that's a, a sign you can see in the toes to know you're engaging the muscle appropriately.

    11. PAPeter Attia1:59:11

        Okay.

    12. CCCourtney Conley1:59:12

        Um, that, like, forward leaning. We want to be able to feel the intrinsic muscles of the foot, so feel the arch. Um, a lot of that helps these patients with this midfoot instability. You know, the intrinsic muscles of the foot. You know when people do, like, uh, the short foot exercise, okay? I kind of call it the clamshell of the foot, because it's a good place to start, but it's not, uh, functional, because the intrinsic muscles of the foot come into play when the heel comes off the ground, at forward propulsion, when those toes need to be strong, right? I mean, if I was treating you for hip pain and I gave you, "I want you to lay on your side and do clamshells forever," I mean, great, but is it functional? Do you ever do that?

    13. PAPeter Attia2:00:01

        Right.

    14. CCCourtney Conley2:00:01

        So we have to marry these, um, treatment plans with function, and I think f- especially with toe strength, you got to really work on that type of, you know, movement and tissue strength.

    15. PAPeter Attia2:00:15

        So let's now go from toe strength back to falls, since you said that the measurement of toe strength is one of the greatest predictors of fall risk. Um, it's a huge problem.

    16. CCCourtney Conley2:00:27

        Yes.

    17. PAPeter Attia2:00:27

        The mortality is enormous once you reach the age of about 65. Um, so w- what do you think are the most important things that we need to be training to minimize the risk of a fall?

    18. CCCourtney Conley2:00:45

        First and foremost, toe strength. That is the single biggest predictor of falls in the elderly, is a weakness-

    19. PAPeter Attia2:00:52

        Amazing

    20. CCCourtney Conley2:00:52

        ... in toe strength. It really is.

    21. PAPeter Attia2:00:53

        I would not have guessed that.

    22. CCCourtney Conley2:00:54

        And when we get in and start doing these exercises, I mean, I think it is an imperative. You know how kids get scoliosis checks? I mean, we should be checking kids' feet. That- that's when we need to start paying attention to this stuff. Because if we start training these things, once we get to this age where toe strength is a massive deficit, we'll be ready for it. So toe strength for certain.

    23. PAPeter Attia2:01:16

        I, I'm very worried about what my toe strength is gonna be when we, when we bust out the, uh, [laughs] the dynometer.

    24. CCCourtney Conley2:01:22

        Well, neuroplasticity is a real thing, so we can train that up for you.

    25. PAPeter Attia2:01:25

        Very good.

    26. CCCourtney Conley2:01:26

        Um, so toe strength. Um, ankle mobility. That's another one that we'll look at.

    27. PAPeter Attia2:01:32

        And more important in the plantar dorsi plane or in the inversion/eversion plane?

    28. CCCourtney Conley2:01:37

        In both. So when I assess, um, you know, I have a fall prevention protocol. Dr. Tommy Show has put together an excellent fall prevention protocol, um, and him and I have worked a lot together on this. So we'll look at, um, ankle dorsiflexion. So we want that to be about 35 degrees, but then we'll also look at inversion and eversion.

    29. PAPeter Attia2:02:00

        Right.

    30. CCCourtney Conley2:02:00

        Which is basically going in and then going back out again. Um, a lot of the receptors on the foot ... live on this outside lateral aspect of the foot. So we talked about how a lot of falls occur with the initiation of gait. The other plane where people will fall is to the outside.
19. 2:06:20 – 2:19:05

    Footwear: advice for picking shoes that promote foot health

    1. CCCourtney Conley2:06:20

       Yeah.

    2. PAPeter Attia2:06:21

       Uh, let's talk a little bit about shoes. We've-

    3. CCCourtney Conley2:06:23

       Yes

    4. PAPeter Attia2:06:24

       ... talked about it a, a bit at the outset, but, um, I know that it's gonna be a topic that anybody who's listening to us right now is going to wanna understand, "Hey, what can I do for myself," presumably as an adult. Um, and I do think there's gonna be a lot of people who listen to us who have kids who are gonna also say, "Hey, if I've taken anything away from this-

    5. CCCourtney Conley2:06:41

       Yeah

    6. PAPeter Attia2:06:41

       ... I've taken away the idea that this begins early in life, and therefore I want to maybe even save my kids some of the challenges I've had. What can I do for them?"

