A First Principles Approach to Preventing and Resolving Foot Dysfunction

Hi there

My name is Nick. I'm the chief education officer at Sole Freedom and the guy who writes our blog posts. Since founding The Foot Collective in 2015 I've been on a journey to better understand feet and how to help people take better care of their bodies starting at the foundation. I'm writing this whitepaper to share the insights I've picked up along the way. This work is my contribution to help raise the bar in how we prevent and resolve foot dysfunction as a community of health professionals.

[A whitepaper is an in depth report on a specific topic that presents a problem and provides a solution]

This is a work in progress. My goal is to have a v1.0 draft completed by 4.20.24 which can then be made available for public review and scrutiny. My hope is that hundreds of peers will eventually review, contribute thoughts and endorse this evolving paper so we can collectively establish a consensus gold standard for how we approach the prevention and resolution of foot dysfunction.

[last edited: 2.24.24]

 

 

Abstract

Effective prevention and resolution of foot dysfunction requires a return to first principles and a focus on education. A paradigm shift is currently underway in how we think of health broadly and foot health specifically. Instead of simply diagnosing problems and treating symptoms, professionals are beginning to help their patients and clients take better care of themselves. This is true healthcare and a much needed change for us to move towards better health. Health is the output of natural behaviors that align with our biology. Within the domain of foot health, it is the duty of care and responsibility of health professionals to protect the patients and clients they serve from the harmful effects of unnatural footwear. Considering 90%+ of humans are wearing shoes that actively disable, deform, and damage their feet, this is a major opportunity. This whitepaper aspires to raise the bar and create a consensus of best practices grounded in first principles that are effective in preventing and resolving foot dysfunction.

 

1. INTRODUCTION

Feet abide by the same first principles of physiology as any other body part yet they are treated in a fundamentally different way. If the natural default state of the human body is to be free of dysfunction and longstanding pain, why then do 75%+ of shod people develop foot pain in their lives? If the body is self healing and self organizing, the only answer to this problem is that unnatural inputs are disrupting the healthy biology we are each given at birth. Armed with a basic understanding of foot function, and the observation that 90%+ of modern humans are wearing unnatural footwear, it becomes very obvious why so many people develop issues with their feet. As a community of health professionals, it's our duty to do better and to protect our patients from the harmful effects of unnatural footwear instead of simply treating the symptoms created by shoes that disrespect our biology.

Feet are the foundation of our body. They are our primary means of transportation and movement independence. To neglect them would be akin to neglecting the foundation of a building.

 

2. AWARENESS

-Awareness that feet are important, that we currently have disease care not healthcare, time preference, impacts of footwear on foot health, that incentives drive human behaviour, about how ineffective our current approach is

 

The design, complexity and importance of the human foot is highly underappreciated. To change that we must begin with awareness. Feet are widely ignored and misunderstood which explains why more than 90% of shod humans are wearing footwear that is actively disabling, deforming and damaging their foot function. As the physical foundation for our body and an essential element in locomotion, feet are one of the most important body parts when it comes to maintaining our function and movement freedom. Simply ask someone who has suffered debilitating foot pain and they will tell you how important our feet are to our independence.

While its easy to view the foot as a single structure, each human foot is composed of 26 bones and 33 articulations which each having 6 degrees of freedom. In the arch of the foot alone, there are 10 muscles and 4 layers of tissue. Nature doesn't make mistakes so that level of complexity tells us that our feet are designed to be dynamic and capable of highly complex patterns of motion. In order to remain mobile, those articulations must articulate and in order to remain strong, those muscles must be loaded.

If we don't view the foot as an important and adaptable structure, we have little reason to pay attention to them or to consider the effects that our footwear might be having on the health and function of our feet.

If we want to prevent and resolve foot problems, we need to begin using our feet as they are adapted to be used. Wearing footwear that respects our biology (natural footwear) and allows our feet to function naturally is the first step to restoring strong, healthy feet.

 

3. A NEW PARADIGM

A paradigm shift refers to a fundamental change in prevailing viewpoints or practices. It's the result of a complete transformation in the underlying assumptions, theories and methodology that guide a field of work. By challenging outdated frameworks and ineffective treatment methods, we are offered an opportunity to explore new ways of thinking and novel ways of approaching problems.

