Leading Podiatrist Dr Nick Defends His Position
Open Letter to All Podiatrists: "Our
Profession Needs to Keep an Open
Mind in Regard to Shoes and
Treating Running Injuries
Posted on 19 May 2013
The following excerpt is from an essay by Nicholas A. Campitelli, DPM, FACFAS that
recently appeared on a popular podiatry forum and website:
Campitelli, or as he likes to be known on his blog as Dr. Nick, does not represent the
majority view and practice of most podiatrists who use orthotics as one of their main
cure for many feet ailments. But Dr. Nick, like others here at the NRC such as the
Sock Doc and Dr. Ray McClanahan, are also in what can loosely be called the antiorthotics
camp (at least, relying on them as a default remedy.)
They are progressively lending their influence to the new movement toward re-establishing
and understanding natural foot health, albeit the education process is still in its
nascent stage. But lets hope its one that continues to grow and have a noticeable
impact, and not only with runners and walkers, but among podiatrists themselves.
Defending My Position On Orthoses
by Dr. Nicholas A. Campitelli
Our profession needs to keep an open mind in regard to shoes and treating running
injuries. People do not change what they are doing unless they have a reason to
change. I continue to see runners not responding to orthotics and stability control
shoes in my practice so I have provided a change, one that is working for others and
myself. Of course, there is not a preponderance of evidence to support this change
but there are emerging studies that support my thinking regarding the use of
minimalist shoes. I have cited these studies in the past and will continue to do so. If
the prior literature on orthotics were conclusive about their effectiveness, I would not
be so strong-minded in my approach. I still feel there is a lack of clarity and
consensus in the literature to support the use of orthotics.
Can orthotics work?
Absolutely. How and what exactly do they do? It is very difficult
to prove given the variability of ones form, training pattern, shoe gear, strike pattern,
biomechanics, body weight, training intensity and change in surfaces. My stance is
that orthotics can treat an injury but this is a very haphazard approach. I think they
are a crutch for treating the underlying problem, which may be overuse, poor form,
weak musculature or improper training patterns.
I use orthotics in my practice, albeit rarely. I have found that by spending more time
educating my patients on proper training patterns, form, foot strike, surface
consistency, strengthening and shoe gear, I can make more of a difference in
improving their injury. It can be more time consuming and challenging, but very
gratifying. I do not encourage patients to discontinue using an orthotic if it is working
for them. Again, I find this is very rare in my practice as most of the patients I see
have already failed this type of therapy. The same applies to traditional running
shoes. Many of the runners I train with wear traditional running shoes (yes, even
ASICS) and I do not persuade them otherwise if it is working for them.
I love running, podiatry and making a different in peoples lives. I am trying to change
the way we think of feet in our society. We live in a society that has the stigma that
we need to support and cushion our feet, which has yet to be proven. Shoes have
evolved with no basis of evidence as to why a raised heel is present among many
other features. I encourage others to be open-minded and consider my approach. I
certainly have leaned more about orthotics and minimalist shoes as a result of being
challenged by my colleagues. Thank you for stimulating my interest and encouraging
Sock Docs View on Orthotics:
DON'T LEAVE HOME WEARING THEM
Its been well over a year since Ive discussed orthotics.
Orthotics, just like stretching, is an emotional and somewhat controversial topic
because so many believe in their effectiveness for injury treatment and prevention.
Others, such as myself, feel as though they either create, provoke, or hide a true
In an earlier article, Are Orthotics Ever Really Necessary? I discuss how orthotics
are never truly fixing any problem. They support, rather than correct, dysfunction.
They also dampen your senses as your feet are no longer allowed to move as
unrestricted as they should. Your sense of body position (proprioception), and
sensory feedback from your feet to your nervous system (kinesthetic sense), are
Yes, often they diminish and even eliminate pain, which is why so many claim they
are successful. Perhaps youve had success with orthotics, or not; or maybe you are
in the foot/footwear business and make hundreds or thousands of pairs of orthotics a
year for your patients as some doctors who (unhappily) contact me have. Either way,
I have decided to look through the eyes of these pro-orthotics people, and try to see
what they see. Okay, its really just one Sock Doc eye; the other is certainly going to
Argument Number One: Orthotics Relieve or Eliminate Pain
Pain is the number one reason someone is going to receive a pair of orthotics, most
often from a podiatrist or chiropractor. Although most orthotic wearers suffer from
foot pain (such as plantar fasciitis), others are using them for knee, hip, or even back
pain. Do they help with pain? If theyre made correctly then yes absolutely. There
are many different types of orthotics as well as ways orthotics are made today so
some of this success is going to be dependent on the skill and knowledge of the
prescriber. Also, other therapies employed at the time the orthotics are prescribed
often help with symptoms. Some prescribers, such as chiropractors, may adjust the
bones of the ankle and foot before fitting the patient for an orthotic. This of course
can also lead to greater success as the foot is in a more balanced and corrected
state before support is rendered.