    7. CCCourtney Conley2:06:52

       Yeah. Um, I love this question. I could talk about shoes, uh, for a very long time. If we talk about kids first, I think first and foremost just let their feet feel the ground as often as they can, all different types of surfaces. Um, there are way more, um, shoe and footwear companies now than there were when I started this whole thing 20 years ago. Um, I think the word is catching on and we're realizing the importance of all of this. Um, with the kids obviously the t- and this is with everybody, the toes need to be able to splay. That's... A wide toe box for me is a non-negotiable.

    8. PAPeter Attia2:07:33

       And are we defining that by the insert test? Meaning the stan- put your foot on the insert and make sure that when your weight is on your foot you can still see insert?

    9. CCCourtney Conley2:07:46

       It's probably the, um, easiest way to, you know, kind of access that, but I will caution you that these companies are getting smarter. I've called all of them pretty much. The last of the shoe... I'll grab a shoe. I have one here. So this is, oh, this is the last of the shoe, okay? In order to change the last of the shoe, it's very expensive. So what the, the companies will do is they'll change the upper of the shoe. So they'll put, like, mesh. So when you go to put your foot in there, it feels like you're, you have all this room, and it's not because the shoe is wider, it's just because they put a material on there where your foot can actually expand in it. And that, there's also a very big difference between a wide toe box and a wide shoe. Those are two very different things. A wide shoe, whi- m- which most shoe companies have, will give you width here, but it will still taper at the toe, and not what we want, right? 'Cause I want... Remember the tie bar mechanism. I have to have that forefoot splay to trigger the response of, "Hey, I better get stable at push off." So that's when I need my toes to be able to splay as well. So a wide toe box is mandatory with kids footwear, adult footwear, whatever. Um-

    10. PAPeter Attia2:09:22

        I mean, I... What are the shoes that have wi- would that be considered a wide toe box?

    11. CCCourtney Conley2:09:26

        Yes. So this is a Xero.

    12. PAPeter Attia2:09:27

        Yep.

    13. CCCourtney Conley2:09:28

        Okay? I'm a big fan of these shoes. Um, there are so many companies out there right now. Um, VivoBarefoot, Tolus. I mean, I could go on and on and on about those. I have a list of them, too. Um-

    14. PAPeter Attia2:09:42

        So we'll, we'll put that list in the show notes so that people can sort of see what you would consider wide, you know, shoes that make a wide, wide enough toe box for-

    15. CCCourtney Conley2:09:50

        Yes

    16. PAPeter Attia2:09:51

        ... for the purposes-

    17. CCCourtney Conley2:09:51

        And I have them listed according to category, right? Like, this is a athletic shoe, this is a casual shoe, this is... I mean, we have so many resources for that because it i- it can get very confusing because you're, people will be like, "I'm in a wide shoe." I'm like, "You're not. You're not in a wide shoe." Um, so that's kind of rule number one.

    18. PAPeter Attia2:10:09

        Mm-hmm.

    19. CCCourtney Conley2:10:10

        The other thing with functional footwear is looking at the heel and the toe, where they sit. So-

    20. PAPeter Attia2:10:19

        So this is a zero drop

    21. CCCourtney Conley2:10:21

        ... this is a zero drop, where the heel and the toe sit on the same plane, okay? That just makes sense, doesn't it? That's how we were designed to walk. Most shoes, and I won't throw out names here, but most athletic shoes, most running shoes, if you Google the model of the shoe and Google heel to toe drop-

    22. PAPeter Attia2:10:44

        It'll tell you how many millimeters of drop

    23. CCCourtney Conley2:10:45

        ... it'll tell you how many millimeters the heel is higher than the toe. Anything that's not a zero drop, by the way, in my world, is a high heel.

    24. PAPeter Attia2:10:54

        Interesting.

    25. CCCourtney Conley2:10:55

        Okay?

    26. PAPeter Attia2:10:55

        Now, I have started, I switched my rucking to a shoe that has an, I think, an eight-millimeter drop-

    27. CCCourtney Conley2:11:04

        Mm-hmm

    28. PAPeter Attia2:11:04

        ... once I was having all of that Achilles tendinopathy, and I have enjoyed that shoe much more. So I no longer ruck in a minimalist shoe, probably because I'm carrying a lot of weight-

    29. CCCourtney Conley2:11:16

        Yes

    30. PAPeter Attia2:11:16

        ... and I want more cushion. Um, but I've y- I, I, I don't care about, I'll throw out the brand, I use the GORUCK shoe.
20. 2:19:05 – 2:23:39

    Footwear for runners

    1. PAPeter Attia2:19:05

       today, competitive runners or otherwise, will run in a minimalist shoe like that. It's a very, you know, very infrequent, um, uh, occurrence. Do you recommend people do that? And if so, how long does it take to strengthen the foot enough to be able to run in a shoe like that?

