Chronic pain is a huge problem globally, in Australia alone, 3.2 million people suffer from chronic pain. But what is a holistic view of pain and is the pain in your shoulders connected to your feet? Podiatrist Mark Ninio joins me to discuss these connections and also define what is normal foot function.
Dr. Ron Ehrlich: Hello and welcome to Unstress. I’m Dr. Ron Ehrlich. Now people don’t give much thought to their feet, that’s not entirely true. If something does go wrong say you stub your toe or you twist your ankle, you very quickly become aware of how important being mobile without having to think too much about every step is. There’s a lot more to your feet than you may have thought about. My guest today is one of Australia’s leading podiatrists Mark Ninio. As you’ll hear, there are some surprising connections between podiatry, how your feet hit the ground and so much more. Mark and I have known each other for many years. We worked very closely with a rather enlightened chiropractor in Sydney almost 30 years ago. The chiropractor realized that in order to get stability in his patients that meant he didn’t really want to have them coming back every month or two or three for an adjustment as they went out of balance whether that was for chronic upper body problems such as tension headaches, neck aches or shoulder pain or whether it was lower back pain or hip or knee problems, recurring problems, he needed to work with a dentist to stabilize the jaw joints and he needed to work with a podiatrist to look at foot function.
Now for many years Mark and I saw the same patients. We noticed that we were affecting each others’ work. We ended up, because of this interest, doing five years of research together. It was one day a week but it went on for five years and it was at the University of New South Wales in the Physiology department. We ended up publishing papers along the way. We learned a lot about each others’ work. I realized there were many similarities between the two professions, dentistry and podiatry, yeah, talk about holistic. It’s also worth mentioning that chronic pain is a huge problem globally. I mean in Australia alone, 3.2 million people suffer from chronic pain and it’s a subject that I’m going to be exploring a lot more in this podcast series. Many of those patients have chronic musculoskeletal pain, headaches, neck aches, upper or lower back pain or a combination of the above. It’s a very complex problem. I believe this is one part of the puzzle that we’re going to be dealing with today but it’s one that’s often overlooked. Whether you’re a pain sufferer or your foot structure affects you in some ways, whether you’re a pain sufferer or not, whether you like it or not, your foot structure affects you in some ways. I think you’re going to find this very interesting. I hope you enjoy my conversation with Mark Ninio. Welcome to the show Mark.
Mark Ninio: Thanks Ron.
Dr. Ron Ehrlich: Mark, now you and I have known each other for a very long time and we’ve worked together for a long time. One of the things we’ve reflected on is that there are surprising similarities between dentistry and podiatry mainly because dentistry is usually … most people associate it with teeth and gums and podiatry with corns and bunions but there’s a whole lot more to that, podiatry and there is. Tell us a little bit about the other aspect of podiatry that people may not be aware of.
Mark Ninio: I think one of the most exciting aspects of podiatry is when we look at posture. When we talk about upper body posture we’ve got to consider the feet and the legs. The feet are your foundations and if your foundations are uneven or imbalanced, then further up the chain you’ve got to compensate. It’s these compensations combined with many other inputs that eventually lead to poor function and pain. If I can give you some understanding on that to understand a bit better, an example is let’s say your pronating, pronation, which is the feet rolling in and the arches collapsing and it creates internal leg rotation or the legs twisting inwards, this leads to an anterior pelvic tilt or the bottom sticking out. Straight away, you’ve got more pressure in the lower lumbar section.
Dr. Ron Ehrlich: In the lower back.
Mark Ninio: In the lower back. With time the shoulders may compensate by dropping back the head goes forward. We see this is a lot of lower back pain and neck tension patients. Anything that helps tuck the bottom in, will give them more upright posture whether it involves core stability, posture awareness or reducing this pronation.
Dr. Ron Ehrlich: Mark, you get a lot of referrals I assume, I know you do, I don’t have to assume, you get a lot of referrals from chiros and osteos who are aware of this structure. A lot of people are seeing these kinds of practitioners, which I think is a great place to start, I think we’ve talked about that. If there’s a problem, manual therapists, whatever description is a great place to start. When you’re continuously going back every month or two for a readjustment, this is what you’re talking about, this foot structure dropping in.
