Rafael E. Salazar II, MHS, OTR/L. “Rafi” is a licensed Occupational Therapist based in Georgia. Rafi has worked in a variety of settings, from orthopedic and musculoskeletal rehabilitation, to academia, and even healthcare consulting. He spent the majority of his clinical experience working at Charlie Norwood VA Medical Center, where he was the lead clinician and clinical education coordinator for the outpatient specialty rehab program. In this role, he treated many veterans with chronic pain and helped to establish an interdisciplinary pain management program. He has worked on projects ranging from patient engagement initiatives to marketing communication campaigns to a multi million dollar project assisting the State of Georgia’s Department of Behavioral Health and Developmental Disabilities transition individuals out of state institutions to community residences. He has worked as an independent healthcare consultant since 2017, as the Principal Owner of Rehab U Practice Solutions, helping healthcare organizations and private PT/OT clinics develop effective patient engagement and retention strategies.
Rafi also hosts The Better Outcomes Show, a podcast that explores the possibilities of a new healthcare and is the author of Better Outcomes: A Guide to Humanizing Healthcare. He has a passion for helping people overcome their limitations & pain to return to doing the things they love. He’s on a mission to make healthcare human again. Rafi also authored the book The Natural Runner: 8 Weeks to Pain-Free Running.
Listen to this episode of The MOVEMENT Movement with Rafael Salazar II about how to enjoy natural running in 8 weeks.
Here are some of the beneficial topics covered on this week’s show:
– How barefoot running doesn’t cause people to have more injuries.
– Why adding support and cushioning to shoes creates more problems than it solves.
– How getting the sensory input of walking informs your movement patterns.
– Why there is a connection between the footwear you choose and the function of your feet.
– How immobilizing your feet leads to intrinsic muscle wasting.
Connect with Rafi:
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@proactive_rehabilitation
Links Mentioned:
pro-activehealth.com
Connect with Steven:
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@xeroshoes
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facebook.com/xeroshoes
Episode Transcript
Steven Sashen:
All right. There are a lot of YouTube videos saying that the barefoot industry is lying to you, and there are a lot of people who’ve been saying that if you go barefoot, you’re going to get injured. We’re going to chat about the reality of that, and what you can do about it if you’re interested in being a happier, healthier runner. On today’s episode of The MOVEMENT Movement, the podcast, for people who want to know the truth about what it takes to have a happy, healthy, strong body starting feet first, because those things are your foundation, and we break down the propaganda, the mythology, sometimes the outright lies you’ve been told about what it takes to run, or walk, or hike, or do yoga, whatever it is you like to do, and to do that enjoyably, and effectively, and efficiently. And did I say enjoyably? Trick question, I know I did.
Because look, if you’re not having fun, you’re not going to keep it up. So make sure you’re having fun doing what you’re doing. I am Steven Sashen, CEO, co-founder of Xero Shoes, and the host of the MOVEMENT Movement podcast. And we call it that because we, including you, are creating a movement about natural movement, letting your body do what it’s made to do. And the part where you can help is really, really easy. There is no cost involved, there’s no time involved, really. It’s simple. If you want to find out more, go to our website, www.jointhemovementmovement.com. You’ll find all the previous episodes, all the ways you can interact with us on social media, and just leave a review and a thumbs up and give us a five star rating, all those things you know how to do to help people find out about what we’re up to.
In short, if you want to be part of the tribe, just subscribe. So before I introduce our guest, you may notice I’m, A, not at the Xero Shoes headquarters with a bunch of shoes behind me, B, I’m not wearing a Xero Shoes T-shirt, and C, I have a whole bunch of hardware all over me because I had some shoulder surgery on Tuesday. This tube is going to the thing that’s running cold water through this, and then I got a brace on… Anyway, blah, blah, blah, blah, blah, it’s all very entertaining. So just wanted to let you know why that’s going on and what’s up. But more importantly, let us chat. Hey, Rafi, do me a favor, tell people who you are and what you’re doing here.
Rafi Salazar:
Sure. So my name’s Rafi Salazar, I’m an occupational therapist by trade. I own a physical therapy clinic in Augusta, Georgia, home of the Masters if you’re into golf. And we’re here to talk about what the research and the evidence shows about transitioning from conventional running to minimalist running, and just a natural gait pattern.