Though orthotics can be very effective in removing pain, (and Im all for pain
removal), this support-system method of treatment often is simply masking the
symptoms and not addressing the problem. Say you have plantar fasciitis, for
example. The fascia running along the bottom of your foot is too tight, torn, or even
degenerated, and its causing pain. Your foot is not moving correctly and most often
this is from a problem (weakness) in the tibialis posterior muscle. The main arch of
the foot is not supported correctly, proper pronation and supination of the foot is not
occurring, and the fascia is working too hard to stabilize the foot. The orthotic will
often help stabilize the foot, but it will not correct the problem because it can not
correct the weakness of the tibialis posterior. Just as if your wrist hurts because of a
problem in the forearm, bracing your wrist is not going to correct your forearm.
Masking the pain is not a correction, though this is often the answer in many types of
medicine which looks for a quick and easy solution to a symptom. Orthotics for pain
and dysfunction are like aspirin in your footwear.
Sure there are plenty of studies to say orthotics are effective. Unfortunately most of
them are very short-term studies and they only look at one parameter for success
the removal of pain. They dont ask or understand that although the <Actinic:Variable Name = 'foot'/> pain may
be reduced or eliminated, there is now pain in the knee, back, or perhaps shoulder
from the new, different, and altered mechanics.
Lets look at a few of the studies which support (haha) the use of orthotics.
1. Saxena & Haddad found that of 102 patients with patellofemoral pain
syndrome, 76.5% improved and 2% were pain-free. 2% is not a huge success, and
the 76.5% is left for interpretation as to what is improved. There were also other
treatments used in this study and the age range was huge 12 to 87 years old.
2. Shih et al found that a wedged insole was useful for preventing or reducing
painful knee or foot symptoms in runners with a pronated foot. This study was only
one 60-minute test and its unclear what a pronated foot is. After all, pronation is
3. Gross et al report great success with orthotics in several symptoms, and this
study is often cited by orthotic proponents. However, the study was a questionnaire
given to 500 runners (262 responded). Thats not really a study, and as mentioned, it
is only asking about the symptoms they were given the orthotic for.
4. Chang et al found that running injuries were related to training duration and use
of orthotics. But just like above it was a questionnaire study of over 1000 runners
(893 responded) and there is no indication between the training and orthotics.
5. Gross et al, (not the same as previous), found a 75% reduction in disability
rating and a 66% reduction in pain with plantar fasciitis. There were only fifteen
subjects, they looked at their 100 meter walk times (not very far) and the orthotics
were only worn for 12-17 days.
Argument Number Two: Orthotics Improve Joint Mechanics
So do orthotics simply support dysfunction as I have stated previously or do they
actually correct dysfunction? Well, that answer depends partly on what you interpret
healthy joint mechanics to be. One study notes less strain in the foot with orthotics
and a possible prevention for a stress injury to the second metatarsal (Meardon et al,
2009). The big what if here, though, is that the subjects couldnt really say too much
regarding what they were feeling since they were all dead. The eight cadaver
specimens were mounted to a dynamic gait simulator to be analyzed.
Controlling undesirable motion is a term touted by orthotic advocates often. They
say there is instability in a joint and it must be controlled, thus improving joint
mechanics and reducing or eliminating pain. Sure instability isnt a good thing in a
joint, but how do you correct instability by stabilizing a joint with any device? You
dont. You stabilize a joint by correcting the faulty mechanics which are resulting in
the unstable area. Actually, one of the best ways to train stability is with instability.
This is why balance exercises are so good for stability.
Youre not going to improve stability very much standing on both legs on a flat
surface, even if you are barefoot. I like to train stability while barefoot on a thin,
uneven log its so unstable; look out joint mechanics! So when a study says that
orthotics may enhance joint mechanoreceptors to detect perturbations (Guskiewicz
and Perrin, 1996), I say that they actually negatively alter these mechanoreceptors.
Mechanoreceptors, by the way, are sensory receptors that respond to mechanical
stimuli, such as pressure. You want as much healthy sensory stimuli getting to your
brain as possible. This is what awakens and vitalizes your nervous system and is
accomplished by interacting with your environment.
