Parallel or Not: Aligning Your Feet

by Baxter

I received this inquiry from one of our regular readers recently:

One of the things I am noticing is, as much as I try, I can't seem to keep my feet parallel in mountain pose or to begin a flow without constantly looking down and re-aligning them.  I'm wondering if this is something I should give up on (keeping my feet straight) or just let them splay a bit and not sweat the notion of my feet alignment looking like my instructors.  I'm wondering if my body is simply built this way and I'm trying to get the proverbial square peg in a round hole.  I am also wondering if this impacts balancing poses since I try to keep my feet parallel with the edge of the mat and I seem to be fighting stability for foot position.
 
Thoughts welcomed if this makes sense or maybe, just maybe I answered my own question about foot position?

This is a perfect question for this week, as I am thinking a lot about feet this week, as I am teaching my annual Yoga for Healthy Feet workshop here in Oakland on Saturday. And our reader’s observations about his feet are not uncommon. Lots of yoga students, when confronted with the request by their teachers to “parallel” their feet find this quite challenging and sometimes downright impossible. It can feel odd or uncomfortable to stand this way.

There are many reasons for this. A common one that shows up in yoga class are ex-dancers who were taught from a very young age to emphasize a turn out of the entire leg from hip joint to feet, as the classical ballet position of the legs. They develop a “functional” turn out, one that was not present at birth, but develops as a result of a habitual way of moving. We see a similar condition in functional scoliosis, where the thoracic spine becomes bent and twisted as a result of some repeated activity, such as carrying an infant on the same hip all the time, or always swinging a hammer with the same arm.

In addition to functional changes in foot and leg alignment, trauma can result in such troubles, especially an injury like a broken bone that does not set in its original alignment as it heals. And then there are genetic expressions of the skeleton in the lower extremities that you see running through family lines, either with the feet or shins turning out, which we sometimes call duck feet, or turning in, which is referred to as pigeon toed. Genetic patterns in the hip joints, thigh bones, knee joints, shin bones and ankles can also affect the alignment of the feet.

And keep in mind that, except for disciplines like yoga, martial arts, dance and such, most of us don’t pay a great deal of attention to our feet being aligned parallel, as in yoga. And many non-yogis who don’t concern themselves with such things have wonderful, happy lives. So some of this is kind of arbitrary, and not always essential for a healthy life. But this foot position might be essential in performing well in certain yoga asanas, like Half Moon pose (Arda Chandrasana), where you have to balance on one foot and leg with only one hand on the floor to help you.

There are also inspirational stories of modern yoga practitioners, like that of Muktananda Stiles, who reported being bow legged, and with specific guidance from an experienced yoga teacher (in his case BKS Iyengar), reversed this to symmetric legs and feet.

So, let’s suppose for a moment that being able to stand with your feet parallel does confer some benefit to your posture and your musculoskeletal health. How would you go about assessing and changing what needs to change? You’ll want to do a self-assessment of your lower extremities or have a friend or teacher do one with you, as sometimes others will see something you do not.  Some things to look at: Are your thighs parallel, knees caps straight ahead, but shin bones turning out and the feet go along for the ride?  Also, look at whether both feet turn out or in the same amount, or if it seems to be a one-sided thing. You might have your teacher look at your hip joints as a source of foot turn out, like in our dancer example, or the knee joint, or the shins. Also, do the feet have high or flat arches at play that could also affect your efforts at symmetry?

Once you have some idea of what could be contributing to your particular asymmetry, a clearer path of action may present itself. One way my colleague and friend Richard Rosen has of working on the thighs generally (as they contribute to the effect on the feet) is to use a block between the mid-thighs to activate the adductor muscles of the upper legs, which are often loose and weak for many of us and can contribute to supination of the feet, where we tend to roll onto the outer edge of the foot. Simultaneously, you can place a strap around the outer mid-thighs and cinch it firm, so you can squeeze the block while also pushing out against the strap. This may seem like a paradox, but play with it and see what you discover. 

For those with tight outer hips, which could also contribute to rolling onto the outer edge of the feet, the strap can bring you back to even.  For those with pronation of feet, where you tend to collapse onto the inner foot, the outer press on the strap can get you more toward the outer foot.

