Michael Boblett: Dr. Samuel Oltman works at Northwest Foot and Ankle in Portland, Oregon, where he focuses on orthopedics and sports medicine. We wanted to speak to someone from this practice after Rolfer Karin Edwards Wagner told us about the good work done there by Ray McClanahan, a sports podiatrist, and his team. Sam, I’m going to start with general stuff. In Rolfing® Structural Integration, we refer to ‘interoception’, which is the client’s awareness of his or her own body. Obviously an important part of foot rehabilitation is waking up sensory awareness that was previously lacking. What are your thoughts about this?

Samuel Oltman: So proprioception is a huge factor in the benefits of ‘going barefoot’ or minimalism in terms of minimalist footwear. There’s actually a distinction in my mind at least between proprioception and interoception. Proprioception describes one’s awareness of body position in space, and interoception means awareness of one’s bodily sensations. [These] are obviously very closely related, but if you take a simple example of your hand, you have the sense that your hand is in a location, in space out in front of your face, a certain distance to your body. But there’s also sensation, the temperature of it, the different actual sensations inside the hand; that’s the interoception piece of it. Both are woken up when you are barefoot and when you are more habitually in minimalist shoes. The sole of the foot has more sensitive nerve endings per square centimeter than any other part of the body. So your contact with the ground is giving your body an immense amount of information. Being in footwear that allows your feet to receive that information is very important for balance as it relates to proprioception, and the ability to know what your foot is doing at any given time. Shoes that are overly supportive and overly cushioned sort of homogenize all those nerve endings so you don’t really have a sense of where your foot is in space; there’s no specificity of data coming from your feet when you’re walking on a pillow essentially.

MB: I’m a big fan of minimalist footwear!

SO: Minimalist shoes have four basic properties: wide in the toe box (so they allow your toes to spread out); no external arch support; no raised heel; and no toe spring (toe spring is where, when the shoes is flat on the ground, the toes are pointed upward, sort of lifting the toes up off the ground). When you get in shoes that have a wide toe box, that don’t have arch support, that have a flat heel (what’s called zero drop), and don’t have toe spring, biomechanically your feet are functioning in a way that evolution produced over millions of years. The foot is an incredible feat of anatomy and physiology; being in minimalist shoes allows all of those internal or intrinsic support mechanisms of the foot to work as they should and work naturally.

MB: So what happens with barefoot walking or minimalist shoes, in your view?

SO: [There’s] the proprioception benefit of going barefoot. When you’re in shoes or in minimal shoes, your foot is still from a biomechanical perspective behaving as if you didn’t have shoes on. Now the next step of actually being barefoot adds another layer – you’re getting all of the biomechanical benefits, but you’re getting even more feedback from the soles of your feet in terms of the texture of the ground. I’m a big fan of earthing and bare feet – walking in the grass, walking on the beach, walking through the forest, anywhere where it’s safe. You get massively greater input in terms of nerve endings and also in terms of proprioception, even [compared to] when you’re in minimalist shoes. Actually being barefoot really teaches your feet to behave exactly as they should given our evolutionary background. So all those things add into proprioception because you’re activating and sort of waking up the nerves in your feet.

A big part of proprioception is your brain’s reconstruction of what’s going on in the joint. The homunculus can be more or less detailed. Our brain, we know through neuroplasticity, is just like a muscle. We can make it stronger in some areas if we practice. This is where interoception really ties in, in the ability to tap into present-moment awareness of a certain part of your body. That’s essentially what mindfulness is. [Through practice you can] make the homunculus in your brain more detailed. If you are barefoot more, you’re waking up your body’s ability to pay attention to the foot, and it makes more and more detailed delineations.

As someone who practices Vipassana meditation, [where you] simply observe your moment-to-moment bodily sensations nonjudgmentally, that’s literally the practice of interoception in a structured and disciplined manner. It really sharpens your homunculus in your brain. Because of a steady practice of developing one’s interoceptive techniques, you can immediately place your awareness [anywhere in the body], given the requisite anatomy knowledge, and just feel whatever sensations happen to be going on in that area.