But there is a fine line between too much and not enough sensory stimulation as well
as the source it comes from. So many people are in such sensory overload already
from excessive lifestyle stresses that they cant even walk barefoot because the
added mechanoreceptor information and kinesthetic sense excite their nervous
system too much, too fast. So they dampen this system with either conventional
footwear or orthotics, and they feel better for it. But dampening the mechanoreceptor
activity because of too much other external sensory noise is not the way to correct
the problem. Its not much different than calming your nervous system with alcohol at
the end of a long, hard day. (Now I can get attacked by linking orthotic use to
Speaking of movement, orthotics can have such negative effects too. Flexible arch
supports have been shown to increase knee varus torque (Franz et al, 2008), and
influence medial tibial stress syndrome (Hubbard et al, 2009). So its not always
good, even when youre in bad shape.
So yes, for those in a state of overall health distress, there may be improved joint
mechanics as well as improved nervous system function with an orthotic compared
to without. Even though I never use orthotics as I have other methods for treating
such problems, I understand how they can so easily be the go-to treatment. If thats
the case, however, then function and health still needs to be addressed. These
patients need to have their health and movement problems addressed and properly
rehabilitated. They need to learn how to move well again, and not be dependent on
their orthotics for so long, as often they are told to wear them for their entire life. The
success of the orthotics will eventually run its course. So have a plan to wean out of
those braces, (see my other article Lose Your Shoes), so you can move with
strength, stability, and grace in any environment.
Saxena and Haddad. The effect of foot orthoses on patellofemoral pain syndrome. J
Am Podiatr Med Assoc. 2003 Jul-Aug;93(4):264-71.
Shih YF, Wen YK, Chen WY. Application of wedged foot orthosis effectively reduces
pain in runners with pronated foot: a randomized clinical study. Clin Rehabil. 2011
Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the longdistance
runner. Am J Sports Med. 1991 Jul-Aug;19(4):409-12. Chang WL, Shih
YF, Chen WY. Running injuries and associated factors in participants of ING Taipei
Marathon. Phys Ther Sport. 2012 Aug;13(3):170-4.
Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom
semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J
Ortho Sp Phys Ther, 32:149-157, 2002.
Meardon SA, Edwards B, Ward E, Derrick TR.. Effects of custom and semi-custom
foot orthotics on second metatarsal bone strain during dynamic gait simulation. Foot
Ankle Int. 2009 Oct;30(10):998-1004.
Guskiewicz and Perrin. Effect of orthotics on postural sway following inversion ankle
sprain. J Orthop Sports Phys Ther. 1996 May;23(5):326-31.
Franz JR, Dicharry J, Riley PO, Jackson K, Wilder RP, Kerrigan DC. The influence of
arch supports on knee torques relevant to knee osteoarthritis. Med Sci Sports Exerc.
Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress
syndrome: a prospective investigation. Med Sci Sports Exerc. 2009 Mar;41(3):490-6.
Minimilism Meets Support - The Minimalism Fad is Slowing
Why the Minimalist Footwear Trend Wont Last
November 12, 2013 by Sock Doc (sock-doc.com)
If you havent heard, the minimalist footwear industry has taken a turn for the worse.
Shoe sales arent booming like they used to and companies are starting to add more
material to their shoes to try to stay with the current market trend. After all, thats what
its about the trend. If youre a shoe company your job is to sell shoes. If shoes with
more padding and more support are selling, well then you better order some more EVA.
The trend doesnt shock me at all.
Actually, Ive been surprised by the number of people
who wear barefoot style shoes, especially the ones with five individual toes. If Healthy
People = Barefoot People is accurate, as I wrote a while back in 2012, then there really
should not be too many people wearing truly minimalist-style shoes. After all, our overall
health is not improving as a society. As I discussed in that article, your feet are a great
reflection of your overall health. So the more health problems you may have, the more
your feet will reflect that, and the more shoe you will need to support your failing body.
Minimalist is not just walking around in less shoe its about your bodys ability to adapt
to the environment, including the surface, regardless of whether youre standing or
walking on tile, concrete, stone, grass or hardwood. A well adapted body is a healthy
body. A healthy body can handle less footwear or none at all on any surface if the
environment is safe.
Follow the Fad or Follow the Research?
Do you need research to tell you what you should be doing? If you truly believe that less
footwear support and cushion is beneficial to your body then you could care less about
what the latest and greatest research says. Remember too that the research is often
funded by shoe companies and their study participants are coined healthy because
they have no known disease and dont smoke. Theyre often considered fit because they
exercise a few times a week and have no current injuries (daily aches and pains dont
count). Hopefully you dont want to compare yourself to these average folks.