Mark Ninio: This foot structure correct. Then there’s some more to it where we might have pronation on one side. The foot is rolling in more on one side than the other and that lowers the foot to the ground. Suddenly we’ve got the pelvis dropping down on one side and again leading to dysfunction and upper body pain. It’s worth noting that even though the feet are not painful when this is occurring, it’s creating problems further up the chain.
Dr. Ron Ehrlich: Yeah well this is this whole story about the difference between chronic pain and acute pain. Acute pain is if you’ve got a whack in the shoulder that shoulder is going to be sore for a period of weeks maybe and then slowly that pain may settle but chronic pain is different. If you’ve got a backache, the problem may not be just the back, there may be other problems. Similarly, headache people think headaches are related to their head but it could be their neck or their shoulders.
Mark Ninio: Correct.
Dr. Ron Ehrlich: This is again, this is this holistic view that we’re trying to promote.
Mark Ninio: This is a holistic view.
Dr. Ron Ehrlich: Let’s go on.
Mark Ninio: It is. Then it gets quite interesting because we talk about limb length. I think limb length is really poorly understood.
Dr. Ron Ehrlich: Yes. Now hang on, this means leg length, length of the legs different.
Mark Ninio: Correct.
Dr. Ron Ehrlich: I know this because we’ve talked about this a lot.
Mark Ninio: We have.
Dr. Ron Ehrlich: There’s two different ways of looking at a leg length difference, give it to us.
Mark Ninio: There are, there are two types of limb length differences, the first is well they’re functional and they’re anatomical. If we talk about what functional is, it’s where the pelvis is down on one side, it’s due to either the foot pronating more on one side or a knee flex position on one side or muscle tightness around the pelvis on one side just to give you a few examples.
Dr. Ron Ehrlich: This is often when people are sitting or lying on a table and the practitioner looks at the leg difference, taps the two legs together and says, “Oh this leg is shorter than that leg” and then they do an adjustment and then they tap them together again and they go, “Yeah now we’ve balanced that out”, that is a functional-
Mark Ninio: That is the functional short leg.
Dr. Ron Ehrlich: But there is a difference.
Mark Ninio: There is a difference because there’s an anatomical short leg. The pelvis is dropping down on the same side just like the functional one however one leg measures a different length to the other leg. In this case, you require precise measurements of the femur and the tibia, then we manage that quite differently. We manage that with heel lifts of chair raises as opposed to constantly looking for other sources outside of the limb lengths.
Dr. Ron Ehrlich: Now when we get onto this putting aside the functional, which responds to all of those things, supporting the feet, relaxing the muscles and all of that, putting that aside, how do we determine an anatomical leg length difference? It’s not tapping the feet together, isn’t it?
Mark Ninio: It’s not tapping the feet. Over the years, I’ve found the best way is to actually take a scan of the legs. Now I’m using an EOS, which is a standing scan where the computer takes a picture of the femur and the tibia and then it measures it. We’re actually given an exact measurement of the femoral-
Dr. Ron Ehrlich: Is that a radiation thing?
Mark Ninio: It’s very low dose.
Dr. Ron Ehrlich: Very low. I remember years ago when we started working together, which I must say is almost 30 years ago, that was a CAT scan in those days.
Mark Ninio: It was a CAT scan. CAT scan is non-weight bearing, still giving a beautiful picture, this is a weight-bearing shot.
Dr. Ron Ehrlich: Okay, okay. The other thing is you talk to some people particularly say orthopedic surgeons who say, “Look anything less than 10 millimeters is not significant”. A difference between say left and right, less than 10 millimeters not really significant. Is that your view of-
Mark Ninio: No not at all. I think there may be a few reasons why that’s the case. Historically, they would take a tape measure and measure the limb lengths. To take a tape measure and measure three or four millimeters of difference from one side to another is very difficult. I can’t do it myself. You’re measuring bone that’s covered with skin. It’s very, very hard to get the landmarks. I believe that in a patient that has pain, let’s say a headache, neck pain, three or four millimeters could be significant. In a patient with no pain, then that could be a non-issue, a total non-issue.