The other things to consider are that if you want to get the musculoskeletal system to change, you will have to practice regularly and give it some time to take effect.  As we have mentioned elsewhere, the bones of the body can remodel as they respond to new stresses placed on them, as in osteoporosis. So we can take advantage of that fact here. 

It may also turn out that after careful evaluation you realize or decide that your feet and legs are better off, in the big picture of things, staying as they are.  In that case, you may have to be more creative about how you modify certain poses, such as balancing poses, to take your unique anatomy into account. In either case, you will have an interesting focus for your mind as you explore this common alignment recommendation in your public yoga classes!

Friday Q&A: Plantar Fascitis

Q: I have a question about flat feet and Morton's toe. I'm a 57 YO man who walks a lot and I have both. I always have difficulty balancing on one foot—tree, eagle pose, etc., and have recently had a bout with Plantar Fasciitis showing up in my left heel. No fun. I was at a yoga class yesterday and some poses felt good, others hurt. When I left the class, I literally limped home and iced it for 1/2 hr. then heat, then rest. I had acupuncture at Quan Yin this morning for it and bought new, sturdy shoes and heel pads. It feels a little better today. Can you suggest any asana or other treatment I can do at home that may help speed the healing process and prevent future trouble?

A: If you can remember way back to three weeks ago to our question of the week, (above) our reader had shared that he had a triple whammy going on in his feet: flat feet (see Flat Feet), Morton’s neuroma (see Morton's Neuroma) AND Plantar Fascitis! We have addressed the first two topics already, and now we now ready to look at what is commonly referred to as heel spurs. This is a bit of a misnomer, as only sometimes does an X-ray of the feet show spurring off the calcaneus bone, a bony deposit of calcium growing forward along the plantar fascia. We’ll come back to this and clarify what these things are in just a moment.

The plantar fascia is a sheet of connective tissue that stretches from the heel bone, the calcaneus, forward along the sole of the foot to the base of the toes. It assists the ligaments and the muscles of the foot in maintaining tension across the bottom of the foot to help maintain the arches of the feet. As connective tissue, it has strength, but does not stretch much before running the risk of tearing or becoming inflamed. And, unlike muscles, it does not contract and create active movement in the foot.

Plantar fascitis (PF) is inflammation of this thick tissue on the bottom of the foot. It almost always occurs where the tissue arises from the heel bone. There are many possible factors that contribute to its development but basically it occurs when the thick band of tissue on the bottom of the foot is overstretched or overused. This can be painful and make walking more difficult. In fact, no one goes to the doctor with this condition unless their foot is giving them pain! According to the NIH, you are more likely to get plantar fascitis if you have (or do) any of the following:

• foot arch problems, either flat feet (ding, ding) or high arches
• long-distance running, especially running downhill or on uneven surfaces (I have four students with PF and all of them are runners)
• sudden weight gain or obesity
• tight Achilles tendon (the tendon connecting the calf muscles to the heel)
• shoes with poor arch support or soft soles

Plantar fascitis occurs in both men and women. However, it most often affects active men ages 40 - 70. It is one of the most common orthopedic complaints relating to the foot. Interestingly, in my practice recently, I have seen more women coming in with complaints of PF than men. As far as diagnosing plantar fascitis, as I mentioned above, PF is commonly thought of as being caused by a heel spur, but research has found that this is not the case. On X-ray, heel spurs are seen in people with and without PF.  So how does the doctor or podiatrist figure out if you have this particular foot malady? 

The diagnosis of PF is usually made based on your history and physical exam. There is usually a complaint of stiffness and pain on the sole of the foot near the heel. It is usually dull or sharp, worse on the first few steps in the morning, better with continued movement if is not super flared, and recurs if you have been sitting for a while and get up and walk again. It can also occur if you are standing for a while or climbing stairs, or after intense activity. One of my students whose PF is improving, notices some lingering pain when the affected foot is the back foot in Warrior 1 pose. We are modifying it for now by using a wedge under that heel in that pose to eliminate the pain. The pain associated with PF can develop slowly over time, or suddenly after intense activities. During your physical exam, the doctor will press on the sole of the foot, especially near the heel bone, and if this elicits pain, this is another piece of evidence pointing to PF. They will also note if you have flat feet or high arches, if there is any redness or swelling near the heel bone, or if any stiffness or tightness can be appreciated on the arch at the bottom of the foot. X-rays could be ordered, too. 

