Heel elevation in footwear may be the most fundamental and significant cause of foot pathologies in our society. There are no scientific studies that I know of that prove what I have learned over the past 5 years. However, the anecdotal evidence is overwhelming.
To give you a bit of a background story, I’ll begin by saying, I’ve practiced Pedorthics since 1990.
I partnered up with a fellow that owned a Birkenstock specialty store in the downtown area. I was already in the business of making custom Birkenstocks for the Podiatric market so the relationship was a natural one.
We began by marketing ourselves to local doctors, PTs, Chiropractors, and Podiatrists. Boise is an active community and since many of the medical professionals are runners, cyclists, skiers, and hikers themselves, my skills and background in this area quickly gave me a reputation among referring physicians, many becoming my clients.
Born to Run Author
In 2010, I met Christopher McDougall, author of “Born to Run”. It was his signature book about the Tarahumara Indian tribe of distance runners in Mexico that started the barefoot/minimal running craze. That year I had the opportunity to speak with Micah True. Micah was the character known as “El Cabello Blanco” in McDougall’s book who befriended the Tarahumara and was responsible for bringing them to the attention of the running world¹. While the book is credited with promoting barefoot and minimally shod running, my takeaway was quite different.
McDougall blames Nike for the dramatic rise in injuries since the introduction of the modern running shoe which was designed to facilitate a heel strike running style¹. The shoes were created with an elevated heel which was supposed to provide additional shock absorption for the calcaneus. No sooner did they elevate the heel of the shoe, and then there was a sudden rise in rotational injuries like shin splints, IT Band, and hip pain. The running shoe industry’s response was to make “motion control” shoes since the obvious cause was that 70% of the population overpronates. I don’t agree. I believe that to a large extent, the cause of the overpronation is the elevated heel causing a premature heel strike that crashes the forefoot to the ground in a lever arm effect.
It was armed with this knowledge, that I discovered a running shoe brand that did not have an elevated heel but was not flimsy or minimal footwear.
I decided to try trail running and hiking in their shoes. Since there were no dealers in our market area, I ordered eight pairs and put seven of them into stock. As I began to have my patients try this new radical, “Zero Drop” shoe I kept getting the same reaction, “Wow!”. Patients started buying the shoes for wellness and got better quickly. Some with orthotics and many without. I wondered why.
Why Zero Drop Shoes Work
I started using the Silfverskiӧld test², the classic evaluation technique for Equinus, as part of my regular evaluation. I discovered that a large majority of my patients had little if any, range of motion in the ankle with the gastrocnemius engaged and not much more with the knee bent. Many people showed classic signs of Equinus. I was beginning to understand why they had problems like plantar fasciitis, bunions, neuromas, Achilles tendonitis, and more. Humans need at least 10 to 20 degrees of ankle dorsiflexion to ambulate normally³ and avoid injury, and the patients in question didn’t have it.
It makes sense, as there is an epidemic of Equinus in our society and the causes are chairs, cars, shoes with heels, and toilets. When do we ever get the natural stretching of the posterior compartment we need?
The hamstrings, Achilles tendon, gastrocnemius, and soleus are all allowed to shorten as we walk around in shoes with 10 – 12mm of heel elevation, sit on chairs at work, and lie in bed at night.
I started using the zero drop shoes with my plantar fasciitis patients. I reasoned that the treatment for plantar fasciitis is arch support, rest, and stretching then bringing down the heel height of the shoes may actually start treating the cause instead of the symptoms. After all, when a patient is sent to physical therapy for the treatment of plantar fasciitis they are going to work on stretching the posterior compartment. The rest of the day is spent with foot plantar flexed. So I encourage my clients to wear zero drop shoes with arch support during the day and Birkenstock sandals (also zero drop) at home. The results have been dramatic.
Case Studies on Zero Drop Shoes
Here are 2 case studies to share showing the zero drop concept on people for whom zero-drop footwear might be contraindicated.
#1, a morbidly obese, diabetic patient with a cavus foot in Equinus and severe callousing on the balls of his feet.
The textbooks say to dispense full contact orthoses and elevate the heels to address the tight Achilles. I made the orthotics and put them in a pair of Altra zero drop shoes. The patient returned for a follow-up a couple of weeks later and he told me I had changed his life. Now, this may seem a little dramatic until you understand that during the evaluation he had neglected to tell me he didn’t sleep at night due to muscle spasms and cramping in the back of his legs. Now that he is getting the stretch from having his heels on the ground he no longer has nighttime cramping. His callouses are gone too.
Patient #2 had acute Achilles tendonitis. The conventional wisdom is to elevate the heels and refer to physical therapy (stretching). I asked her if she was comfortable barefoot at home. She said that other than the discomfort from a lack of fat pad on the balls of her feet she was fine and was most comfortable in her Birkenstocks. She told me “it only hurts when I wear my shoes”. I put her in a pair of zero drop shoes and she had instant relief.
I have sold over 4,000 pairs of zero drop shoes over the past 5 years. I repeatedly have positive results. While zero drop shoes may not be the solution in all cases, the efficacy of this approach to the treatment of foot pain has been more than amazing.
Equinus in Americans
A recent edition of Podiatry Today features an article titled Understanding the Biomechanics of Equinus. The article, written by Craig Clifford DPM, claims that Equinus is the root cause of most foot pathologies including plantar fasciitis, neuromas, bunions, flat-footedness and Achilles tendonitis. He goes on to say that the common treatments include, intense physical therapy, taping, Botox injections, surgical elongation of the tendons, and…heel lifts?²
Although this is based on anecdotal evidence, I think that many of the conventional approaches for treating common foot problems are fundamentally incorrect. Consider adding 6mm of a heel lift to a shoe that already has 12mm of the drop. This puts the foot at 18mm of plantar flexion. This patient is then sent home to do their stretches. We should be recommending footwear that encourages the same stretching of the posterior compartment that we would get in our natural condition. Elevating the heels in shoes even 6mm promotes poor foot health and function.
Our success with zero drop shoes has not gone unnoticed by the other medical professionals in our market. We routinely get referrals from podiatrists, physical therapists, chiropractors, and rheumatologists now for zero-drop footwear and it is not hard to understand why. They want to refer their patients to someone who can help them.
Today, I have nine employees and we have become one of the largest brick and mortar retailers of Altra footwear in the country. We are also the largest Birkenstock dealer in Idaho and one of the top in the Northwest. This is not because we are clever retailers, it is because we have gained a reputation for helping people. When we explain the benefits of zero-drop footwear, and the patients experience the difference, they not only continue to buy shoes from us they tell their friends and family as well.
¹ McDougall, Christopher. Born to Run: A Hidden Tribe, Superathletes, and the Greatest Race the World Has Never Seen, 2009
² Clifford Craig. Understanding the Biomechanics of Equinus, Podiatry Today Vol. 27 Issue 9 September 2014
³ Root ML, Orien WP, Weed JH. Clinical Biomechanics. Vol II: Normal and Abnormal Function of the Foot, Clinical Biomechanics Corp. Los Angeles, 1977