 Produced from theCUBE Studios, this is Strong by Science. In-depth conversations about science-based training, sports performance, and all things health and wellness. Here's your host, Max Schmarzo. All right, what's up, guys? I got Dr. Mohamed Ramari here with me today. He is a bore-qualified foot and ankle surgeon, an expert on all things when it comes to foot. I'm really excited about this podcast. Him and I have spoke off here a couple of times, and honestly, I have to tell him, you know, hold it right now. I want to hear on the podcast because some of the stuff is just gold. Dr. Mohamed, thank you for being here. Really appreciate you coming on. Thank you for that introduction. I'm really excited. You know, I've seen a bunch of you guys' stuff, and I really, really think your audience is going to benefit from what we're going to talk about today. So I'm glad you just gave me a platform to present it on. Oh, it's awesome, guys. So if you guys listen and get your notepads out, because I had my notepad out earlier, we're before air on here, and Dr. Mohamed's rallying off a whole bunch of stuff, and my mind's already racing with about 2,000 questions. So we'll try to keep this really excited. It's a really good podcast. I'm pretty adduced about it. So, Dr. Mohamed, we're talking about the foot. Right. People talk about the foot a lot, and we, unfortunately, in simplistic terms, I guess the most painful version is we go to Walgreens and we stand on a little pad that tells us everything we need to know about our foot, and obviously our foot is a little more complex than that. We don't mind, could you dive into some of the details of the foot lower extremity and ankle complex, why it's important for our health, what specifically is it comprised of, and then we can dive into some of the details after? That's great. I love to start off this convo with a quick statement by DaVinci, right? DaVinci once said that the human foot is a masterpiece of engineering and a work of art. Now, DaVinci wasn't some creep who was just fascinated with the feet. He was ahead of his time when he said this quote. Now, we're gonna break down just the foot alone. So the foot is compromised of nine compartments. Each compartment has its own blood vessels, muscles, bones. From nine compartments, we have 33 joints in each foot, period. After that, we're gonna take it into 26 bones in each foot. Combine both feet, have a quarter of the body's skeletal system right at the level of your foot and ankle. And then we ask our feet many different things that form every day. So the average American takes anywhere from five to 10,000 steps. We're not even including the hit training, fanatics, crossfit, runners and what now. We're just talking about your average day person, go to from work, to the store, shopping, whatever it may be. That equates to 110,000 miles in your lifetime. So you can imagine the ground and pound your foot takes just as an average person. And then the things we demand of our foot and ankle are kind of out of the ordinary. So if you're a runner or a wide receiver, we expect our foot and ankle to be able to make cuts and move as fast as we demand it to move. If you're a ballet dancer, you wanna be as precise as possible when they get on their tippy toes and get on point. If you're an MMA or a karate instructor, you're asking your foot to be strong enough to break through wood or concrete. And one has to be marvel at the idea that the foot can have all these different functions from precision to mobility to strength. And the reality of the matter is this is all possible because of the human structure and the anatomy of the foot. And we, as just normal day-to-day humans have to make sure to take care of that because when this is disrupted, it's a slippery slope into an array of problems. And anybody who's ever had a foot and ankle injury will tell you, honestly, I finished rehab, I'm recovered, but I'm never the same. So my whole spuel is let's get to that point where you never have to go through that route. And if you look at people who really take care of their body and these athletes, we're talking about a full workup and the foot and ankle is a crucial point in that. And we'll talk about sports injuries and how nearly half of all sports injuries are in the foot and ankle, from minor to severe. So you're thinking about people love to talk about shoulders, Tommy John surgery, whatever it may be. Look no further, the foot and ankle is the foundation of stability. It's the initiation of the kinetic chain. You wanna begin a movement, you're gonna start with the foot and ankle. And we all know you're only as strong as your weakest link, right? So you wanna make sure you're top notch from head to toe, no pun intended, you know? Yeah, go ahead, go ahead. I totally agree. I couldn't agree more. I love it, yeah. Yeah, and there's so much to talk about for your audience because I know they wanna be, you know, the optimal and the best from top to bottom, like we talked about. So my indulgement came in from experience. Everybody, it's a cliche story for people in the healthcare profession, but I played three sports growing up. Basketball was my favorite one. And I sprained my ankle numerous times and thought nothing of it. You know, when you're growing up, sprained ankle is just the norm, right? You tighten up your sneakers, you wear high tops and you call it a day. You get back on the court same day, if not the next day. Until once I sprained my ankle so severely that it never got better. Come to find out, I ruptured a very important ligament in the ankle and I'll be honest with you, I've never been the same. Since 17 years old to now 29, I play in red leagues and I play in seasons and I'm just, people are like, I'm that old guy that says, you know, I used to be nice