Yoga for Foot Pain

by Baxter

Study of Hands and Feet for the Golden Age by Ingres

As I was preparing for an upcoming workshop on Yoga for Healthy Feet at Mountain Yoga in Oakland, California, I happened to review our recent communications from you, our readers (thanks for all of these questions, by the way, and keep them coming!), and came across this timely inquiry:

I am a 67-year-old female in good physical condition. About 10 years ago, I slipped down a steep hill and came to a stop half way down the hill, using my foot to stop. I immediately had severe pain in the arch of my foot to which I applied ice. Every since then, I have had pain in the arch of my foot, to varying degrees. I now have that pain wrapping around from the arch to the top of my foot and pain that wraps around my ankle. Even the bone on the medial side of my foot, above the arch, becomes sore at times. I frequently wake up in the middle of the night with arch pain. When I walk fast at all, I get shooting pain in my arch. I have been to the orthopedic doctor and they have injected steroids into the tendon sheath in the bottom of my foot and also by the ankle. These injections have helped for a short time. I don’t want any more steroids. Are there any yoga exercises that I could be doing to strengthen this area and to decrease the inflammation that is there? Any suggestions would be very much appreciated.

I’d like to start by acknowledging how challenging traumatic injuries can be to our bodies, and how they sometimes don’t easily heal and allow us to feel like our old selves again, at least not on the timetable we would prefer! Our reader’s situation appears complicated in the sense that the pain she experiences moves around, is aggravated by certain activities, has been around a long time, and even wakes her up at night. And despite seeing an orthopedic specialist and getting some steroid injections to decrease inflammation in the tissues of her foot, her pain persists. Although I cannot make specific recommendations for this person without a more thorough history and physical, I can provide some general recommendations on approaching foot pain and working toward stronger and more supple feet and greater pain-free movement.

Non-Weight Bearing Mobilization

It turns out the feet are quite complex parts of the body. There are 52 bones in the feet, and each foot has approximately 33 joints, each of which can move in multiple directions. The possible number of distortions of the foot is a huge number, something on the order of 8x10 to the 36th power. In contrast to the foot’s huge variety of possible shapes and movements, we usually wake up, are in bare feet for just a few minutes in the morning and then jam our feet into shoes all day, which protect the feet for sure, but limit movement dramatically. So the first wonderful thing about practicing yoga is that you liberate your feet from shoes for however long your home practice is each day. In the context of painful feet, it may be a great starting place to do yoga practices that are non-weight bearing, since things like brisk walking, as in our reader’s case, might be influencing the persistence of pain.

A good place to start would be with any “warm-up” practices that involve lying on your back or belly and moving your limbs and feet around. An example would be Legs up the Wall pose (Viparita Karani), in which you could add in movements of your feet and ankles to promote mobility of the joints and soft tissues of your feet. Other examples of poses where there is no or very little pressure on your feet include Thread the Needle pose, Locust pose (Salabasana), and Reclining Twist pose (Jathara Parivartanasana). In all these poses, you can deliberately choose how you want to position your feet and ankles—whether you want to spread or curl your toes or vary other foot movements and positions—to bring greater awareness to how your feet are doing moment to moment. Once you are comfortable in these poses and your foot pain doesn’t flare, you are ready to move on.

Locust with One Leg Up

Mild Weight-Bearing Poses

There are several basic yoga poses that begin to require more of your feet in terms of dealing with forces to the soles, the tops, and the edges of your feet. As you introduce this new group of poses, you will again be monitoring how your feet respond during the practice, as well as after the practice, such as overnight. Some of my initial choices include:

1. Reclined Leg Stretch pose (Supta Padangustasana)
2. Bridge Pose (Setubanda Sarvangasana)
3. Seated Crossed-Legs Pose (Sukasana)
4. Cobblers Pose (Baddha Konasana)

With Reclined Leg Stretch, you are still not bearing weight but you are bringing pressure onto the sole of your foot with the strap. You can vary the location of the strap; I like the heel pad, the mid-foot, or the ball of the foot. And you can vary the intensity of the pull of the strap to gauge how much your foot can handle.