One of the reasons students will sometimes come to me for yoga or acupuncture treatments is the long course of recovery or resolution of the symptoms of PF.  It can take from two months to two years for this condition to resolve! The average is nine months, which in this day and age can feel like an eternity. And on rare occasions, the pain could persist beyond two years, and some folks opt for more invasive (can you say “surgery”?) treatment at that point. Here in the US, a typical treatment plan by your doc could include, ice, resting by not doing aggravating activities, anti-inflammatory meds, wearing an immobilizing splint at night and physical therapy stretches for the Achilles tendon and feet. Commons sense recommendations include wearing shoes that fit properly and have good arch support. In addition, heel cups for your shoes or other more sophisticated arch supports might be recommended. If things don’t improve, steroid shots and more invasive treatments might be added.

How might yoga help out?  Well, in addition to what we have discussed in the last two weeks, resting poses, such as Legs up the Wall pose (Viparita Karani) and all the inversions that involve having your feet in the air could assist in resting the plantar fascia. Many of our modern poses could also assist in stretching the Achilles tendon and the feet, if done with mindfulness, so as to avoid aggravating your foot symptoms. Almost all of the standing poses could have possible benefits in this regard, and Malasana, Garland pose, which is a deep squat, could do double duty. 

The opposite case could be made if the poses are aggravating the foot, in that you may need to do some creative propping to permit your practice to continue without worsening your symptoms. Doubling up your sticky matt for more cushioning can help, as can using a wedge under the ball of the front foot or heel of the back foot to minimize stretch during flared times. An example of a pose that puts a lot of pressure onto the front foot heel is Parsvottanasana (Pyramid pose).  Here I would use the wedge under the ball or the front foot. As always, if you want yoga to be in the mix of your healing plan, work with a teacher with experience around PF for the greatest chance of success. We’ll leave the feet behind for now, and I look forward to your upcoming questions!  Don’t be shy, ask this guy!

—Baxter

Friday Q&A: Morton's Neuroma

Q: I have a question about flat feet and Morton's toe. I'm a 57 YO man who walks a lot and I have both. I always have difficulty balancing on one foot—tree, eagle pose, etc., and have recently had a bout with Plantar Fasciitis showing up in my left heel. No fun. I was at a yoga class yesterday and some poses felt good, others hurt. When I left the class, I literally limped home and iced it for 1/2 hr. then heat, then rest. I had acupuncture at Quan Yin this morning for it and bought new, sturdy shoes and heel pads. It feels a little better today. Can you suggest any asana or other treatment I can do at home that may help speed the healing process and prevent future trouble?

A: This question from last week was really a three-parter, and I covered flat feet with you all last week (see Friday Q&A: Flat Feet), so let’s turn to the second issue that came up for our student last week, Morton’s neuroma. It turns out this particular condition can cause pain in the ball of the foot, as we shall see below. 

According to the Mayo Clinic, “Morton's neuroma is a painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes. When it develops, it may feel as if you are standing on a pebble in your shoe or on a fold in your sock. Morton's neuroma involves a thickening of the tissue around one of the nerves leading to your toes. In some cases, Morton's neuroma causes a sharp, burning pain in the ball of your foot. Your toes also may sting, burn or feel numb. Morton's neuroma may occur in response to irritation, injury or pressure. Common treatments for Morton's neuroma include changing footwear or using arch supports. Sometimes corticosteroid injections or surgery may be necessary.”

Interestingly, there's no outward sign of this condition, such as a lump or swelling on top or bottom of the foot. Instead, any of the following symptoms could appear: a feeling as if you're standing on a pebble in your shoe, a burning pain in the ball of your foot that may radiate into your toes, or tingling or numbness in your toes. We don’t know what causes this problem to develop, but it is theorized that irritation, pressure or injury to one of the nerves that lead to your toes may be the culprit. High-heel shoes, high-impact sports or sports with tight fitting shoes (can you say sport rock climbing?) or the presence of other foot deformities are all considered risk factors for developing a Morton’s neuroma. I could hypothesize that our student’s flat feet may have put him at risk for developing one of these buggers, but I don’t know about other activities that he was doing when it showed up. Obviously, the first two risk factors are addressable with lifestyle changes and choices.  Not so much the foot deformities.