and they go, wow, really? They must have been really bad back in the day. You know, so it really touches home when I see an athlete come into my practice and kind of not take this seriously because I could kind of foresee what's gonna happen if you just neglect these things. So what I wanna preach today is, you know, preventative medicine is the best medicine and prevention is better than the cure. You know, you could do so much as a clinician, but the best thing we can offer is expertise on how to make sure you never get to that point. There are some things that are unavoidable, but for the things that are, I hope to address them in your podcast today. No, I love it. I couldn't agree more and that basketball example it rings home with me. I played in a small D3 hoops in college. In high school, I had a really severe left ankle sprain and to this day, it must be a 15 to 20% difference in dorsiflexion, so how far my ankle's moving. And it affects me in so many different ways and not to be on a rant, right? If we're talking about the foot, well, if we're doing a closed chain activities, it's gonna start at the foot, right? If I'm squatting and I don't have ankle dorsiflexion, well, what do you think the motion's coming from? My hips, my low back, my T-spine, something has to compensate for my inability to move. So I work at a really a facility, I'm biased, I love it. And we have, it's a treadmill that is about 20,000 microsensors on it. And so when we talk to our clients, we get to see every foot contact, the timing from the fifth to the first metatarsal. And I found it to be one of the most useful screening tools for anybody because you can't hide an injury in your footprint. I had to tell people, right, it's the first thing that hits the ground and interacts with it and it's the last thing to interact with the ground. And so it's almost like the fingerprint of your movement signature. As a person, what our body is doing really reveals itself and how our heel hits the ground or we get into our big toe to actually get the push off. Is our foot functioning the way it should be? Now you talked about the foot has to function about precision, but also in strength and mobility and it has all these different demands that maybe other parts of our body don't have because of the complex nature of the foot itself. When we're talking about that, how do you address that, you know, the complexity of it in nature and how as an athlete, someone who maybe is looking to optimize my health, starting with my feet, might wanna seek out some advice or how do I address it myself? Absolutely, that's a great question. I'm glad you guys have those tools in your facility. That's amazing. And anybody who's hearing this should take advantage of something like that. So I like what you said, your foot type, there's different types of feet, whether you're flat footed, high arched or normal, the foot type is a fingerprint, just like you said. And that's gonna dictate because certain foot types have certain predilections to different injuries. So if you have a high arch foot, you're actually more prone to injuring the outside of your foot than someone who's flat footed who's more prone to injuring the inside of their foot. And that could only be known through a proper examination, whether it be through pressure points or just a stance exam. Now as far as optimal function for a athlete, you have to ask that athlete, what is your demand? What are you looking forward to? Because the foot is contributing to many different sports from golf even, golf when they swing and follow through. A lot of that comes from the big toe. So any golfer who has big toe arthritis still notice a difference in their swing because we talked about kinetic chain and how it functions in a whole. I mean, everything is interconnected. You also mentioned compensation. If your big toe doesn't have the motion it needs, guess who's gonna compensate it for the next joint proximal? That's gonna be the midfoot and the ankle then the knees, the hips and the back and all of a sudden your swing is completely off and you have no idea why. So that question is tailored to every specific athlete. So if I'm dealing with a basketball player, right? The ankle is gonna be the most demanding aspect for me. So what are we gonna do? We can't strengthen ligaments as much as we want. We know the anatomy, but what we can do is strengthen everything around those ligaments. We wanna strengthen the muscles and the tendons around them. So they create this construct of stability. So when your ankle wants to invert and sprain this way or outwards, the muscles will kind of act as an internal splint, right? And they'll keep everything within itself. If you look at a ligament, I mean, their job is demanding. Their sole job is to take two bones and keep them together at all times. Throughout all the demanding you're doing, running up and down the court, jumping, running, whatever it may be, their job is to maintain this structure without separating the two bones. Now that's gonna be hard to pinpoint each ligament and strengthen, but what we could do is strengthen the muscles around them. And how we're gonna do that, it starts from day one, training the proper way, getting the proper evaluation. You mentioned dorsiflexion, that's a big killer for me. If someone has limited ankle dorsiflexion, I'm working on that from day one. You talk about Achilles tendonitis, you talk about shin splints, you talk about an array of conditions that could all be related to Aquinas, which is the lack of ankle dorsiflexion. As far as like soccer players, you're looking at something different for them, as far as stability and maintaining different things, whereas the midfoot, the list-frame complex, increasing strength in the intrinsic muscles. So for soccer