People follow the fad and the media. If five-toed shoes are hot then lets all wear them
as we grab our gluten-free bagels and soy latte coffee. Its the cool thing to do. If you
really understand how beneficial something is to your health then the fad doesnt matter.
You were hopefully eating eggs when your doctor told you it would result in high
cholesterol. You were using salt while the media warned you that it would harden your
arteries. And you were staying away from hydrogenated fats at the time when everyone
was told margarine was the food of the future and butter was dangerous. So, now that
the minimalist industry is going backwards after only a few short years are you going to
stick more cushion in your shoes or stick to what you truly believe in? After all, theres
really not a whole lot of funding for the barefoot walking/running movement because
there is no money to be made here; dont expect some mind-blowing beneficial barefoot
studies to pop up anytime soon.
You Aint Wearin Minimalist Anyway
So what really constitutes a minimalist shoe? Is it a 4mm or less drop? Is it a certain
width in the toe box? Is it a shoe that a Leprechaun can fit into? There isnt a set criteria
for a minimalist shoe or even the ones that claim to be barefoot-style shoes.
Shouldnt a barefoot shoe be just that barefoot with no shoe?
Without naming names ah screw that lets talk Hokas and the many other
minimalist running shoes out there that are far from that most are maximalist shoes. I
completely understand that if you can hop into a Hoka and run again then its a beautiful
thing but perhaps you should be asking yourself, Should I really be running if I need
these devices on my feet?
Ive said before that most people should NOT be running because they are broken
their health and fitness is so poor, their mechanics are poor, and they dont move well.
So if thats you, why would you want to go and run when you cant perform basic
essential human movements such as walking, squatting, and balancing? Running is too
far advanced for you and putting on a shoe that gives you the false reality that you can
now perform such activity is just like taking a sleeping pill and thinking youre getting the
benefits of sleep. Yeah you fell asleep, but you really didnt go through the proper sleep
cycles necessary for a restful night sleep; you cheated the system and itll catch up with
you eventually. Step back and learn the basic mechanics before you run.
Saucony Kinvara and Virrata, Brooks PureFlow, and all the other feel the ground shoes
out there that many think are minimalist are not even close to my definition of such.
Being zero drop with a +15mm stack height or a 4mm drop and a crazy amount of
cushion and motion control are a far cry from letting your feet move as they are designed
to do. I know they make a lot of people feel good when theyre able to step into a trendy
barefoot-style shoe while drinking their Kombucha tea, but your shoes probably arent
much better than what you were wearing before you stepped on the trend-train.
My definition of a minimalist shoe is one with <10mm stack height, zero-drop, a firm,
motion-free and cushion-free midsole, and enough room to allow your toes to not be
mashed together. But regardless of what I think, the idea here, (well one of them
anyway), is that less is usually better. If you cant get away with less then you need to
ask yourself why.
More Footwear Just Delays the Inevitable
Everyone is going to break down at a certain point. Muscle imbalances occur at this
point when the nervous system has met the maximum amount of stress it can handle,
(different for everyone and always changing in each individual too), and then fatigue,
pain, and possibly an injury sets in. Many distance runners feel that more of a shoe is
better because it allows them to run further without pain or injury. I understand this
concept but I also think that if you need a shoe to support you at a certain distance in
training or in a race then maybe you shouldnt be running that distance in the first place.
After all, more shoe, just like an orthotic, is not going to truly correct any imbalance, it is
just going to support the imbalance while altering other aspects of your body such as
your proprioception, and therefore your muscles, tendons, and ligaments will pay the
price. So if you cant run 20 miles without Hokas, you should be running much less.
Something to think about.
Remember that shoes are for protection only. And of course I can see style at times; you
dont need to be some barefoot hippy that shuns all footwear all the time because
theyre evil. (But if youre into that then good for you, hippy.) You might not want to, and
maybe in some cases youre not allowed to, go barefoot, but you should be able to. You
should be able to walk with only a few millimeters of material between you and the
ground on any surface for any period of time.
If you always need foot support then youve got problems or youre doing more than
what youre currently capable of. Wear the footwear you need to as you address why
you cant wear less but dont do more with more footwear thats the completely wrong
idea. Minimalism and barefoot is about injury prevention and treatment as well as
performance regardless of what new and exciting research the NY Times might come
out and discuss tomorrow.