If you go in for evaluation for foot pain on the ball of your foot, your doc will likely press around on the foot, especially between the third and fourth toes, to see if you are tender there or have a fullness that is not visible from the exterior. In addition, X-rays may be ordered to rule out a fracture as a cause for your pain, or an ultrasound may be used to look for the swelling of the nerve indicative of a neuroma. Typical western medical treatment usually starts with the least expensive and simplest approach. This could include over the counter arch supports and pads to take pressure off the neuroma. Your doc might go so far as to recommend you get special customized arch supports made for your shoes. Another fairly common treatment involves injection a steroid medication into the swollen area, as it is a strong anti-inflammatory medication. There are three other more extreme surgical approaches that are invasive and beyond the scope of this blog post. My hope is that you would not have to go to that extreme.

The folks at the Mayo Clinic do have some other ideas that could help, which are pretty common sense, too, like taking anti-inflammatory medications like aspirin or ibuprofen, as they can help with pain and swelling. Or try an ice massage. Regular ice massage may help reduce pain. If you have not already changed your footwear, what are you waiting for? Get rid of those heels and make sure the box of your shoes is wide enough!  Finally, they suggest you give your foot a break. For a few weeks, reduce activities such as jogging, aerobic exercise or dancing that subject your feet to high impact.

How might yoga fit into this healing process? Well, I, and many of my students, have noted that regular asana practice leads to a slight widening of the feet. This may be because the practice is done with bare feet (no shoes!). Regardless, this additional space might translate into enough space between your metatarsals to relieve the pressure on the nerve and allow healing to take place. We also often encourage students to spread their toes wide, which could travel upstream a few inches and also provide some much-needed space in the front foot. Finally, a modified practice, done with the buttocks supported on a chair for standing pose variations, as an example, could keep much of your body active while allowing your feet to have less pressure on them. And, of course, a regular practice of inverted poses could relieve all of the blood pressure effects of normal upright walking and standing, giving your feet a real rest. I’d recommend Legs Up the Wall as a “must do” on a daily basis for healing and recovery.

Next time, we’ll look at heal spurs in the mix of the other things our student has going on.  Until then, tread lightly!

Friday Q&A: Flat Feet

Q: I have a question about flat feet and Morton's toe. I'm a 57 YO man who walks a lot and I have both. I always have difficulty balancing on one foot—tree, eagle pose, etc., and have recently had a bout with Plantar Fasciitis showing up in my left heel. No fun. I was at a yoga class yesterday and some poses felt good, others hurt. When I left the class, I literally limped home and iced it for 1/2 hr. then heat, then rest. I had acupuncture at Quan Yin this morning for it and bought new, sturdy shoes and heel pads. It feels a little better today. Can you suggest any asana or other treatment I can do at home that may help speed the healing process and prevent future trouble? Any suggestions for flat feet in general?

A: Wow, this is a great question! It is actually a triple whammy: flat feet, Morton’s neuroma and plantar fascitis! With that in mind, I suggest we address each condition individually over the next three Fridays, to get a better understanding of each condition.

So let’s start with the most common of the three, flat feet. Technically known as pes planus, flat feet are extremely common. In fact, we all start out with flat feet as infants, due to the fact that our muscles and tendons that create the arches in the feet (which number three, by the way) are not fully formed, and because we have a pretty good fat pad in the feet then that contributes to the relative flatness of the feet.

As we grow and walk and run, the muscles develop, the tendons tighten a bit and our arches begin to appear around age three or so. The most obvious of the three arches is the one that runs along the inner edge of the feet from heel to ball of the big toe, which is called the inner or medial arch.  When this arch is not present, the inner edge of the foot rests on the floor with the rest of the sole of the foot. Again, this is a fairly common occurrence in many adults, and unless you experience pain, either in the foot, ankle or knee, it is not really anything that needs direct intervention to change.