players, I'll tell them, listen, don't be ashamed to train barefoot from time to time. Don't be ashamed to walk barefoot time to time. Sneakers are a great thing. They protect us from ground reactive forces in a prolonged period. They'll protect us from tendonitis, stretch fractures, and so forth. But at the same time, they do weaken our intrinsic muscles of the foot, and we have to wake them up from time to time. So doing barefoot training at a certain limit and doing barefoot around the house will actually be a positive benefit to those type of athletes. I know I'm going on a little bit tangent, but I hope you kind of get that. We're trying to create a splint around the structures to maintain that. So it's gonna be through strengthening the muscles around the ankle complex, the foot complex. It's gonna be through strengthening the proprioceptive balance, right? So proprioception, your balance in space, that's probably the biggest factor. And if you read research, they'll say proprioceptive training is probably the number one factor preventing re-injury. So if someone has an ankle sprain and they're getting rehab and they're healed, if they're not getting proprioception training, or proprioceptive training, the chances of them respraining their ankle is like 10 fold. And we saw that with Steph Curry, right? Steph Curry, when he first started his career, he kept spraining that same ankle. And the reality is all he had to do is increase his proprioceptive training. And you see a lot of videos of Steph, he's like hopping on one foot on these balls and he's trying to keep in balance. You see Kyrie Irving doing the same thing. And that revolves around proprioceptive training. It's very important and demanding for an athlete in the basketball realm and in any sport, really. Yeah, no, I got 45 questions off that. And I love all of that. Yeah, yeah, yeah. Bring some clarity to listeners, guys. We're talking about proprioceptive training. We're talking about we have these sensors in our body, essentially, for lack of better words, that are talking to our brain and understand where our joints are in space. So if you either close your eyes and move your arm around, your proprioception is the ability to know where that limb is. And so the doctor's talking about here is, right, we have our foot and we sprain it. And what happens is that muscle and the tendons and all the ligaments are perturbed. And it's something called neuro-mechanical coupling. That's how our brain talks to our body. And when our foot's perturbed from an injury, that pathway gets dysregulated. And it's a great thing, actually, because your body's awesome at surviving. It says, you know what? We know you still need to use your foot. So we're gonna kind of shift a little bit the demand on something else. And it's gonna allow you to function, have kids and die one day. But as an athlete, you don't really, you don't want to get back to okay, you want to get back to optimal, to what you were. And so what that does now is we have to train the body, train the mind-body connection, which is the proprioception, right, where we are in space, to re-educate that pathway to fire in an appropriate way. And so when we're talking about proprioceptive training and not to go on a rant here, people bash a lot. They go, oh, that guy's on a balance ball. That doesn't matter. Or that guy, you know, you couldn't do this, you can't do that. But if you guys listen, Doc talked about how we need to have strength, right? We're doing things like we're training barefoot, but now we need to train the sensory system itself. So instead of thinking, hey, we only gotta train one of these, we're looking at as a whole, how do I challenge my sensory system, my proprioceptive abilities? How do I challenge now the intrinsic foot musculature? How do I make it now in a way that I'm not gonna go around nine miles barefoot the first time, but in a progressive manner, right? And so I love what you're talking about, Doc, in regards to how we were really going into the specifics of the foot, and we're not taking this generalized approach. I wanna kind of reel it back one second before we dive into some of that. You talked a little bit about understanding what kind of foot type you are and what you need. You talked about dorsiflexion and basically a foot eval. What does a foot evaluation look like for yourself? How do you determine what type of foot type someone is? And then based on that, are there specific interventions you might provide? Absolutely, absolutely. So when someone comes in just strictly for an eval, it becomes a whole biomechanical assessment. So I'm looking at limb length, right? I'm looking if one limb is longer than the other because that's gonna change the way I think because we talked about compensation. And one of the ways your foot compensates for limb length discrepancy is that the longer limb, the foot will flatten out to kind of even yourself and become on port when you balance. You're looking for ankle range of motion. That's probably one of the most key things I'm looking for. If the patient has lack of ankle dorsiflexion, I mean, we're talking about a slippery slope of conditions which I won't go into again. I'm talking about sub-tailor joint motion. That's the joint right under the ankle. So sometimes when the ankle will lack some of its motions because the ankle is a triplanar motion but for the most part, its job is to go up and down. But it does have the ability to go side to side and move in the frontal plane. But the reality of it, most of the frontal plane motion is actually in the joint underneath the ankle. So you have to understand if the ankle's lacking something, the joint underneath that's gonna compensate. So a lot of times if someone's going through prolonged compensation of lack of