A Multifaceted Approach to Working with Foot Pain
Thursday, January 24, 2019
by: Mary Klueber, GCFP

Section: Practitioner Spotlight

As a Feldenkrais® practitioner, I have found that educating clients about the importance of properly fitting shoes is as critical as the Feldenkrais work I do to address issues with the feet and the whole neuromuscular system.
Shoes affect the function of the feet and thereby movement and balance. The feet inform the nervous system profoundly: when we limit the foot’s ability to connect to the ground in its entirety, how can we not be compromising the input to the nervous system as to where we are in space and how to navigate that space? As we work to enhance our clients’ capacity to function, would we not want to give them the best advantage in their connection with the ground?
Food for thought: Most of us are born with perfect feet. Our broad soles and splayed toes provide balance, stability, amazing mobility, and a foundation for a healthy musculoskeletal system. The myriad of bones (26), joints (33), muscles (over a hundred), plus 200,000 nerve endings, create this extraordinarily complex platform: one designed to flex, stabilize, balance, mobilize, rebound, and absorb shock, lessening impact on joints higher in the body and enhancing the functional organization of our skeleton and movement.
As we subject our feet to conventional shoes, unbeknownst to us, the muscles in our feet and lower legs shorten (or over-lengthen) and become significantly immobilized and atrophied. Our balance and proprioception dull; the broad sole and splayed toes we had as babies become compressed. Our once dexterous, prehensile toes are reshaped and lose their ability to move independently of one another with sequential and nuanced coordination. These issues arise due to the features of conventional footwear: rigidity of the shank, raised heels, arch support, and tapered, upward-angled toe boxes. Mostly below our radar, conventional footwear impacts our foot health and function in remarkable ways.

Indigenous cultures which have remained barefoot or minimally shod have preserved dexterity and foot strength, as well as the naturally splayed shape of the foot — creating a powerful foundation from which to move and balance.  Imagine if, early in life, we began to wear stiff, short, and narrow mittens. Imagine if we continued to wear those mittens throughout our lives. Like the movement restriction that remains after a cast or brace is 
removed, or the lack of balance following a sprained ankle, wearing shoes of this conventional nature affects and harms not only our feet but our entire bodies. It follows that when we work with a client, and they leave a session wearing shoes that compromise the skeleton’s structural foundation, it diminishes the benefits of our work. Shoes that raise the heels, pinch and compromise bones, tissues, and nerve endings send unintended feedback to the brain — impacting the kind of patterns we, as practitioners, are working to help clients rewire. 