Steven Sashen:
Before we do that, I didn’t know you were in Augusta, when I was doing standup comedy for a living, one of my first gigs was in Augusta, Georgia, where, on the opening night they surprised us by saying, “Hey, Soupy Sales wants to come and do 10 minutes.” It was like, “What?” I don’t know that anyone even knew who Soupy Sales was then, and I know a lot of people don’t now. But FYI, really nice guy, largest head I’ve ever seen on a human being. Utterly, utterly fascinating, just ginormous noggin. So now, before we jump into this… and first of all, thanks, one of the things that I’ve noticed in the people who are complaining about the whole barefoot world… and by the way, we’re not even necessarily going to suggest that you run in bare feet, that’s a whole other story.
But one thing that I hear people saying all the time is… one of two things. One is, “Hey, the barefoot industry is lying to you,” which I find very interesting, because the things that these people then say are things that I have never said. In fact, I say the opposite of many of those things they say. And the guys at Vivobarefoot, same thing, have never said those things. And the two of us are the two largest companies in the world promoting minimalist footwear and natural movement. So that part’s really interesting to me. But there’s one other part that I want to see if we can start with, and that is, when people talk about switching to either running barefoot or in minimalist footwear, they talk about injuries and the possibility of getting injured, and they never compare the potential injuries, or the actual injury risk in running barefoot or minimalist, to the actual injury risk that has been measured for 45 years of people running in regular shoes. I can say more about that, but do you want to jump in on that one?
Rafi Salazar:
Yeah. I think the reality is, running as a sport in the amateur world anyways, probably in the pro world too, has one of the highest injury rates. In some cases, some studies put it as high as 85% of amateur runners experienced some kind of injury over the course of their running career. So basically, eight or nine out of 10 runners experienced some kind of running related injury, and it’s usually lower extremity, foot, plantar fasciitis, hip, knee, back issues, something like that.
Steven Sashen:
The number that come and gets banded around quite a bit also is 50% of runners, 80% of marathoners, get injured every year. But my favorite thing about this, and I’m going to see if we can get it in the show notes, Nike did a study about four years ago. They published it right before COVID, partly, they sent out a press release, they never actually published the study. But the press release said that they had a new shoe that reduced injury rates by 52%. And on their website now, they actually have the abstract, but they still haven’t published the study for a couple of reasons that I just realized, where it says they compared their bestselling running shoe to a new running shoe, and the new running shoe reduced injuries by 52% over a 12-week half-marathon training program. And in fact it did. But then you have to look at the numbers.
In their bestselling shoe, in 12 weeks, over 30% of the people got injured. And in the new shoe, only 14.5% did. Now, this is an amazing thing, this is like me saying to you, “All right, I’m going to buy you dinner every night this week. You can pick one or two restaurants. One, where you’ll get food poisoning roughly… the odds are about one in seven, and the other where the odds are three in seven. Which one do you want to go to? And of course the answer would be, “What, are you crazy?” But I think they haven’t published the results because they defined an injury as anything that kept people from running for at least three training sessions.
Now, I suspect that if they actually showed how long people got injured for, those numbers were much, much higher. And so if after 45 years, this is the best they can do, is injuring 15 to 30% of the people in just 12 weeks, the rates go up, then that’s a problem and that’s what we need to compare ourselves to. If anything, my God, look, at Xero Shoes, if we were injuring 30% of the people wearing our shoes in 12 weeks-
Rafi Salazar:
We’ve probably got a business.
Steven Sashen:
I’d probably be in jail. So it’s an amazing standard that we are not being held to, or even more interestingly, they’re not being held to. So anyway, I just want to frame that in this conversation about what it takes, from your perspective, and the research, for people to… and again, I think this transcends running, but anyway, to have a transition from whatever they’re doing in whatever shoes they’re currently wearing, to something more natural and arguably better for you.
Rafi Salazar:
Yeah. Well, I think from a standpoint of just on the logic of it, if you get injured, you get plantar fasciitis, or whatever, you have weak arches, the idea of, “Okay, we just need to put more support, or more cushion,” or whatever, makes a lot of sense on the surface. Like, “Oh, that’s common sense. I get injured because of the way my foot is striking the ground. So I just put more cushion and I’ll be fine because it won’t be striking as hard.” But what we fail to really understand in that logic is what it does, one, to the entire kinetic chain, but then the whole neuroscience of it, and motor control, and what it does to have impaired or inappropriate motor patterns when you’re doing something over the long-term and what that does for repetitive strain injuries, and all of that. So on the surface, cushioned supportive shoes sounds like a great idea because, of course, we’re going to be decreasing the impact force, but the researchers suggest something-
Steven Sashen:
Yes, I was going to say except, and I’ll let you continue. I’ll give you a little one-liners just to keep rolling on this. Yeah, it does, quote, “make sense” if you don’t think about it too hard, if you don’t know anything about physics in particular. When the big maximally cushion shoes started coming out, I’m a former All-American gymnast, and the first thing I thought literally immediately was, foam is like a trampoline. It doesn’t give you anything back, it’s what you put into it. And like a trampoline, it’s tuned to a particular weight and a particular speed. If you are not at that weight and running at that speed, it’s just going to get in the way. There’s no such thing as energy return, there’s just energy loss, and it’s just a question of how you mitigate that. This is a bit of a tangent, but something I’ve been thinking about a lot lately. In 1971, a guy named Delano Meriwether, do you know him?