ankle joint motion, they'll have arthritis in the joint underneath and it becomes again, this slippery slope. It's a common theme. When one thing's wrong, things will follow suit. After the sub-tailor joint range of motion, I'm looking at the midfoot abduction. I'm seeing how much range of motion. Now at the list frank in the midfoot level, we're not expecting a lot of range of motion. We're expecting stability and that's what we wanna see. So I'll test out the list frank joint by doing what's called the midfoot abduction test. I'll make sure they have no pain in that area and I'll make sure that they don't feel too flabby in that area. And then I'll move a little more distal. And then the last thing I wanna talk about is the first MPJ range of motion. Now the first MPJ, which is the big torque, is what we use for propulsion, right? That's the last thing that comes off the ground when we're finally making that step and going into what's called swing phase. Meaning that slight moment where your foot's not touching the ground. That joint is very demanding. It will absorb 80% of your body's weight at certain points of 80. If you're lacking motion in that joint, everything is thrown off. And that's why someone when he has a stiff first MPJ, they'll tell you, oh my God, everything's gonna, my heel hurts, my midfoot hurts, my ankle hurts, and I just can't explain it. And I'm going through the biomechanics and I'm telling them, listen, I think if we take care of this, everything will follow suit. And that's when you kind of become a detective because you can't just treat all the symptoms at the same time. At some point you have to ask yourself, what's the root of the problem here? And how do I figure this out? So that for me is the standard biomechanical exam. Now as far as the foot type, simple stance. I tell them, get up. I look at them from the back of the heel, see if they're in what's called valgus, varus, or neutral. I'll tell them to face right. I'll see the arch if it's collapsed and the arch goes in levels. If you're a zero, you're completely flat. If you're one plus, you have a little arch. If you're two plus, you're normal. If you're three, you're high arch, which is actually pretty bad. You don't want to be high arched. And then I'll rotate them around 360 and kind of make a judgment from there. Now your foot type is going to dictate what kind of sneakers you're better in or what kind of orthotics you may be better in. Your biomechanical exam also dictates what kind of sneakers you may be better in. So if you lack ankle dorsiflexion, wearing a sneaker with a thicker heel is only going to exacerbate your symptoms. Whereas if you don't lack it, then you can wear the kind of normal type of sneaker. I hope that kind of answers what you were looking for in terms of foot type and what I'm looking for in terms of biomechanics. No, I really like that. And what I like about that is you have this assessment protocol that you're going through. Oh. And when you're looking at the foot, as a coach, you don't need to be a podiatrist to observe the foot. You can look at it. But what you can see is just like Doc rattled off there, if there's a flat arch, if the foot is valgus one way or the other, I believe you said, right? We can refer, right? We can get that athlete in the hands like someone like yourself or someone who's trained in that area. So now I'm equipping myself as a coach, as a general population to understand that I might need to go see X, Y, and Z just based on something that I can see visually, right? That's a tool I feel like we see at times as coaches, but we don't always act on it. We say, oh, you know, it's just a foot, it's just whatever. But small things really add up. You're talking about making sure the right shoe is for the right individual. And with that, you see it so often where there's been a big kind of spike in Liz Frank fractures in the NFL, as well as the NBA. And a lot of it is these guys' feet are like size 16 and size 18 and the shoes themselves aren't always custom fit and made for that individual to the extent that maybe it could be or should be, especially shoes that say aren't their basketball shoes. Maybe they got size 14 or 15 dress shoes and all these things, because every step adds up. For those of you not aware, the Liz Frank is on the outside of the foot. That's where that stress fracture occurs. Is that correct, Doc? I don't wanna be wrong on that. The Liz Frank, so it's a complete complex of the midfoot and the main connection is between the first bone and the middle bone in the midfoot. That's the strongest ligament. It's a multiple assessment of ligaments, but that one, if that one goes, everything tends to fall apart and it's a devastating injury, really is. I mean, it'll end your season for sure. Gotcha, and that can come from footwear possibly not being fitted properly. 100%, 100%. If you're in a bad footwear, you put more stress on that ligament than you need to and one wrong cut will eventually snap that ligament. And when that ligament snaps, the whole complex kind of deviates. Sometimes you get lucky and it's just a single column. Sometimes you get unlucky and it's one whole column and then sometimes you really get unlucky and what we call divergent is that the two columns will split like the C. And again, you're talking about a rehab process. Surgery is almost, is 100% necessary. There's not many people who are gonna say it's a non-surgical thing. It just depends what kind of surgery you're gonna do. Are you just gonna throw screws or are you gonna do what's called a fusion? That's the real debate. And then on top of that, that's gonna take anywhere from eight to 10 weeks just to heal. We're not even talking about the rehab process. We're talking about healing. And then after that, you're gonna