Dr. Ron Ehrlich: Yeah because again this is you talking about chronic pain so people with chronic backaches, that’s a pretty big problem in our society, I mean it costs literally billions of dollars. I think I saw a statistic that over three million people in Australia suffer from chronic pain at any one time, which is pretty enormous. People with chronic pain who are being frustrated with their healing and are going for practitioners finding not a lot of help or the help is transient, only last for a few days or even weeks, this leg length difference of up to three millimeters can make a difference.
Mark Ninio: It can make a difference. I actually don’t believe it does make a difference in the fact that you are physically moving the part up two or three millimeters because you can have variations in sock thickness and shoes worn a bit on one side. I believe that it’s affecting more than nerve pathways, the afferent, efferent nerve pathways we’re getting a change in function and that’s how it appears to work on the lower measurements.
Dr. Ron Ehrlich: It’s almost like when you’re in chronic pain, there are those nerve pathways that are established as chronic pain patent and muscles compensate accordingly so by lifting or altering foot structure, you’re changing that whole dynamic and letting it hopefully relax and reduce the pain. Great, so we’ve got functional leg length difference, which we’ve talked about and we’ve got anatomical leg length difference-
Mark Ninio: Then it’s worth noting Ron, I probably see most of my patients with a combination of functional and anatomical.
Dr. Ron Ehrlich: Yeah, yeah, yeah, yeah. We’ve got pronation with the foot dropping in and it could be either one side or both sides and we’ve got functional leg length differences and anatomical leg length differences, what else can go wrong?
Mark Ninio: I think it’s probably important to understand what foot function is.
Dr. Ron Ehrlich: Yes let’s talk about what’s normal.
Mark Ninio: There are 26 bones in the foot, 28 if you include the tibia and fibula, which help to make up the ankle joint, that’s a quarter of the human body’s bones are found in the foot. There are 33 joints and more than 100 muscles, tendons and ligaments in the foot so it’s quite complex. As podiatrists, we’re usually focused on a few joints in the foot, we’re focused on the subtalar joint, which is supination and pronation.
Dr. Ron Ehrlich: Well hang on the subtalar joint is around the ankle.
Mark Ninio: It’s just underneath the ankle correct, just underneath the ankle joint, we’re focused on the metatarsal joint, which has two axes and this is in the midfoot and on the first metatarsophalangeal joint or the big toe joint.
Dr. Ron Ehrlich: Okay thank you. I think you almost lost me there. You’re either talking about the back of the foot, the middle of the foot or the front-
Mark Ninio: The front of the foot exactly. This first metatarsophalangeal joint requires a certain amount of bend or dorsiflexion so we can push off. The feet remember are the first part of the body to make ground contact. If the foot is not working well, it creates an effect for other parts of the body to start compensating, it leads to dysfunction and ultimately pain. We require the foot to do a few things, Ron. We require it to absorb shock at heel contact, we require that then to unlock the front of the foot so it can adapt to differences in terrain, we need a mobile adaptor and then we need the foot to lock up for propulsion. We need it to be a nice rigid lever as opposed to a loose bag of bones, so that’s what’s going on through yeah-
Dr. Ron Ehrlich: What is involved in a podiatric assessment? I mean what are you looking … you get people on a treadmill and then-
Mark Ninio: Yeah, what we do with a podiatric assessment is we go through a range of motion and quality of motion of certain joints of the foot. I’ll do a visual of limb length and if I’m concerned, I’ll definitely send people off for an EOS scan.
Dr. Ron Ehrlich: That is measuring those limb lengths.
Mark Ninio: Measuring the length yeah. I want to know what the strength is like in the feet and certain muscle groups. I want to see what the ranges of motion are like in the knee joint, in the hip joint, and then I’ll get them to stand up. I want to observe them the feet pronating. Is one foot pronating more than the other? Are the hips level? Are the shoulders down? Is the head tilted to one side? I’ll get them to stand on the side and see if the head is forward. Do they have an increased lumbar lordosis? Is there an obvious scoliosis present?
Dr. Ron Ehrlich: That is the twisting of the spine.