If you follow the trend you will soon be wearing more of a shoe next year than you were
last and youll miss the health and fitness benefits without even knowing it because
fewer and fewer people will be talking about it. Stock up on truly minimalist shoes
now because 2014 minimalist shoes are only going to be thicker and softer,
much like the average human being.
How Runners Can Avoid Plantar
If you have plantar fasciitis and have been told by a doctor to wear a stability shoe,
orthotics, and never go barefoot, do yourself a favor and immediately switch to
another doctor, preferably one who has read about how the foot functions, and not
just knows all the names of the bones, tendons, muscles, and ligaments.
I speak from experience, since I was given this advice by a well-meaning podiatrist
when I had plantar fasciitis over a decade ago. After he finished telling me of the dire
consequences which would affect my feet if they were not externally stabilized, I
asked him how long I would have to follow his program. His answer was simple: for
I wisely didnt follow his instructions, but I did do a little research about feet and the
maladies which affect them, and then I did some more fact-finding, and I never really
stopped my quest because what I discovered was fascinating: barefoot populations
do not have the foot problems that afflict people who wear supportive shoes. In fact,
the characteristics of traditional shoes are often the most harmful, but which sound
the most positive and comforting: supportive, stable, and cushioned. These features
are actually the ones that are the worst for the strength and health of your feet.
So much of what I was reading was different from what I had been taught that I had
to suspend my previous beliefs about shoes. So, although I knew that weak feet
were obviously more prone to dysfunction, I initially found it difficult that high-quality
shoes could be the major cause of this weakness. If I had been more systematic in
my thinking I would have realized that injuries associated with running had not
decreased, despite all the the technological advances advertised by the major shoe
One of the most common foot problems, both for runners and the general population,
is plantar fasciitis a (de)condition that seems to have reached almost epidemic
proportions, since it eventually affects one out of ten U.S. residents. Among certain
populations, including runners, those who stand for long periods of time, the
overweight, and sedentary, the rates are much higher.
Eventually I found the evidence overwhelming and was willing to enter a finding for
the prosecution: traditional shoes are the major source of maladies affecting the foot
and a significant contributing cause of other structural problems further up the chain
of movement. I was now able to ask one major question and give a simple and
accurate answer. But before we get there, lets go into some detail about the exact
nature of plantar facsiitis.
The plantar fascia is a broad band of connective tissue stretching from the front of
the bottom of the calcaneus (heel) to the phalanges (toes). Its purpose is to transmit
stress through the foot by acting as a truss to help support the weight of the body
when standing and to stabilize the foot and improve its function as a lever as part of
the windlass mechanism while walking, running, and jumping.
Plantar fasciitis (PF) is an inflammation of the plantar fascia caused by excessive
stress. The major symptom is pain of varying intensities near the origin of the tissue,
right where it attaches to the calcaneus. The dysfunction or excessive stress is
caused by the foot being forced to operate in an unnatural way and without the full
muscular capacity that is often caused by the construction of traditional (rigid,
heeled) shoes, both running and casual. A shoe with a difference between the
height of the heel and forefoot immediately places the foot in a weaker mechanical
position by shortening the effective length of the plantar fascia and the Achilles
tendon which, in turn, forces both to become overworked. Depending upon the
frequency, duration, and intensity of the exercise, the plantar fascia can become
Q. What can you do to maintain or retain healthy feet and avoid plantar
A. Be barefoot or wear minimal shoes for as many activities as possible.
Just like minimal running shoes minimal casual shoes should fit the anatomy and
function of your feet. With no restriction of its natural range of motion, the foot is able
to maintain its strength, balance, flexibility, and responsiveness. The truth is,
theoretically we should always be barefoot, but in todays world that is not always
possible of feasible. Fortunately, by wearing minimal shoes, almost all of the
advantages of being barefoot are preserved.
Several companies (Vibram FiveFingers, Merrell, Altra, Skora, Xero Shoes) make
excellent minimal running and athletic shoes, but there are relatively few companies
that make true zero-drop minimal casual shoes. In addition to Merrell, two footwear
brands excel: The first is Vivo Barefoot. This company, which is part of a larger U.K.-
based corporation, Terra Plana, makes approximately ten models of minimal casual
shoes, half for men and half for women. Some have laces and others are slip-on
models, but all are lightweight, flexible, and very comfortable. The other is a fairly
new U.S.-based company called Lems, and their zero-drop casual shoes have
ample-sized area for your entire foot.
Each step you take with a minimal shoe, no matter what the activity, allows you to
strengthen your feet and reinforce proper patterns of movement
This essay originally appeared here: http://motioncenterstl.com/minimal-casualshoes-