So the same thing goes with the feet and with barefoot activity; [you] wake up your foot and wake up your brain’s awareness of your foot, and there’s this constant feedback between those things. [This will help people who get] chronic ankle sprains or feel clumsy.

MB: You mentioned anatomical awareness, and this leads me to a question about demographics. I don’t generally work with sedentary people. I prefer to work with people who are physically active. What is the demographic that you tend to serve and how does that affect foot work in your practice?

SO: [In my] orthopedic practice at Oregon Regenerative Medicine, it’s [people in their] thirties, forties, who are very active – running marathons, doing Crossfit®, playing in different sports leagues, rock climbing, surfing . . . people who are of a proficiency level in a certain activity [and] are pushing their bodies. A group like that tends to be much more preventatively focused because they are active. They want to stay active, right? So it’s not what can I do to avoid arthritis when I’m seventy; it’s what can I do so that I can do my thing next week. So they tend to be more motivated, [and it] is always nice to work with people who are highly motivated. In that group, the types of things that we see are obviously much more acute injuries – different sprains and strains, actual toe fractures, Achilles and heel issues, and then your ankle injuries. And in a broader sense, knee injuries, meniscal stuff, MCL, shoulder injuries, back pain.

The best way to keep moving is to prevent injuries in the first place, so that’s where counseling around healthy footwear and getting your feet in shape [comes in]. One of the big things about making a transition to more minimalist shoes is that you’re asking your feet to do something very differently than what they’ve been doing in the past and you’re activating muscles that have previously been lulled to sleep. It’s like training any other part of your body, you have to give yourself time for your muscles to adapt for you to get stronger. It can take a long time, especially for runners, to fully transition to barefoot running to get to an equivalent level of distance – not because it’s harder to run barefoot, but just because you are recruiting a whole different biomechanical pattern. There’s a really great website through Harvard, an anthropologist who studied different cultures’ running forms. It’s essentially the difference between doing a heel strike [or doing] a forefoot or mid-foot strike. It changes your biomechanics and your ankles, knees, and hips pretty dramatically. So approaching all of that from [an injury-prevention] standpoint is really important, especially in that younger group.

And then the second demographic that I see a lot of is people with osteoarthritis who are sixty, seventy, sometimes eighty, [but] sometimes fifties. And there’s a lot of ancillary or secondary conditions that come along with that. Essentially the person who’s sixty-five and has osteoarthritis in the big toe along with a bunion and some knee osteoarthritis and some hip [issues]. That’s a demographic that’s not necessarily active.

Part of the connecting piece between those two demographics is that it’s very, very clear through the evidence now that any acute injury increases your risk of osteoarthritis in that joint down the road. So a lot of times you have people who are in their sixties who are in phenomenal shape, very active, but have osteoarthritis because they have a history of injuries. So we know that osteoarthritis isn’t just a case of a sedentary life and metabolic decline, it can also be post-traumatic. So there’s a mix for that older demographic between people who have had traumatic injuries and develop osteoarthritis, and people who essentially have ‘diabetes of the joint’ – which is in large part what osteoarthritis is, a sort of insulin-dependent degradation of the joint surface having to do with inflammation related to high blood sugar and metabolic syndrome. ‘Diabetes of the joint’ doesn’t quite capture it all, but it’s sort of a good sort of synopsis of the connection between the degeneration in the joint and the metabolic processes that are happening throughout the whole body because generally in something like that there’s rarely ever arthritis in only one joint.

In my practice at Northwest Foot and Ankle, that demographic is bunions, hammertoes, heel pain, and – across the board regardless of age – ankle instability. Chronic ankle sprains, in my opinion, a lot of times are through the use of improper footwear. If you think about how an ankle sprain happens, you have to have something to roll your foot off of. [Putting] yourself on a big heel increases the likelihood that your ankle can roll off of the heel of the shoe, which is basically acting like a fulcrum for the kind of sprain to happen. I’ve found that being barefoot and having the heel actually on the ground, having the whole foot on the ground, really decreases the amount rolled ankles that I’ve seen in my patients.

