Assessing The Impact Of Emerging Fitness Trends On The Foot And Ankle

I recently interviewed a certified personal trainer regarding the impact of fitness, strength and training, and the relationship with podiatry. It was interesting to learn about the evolution of the world of fitness over the years. We know the importance and benefits of keeping our bodies fit, but I was interested in how this relates to our feet and perhaps the practice of podiatry.

Tracy Schy is a health and wellness professional, and a certified personal trainer (CPT). She is the founder of Local Sweat and JAL Fitness Consulting based in Northbrook, Ill. She is also certified by the National Academy of Sports Medicine (NASM) and the Athletics and Fitness Association of America (AFAA). 

Dr. Levick-Doane: What workout trends are you seeing today? How has the fitness world evolved?

Schy: Hybrid classes (strength and cardio together) or high intensity interval training (HIIT)-based training are the new norms of the fitness industry. One could include fusion classes that combine barre and yoga. Once the COVID-19 pandemic hit, the fitness world, like many companies, changed. For example, according to a recent article “Peloton saw 66 percent in sales increase in April alone. It ended the quarter with over 866,100 connected fitness subscribers in total – customers who bought either the bike or the treadmill – which marked a 94 percent increase from this time last year.”¹ Another example was Lululemon acquiring the Mirror.² The Mirror is another at home fitness-based technology. These are just two examples of many that demonstrate the shift to home fitness, an increase of personal training and small group outdoor training.

Dr. Levick-Doane: Part of my workout is to cycle but I am not too fond of the cycling shoes that come with the Peloton bike. I switched out the pedals for Shimano Pedaling Dynamics (SPD) clips. Shimano Pedaling Dynamics, also known as the SPD system, is a design of clipless bicycle pedals. In fact, several of my patients complain of stress injuries or metatarsalgia. Currently, I have seen one study that mentions cleats and hip pain, but there are no studies that I’m aware of on cleats and foot/ankle pain.

Schy: The Peloton cleats are Delta cleats, which are wider, made of plastic and are used primarily for indoor cycling. They are often used by beginners because the width makes it easy to clip into a pedal. The Delta clip sits out a full inch from the shoe. Most people must walk on their heels when using shoes with Delta clips, which can lead to slipping on wood floors. There are increased plantar pressures on the forefoot that could correlate to stress fractures or metatarsalgia.

A Shimano Pedaling Dynamics cleat is small, made of metal and primarily used outdoors. Most professional cyclists enjoy this cleat indoor as well. One places the cleat within the shoe near the ball of the foot so a cyclist can walk with a typical heel-to-toe gait. 

Toe cages are small frames that attach to the front of platform pedals and surround the toes. Cages are by far the most detrimental to the body. Cages can be standard on a new bike unless they are switched out by the buyer. Cages increase subtalar joint range of motion, remove ankle motion and risk hyperextension of the knee to compensate.

Dr. Levick-Doane: Many people have purchased treadmills during the pandemic as well. There are numerous models available. Can you speak about the differences and how that may impact our patients?

Schy: Treadmills, in general, are horrible for ankle dorsiflexion. The treadmill is moving for you. That means there is no strengthening of the ankle joint. In turn, it puts stress on the forefoot. I prefer having my clients run outdoors where they control heel strike to toe-off motion. If you do run indoors, I suggest running on an incline as it promotes a heel strike. A Woodway treadmill and a FreeMotion USA Reflex t11.3 treadmill (Orangetheory) also support this natural motion of the foot.

Dr. Levick-Doane: Plantar fasciitis is usually the result of the contracture of the posterior chain, including the calf and hamstrings. Additionally, metatarsalgia is a common issue also exacerbated by a tight posterior muscle group. Do you have any fitness tips to prevent this? 

Schy: Stretching before and after a workout is essential. Knots, or stress of a muscle usually due to stress, dehydration and improper nutrition, can be detrimental if one does not work on them after a workout. Knots prevent full lengthening of the muscle and weaken the muscle.³ They cause muscles to become shorter and contracted, instead of long and lean. Unfortunately, many physical therapists focus on “knots” solely on the gastrocnemius and soleus. Hamstrings and hip flexors are equally important to stretch. These ligaments and muscles are deep. Proper massage and manual manipulation can rid the body of knots.

I like using a foam roller with knobs and rolling it over the hamstrings and iliotibial band. It is like rolling out cookie dough. Hold the roller for more than 20 seconds for fascial release. The Theragun is a new percussive massage device that also improves fascial release. The key is to have a long lean muscle tone, which will create a more extended lever arm and reduce injury. 

Dr. Levick-Doane: Strengthening the intrinsic muscles in the foot can help with balance and stabilization, especially in the elderly population.⁴ What kind of exercises do you suggest? 

Schy: First, form is critical. We then work on balance. People learn to place appropriate weight on foot (ball and heel). That is why I like to train barefoot or in minimalist shoes because it forces proper distribution. Once we perfect balance and form, we add resistance or weights. 