    2. CCCourtney Conley2:19:24

       I know I keep saying this, but it is very patient specific. You look at their history of traumas, you look at their history of injuries. Um, I will always implement some type of functional footwear regardless. It's just a matter of what we're gonna be doing with it. So for example, if I'm working with, you know, just someone who wants to walk, for example, we'll put them into a, um, Altra, for example, wide toe box shoe.

    3. PAPeter Attia2:19:55

       Mm-hmm.

    4. CCCourtney Conley2:19:55

       Zero drop, and we'll just have them start like 5 or 10 minutes, see how they feel, and then we can start to transition the stack height. So if they're used to wearing this big, bulky cushioned shoe, you don't wanna take them into something like this too soon. They'll be like, "This sucks, and I don't wanna do it."

    5. PAPeter Attia2:20:14

       Yeah.

    6. CCCourtney Conley2:20:14

       And then you lose them right out of the gates.

    7. PAPeter Attia2:20:17

       For a person to run in a shoe like that, must they give up a heel strike in running?

    8. CCCourtney Conley2:20:24

       Um, oh, you got all these good questions. When you change, um, your footwear, you start to change how your body feels the ground. So with runners, for example, everybody gets all up in arms about heel strike, right? Heel striking's bad, heel striking's bad. It, it's not that it's bad, it's just where the load is going. When I'm running, it's not necessarily, um, how my foot is striking, but where my foot is striking. So over-striding is the enemy. I don't wanna have my foot well in front of my body when I'm running. There's too much ground reaction force happening there.

    9. PAPeter Attia2:21:12

       Hmm.

    10. CCCourtney Conley2:21:12

        We want the foot to strike as close to the center of mass as possible. There have been runners who have won marathons with a heel strike that's at their center of mass. They just have more knee flexion, for example. The further the foot is away-

    11. PAPeter Attia2:21:32

        That would almost feel like they're run- they're falling forward, wouldn't it?

    12. CCCourtney Conley2:21:35

        Almost.

    13. PAPeter Attia2:21:36

        Yeah. Wow.

    14. CCCourtney Conley2:21:38

        So when I'm striking with a heel strike that's in front of my center of mass, okay, when I heel strike, I have a lot of ground reaction force going through my knee, through my hip, and through my low back.

    15. PAPeter Attia2:21:50

        Hmm.

    16. CCCourtney Conley2:21:52

        When I switch and run to a midfoot or forefoot strike, all I'm doing is taking the load out of the knee, hip, and back, and putting that into the foot and to the calf.

    17. PAPeter Attia2:22:06

        And theoretically, isn't... I mean, that just seems like, given the structure, it seems like that's how it should be, isn't it? I, I don't wanna... I mean, I have no dog in this fight as a non-runner.

    18. CCCourtney Conley2:22:16

        Yeah.

    19. PAPeter Attia2:22:17

        So, um, but, but w- what, what do most elite runners do?

    20. CCCourtney Conley2:22:23

        Um, you will see all across the board different strike patterns.

    21. PAPeter Attia2:22:29

        Mm-hmm.

    22. CCCourtney Conley2:22:29

        You truly will. Um, when you are running though efficiently, when you look at cadence and you look at, um, you know, I call them running fairies 'cause it just looks like they can run forever, their foot will be close to their center of mass, and it is more likely that they will be at a midfoot and forefoot strike when their foot is underneath them.

    23. PAPeter Attia2:22:49

        Yeah, yeah, it seems like, exactly, just anatomically, if you can bring the strike towards the center of your body, you're much more likely to be not heel striking-

    24. CCCourtney Conley2:22:57

        Correct

    25. PAPeter Attia2:22:58

        ... because it would be very awkward to heel strike at that angle.

    26. CCCourtney Conley2:23:01

        And you take out, you know, when you're running, right? So if I have heel strike, then I have to go to my forefoot, and then I have to drop that heel down again-

    27. PAPeter Attia2:23:07

        Yeah

    28. CCCourtney Conley2:23:07

        ... versus just running midfoot, forefoot, which, yes, I think that is a more ideal position to run in from an efficiency perspective. With that being said, if you have a history of heel pain, Achilles tendinopathy, and you tell your runners, "Hey, we're gonna take you out of this heel strike, and we're gonna get you to run on your forefoot," you better prepare them for it. You, they better have good capacity at their foot and at their calf, or else what you're gonna give them is more foot and calf problems.