In the photos [above], notice the difference in shape between a baby’s foot that has never been shod; a person’s foot after a lifetime of wearing conventional shoes; and another individual, who has been unshod for a lifetime. In a naturally shaped foot, the broadest part of the foot is at the toes. In a foot conformed to conventional shoes, you can see that the foot bone and tissue structure is very compromised. This is because the foot has been molded to fit within the shoe, and conventional shoes are broadest not at the toes (where they should be), but at the ball of the foot (and, even there, are too narrow). To make matters worse, the vast majority of us wear our shoes at least one size too small.
As part of my practice, I have come to address not only the issue of educating on the absolutely critical importance of shoes that allow the foot and toes to rest in their broadest capacity inside the shoe. Additionally, I assist in the return of the foot to its most natural shape possible and to increased vitality: including mobility, dexterity, circulation, strength, and balance. This is accomplished through hands-on Feldenkrais work to mobilize, activate and re-educate the feet, broaden the forefoot and strengthen the feet to support our skeletal system again.
I assess the current condition of the foot during our first visit, then offer the client a beginning set of movement exercises that work with the tissues/muscles. The increase in circulation in these tissues through this movement is as essential as the neuromuscular component in returning the foot to as healthy as possible condition. We also begin the journey of strengthening the atrophied musculature within the feet.
The initial Feldenkrais movement sequences I give clients have some consistent themes,  branching off into broad variations to meet the needs of individual clients. These are most often simple, straightforward, movements. I have found them to be very powerful and sometimes profound, as most of us rarely, if ever, move our feet and ankles outside of the simple plane of walking. 
The first series I teach the client is the cardinal movements with the ankle. We point and flex the ankle; invert and evert the foot with the ankle held at 90 degrees; then do ankle circles in both directions. I also teach them “bell hand”/wave-like movements with the foot. These are quite a bit more difficult for clients, as there is sequencing coordination required, which is rarely neuromuscularly available or activated. I usually provide clients with the booklet, "Learning how to Learn," to give them a more informed sense of the possibility of these simple movements’ ability to make a real impact over time, and for them to engage with a new curiosity and gentleness with themselves. Through the course of the initial visit, clients are often amazed that just these simple movements done in such a gentle manner can make such an impact on what they feel when they stand and walk at different points in the session.
I suggest they perform these movements in bed before they get up, both with legs extended and with knees bent positionally, thereby beginning their day—before weight bearing—with an awakened and stimulated platform on which to start navigating their day in gravity.
I also suggest these same movements be done in sitting orientation, either as an alternative or supplementally at any time to further the progress of waking up the feet.  And, as we know, many traditional ATM® lessons address this scenario. Depending on the client, I may or may not initially suggest beginning an ATM practice—either attending a class or listening to the lessons at home. Each client has their own unique level of engagement initially, and I work to give them a program of activities that will best suit and encourage this engagement. The series “Focus on Knees and Ankles” by Elizabeth Beringer is my favorite to recommend to clients.
I teach a basic top of the foot stretch that is to be done mindfully and gently as well as an individually curated beginning series of basic strengthening exercises, that, done with gentle mindfulness, will begin the process of regaining strength in those mostly-atrophied foot muscles. These exercises also assist in the re-awakening of neuromuscular coordination and circulation that is generally, if not consistently, so vitally lacking within the feet.
Though appropriate for most but not all clients, this rejuvenation of the foot back to its most natural state possible can be supported by an orthotic device that helps gently spread the toes and thereby re-create a broad, stable platform for the skeleton and musculoskeletal system.  The inventor of the device "Correct Toes" was my original inspiration to pursue this work of focusing on resolving foot pain through the lens of the Feldenkrais modality. Information about the product can be found at www.correcttoes.com. It is a profound tool in the regaining of a broad soled/splayed toe foot and resolving almost any painful foot condition that exists.
In support of this critical element of providing an ideal platform from which to work with the client dealing with neuropathy, I propose that we educate ourselves and our clients on the basics of shoe fit. A properly fitting shoe enables the feet to regain some of their natural shape, and benefits the rest of the body accordingly, by providing a broader, more stable skeletal platform for movement. The basic steps for finding a shoe that fits properly are as follows:
1. Most importantly: pull out the liner from inside the shoe and stand on it. This is the single best measure of a good fit. The whole foot and all toes should fit on top of this liner, and not spill over. If the shoe does not have a removable liner, you can bring a traced cut-out of your foot shape from home and place it inside the shoe to see if the edges of the cutout curl up in any way (indicating the shoe is to narrow/small). Don’t rely on widths provided by manufacturers, as these are inaccurate.
2. Look for shoes that are straight on the big toe side of the shoes, as opposed to curving inward toward the second toe.
3. Only use a Brannock device (the standard foot measuring device) for a ballpark measure of foot length and heel-to-ball length, as all shoes fit differently and can vary significantly between sizes. Additionally, Brannock devices do not provide useful measurements of foot width, as they measure the diameter at the ball of the foot instead of at the ends of the toes. 
4. Try the shoes on both feet, as your feet are almost always differently sized. The fit should accommodate the longer foot.
5. Proper length can be determined by sliding your longer foot forward in the shoe until the toes lightly touch the end inside and you can slide a finger’s width (neither tight nor loose) behind your heel.  
6. The shoes should be comfortable across the top of the foot when laced, e.g., there should be no pressure.
7. The shoe should hold the foot securely, without any tightness or discomfort, and should not bend uncomfortably in any way (areas of discomfort occurring where shoes bend will almost always continue to be an issue).  
8. When shopping for shoes, wear the socks you plan to wear with those shoes – not the store’s single-use socks. 
9. Shop for shoes towards the end of the day, when your feet are largest. 
10. The list of natural foot-shaped shoe brands is expanding. For a list of some of the brands, go to www.maryklueber.com/resources
Finding properly fitting shoes is a multi-faceted project that is mostly under-appreciated in its complexity.  Most people “settle” knowingly or unknowingly for a shoe fit that is not ideal in many aspects, which in turn compromises the health of their feet (and thus, over time, their body).

Additionally, for individuals who need extra protection on the inside of the shoe due to the risk of wounds, or extra depth to accommodate edema or orthotics, the list above still applies. (Statistically, the primary cause of wounds and ulcers in diabetic feet is improperly fitting shoes.). Even companies that purportedly make shoes for those with neuropathy do not necessarily make shoes shaped to the natural, unconstrained contours of the foot, creating even more risk of injury in neuropathic feet.  

As a majority of my practice, I passionately focus on helping people resolve their foot pain and related movement challenges. Foot pain has reached epidemic levels in the present day.  For so many, it has a debilitating impact on their freedom to move and walk. And as we know, "Movement is Life!" As we age, the amount we are able to move, exercise, and balance 
is profoundly and directly linked to our well-being and longevity.
Mary Klueber lives and practices in Seattle, WA, specializing in resolving foot and ankle pain and associated movement challenges. She brings a lifetime of movement studies as an athlete, coach, Feldenkrais teacher, and Physical Therapist assistant; has fit over 16,000 pairs of shoes and boots; and has studied with a renowned natural foot health podiatrist. This is a personal and heartfelt mission, based in her own experience navigating injury and recovery, and returning to a place of health and vitality. You can learn more about her work at www.maryklueber.com.
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