Mark Ninio: That’s the twisting of the spine. I’m doing an observation. Before I do that though, I’ve asked them quite detailed questions. I want to know what their medical history is, if they’ve had any major operations, illnesses, diseases, broken bones in the legs or the feet, if they’re on medications? Was there a trigger to their symptoms? Where are they getting pain? Have they moved house? Have they gone onto from softer floors to hard floors? Did they start a get fit campaign? There’s usually triggers involved with my patients that are presenting their pains. Then I’ll have a look at their gait. I’ll watch them walking. I’ll get them to walk up and down quite a few times, eventually placing them on a treadmill, videoing them and then I’ll go back with the patient with the film that I’ve captured and shown them what’s going wrong and what we need to do.
Dr. Ron Ehrlich: When people have had an accident or a fall or some kind of trauma, how far back do you think you need to go for it to be significant?
Mark Ninio: Quite far back actually. We want to know what the birth was like.
Dr. Ron Ehrlich: Wow okay. Really, okay.
Mark Ninio: We would like to know was it a normal birth, was there forceps? We’d like to know what age they were when they started walking. We’d like to get as much information as we can. Major accidents, that can make a big, big difference.
Dr. Ron Ehrlich: At any age?
Mark Ninio: At any age. Major diseases can make a big difference. I mean you want to get as much information as you can to get a good diagnosis.
Dr. Ron Ehrlich: Yeah. Now, what can we do about it? You’ve got a foot that’s dropping in or a foot that’s rolling out or a leg length difference anatomical as people know compared to functional. What are some of the solutions?
Mark Ninio: Well we have a variety of options, which is great. Sometimes it’s a matter of observing their footwear and changing their shoes, a more appropriate shoe, sometimes it’s changing their program. If they’re into fitness or a get fit campaign, mixing it up, seeing what they’re doing incorrectly. Looking at their posture, if they’ve got a short leg, we’ll put in a raise. We’ll start to change the way the pelvis functions. If they have pronation on one side or bilateral pronation, we’ll use prescription orthotics. Prescription orthotics are inserts made from molds of peoples’ feet in a corrected position. They work very, very well so we’ll use that. We use laser treatments on joints and on soft tissue lesions, mobilization of the feet, we’ve got a wide variety of treatments available.
Dr. Ron Ehrlich: When you’ve having an orthotic, ’cause there are different kinds, there’s off the shelf orthotics and as you say custom-made orthotics, I know in the dental field, there’s a very big difference between those two but sometimes those off the shelf ones are just enough to get people out of pain?
Mark Ninio: Yes they are. They’ll get people out of pain but they might not be enough to get them out of dysfunction. What we use off the shelf, they are very useful but they don’t do as good a job as a prescription device.
Dr. Ron Ehrlich: With those prescription devices ’cause you take the mold of the foot … I mean I’ve had this done with you I know, how long should you keep wearing a prescription device?
Mark Ninio: That’s a very good question. It’s a bit of a gray area. We need to decide whether we are trying to prevent something from occurring or if we’re only treating symptomatically. I tend to be a little bit relaxed with my patients in so that they can wear orthotics until they get rid of their pain and then they can wear them some of the time but they don’t need to wear them all of the time. The more they wear them usually the better foot function they’ll have.
Dr. Ron Ehrlich: We’ve covered a lot of territory there, it’s been amazing. I mean I mentioned you in my book of course ’cause you and I have done research together. We were working together at New South Uni for many years and we learned a lot about podiatry and you learned a lot about dentistry. I don’t think I’ve ever met a podiatrist who could identify a jaw joint problem better than you. I ask one question I always ask my guests is, “What do you think the greatest challenge is for people on their health journey in today’s world in the modern world? What do you think the biggest challenge is”?
Mark Ninio: Choice. I think that it’s complicated. I think you walk into a running shoe store and you are bombarded with so much choice. You don’t know what is right for you. I think that there are a lot of devices out there let’s say for orthotics et cetera that have many claims but they don’t step up to the mark. I know a lot of my patients get quite confused, they google things, they come to me thinking they’ve got the worst of something where they’re really not bad at all or they’re quite confused by what they should be doing and they need a bit clearer direction.
Dr. Ron Ehrlich: Yeah, that’s true. I go into … I don’t know CrossFit, am I cross train? Am I free? Nike, I’m not doing ads here but the free all this, how do I navigate through that? What are some guiding principles? How would an ordinary punter navigate their way through the sales pitch?