Reclined Leg Stretch Pose

With Bridge Pose, you are beginning to bear weight on your feet, but not your entire body weight, so this pose provides is good way to test the waters to see what your feet are ready to handle. The other seated poses put a bit of pressure on different parts of your feet and can help reveal areas of ongoing tenderness that might need a slower approach towards full function.

Full Weight-Bearing Poses

When you are feeling ready to stand up and see how your feet handle more challenging situations, you can begin to explore the basic two-legged standing poses. Mountain pose and all of its variations—arms overhead, side bending, and so on—are the starting place and a good home base to return to for this group of poses. 

Arms Overhead Pose

From there, move on to the classic two-legged standing poses, such as Triangle pose (Trikonasana), Warrior 1 and 2 (Virabrdrasana 1 and 2), Extended Side Angle pose (Utthita Parsvakonasana), Pyramid pose (Parsvottansanas), and Widespread Standing Forward Bend (Prasarita Padottanasana). Each of these poses will bring slightly different challenges and forces to your feet and ankles. You might add them gradually over time and assess how each one affects the feet.

Triangle Pose

Once poses on two feet are becoming easier, add more challenge by working on one-legged poses, such as Tree pose (Vrksasana), Half Moon pose (Arda Chandrasana), Eagle pose (Garudasana), Warrior 3 (Virabradrasana 3), and Dancer pose (Natarajasana). Be willing to go more slowly with these pose, however, as they will focus more force and pressure onto your feet and ankles, and may require more time and attention to get better at. 

Warrior 3 Pose

Dynamic Movements

In real life, we are moving around on our feet quite a bit, walking, occasionally squatting, and periodically dancing, cycling, or running. You can ready and train your feet for these variable movements by practicing dynamic yoga sequences. The most obvious choices are Sun Salutations and Moon Salutations, but I suggest that you can also allow yourself some creative license to invent your own dynamic movement using yoga poses. Keep a playful, yet focused attention as you move in and out of various yoga poses with clear awareness of your feet. 

See Agility Practice and  Want to Improve Your Balance? Take Off Your Shoes! for more ideas.


Finally…

Hopefully these suggestions can assist in the healing process from a variety of painful foot issues. There are certainly many other non-yoga practices and therapies we cannot cover here, but you have a starting place with yoga to begin your healing journey.

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Want to Improve Your Balance? Take Off Your Shoes!

by Nina

Eagle Pose Outside by Melina Meza

“Balance is a complicated equation involving vision, muscle strength, proprioception (the body’s ability to know where it is in space), and attention. As people age, those elements deteriorate.”

Well, if the New York Times can write about falling twice in one week (see A Tiny Stumble, a Life Upended), then so can I! Because after reading part 2 of their series on falling, I have a lot more to say. The main article detailed what can happen after an older person falls, saying, “life is upended in an instant — a sudden loss of independence, an awkward reliance on family and friends, and a new level of fear for those who fall, and their contemporaries.” So, there I was, getting all depressed again. But at least the article end with a quote that confirmed what I wrote on Monday (see Morning Wakeup Call: Preventing Falls with Yoga) about the downward spiral that happens after people fall and become fearful of falling again.

“Dr. Tinetti warned that excessive tentativeness can actually increase the risk of falling. “People who are more cautious cut down on their activity,” she said, “which makes their balance worse, their strength worse, and reflexes that prevent falls worse.”

But it’s the supplementary article on Steps to Avoid an Accident  that really got me upset. (Yes, I feel a rant coming on.) Here is what they recommended:

“Regular exercise classes can help, especially those that include balance drills, such as standing on one foot, or working with Bosu balls, the squishy hemispheres seen at gyms.

"The regular practice of tai chi has also been found to help. Tai chi involves very slow, purposeful movements in coordination with breathing and muscle activity, which in turn affects respiration, balance, and gait.

"Integrating balance and strength work into daily life — standing on one foot while brushing your teeth, for instance, or simply putting one foot in front of the other — can help as well.”

Uh, yes, although they came up with the brilliant idea of brushing your teeth while standing on one foot, they did completely forget to mention yoga. Yoga is particularly beneficial for balance not just because it includes so many balance poses but also because it cultivates muscle strength, proprioception (the body’s ability to know where it is in space), and attention, which the NY Times mention as being needed for good balance. When we work in our all our poses—whether or not they are balancing poses—with careful attention to our alignment, we are developing our proprioception and our attention. (My teacher, Donald Moyer, who always has us work with subtle alignment cues in our poses, has observed how his long-time students have developed very refined proprioception over the years.)