MB: This is really helpful. I am totally stealing that metaphor, if that’s what it is, of diabetes of the joints. That is really good.

SO: It’s not mine so go ahead and steal it.

MB: I have so many clients where one of the first things I say is, “I’m not going to see you if you don’t also see a nutritionist because I can’t keep putting out fires where you keep on setting off fireworks.”

SO: It’s a primary point of emphasis that I use with all my patients. A big modality that I use in both my practices is regenerative injection therapies – dextrose prolotherapy, platelet rich plasma (PRP). These are therapies that help to induce your body’s healing response; you inject PRP into a joint that has osteoarthritis and your body is activated to rebuild cartilage, repair the connective tissue, the ligaments, the tendons in that area where the injection is done. But those injections don’t have the same kind of durability if the person is continuing detrimental lifestyle factors – especially with PRP, because PRP is made from the patient’s own blood, right? We take the patient’s blood, spin it down, and extract and concentrate the growth factors that are in the blood. You’re PRP is only as good as the blood your body is making. With PRP you really are making your own medicine. It makes a lot of intuitive sense to use your body’s own growth factors, sort of in a concentrated form, to put back into the joint. But a lot of people have inflammatory blood and it can diminish potentially the effect that PRP has for someone.

So getting people on an anti-inflammatory diet; low low-glycemic, plant-based, basically a Mediterranean diet. As a naturopathic physician, I have been exposed to diets that are really all over the map, and pretty extreme restrictive diets for a lot of different conditions. But I think, in general, just eating a common-sense plant-based diet – I really like what Michael Pollan summarizes, eat real food, mostly plants, not too much. That’s essentially what the Mediterranean diet is; it’s the most scientifically valid. There’s some cases where eating paleo can be helpful, there’s some cases where going vegan can be helpful, and everything in between. [For] the insulin resistance that is the basis of diabetes, just eating real food is a pretty big shift for a lot of people. And so I find that keeping it simpler is usually better for most people. In terms of joint health and doing different injection therapies and working with people’s feet, diet always comes up.

And it’s actually a special interest working in podiatry because of things like diabetic neuropathy. The foot is, in most cases, the first area of the body that tends to be symptomatic for diabetes. That comes up fairly regularly at my practice at Northwest Foot and Ankle. There’s some supplements that can be helpful. Pharmaceuticals have their place, but pharmaceuticals – especially for lifestyle diseases – are really just kind of plugging holes in the boat as it springs a leak somewhere else. So the conversation about diet never ends and it’s almost always relevant. Everything that your joint is doing and everything that your feet are doing, it all is made up of the stuff that you’re eating. Every molecule of it. And it just so happens that insulin resistance is the most prevalent metabolic dysfunction in this country right now due to processed foods and sugars and artificial sweeteners and everything like that.

MB: Beautiful. And you totally had me, Michael Pollan happens to be the Bible writer of our particular family religion. Eating mindfully and eating with joy.

SO: A lot of times in medical nutrition it’s really over-emphasized about calories and macronutrient distributions and eating a prescribed diet. There’s places for those things for sure. But for most people, I’ve found that creates another neurosis around food. One of the things I really appreciate about Michael Pollan is he emphasizes the fact that food and eating are really essential

to the social fabric, not just an event, but a ritual, something to really enjoy and take pride in. So the eating alone in your car during rush hour is so antithetical to what healthy digestion is in terms of your nervous system and digestive activity, and is sort of the opposite end of the spectrum from eating a long relaxed dinner with loved ones in the comfort of your own home. And so those things are, even if you’re eating the same substance, massively different in terms of the way you digest them and your response to those foods. There’s actually been really interesting studies where they take two groups of people and they feed them the exact same milkshake, except they tell one group that the milkshake is like an indulgence dessert milkshake, and they tell the other group that the milkshake is a diet, sort of like a lean shake thing. And people’s attitude toward what they’re eating changes their hormonal response to that food and changes the insulin response. So the attitudes about your food and the state of consciousness and the state of mental activity that you’re in while you eat also play another role.