So why does having a collapsed inner arch cause ankle and knee pain? Well, if the inner arch is collapsed, it can force your ankles to turn inward, which throws off the alignment of your legs and can influence the knees just above.

What causes flat feet? Probably the most common is that the arches don’t develop in childhood. Other causes include injury or simple wear and tear stresses as we age (there it is again, age!). Risk factors for developing flat feet as an adult include obesity, injury, other conditions such as rheumatoid arthritis and, yikes, aging! An interesting distinction is made between flexible and rigid flat feet. Someone with flexible flat feet who stands on the balls of their feet, with heels lifted, will have an arch appear. Someone with rigid flat feet will not. The later case is often associated with pain and greater dysfunction, and may need the help of a foot doctor to address their symptoms. 

Another interesting finding is that people with flat feet may have a very tight Achilles’ tendon, so specific stretches for the calf muscles can be potentially helpful: do I hear anyone out there thinking Warrior 1, back leg?

Many students have no symptoms associated with their flat feet. But others note some foot pain in the heel or arch area, difficulty standing on tiptoe or swelling along the inside of the ankle. Usually it is foot pain that will prompt a visit to your doctor, who will likely examine the foot, may order X-rays and could recommend meds for pain, and possiblly some sort of shoe insert. Rarely do you need to go further with treatment.

I know of at least one yoga student with flat feet who claimed that working with yoga poses in a particular way helped him reform his arches. I know this is just anecdotal evidence for the benefit of yoga, but it is still encouraging, as this student felt better after the change. How might you experiment with this? As already stated, you might work on releasing tension in the Achilles’ tendon, carefully, via standing poses like Warrior 1, Pyramid pose (Parsvottansana) and squatting yoga postures like Garland pose (Malasana). In addition, I find that keeping the ball of the foot on the floor while lifting all the toes up while doing standing poses seems to create an inner arch lift. It may be strengthening the muscles enough to provide the lift needed for an arch in that area of the foot.

Another way to work with the feet is in Reclined Leg Stretch pose (Supta Padangusthasana) with the strap positioned across the center of the sole of your foot, the location of the transverse arch of the foot. As you pull down on the strap, push your heel and the ball of your foot up toward the ceiling and spread your toes wide. This will simulate and possibly stimulate the medial and lateral arches of the feet to appear. Hold the action for a minute or so and repeat on the other foot. Those of you out there with Morton’s neuroma or heel spurs can give this a try and I’ll take up the neuroma next time!

For more information on feet, see Your Feet on My Mind and Friday Q&A: Feet.

—Baxter

Your Feet on My Mind

by Baxter

I just returned from a five-day trip to Jelapa, Mexico, where I spent the vast majority of my walking time barefoot. I explored the beaches, the cobblestone town, and the dusty dirt trails leading inland, and my feet were in heaven. I was amazed at how quickly I acclimated to being barefoot, and delighted in the adaptability of those two pals of mine as they maneuvered over uneven surfaces efficiently and without any complaints. So it has been an interesting transition back to Oakland and to shoes and boots for urban living. Of course, I am fortunate to practice and teach yoga every day, so I get to spend a decent amount of time barefoot, but not out on the paths and trails as I did in Mexico.

Bare Feet by Michele McCartney-Filgate

The day after my return, I presented a workshop on healthy feet. In my preparations for the day, I encountered again and again foot-related problems that were directly attributable to shoes! A few months back we talked about one of those conditions, bunions, which certainly are strongly influenced by the shoes we wear. But I came across others, such as toe deformities, including claw toes and hammer toes, which are often a result of high-heeled shoes, and Morton’s neuroma, a painful swelling of the nerve that goes between your third and fourth metatarsal bones in the midfoot, also worsened by shoes too tight in the box.

In addition to this, I came across some interesting facts about human vs. other animal feet. From the Trail Guide of the Body came a fascinating comparison. Mammals such as cats and dogs are called digitigrades, as they actually walk on their toes or phalanges, whereas hoofed animals like horses, called unguligrades, are actually walking on the tips of their toes all the time. We humble humans are classed plantigrades, meaning we walk on the soles of our feet, although some dancers and rock climbers are known to imitate our other mammalian relatives on occasion!