But in the end, there was something else the article didn’t even mention that made me feel rant-y: our feet! I’m a firm believer that exercising with bare feet is the best way to keep your feet healthy, strong, supple and agile, which in turn will improve your ability to balance. 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. No wonder so many older people become less agile. 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. That was a lesson to me about the power of our feet that I will never forget.

Of course we do yoga with bare feet. And moving into and out of a variety of yoga standing poses in bare feet definitely helps keep our feet more agile. As a matter of fact, in an early post of ours Friday Q&A: Feet and Comments, we addressed a question from someone who had trouble balancing in Tree pose and who also wore orthotics. Shari actually recommended that the reader spend at least some of her time practicing with bare feet to help her with her balance:

“If you wear orthotics in my mind it might be good to explore in yoga wearing them in some type of non-skid sock so your toes can still feel the floor when you are practicing your balancing poses. It sounds like you have very high arches so to contact the floor without your orthotics will be difficult. I might suggest that you explore doing the balancing poses (such as Tree pose) with your orthotics and non-skid socks, then take them off and try in your bare feet directly afterwards. Sometimes this can work to build muscle memory to teach your feet what to do. I wouldn’t push your feet to hurt your knees though. Be patient and kind to yourself when you try this.”

The NY Times article didn’t even mention how important it is to walk on uneven surfaces! If you’re always walking on a flat surface—especially wearing shoes—your feet and the rest of your body are going to be, well, just plain inexperienced and unprepared to handle any sudden unevenness, like a crack in the sidewalk. Of course, hiking on a dirt trail is effective for training your body to handle uneven surface. But it strikes me now that all those people taking photos of themselves doing yoga out in nature are doing something really good for their feet—and their balance—even if they are torturing us with their selfies. So maybe we should all start experimenting a bit with doing yoga outside.

But if you're not ready for that, in the same post in which Shari stressed the importance of balancing in bare feet, Baxter recommended a very simple yoga vinyasa, Tadasana (Mountain pose) to Urdva Hastasana (Upward Arms pose), to help keep your feet healthy and improve your balance. He said that this exercise can strengthen the foot muscles that are associated with a healthy arch. 

1. Start in Mountain pose.
2. Inhale and lift your heels off the floor as you swing your arms up into Upward Arms pose. Focus on keeping the balls of your feet even on the floor as your rise up.
3. Exhale as your lower your heels down to the floor and release your arms by your sides. Focus on keeping the balls of your feet even on the floor as your lower down.
4. Repeat for at six rounds or more.

Baxter also recommended that practitioners with flat feet should practice their standing poses keeping the balls of their feet grounded as they lifting their toes off the ground. This will encourage strengthening of the medial and lateral arches of their feet.

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Yoga and Foot Cramps

by Baxter 

One of our readers sent in a question that I was surprised we had never received before:

“I'm having this ongoing cramping of the feet, mostly the arch during yoga classes. The cramping I experience happens is not flex, such as in seal or cobra or even in a kneeling pose where the top of my foot is on the mat. It's then I get the cramp in the upper arch of my foot. Each foot will cramp and sometimes both cramp at the same time. I've read about electrolyte balance and eating bananas and I have a pretty healthy diet and I practice yoga in a studio 5 days a week. I've been cramping almost from the beginning of doing yoga, about 2 years ago.”

This is such a common experience for most yoga students, certainly when they first begin doing yoga asana, but even over time. I know that both Nina and I have experienced this first hand, so we are empathetic to our reader’s plight! That said, it might be nice to have a better understanding of what I jokingly refer to as “the deadly yoga foot cramp” (news flash: no one has actually died from these inopportune and usually harmless cramps that anyone at YFHA is aware of, but, boy do they hurt!).