Firstly, It's important to acknowledge that the predominant system that exists today is disease care. This system revolves around the diagnosis of disease and treatment of symptoms. Even with good people and good intentions, this system is disempowering, myopically focused on short term suppression of symptoms, and built on a framework of financial incentives that reward intervention instead of positive long term health outcomes. While many professionals working in disease care view themselves as healthcare professionals, the truth is that disease care has nothing to do with health and disease care professionals are in fact not trained to address root causes while being financially dis-incentivized to help patients heal.

In economics, time preference is a term used to describe the relative value we place on the present moment versus the the future. Someone with a very high time preference cares more about the present than the future and someone with a low time preference cares more about the future than the present moment.

For example, when offered a drug that will reduce pain in the short term but will create more problems in the long term, someone with high time preference will choose to feel better right now regardless of the long term consequences whereas someone with a low time preference will accept feeling less comfortable in the present moment in order to have a better long term outcome.

Disease care has a high time preference bias. The system offers interventions that manage symptoms in the short term while creating unintended negative consequences in the long term. A blind spot about long term consequences is created because most research measures only short term effects while completely ignoring long term issues that are created.

Improving one's health is a long term endeavor that requires a low time preference. Being healthy requires us to forfeit the donut today in order to have better health tomorrow. It requires us to forfeit the pain medication today so we can continue receiving the crucial feedback loop of pain and engage with the process of rebuilding capacity. The paradigm shift from disease care to health care is fundamentally a return to low time preference thinking and the adoption of a long term mindset. 

In contrast to disease care, health care revolves around education and empowering individuals to take better care of themselves. By helping people address the root cause of problems through lifestyle change, healthcare puts primary responsibility back on the patient/client which are the only ones who can make better daily decisions that restore optimal health. 

Disease care creates dependence and reliance on "experts" who must intervene with short term measures to ease pain which comes at the expense of long term health. Health care fosters independence by offering individuals an increased ability to respond effectively to the challenges they face. Instead of focusing on pain, the objective is to improve long term function and resilience while understanding that pain is our most powerful teacher along the process of healing.

In our instant gratification culture, disease care appeases to our desire to take shortcuts and to feel better today regardless of the long term consequences. Health care is a return to rational discipline and asks us to prioritize the future over the present moment. Health is a long term endeavor and requires a long term mindset if we are to meaningfully improve our well being. Focusing on eliminating the root cause of problems instead of simply treating the symptoms is a return to effectiveness. Helping people take better care of themselves requires us to educate our patients about eliminating unnatural inputs causing issues and reincorporating natural inputs that nudge our bodies to adapt back to default, healthy settings.

Within the legacy paradigm of foot disease care, we wait until people encounter foot problems and we treat the symptoms of those issues without addressing root causes of what is creating them. This framework is based on the approach of acute medicine and while it can be effective for emergencies, it isn't effective for issues created by lifestyle choices.

Within the new paradigm of foot health care, professionals are responsible for educating their clients and patients with a fundamental understanding of how the body works so they can wise choices and take care of themselves. This focus on prevention and education helps to eliminate the vast majority of foot dysfunction we see today. This same approach underlines the resolution of foot dysfunction.

 

4. FIRST PRINCIPLES

An axiom is a principle we know to be true. An indisputable and undeniable assumption. An a priori truth which serves as a premise for further reasoning and arguments.

Begin with what we know with certainty to be true. Apply first principles through a long term lens to understand second and third order effects. Weighing long term tradeoffs with short term benefits. Considering unintended consequences. Desired outcome: better function and resilience.

Our guiding axiom in human physiology is the assumption that the human body is self healing, self organizing and adapts specifically to the demands we place upon it. Also known as the S.A.I.D principle, this axiom applies globally to all body systems and that includes feet.

By using this axiom as a lens through which to view foot health, we are able to orient our efforts around the elimination of unnatural inputs and the addition of natural inputs in order to restore the body back to it's natural, healthy settings.