initiate rehab. So that's why I told you that's a season ending surgery. Another thing for improper footwear with people with high arch, they're more predisposed to outside of the foot injuries. So people like Ben Simmons or KD, they had what's called a Jones fracture and that's breaking the bone on the outside of the foot. That's a surgical problem. And you wanna make sure that they're wearing the proper shoe gear because if they're not, they're constantly adding force on that area. Newton taught us this thing. He said for every action there's a reaction. So don't think when you're walking or you're running, the ground isn't shooting up forces on your foot. It really is. Now the shoe, the beauty of footwear is it's kind of buffering out those forces for you. So if you were to go completely barefoot and just run full throttle, those forces may be too hard for you to handle on your bone density. But when you wear a sneaker, that kind of again buffers out those forces, though it protects us from any fracture. Now if you wear a high arch foot and you're already prone to breaking that outside of your bone and you're wearing improper shoe gear because you just buy generic shoes. Again, you never really got opinion on that. You may be even at a higher chance of breaking that bone. And that's why again, just like you said, a lot of people, coaches, trainers, physical therapists, they're becoming more aware of that. And a lot of my connections are through referrals. They'll say, hey, listen, I could only do so much for you. My job is to find the problem and send you into the right hands. And it's vice versa. I can identify the problem such like a plantar fasciitis, which is an inflammation of the ligament on the bottom of the foot. But in all actuality, I know my limits on what I can offer you. And I have to know that I have to send you to a PT or some sort of therapy to get you better. And this holistic approach to medicine is really coming full circle. I'm seeing it more and more now that I'm in private practice and I promote it completely. As a doctor, you can't be this superhero. You have to know this is my limit and I'm gonna send you in the proper way. And I'm glad that you guys are also taking a notice on foot type and proper footwear and whatnot. It's crucial. Yeah, no. And first off, all my ATCs out there are probably gonna yell at me because I meant to say Joan's Fraction. I call the Liz Frank outside of the foot. You're right. You're right. Yeah, you got it. It is not now. I started getting missed on that one. I had to deal with the one around us in school and not myself, but an individual going through it and they actually had to put a screw through it and just see the surgery firsthand. You realize, let's do what we can to avoid this, right? Because, and we wanna talk about avoiding it too. It's the way, the time it takes for bone ligament and tend to heal, especially bone ligament. Ligament may never heal the same and neither will bone. Actually never will, the ligament will never. So the beauty of bone is bone will heal and it might heal stronger. That's the reality of it. So a lot of boxers, they used to like punch the walls to break the knuckles because bone, if you're healthy enough, will heal and it'll heal stronger than it once was. That's the beauty of bone. Ligaments and skin, they never do because the tissue that replaces your original tissue isn't the same type of collagen or soft tissue that it originally was. So forget ligaments. They'll never retain that strength and that it once had bone maybe. But again, bone takes six to eight weeks on a healthy patient. If you're a smoker, you're diabetic or you have any other comorbidity, you might as well double that time. Yeah, I know I love that too because you mentioned there, right? All these things that go into healing, right? If you're a smoker, you have poor diet, all this impacts how your healing is gonna take place. It's also gonna impact your predisposition to actually get hurt, right? If you're not able to, because when we work out we actually have osteoclast, osteoblast activity. We're constantly breaking down and rebuilding bone but if we're always breaking it down, we're not rebuilding it. If we're not providing the right nutritional support, whether it's inadequate macros and micros and all that that go into that process then we're not allowing the body to function like it should. And with that you mentioned earlier, that's why we wanna progress properly if we are training barefoot. Don't say, oh, barefoot's the greatest thing. Let's go practice the next four days barefoot because what happens is your muscles will rebound, your tendons and ligaments don't rebound that quickly, you gotta take some time and let it build up. If you could talk a little bit about that time process and how maybe you might see progressing someone who's never walked barefoot, I guess at any sort of distance outside the house, how might you progress someone from barefoot to doing something actually active on their bare feet so where they can have a stronger foot? Cause I can hear a lot of people going, oh, you know, barefoot, barefoot, this is great, let's do it. And now all of a sudden everyone's hurt because they thought barefoot was awesome and submit doesn't act the same way as their body likes it to. You know, I'm glad you have the same mindset I have because I really thought we're gonna fight about this because people who do barefoot training and running, they just, they believe in it in their heart and it's hard for them to hear anything against it. One of my good friends wrote a piece for Men's Health Magazine on barefoot training and he asked me to contribute to it so people can look at that article for some certain exercises to ease their way into trans, transitioning into that. But...