A foot cramp is a sudden and involuntary (you can say that again!) contraction of one or more of your muscles. In the case of the foot, it is most likely the smaller muscles that reside solely in the foot, called “intrinsic" muscles, but may also involve those that originate near the knee and end on one of the foot bones, called “extrinsic” muscles of the foot. Your average person may have experienced a sudden muscle cramp elsewhere in the body, quite commonly in the calf at night (Charlie horse), which can be very painful until the cramp subsides. If it weren’t for the pain and the muscle going offline temporarily, we wouldn’t likely even talk about muscle cramps. And, although when you are in the midst of a sudden foot cramp in class or at home, it seems like it may last forever, it usually resolves in seconds or minutes, especially if you come out of the pose you’re doing and do a little self-care to help things along.

Even though in many cases the exact cause of muscle cramps is not known, there are certain causes for having them more often. The National Institutes of Health (NIH) website has a pretty exhaustive list of possible causes:

• Brain disorders, such Parkinson’s, MS, Huntington’s Disease, to name a few
• Chronic kidney disease and dialysis
• Damage to a single nerve or multiple nerves that are connected to muscles
• Dehydration (not having enough fluids in your body)*
• Disorders or injuries that involve peripheral nerves
• Heavy exercise*
• Hyperventilation, which is rapid or deep breathing (can occur with anxiety or panic)*
• Increased levels of phosphate in the body
• Overuse of muscles during sports or work activity*
• Pregnancy, more often during the third trimester*
• Reduced levels of magnesium or calcium in the body*
• Thyroid disorders
• Too little vitamin D
• Certain medications*

* Indicates conditions that are easier for us yogis to evaluate or have checked out by our docs if foot cramps don’t gradually subside over time.

That list above does include some serious and somewhat scary possibilities, so if your foot cramps lead to any of the following conditions, you may want to have a more thorough evaluation with your physician:

• Cause severe discomfort
• Are associated with leg swelling, redness or skin changes
• Are associated with muscle weakness
• Happen frequently
• Don't improve with self-care
• Aren't associated with an obvious cause, such as strenuous exercise

(List from the Mayo Clinic.) 

Factors that may increase your risk of muscle cramps include:

• older age, when sarcopenia or muscle mass loss has set in and the remaining muscle may be more easily overstressed
• dehydration, which is both a cause and a risk factor, especially in athletes who become fatigued and dehydrated while participating in warm-weather sports
• pregnancy, when muscle cramps are more common
• medical conditions, such as diabetes, or nerve, liver or thyroid disorders

So, some common-sense actions may reduce the chances of continued problems with foot cramps during yoga practice, such as staying well hydrated, and stretching your muscles in sensitive areas before and after your yoga practice. But, hey! Wait a minute! Aren’t I already stretching my muscles simply by virtue of doing yoga poses? Well, a beginner might think such a thing, but experienced yogis know that many poses involve the contraction and strengthening of muscles to enter, maintain and exit a pose successfully. And, in some traditions, the poses are held for several minutes, probably enough time for a sensitive muscle to cramp and spasm. So, if you suffer from frequent foot cramps during your practice, you might want to develop a foot warm-up sequence to do before or/and after your regular class or home practice—more on that in a moment!

During an acute foot cramp, I have always found that coming out of the pose that is triggering it, and stretching and massaging the part of my foot that’s cramping seems to speed up the release of the cramp and my return to my practice. Medical sources suggest the use of ice or heat, but I always find that the foot cramps resolve long before I am able to get to anything like that, so that suggestion would be for the more unusual and persistent forms of cramping.

A few ideas for a foot warm-up sequence:

• Massage the foot by hand for a minute or so before activity.
• Sitting or standing, roll a tennis ball systematically between the sole of your foot and the floor to massage and release tension in the muscles of the foot.
• From a kneeling position, turn your toes under and sit back on your heels with your hands on the floor in front of your knees or on your thighs to stretch the soles of the feet, possibly even the plantar fascia as well.
• In Reclined Leg Stretch pose on your back, put the strap on the arch of the foot and rock it side to side to massage the muscles on the sole of the foot.
  