 

5. SYSTEM INPUTS

Our foot health is the end result of adaptations which occur based on how we use our bodies. In engineering terms, foot health is the output and the way in which we use our feet provides the system inputs. Provide the foot with natural inputs (varied sensory input, load and motion) and the result is natural foot health - feet that are strong, mobile, stable, resilient and free of longstanding pain or dysfunction. Provide the foot with unnatural inputs (sensory deprivation, artificial support, lack of varied motion) and the result is unnatural foot health - feet that are weak, stiff, unstable, fragile and commonly painful.

The solution to preventing and resolving foot dysfunction is actually quite simple: subtract unnatural inputs and gradually add natural inputs as our feet adapt and gain capacity over time.

In a complex, dynamic system like feet, we often apply complex unnatural inputs in our quest for short term relief but these interventions often come with negative consequences long term and increased reliance on the external inputs as the body adapts.

Our foot health is primarily determined by the environment they spend the majority of their time within - our shoes. If our shoes are compressive, stiff, angled and deprive us of sensory input, we will be left with damaged, weak and fragile feet. If our footwear allows our feet to function as they are naturally designed to function, we develop strong, resilient and stable feet.

 

6. SYSTEMS THINKING

Systems thinking is a way of making sense of the human body complexity by looking at it through a holistic frame of reference and considering relationships rather than splitting down into isolated parts. Lower body is an integrated system.

Instead of thinking about what things can be done to a specific body part, thinking about what set of factors and interactions might be contributing to a certain outcome. The function of a system is a product of the interactions of different parts, not simply the sum of its parts. 

Systems thinking invites us to understand the interconnectedness of subsystems and feedback loops that govern how our bodies adapt based on the inputs we provide it.

By taking a systems approach to foot health, we considers the lower body as an integrated system whereby no singular element of the system can be meaningfully optimized in isolation of other elements. Our feet, ankles, knees and hips are a tightly interlinked network of joints that must be considered together in order to effectively resolve dysfunction. A foot conversation must always be a lower body conversation. Isolating the foot is ineffective and futile.

 

7. FOOTWEAR

Footwear is clothing humans initially wore on their feet to protect them from potential environmental dangers like sharp objects or temperature extremes. In our current modern world, footwear has become largely a fashion consideration and the unnatural shoes that 95% of people wear are disabling, deforming and damaging their feet. In contrast to these unnatural shoes, natural footwear respects the shape and function of our feet and should be recommended as our primary tool to prevent and resolve foot dysfunction.

Footwear is both the primary root cause of foot dysfunction and also the primary treatment for resolving foot dysfunction. By eliminating unnatural footwear and wearing shoes that allow our feet to function naturally, we offer our bodies an opportunity to heal and recalibrate from the damaging effects of poor footwear.

 

8. RESPONSIBILITY

As individuals, our health is fundamentally our responsibility. As health professionals, our responsibility to those we serve is to offer truthful, helpful, applicable education that empowers our patients and clients to make wise lifestyle choices.

I define health professional as any individual who earns the majority of their income from helping others improve their health. It is the responsibility of these individuals to be informed, and to offer guidance that helps those they serve make better decisions in their day to day lives. Based on that definition, health professionals include movement coaches, yoga instructors, physicians, physiotherapists, chiropractors, massage therapists, podiatrists and many more professions who aspire to empower those they serve with information that guides healthy behaviour change.

It is my opinion that in order to remain effective and preserve a reputation of competence, disease care professionals will be required to shift their approach to align with the health care paradigm that has begun to emerge.

Responsibility is our ability to respond. The ability to effectively respond to a problem first requires an understanding of the problem. In order to do better as a community of professionals, we must first unlearn information that no longer aligns with healthcare, and update our understanding so we can build our ability to effectively guide those we serve towards better health. Within the context of foot health, we must understand the effects of our footwear choices on foot health and nudge our patients and clients towards wearing footwear that supports a healthy foundation.

"A problem well stated is half solved"

As health professionals we must elevate our understanding of feet and the effects of footwear choices so we can help our patients effectively respond to the challenge of foot dysfunction.

 

9. DUTY OF CARE

As health professionals, it's our duty to protect our patients and clients from behaviors that harm their health. By offering them truthful, applicable education, we enable them to make wise choices and take better care of their bodies. Within the context of foot health, our duty is to protect them from the dangers of unnatural footwear that disables, deforms and damages their feet.