When we age, balance becomes an issue for many people. Helpful exercises include: Russian dead lifts (RDLs), single-leg Russian dead lifts, squats and lunges on a BOSU ball (a BOSU ball consists of an inflated rubber hemisphere attached to a rigid platform). People often use the BOSU ball for balance training and yoga balance poses including: the tree pose, warrior 3 pose and half-moon pose. 

In the elderly population, the focus should include more attention on the muscles and tendons crossing joints. It is imperative to integrate these exercises into the area where there are bone density issues. For instance, allow the person to lay on his or her back and lift his or her hips. Alternately, have the patient stand with one foot on the ground and toe touch in front, to the side and back. Simple as this may seem, it is not easy for the elderly.

Dr. Levick-Doane: Physical fitness is an essential component of diabetes management, which slows the development of peripheral neuropathy. However, because of impaired sensation, a person with diabetic peripheral neuropathy is at risk for developing infected foot ulcers when exercising.⁵ These infections can eventually lead to lower extremity amputation. Can you talk about your work with individuals with diabetes and the progress you have seen?

Schy: High-intensity training (HIT) is critical for people with diabetes. Interval-based cardio and strength training will get the heart rate elevated quickly. This, in turn, helps someone who is overweight and has diabetes lose weight. Since one's metabolism can spike 48 hours after a workout, cardio and strength training are ideal. Swimming, biking and Pilates on a Pilates reformer platform are all exercises that avoid friction on the foot, which is preferable for people suffering from peripheral neuropathy.

Dr. Levick-Doane: Since we work collaboratively with physical therapists, I am curious as to your thoughts about the work they do.

Schy: Certainly, physical therapy is an integral part of the patient’s treatment plan. Physical therapy is the second step of the healing process after they see you. The third step is the inclusion of appropriate exercises and this is where I come in. After an ankle fracture, for example, a person is often put into a CAM boot. This can cause issues with shoulder drop, knee hyperextension, glute weakness and hip pain. Unfortunately, some physical therapists only teach the person how to strengthen or gain range of motion in the ankle and lower leg, thereby neglecting how to strengthen the other aforementioned areas. In the end, you have overdeveloped the weak muscles and ignored the strong ones. This, sadly, can lead to imbalance issues. 

A better approach is Pilates and strength training. Pilates is rehabilitating. The cables that connect to the Pilates reformer platform provide resistance to more than one muscle at a time. They not only increase joint range of motion but strengthen the ligaments and tendons. The more cables, the more resistance is induced. It provides long, lean muscle tone. Patients can rehab faster and safer in a more controlled setting. The exercises are designed to increase muscle strength, endurance and flexibility, and improve posture and balance as well.⁶ Intrinsic tone, which is lost during rehab, can increase in this setting.  

Dr. Levick-Doane: There is a strong link between physical fitness and one’s overall health. Where do you see it in the next five to 10 years?

Schy: It is all about wellness. Corporations are offering wellness programs and compensate employees for taking part in the program. This benefits not only the employee but the organization as well. A healthy and happy employee is a long-term employee.⁷ Social programs promoting health, safety, and wellness can improve overall morale and reputation.⁸  

A program that includes physical fitness, a long-term nutritional plan and mental wellness is the ideal approach.  

Dr. Levick-Doane is a Diplomate of the American Board of Foot and Ankle Surgery and the American Board of Podiatric Medicine. She is a foot and ankle surgeon at Kipferl Foot and Ankle Centers in Des Plaines, Fox River Grove and Algonquin, Ill. Dr. Levick-Doane is also an affiliate attending for the RUSH podiatric residency program in Chicago. 

References 

1. Hanbury M. Peloton reports 66% increase in sales as coronavirus keeps consumers working out at home. Business Insider. Available at: https://www.businessinsider.com/peloton-sales-surge-coronavirus-keeps-consumers-working-out-at-home-2020-5 . Published May 7, 2020. Accessed August 26, 2020.
2. Maheshwari S. Lululemon to buy Mirror, a fitness start-up for $500 million. The New York Times. Available at: https://www.nytimes.com/2020/06/29/business/lululemon-buys-mirror.html . Published June 29, 2020. Accessed August 26, 2020.
3. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439–444. 
4. Short-foot exercise promotes quantitative somatosensory function in ankle instability: a randomized controlled trial. Med Sci Monit. 2019;25:618–626.  
5. Ward SA. Diabetes, exercise, and foot care: minimizing risks in patients who have neuropathy. Phys Sportsmed. 2005;33(8):33-38.
6. Kloubec J. Pilates: how does it work and who needs it? Muscles Ligaments Tendons J. 2011;1(2):61–66.
7. Healthy Employees. American Mental Wellness Association. Available at: https://www.americanmentalwellness.org/prevention/healthy-employees/#:~:text=Studies%20have%20shown%20that%20happier,obvious%3A%20focus%20on%20employee%20health. Accessed August 26, 2020.
8. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes. JAMA. 2019;321:1491-1501.