• Stand facing a wall and step one leg back into Warrior 1 position, bending the front knee toward wall and getting a good calf stretch for the back leg.
• When doing standing poses, imagine the toes relaxing and releasing away from the balls of the feet, instead of clawing the floor.
• And for our reader who is experiencing cramps in a more unusual location of his foot, poses that stretch the tops of the feet, such as, Hero pose (Virasana) and Thunderbolt pose (Vajrasana), or if it’s comfortable for you, Reclined Hero pose (Supta Virasana) might be helpful.

A final note from Nina, who finds that in Cobra if she activates her hamstrings, her feet don’t cramp! Thanks, Nina, and good to know! 

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New Tricks for Old Dogs: Working with Bunions (Rerun)

by Baxter

It was my first class with Donald Moyer in the new year, January having flown by and February upon us. I checked in with him before class began and mentioned an unusual aching in the lateral aspect of my left foot that I had been experiencing for about two months. It was not bad enough to prevent me from participating in my normal activities, but I noticed it when turning my left foot out to 90 degrees for many of my standing poses. He gave me some pointers for the day’s practice, and then class began.

About half way through the class, while we were in Standing Forward Bend (Uttanasana), Donald had us slip a strap between our big and second toes, and bring the loose end over the top of the big toe and down to the floor to the inside edge of the toe. He asked us to gently pull the strap to move the big toe medially, so that it lined up more evenly with the first metatarsal, the foot bone just before you get to the toe itself (the toe bones are called phalanges, and the big toe has two, the other toes all have three).

In addition to re-aligning these two parts of the foot and toe, the bones of the toe rolled a bit medially on their axis. Donald made an offhand remark about this being beneficial for treating bunions (hallux valgus for you Latin lovers) and then we moved on. But treating bunions! Sweeter words were never spoken. I come from a family of bunion formers, my mom’s mother, my wonderful Grandma Lopresto, had an impressive one on each foot for as long as I could remember. Interestingly, I don’t remember her complaining about them much.

What, you may be asking yourself, is a bunion? Well, a bunion is a condition in which your big toe deviates toward your second toe instead of lining up with your first metatarsal. And although bunions have a genetic component and do tend to run in families, another huge factor is shoes that smash the toes together. While these shoes are often for fashion purposes only, I do teach to one group of students whose shoe wear is all about function and their passion for climbing. And while the shoes these folks wear help keep them on razor thin ledges, they do lots of harm to their impressionable toes and feet.

According to the PubMed Health website, bunions occur more commonly in women and people born with abnormal bones in their feet. Certain kinds of shoe wear, specifically narrow-toed, high-heeled shoes, may also lead to bunion formation. And although it can seem a bit unsightly, it is only when pain develops that most people seek help.

How can you tell if you are developing a bunion? You may begin to see a thickening or actual bump forming where the toe and foot meet on the inner edge of the foot. On the inner side of the big toe, a red callous may form from the big toe and second toe rubbing on one another. Pain can occur in this joint, aggravated by certain shoes.

What is the mainstream treatment for bunions? First off, they often tell you to wear different shoes, ones with a low heel and a wide area for the toes. That alone could do the trick. Sometimes special pads can be placed on the bunion or between the big and second toes, and wearing a toe spacer at night can start to influence the alignment of the toes. If that does not work, there are only a mere 100 different surgical approaches to treat bunions. One of my long time students has had both toes operated on, and says it made a huge difference for her, eliminating the pain. However, it has had an effect on her balance.

So, here was Donald offering up a really simple way to affect the toes! A few years back, my colleague and friend JJ Gormley shared her favorite method to get the big toe back on track, which you can do at your desk. With your feet parallel, place a can of your favorite organic goodies between your inner arches and put a veggie rubber band, one of those strong ones, around the big part of your big toes, so they deviate a bit towards the midline between your feet. You can do this for 10-15 minutes a few times a day, and watch for results.

Obviously, if either Donald or JJ’s techniques result in worsening symptoms, stop them right away! But if not, give it a go. And remember, since a lot of the problem stems from being in shoes, yoga itself can go a long way to help the problem, as you are barefoot and you are strengthening and stretching many of the muscles and other structures that can affect the big toes.

For more information on yoga and bunions, there is a good article by Doug Keller in Yoga + Living Magazine from 2008 that you can find online. I hope the photos of Donald and JJ’s bunion recommendations are helpful in your home practice.

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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!

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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!

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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

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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.

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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

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