And I am not certain which source proffered this opinion, but I read that it that plantar fascitis or heel spurs can result from shoe wearing by weakening the intrinsic muscles of the feet (those that arise and insert within the foot) such that the force of our weight is transmitted to the plantar fascia, a thin yet tough sheet of connective tissue that spans the sole of the foot, from the heel bone to the base of the toes. Once asked to take on such a big load, the plantar fascia often protests by becoming inflamed, especially where it attaches to the calcaneus bone, or heel bone, which can eventually lead to the formation of a calcified spur of new bone growing out into the fascia…owww! 

If we step back from all this news about feet gone bad for a moment and consider the primary functions of our feet, I immediately think of two. First, my feet have to provide stability for me to be able to stand upright like when I am in line at the bank. And, second, my feet have to allow for mobility when I am in movement. So, stability and mobility, all delivered in one package, is called a foot. Yoga, via being practiced in bare feet and involving both stationary or static poses as well as dynamic movement between poses, is a great way to help your feet fulfill their dual role.

Some of us tend to have feet that are a bit stiffer, possibly with a higher arch, which are better suited for stability. Others of us tend to have more pliable, mobile feet, which adapt nicely to changing surfaces as we move about and are in motion. And there can be a nice mix of qualities in some feet. But feet that are very loose and mobile can even go to the extreme of having a collapse of the arches, especially the medial arch, which runs along the inside edge of the foot. For these students there is a unique way to practice standing poses that can help strengthen the intrinsic muscles, as well as those arising above the ankle but inserting on the foot called extrinsic muscles. Keeping your heel grounded as well as the ball of your foot, with a focus on the big and little toe side of your feet, try lifting the toes (not the ball!) of each foot off the floor as you explore the standing poses, starting with Mountain pose, and even working your way eventually to Tree Pose and Warrior 3!  If you can do this regularly in your home practice and stay with it for months or longer, you may find that you have re-established your medial arch! Then of course you will need to relearn how to lower your toes without loosing your newfound springy arches. Sounds worth the journey to me.

Running with Bare Feet

Yoga with Bare Feet! From "Yoga: The Poetry of the Body"

I just finished reading Chris McDougall’s piece on running barefoot in the NY Times magazine called “The Once and Future Way to Run” (see here). Having read his book Born to Runlast year (loved it!), I was familiar with the story McDougall was sharing once again in the magazine. Yet in the few years that have gone by, many more long-time runners and researchers are coming on board with his discoveries about technique. Check out the article and the video to learn this rediscovered training technique from the 1800s called the 100-Up.

As a yogi, I was particularly taken with the author’s assertion that technique and alignment would result in running without injury! We hear the same suggestions from our teachers in class, but sometimes find ourselves not actually following the recommendations. Yet, just like Chris and his desire to run for the rest of his life, I too would like to practice yoga for the rest of mine. So, when we find things that aren’t working and injury rears its unwelcome head, we all may need to look back in time and also around us to find the latest old and new thinking on yoga, too.

—Baxter

I also found this article fascinating, but what really struck me was the emphasis on running with bare feet. Of course we do yoga with bare feet! And I’m a firm believer that exercising with bare feet is the best way to keep our feet healthy, strong, supple and agile. Imagine if you wore thick mittens all the time. Wouldn’t it be hard to use your hands effectively? Now think about your poor feet being trapped in their shoes all your waking hours. (I once watched a woman who had been born with no arms eat an ice cream cone and take care of her baby just with her bare feet; they’re capable of so much if we just let them out of their little prisons.)

But what about our time outside the yoga room? This article exposed the fallacy of the idea that “good” shoes are those that insulate our feet from the ground on which they walk, with their thick, cushiony, high-tech soles. Of course we all know that stiletto heels aren’t the best footwear, but it’s now beginning to look like that all those fancy running/walking/hiking shoes we thought were so good for us might be throwing us off our healthy, natural alignment.

If running barefoot is good for us, wouldn’t the same be true for walking around the house or even out in the garden? And what about those times when we do need to wear shoes? Wouldn’t a “less is more” approach be the most beneficial for our feet?

—Nina