Mark Ninio: That is the biggest challenge. It’d be really good if you know what foot type you are. If you don’t then hopefully one of the shoe fitters will assess you by at least looking at the way you’re walking and have an idea of what foot type you are and therefore what shoe you should be guided towards. Also, they need to know what the shoe is for. A running shoe is quite different from a cross-training shoe. A good shoe fitter will guide you correctly.
Dr. Ron Ehrlich: When you say foot type you mean are you a pronator, are you rolling in, rolling out?
Mark Ninio: Rolling out exactly.
Dr. Ron Ehrlich: They should be looking at the biomechanics.
Mark Ninio: They should be looking at that.
Dr. Ron Ehrlich: Then from that say, “That shoe is not as good for you as this shoe”.
Mark Ninio: Correct because shoes are quite specific to foot types nowadays.
Dr. Ron Ehrlich: As a runner versus a cross fitter versus … should the runner have more flexibility in the shoe? Is it more flexible or more support? What should it be?
Mark Ninio: No.
Dr. Ron Ehrlich: Barefoot has become very popular.
Mark Ninio: Barefoot was very popular but it’s become a lot less popular now. As a runner, a running shoe is a mono-directional shoe, it’s activity in one direction only whereas basketball or tennis is multidirectional, you’re twisting and turning. A running shoe is made for that one direction, less weight usually, less stability in the front because we don’t need the twisting action as opposed to a tennis shoe or a basketball shoe, which requires a lot of twisting, a lot more stable, the sole is quite different as well, the sole contour.
Dr. Ron Ehrlich: What about CrossFit? That’s multidirectional too I guess.
Mark Ninio: Crossfit is multidirectional.
Dr. Ron Ehrlich: But not to the same degree as tennis or basketball?
Mark Ninio: Different surfaces but there’s definitely a requirement in the shoe especially if you’re twisting and turning that would be present in a tennis shoe or a cross trainer as well.
Dr. Ron Ehrlich: We mentioned barefoot being very popular in those Vibram where you slip your feet into all those do toes … I’ve got a pair of those too, they reminded me of being a hobbit. What was the story there? Was that a good thing you think from a podiatry biomechanical point of view? What do you think of those?
Mark Ninio: I think what podiatrists learned, we definitely learned something from this and that was it’s important to cross train the foot. We shouldn’t just be stuck in a pair of shoes, a pair of orthotics, we need to get different inputs coming into the foot. A little bit of walking barefoot is good, a little bit of walking on the grass, a bit of walking on the sand, walking in shoes, mixing it up is good. I’m not suggesting that somebody that has a lot of pronation that needs correction should go for a long walk bare feet because they’ll come back with a lot of issues, a lot of problems and won’t be happy. To get different inputs is an important thing. It follows work by Beno Nigg, who is somebody I like reading-
Dr. Ron Ehrlich: That’s Ben-
Mark Ninio: Beno, B-E-N-O, and then Nigg, N-I-G-G-
Dr. Ron Ehrlich: Nigg okay.
Mark Ninio: Yeah and he believes that the purpose of let’s say orthotics is to improve the energy, improve muscle function but get comfort and get a complex that’s functioning a lot better.
Dr. Ron Ehrlich: Here’s a little bit of a question left of center and that is reflexology. People love the idea of body being connected and here you can look at a map of a foot. I know we’ve got it in the mouth too, we’ve got a map of different organs connected to different teeth, what are your thoughts on that?
Mark Ninio: I used to actually lecture to the School of Reflexology Ron in biomechanics, at least allowing them to understand what some of the biomechanical principles of the feet were. I think there’s something there. I believe also that meridians exist in the whole body as acupuncturists use constantly so why shouldn’t meridians exist in the foot? I don’t want to base my diagnosis on those meridians or purely my treatment plan but I believe that there is something going on there.
Dr. Ron Ehrlich: I’m similarly in dental … I mean I’ve been in practice for almost 40 years and I still find it fascinating but I don’t build my whole practice on it. Mark, in terms of foot function, what else can go wrong?