MB: Let’s talk about client expectations and managing expectations, managing how the client responds. And this I find happens in both the demographics that you talked about – the younger more athletic and the older, more sedentary. I find that when feet wake up, one of the first things they do is complaint. And this happens in session, it happens between sessions. All of a sudden a metatarsal that has never rotated starts to rotate. A toe that has never said anything suddenly has said, “I haven’t said anything for sixteen years, so ergo, I’ve got some stuff I have to say.” So with clients whose arches, for example, are starting to open up, or whose toes are beginning to develop some independence from each other, how do you handle this?

SO: That’s a really good observation. I definitely tell patients [we are] asking your feet to do something very differently, and so within that, new things might come up along the way. There are going to be different sensations, and part of that may have to do with waking up the proprioception ability. Simply becoming more aware can open up some unpleasant sensations. We talk about increasing awareness, or increasing body awareness. When you increase your body awareness, you don’t get to choose what to be aware of, right? You’re just being more aware of your body, whatever happens to be there. And a lot of times what happens to be there is discomfort. And so I think that can definitely be a part of it, from a more basic kind of physical or physiological level, when people use their feet more. When you wear more minimal shoes, when you’re barefoot more often, your feet are working harder. They’re going to feel like they got a good workout. I talk a lot with my patients about trying to distinguish the difference between good pain and bad pain.

One of the primary tools that I use at Northwest Foot and Ankle is called Correct Toes® (see Figure 1). They are a toe spacer product made to be used with activity. [Most shoes have] a tapered toe box; not just high heels and cowboy boots but pretty much 95% of shoes on the market. If you look at a baby’s foot, the widest part is at the ends of the toes, but if you look at most American adult feet, the widest part is down at the metatarsal heads and MTP joints because all the toes have been squished together by wearing shoes that are forcing them to conform to fashion.

You would think that running shoes would be made purely for foot performance. Most companies are marketing foot performance but under the guise of current fashion standards [of] having slender, pointed toes. And that’s a carryover [of the] cultural evolution of footwear and other related clothing or adornments. We had heels on our shoes so they would fit in the stirrup [when we were riding] horses around. And those aspects of footwear have persisted to an incredible degree, to the point where now athletic shoes are made with pointed toes, for no reason other than people are used to it.

Figure 1: Correct Toes®, toe spacers developed by Dr. Ray McClanahan, the founder of Northwest Foot and Ankle; see https://www.correcttoes.com.

Reversing that takes a lot of the time. When you transition to bare feet, the Correct Toes spread out your toes and reverse what narrow-toed shoes have done in terms of compressing the toes together. So they re-spread your toes out so that the ends of your toes are again the widest part of your feet. And doing that’s a pretty big change. Take that older demographic with bunions, for example, they’ve spent fifty or sixty years getting their toes compressed on a daily basis to the point where they now have pretty severe deformities in their feet. If you think about how long it took your feet to get to this point, it sort of gives you an idea of how long it will take to get complete reversal. The big delineation is a lot of people want their feet to look different. As a doctor I’m less concerned with aesthetics and more concerned with pain-free function. Aesthetically it’s hard to reverse a lot of the soft-tissue changes over a short period of time. It does happen over the years – it happened with my feet, it happens with patients’ feet all the time. But it takes years to really change the resting position of your big toe so that it’s more in line with the first metatarsal. However, from a functional perspective, getting your feet to feel better and to function naturally and well is a much, much shorter rate of change. Wearing the Correct Toes is powerful because they kind artificially align them without having to wait for your feet to realign themselves over the next couple decades.

All of those changes can cause some either previously unknown [pains] or [cause] past pains to come back up. The fact that you maybe have a new sort of soreness in your foot that you’ve never felt before is a sign of your foot changing, and getting stronger. And that happens a lot with other joints too, like when we’re doing regenerative injections for knee arthritis. When the knees feel better, you start to notice maybe other joints in your body that you didn’t really notice before, that are hurting you now. I think that’s a part of it as well, when you have one part of your body that’s in severe pain, you don’t notice the other parts, or at least you’re more apathetic to them. So when you resolve the major pain, then you become aware of smaller pains. That’s the continual journey of optimization, just continuing to address whatever happens to be at the top of the list in terms of pain and dysfunction.