 

10. BEST PRACTICES

Best practices are a standards or a set of guidelines that are known to produce good outcomes if followed. Assessing our patients barefoot, educating them about natural footwear and warning them about the dangers of unnatural footwear are the simple yet effective best practices that enable us to achieve good outcomes.

It is no longer acceptable to ignore foot health. A simple 60 second conversation can dramatically change a persons understanding of how to care for their feet and empower them to protect themselves from potentially debilitating foot problems in future.

 

11. INCENTIVES

Incentives are the hidden forces that govern human behavior. Whether they are obvious or hidden, they are always present and their impacts are significant.

"Show me the incentive and I'll show you the outcome"

The quote above is by Charlie Munger and serves as a great reminder that when trying to make sense of people's actions, understanding incentives can offer great clarity. In the old paradigm of disease care, professionals are financially incentivized to treat symptoms of disease with complex, expensive interventions that are often ineffective or worse when long term consequences are considered. The incentive to treat without regard for effectiveness or long term consequences is a perverse incentive causing wasted resources, and an implicit dis-incentive to help people understand and resolve issues by addressing the root cause. Until we acknowledge that current reality, we won't be able to move beyond it.

Incentives are about more than money but monetary incentives are important because health professionals must generate income in order to pay their bills, feed their families and run viable business ventures.

The desire to help others, to do what's right and to be effective is strong, but when placed in opposition to financial incentives, professionals often default to doing what makes them money regardless of their desire to help people improve their health.

Designing aligned incentives within foot health is actually very simple. If the footwear we wear is the largest determinant of our foot health and everyone wears shoes, it makes sense for health professionals to be financially rewarded when their patients purchase and begin wearing natural footwear. This commission framework is ethical, effective and aligns the interests of all parties involved (patient, provider, retailer). It's a win-win situation. Our mission with our pro partner program at Sole Freedom is to share a portion of revenue from each pair of shoes sold with the health professional who referred the customer.

The uncomfortable truth is that many disease care professionals specialized in treating foot problems are incentivized to remain ignorant. It's hard to get someone to understand truth when their salary depends on them not understanding it. If we want to change how disease care professionals understand foot health, we must first help them change how their salaries are earned.

Economic incentives, social & moral incentives, psychological incentives.

We are dis-incentivized from believing anything that is in opposition to our current beliefs, especially if we spent a lot of time, energy and money acquiring those beliefs. The sunken cost of disease care degrees creates a false sense of confidence and a blind spot for many professionals.

New economic incentives. New social and moral incentives that affect our reputation. New psychological incentives contributing to increased satisfaction and meaning in our work because we are helping people improve their health instead of simply treating symptoms without addressing the issue.

Misaligned incentives are no longer acceptable.

Natural footwear: inexpensive, effective, benefits the patient, benefits the provider if they are paid a commission, retailer benefits from the business if they provide a good experience

Orthotics: expensive, ineffective at restoring natural foot function, benefits the provider but makes the patient dependent, reduces foot function over time

Current financial incentives revolve around the treatment of symptoms and this presents a major obstacle to progress. New business models and financial incentives must be created that reward professionals for being effective in helping their patients restore natural foot health.

Footwear recommendations are the domain of modern day health professionals and footwear retailers and manufacturers would be wise to partner with pros and compensate them for recommending footwear that aligns with foot health.

Footwear commissions can become a significant revenue stream for health professionals. Getting paid to recommend natural footwear is ethical, upholds our duty of care and aligns with better foot health.

It's time to create financial incentives that reward pros for effectiveness so we can replace existing incentives that reward ineffective, expensive, complex treatments that fail to address the root cause of foot problems.

 

12. CONCLUSION

 

 

Financial incentives must reward effectiveness if we want better foot health outcomes. Natural footwear offers a new opportunity for aligned incentives that generate income for pros who protect their patients and clients from the damaging effects of unnatural footwear.

 

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Our hope as a collective of co-authors is to spread this message and create a new standard for health professionals. We aim to create consensus agreement and make this paper widely available for health professionals everywhere. If you wish to contribute to this whitepaper or wish to formally endorse this work, please contact [email address].