Mark Ninio: Ron like any correction, we need to have good quality of motion and good range of motions in the joints. If we try with too much correction and the joints won’t allow you to make that correction, you create pain and sometimes more than what they started with. If you’ve ruled out any major diseases, significant arthritis, then you should be okay, but there are some traps. For example, medial meniscal pain, which is medial knee joint pain as opposed to something else called patella femoral pain-
Dr. Ron Ehrlich: Hang on, patella fem … Let’s define … just point, not point, visualize those two different pains, one is in the front of the knee-
Mark Ninio: Well no, both are on the side of the knee.
Dr. Ron Ehrlich: Both are on the side of the knee.
Mark Ninio: If you’ve got pain on the side of the knee, you could have either, well you usually would have patella femoral pain but you could have medial knee joint pain or meniscal pain or cartilage, medial cartilage pain, that requires lateral wedging regardless of what the foot is doing. You may have a foot that is pronating or rolling in and instinctively what you want to do is to stop the foot from rolling in. If you do that, you’ll actually close the medial knee joint and create more pain. What you need to do is actually pronate the foot more so and this creates what’s called internal rotation of the leg and in turn, it helps open up the medial knee joint space. It’s really important to get a good assessment, ask a lot of questions and look holistically at the body never just look at the feet and stop there.
Dr. Ron Ehrlich: That’s good. What about when people have hip replacements or knee replacements? I mean that’s got to change your gait pretty dramatically, doesn’t it? What are your thoughts on knee and hip replacements and how people should approach those?
Mark Ninio: We see a lot of hip replacements, a lot more than knee replacements. Typically, they give the patient a better quality of life but they can leave the patient with a short leg. It’s really important to see post hip joint surgery if the patient is limping and if they continue to limp and if so, we should be looking straight away at the length of the bone and then making some adjustments.
Dr. Ron Ehrlich: Okay so that’s good because I mean a lot of people are having hip replacements. They usually have it because they’ve been in a lot of pain and then they have the hip replacement and they get out of pain for a period of weeks or months or maybe even a year or two and then if that imbalance persists, then a back problem could-
Mark Ninio: Exactly. The hip would be fine and they probably won’t have any more pain in the hip but they’ll have pains elsewhere in the body.
Dr. Ron Ehrlich: Compensation.
Mark Ninio: This is what we were talking about in the beginning about the difference between chronic pain and acute pain.
Dr. Ron Ehrlich: Yeah, yeah, yeah, okay. I mean I think from my experience talking to people, hip replacements have seemed to be far more straightforward and successful than knee replacements, is that your experience?
Mark Ninio: Yes, yes, I believe that’s the case.
Dr. Ron Ehrlich: Okay, Mark that was terrific, thank you so much for joining us. We’ll have links to your web page.
Mark Ninio: Thank you.
Dr. Ron Ehrlich: Look forward to speaking to you again.
Mark Ninio: Thank you very much, Ron.
Dr. Ron Ehrlich: Something you may have missed when I asked Mark how far back in the history taking of the patient, he believes trauma is significant. He said, “Any trauma may be significant”. That is a really important point that is often overlooked in what is often a really frustrating chronic muscular skeletal pain problem. People are often in pain and they often have x-rays taken and MRIs and they’re told things, “It’s not a problem” and they have to learn to live with it. I don’t believe they do. You see, soft tissue, now that means anything that’s not bone, it means muscles, tendons, ligaments, joint capsules, all the actual attachment of the muscle to the bone has memory. That memory can last a lifetime. That memory is often associated with chronic inflammation at a microscopic level. If you tear or damage any of those soft structures, they may never heal and you may still be in chronic pain. This was really important. These are some of the similarities between dentistry and podiatry and that are that biomechanics of both are often overlooked. When both are addressed and they’re supported, they can actually facilitate healing of these soft tissue problems and a reduction or even dare I say an elimination of chronic pain that has gone on for years.
Look, there are other things that can help too and we’re going to talk about those in the upcoming podcast, a low inflammatory diet, meditation, manual therapies, chiro, osteo, physio, massage therapy, acupuncture, a lot, a lot of other stuff. This is one part of that puzzle. That was quite a lot to digest but basically, the way your feet hit the ground and then take off whether your foot rolls in or out as you do that and the difference between actual leg length differences can be a significant part of a problem. It can affect your posture, it can affect chronic pain. I hope you enjoyed this week’s episode. Until next week, this is Dr. Ron Ehrlich, be well.
This podcast provides general information and discussion about medicine, health and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.