MB: Do you work with pregnant clients and what happens with that?

SO: Women’s health isn’t something that I focus in. But I do see a lot of women who develop soft-tissue dysfunction post-pregnancy. The hormonal changes that happen in pregnancy are geared towards making soft tissue more pliable. To get the body prepared to deliver a child, the connective tissue has to be pliable so the baby can pass through the pelvis. Those changes happen not just in the pelvis, and not just locally where they really need to happen. They happen systemically. So women who have just delivered have more pliable and sort of loose connective tissue. That can cause different issues, especially in terms of foot and ankle issues. Chronic ankle sprains and ankle instability are pretty common in pregnant women, also knee or hip symptoms through valgus deformities and things like that. Having the connective tissue more pliable throughout the whole body sets them up for increased risk of injury through ligament laxity.

Even if it doesn’t come down to a full ankle sprain, just the sensation of instability is something that I find to be fairly common post-pregnancy. A lot of times it’s not a big enough issue to where people will need treatment per se. If someone’s already living more of a barefoot kind of lifestyle, so to speak, then they’re going to be in a better position when those changes do happen to not have them cause any injury. If there is chronic ankle instability and that’s manifesting as ankle sprains, using dextrose prolotherapy is my go-to; that’s a type of injection therapy that utilizes dextrose, just a simple sugar solution mixed with anesthetic at a certain concentration to make it a hyperosmotic solution. When you inject that into the ligament attachment points on the bones, it attracts white blood cells and fibroblast activity among other things in a controlled inflammatory response. It helps to build and strengthen collagen and can essentially shrinkwrap the joint and make it more stable through strengthening the ligaments.

Essentially what prolotherapy does is mimic tissue injury without injuring the tissue. So it mimics on a chemical level what would happen when you have an acute injury, except with the injections there’s no actual tissue damage. So you’re getting the healing response from your body in the absence of any actual injuries. You can help to strengthen up specific areas through these injections. I find that I can get really pretty distinctly verifiable results in terms of orthopedic tests and symptoms within several treatments. So that’s the main thing I use for ligament laxity. But in terms of pregnant women, ligament laxity is definitely the biggest thing from a musculoskeletal perspective that I see.

MB: Excellent. Well, you’ve been extremely helpful. I’m very grateful.

SO: I really appreciate you reaching out, Michael, it’s been really nice chatting with you today. If you have any questions let me know.

MB: I do know that I will be selling Correct Toes now through my practice, and I’m grateful to learn about the various kinds of injections that you mentioned as well.

SO: Excellent.

Samuel Oltman graduated with a BS in exercise and sport science and then obtained his Naturopathic Doctorate (ND) from the National College of Natural Medicine. He completed a rigorous two-year primary care residency at Grain Integrative Health in southeast Portland and has advanced training in pain management, orthopedics, and regenerative injection therapies. Dr. Oltman treats patients with the underlying presumption that the body contains the wisdom to heal itself – with the requisite inputs for enhanced healing and the removal of barriers that prevent healing. He views symptoms are nature pointing to where imbalance lies. A lifelong athlete, Dr. Oltman is interested in how to optimize performance and physical fitness. Restoring natural foot function to his own feet made him a true believer in the barefoot lifestyle. He is on the staff of Northwest Foot and Ankle in Portland, Oregon (https://www.nwfootankle.com) and has a second practice, Oregon Regenerative Medicine, in Lake Oswego, Oregon.

Michael Boblett works in San Diego, California. He has been a Certified Rolfer since 2003 and a Certified Advanced Rolfer since 2008. Michael is a retired Unitarian minister. His advanced degrees (MA, MDiv, and DMin) are from Pacific School of Religion in Berkeley, California. At seminary, he focused on the anthropology of religion, with experiential training under Michael Harner, author of The Way of the Shaman. Michael runs marathons and hikes up mountains wearing Vibram® Five Fingers. His website is www.rolfer.biz.

Feet from Another Perspective[:]