    29. PAPeter Attia2:23:38

        Are there any

21. 2:23:39 – 2:34:05

    The importance of prioritizing footwear that promotes natural foot movement & strength while considering individual comfort & foot health needs

    1. PAPeter Attia2:23:39

       other characteristics of a shoe besides the big three you've mentioned that you, you... I mean, you have pretty strong feelings about all of them-

    2. CCCourtney Conley2:23:47

       Yeah

    3. PAPeter Attia2:23:47

       ... but in descending order, right? Of the three we talked about it-

    4. CCCourtney Conley2:23:50

       Yeah

    5. PAPeter Attia2:23:50

       ... your strongest feelings were at the outset.

    6. CCCourtney Conley2:23:53

       Yeah, I mean, you wanna put the foot in its most functional position. I think that's the rule, and that means allowing the foot to splay and trying to keep it on a level ground. And then you can play around with, you know, based on activity, with the amount of stack height. But they have shoes now, right, where they have the wide toe box, but they'll still give you like a three to five millimeter heel-to-toe drop, the Topo Athletic, for example.

    7. PAPeter Attia2:24:21

       Mm-hmm.

    8. CCCourtney Conley2:24:22

       Okay, Altra actually now has a four millimeter heel-to-toe drop. So I'll kind of transition them. If I know this person has poor ankle mobility and poor foot strength, I'm gonna say, "Listen, we're gonna get you in a wide toe box. I'm gonna drop you down from your 10 into, say, a five," right? Slowly bring them there. They're gonna be like, "Oh, this feels great," 'cause they always do. And then we start working on their strength, and then we can continue to drop them down into a more functional shoe. But, you know, you think about, um, hockey players, rock climbers, um, where shoes are just what they are. You can't... You know, I'm not asking everybody to run around barefoot all the time. It's not, it's not reality. So when, if you do wanna run in a super shoe or you do play hockey a lot, don't panic. It's just do the stuff.

    9. PAPeter Attia2:25:16

       Do the work outside.

    10. CCCourtney Conley2:25:16

        Do the work outside. Get a pair of minimal shoes, grab some toe spacers, and walk around for 30 minutes a day. Keep it simple.

    11. PAPeter Attia2:25:24

        Is a good rule of thumb that a shoe is a, is a wide enough toe box if you can wear the toe spacers in the shoes?

    12. CCCourtney Conley2:25:31

        Yes. And if you-

    13. PAPeter Attia2:25:32

        And, and you-

    14. CCCourtney Conley2:25:32

        Go ahead

    15. PAPeter Attia2:25:32

        ... you, you're pretty much in... I've never seen you not wearing toe spacers.

    16. CCCourtney Conley2:25:35

        I do wear them.

    17. PAPeter Attia2:25:35

        Do you sleep in them?

    18. CCCourtney Conley2:25:36

        [laughs] I don't sleep in them.

    19. PAPeter Attia2:25:37

        You don't. Okay, good to know.

    20. CCCourtney Conley2:25:38

        But I do wear them all the time. I wear them when I run as well.

    21. PAPeter Attia2:25:42

        Okay.

    22. CCCourtney Conley2:25:42

        You know, I have that his- the history of bunions, the hallux valgus, so my foot has gotten so much stronger over the last 10 years. Um, my, you know, prognosis was they wanted to surgically correct my, um, bunions, and I was like, "That's not happening." I'm way too active [laughs] um, for my mental health, for the, for that, for me, that to sideline me, 'cause I see it all the time. It's a, it's a high rate of failed surgery. Most foot surgeries are.

    23. PAPeter Attia2:26:11

        Hmm.

    24. CCCourtney Conley2:26:13

        So, you know, I wear them all the time. I wear them in all of my shoes and, um, it's helped me immensely, and it has helped so many of my patients.

    25. PAPeter Attia2:26:25

        Um, the brand that you wear is the brand I have as well. It's, uh, what is it called?

    26. CCCourtney Conley2:26:31

        It's the w- the toe spacers-

    27. PAPeter Attia2:26:33

        Yeah

    28. CCCourtney Conley2:26:33

        ... that we have is from a company, Podiatry Essentials.

    29. PAPeter Attia2:26:36

        Okay. They're clear and they-

    30. CCCourtney Conley2:26:37

        Yeah

Episode duration: 2:34:05