Rafi Salazar:
I heard his name, yep.
Steven Sashen:
Then you’re a rare one, because most people don’t. He has the world record, to this day, in 100 yard dash, because they switched to meters after he set that world record. And he was running in shoes that are much more like ours, thin, flexible, lightweight, on a crappy track surface, frankly. And he ran a nine flat hundred yards, which equate to about a 9.8 hundred meters, which would make him the fourth fastest guy in the world today, and he wasn’t even taking any drugs. So people have no sense of history as well when we have this conversation. So in addition to the misunderstanding of physics and kinetics, they don’t have a sense of history.
Rafi Salazar:
Yeah. Yeah, for most people, history starts the day you were born, right? So there’s that.
Steven Sashen:
I never thought about that. Yeah.
Rafi Salazar:
That’s one of the things you hear on the politics side of things, oh, history starts for many people the day they were born. So if it happened before that, they’re not even listening. The same is true for-
Steven Sashen:
For anything, it seems. Well, it’s because we’re Americans. In Europe, they have a whole different sense of that, and Asia as well. So before we jump into the specifics of this, I’m curious, what got you here? Now, first of all, 13, 14 years ago, when the barefoot boom started booming, there was very little research, and there was very little incentive to do any research because who’s going to pay for it? But now, it’s a different story, both research about what we are doing, and research about what normal studies are doing. But where did you start and how did you end up here?
Rafi Salazar:
Sure. Yeah. So I was 29 years old, and after having been relatively sedentary, I wanted to run a half-marathon before my 30th birthday. I’d had a kid a couple of years before that. So 2015, I had my first son and I was like, “I want to be one of those active dads. I don’t want to be like, “Oh, go play out in the backyard, I can’t move, my back hurts,” or whatever. So I started running back in 2015, had been doing that on and off for a few years. And then 2019 rolled around, I was like, “You know what? I’m going to run a half-marathon.” And in that half-marathon, which I ran in a time of 1:58:22, so I’m proud of that, under two hours, ended up having a stress fracture in my foot.
And it was one of those… you cross-train for a while, maybe on a stationary bike, until the foot heals. And then for the next couple of years, I was really just plagued with all kinds of running injuries. It was right knee pain, and left knee pain, and back pain. I had an MRI on one of my knees and was told that I had chondromalacia patella, and would need to take it easy and buy some supportive shoes. And shortly, after getting over the knee pain was, it was my mom, actually, she was like, “Oh, I just got these Xero Shoes. You should really look into them.” And at the time, I was a professor at the university teaching in the OT department, teaching evidence-based practice. And everything she was saying was one of those… The spider sense in the back of my mind was like, “No, there’s no way this is true. There’s no way this is curing plantar fasciitis, there’s no way it’s doing all that.”
So I dug into the research a lot. And what I came to find was that, and I’ve heard you say this, I think, a few times on different podcasts, when you dig into the research, it’s not so much that the shoes themselves are fixing the problems, it’s the benefits that you receive by having more proprioceptive input in the bottom of your feet. Because the proprioceptive input are really just the sensory input of walking and having flexible footwear and forms your movement patterns. And over time, doing one movement pattern one way for five miles either leads to some injuries or you can build real strength. And that’s what got me started on it. So I was like, “You know what? I’m going to try some of these natural or barefoot running shoes.”
And I started doing that, I don’t know, 2020-ish, 2021-ish, and just haven’t looked back. I don’t think I’ve run in a pair of cushion shoes in a long time. And what I tell people that come into the clinic, what I tell folks on the podcast and stuff like that is, again, the shoes themselves are not a cure-all, it’s the benefits that you get from wearing those shoes. So my mom was right, the shoes were helping her, but not in the way that she thought.
Steven Sashen:
So that’s true. So I’m intrigued by this, it’s a rare human being, who, when presented with information that conflicts with what they believe goes, “Huh.” Instead of immediately thinks of a million ways to argue against that point.
Rafi Salazar:
Yeah. Confirmation bias, right?
Steven Sashen:
Yeah, exactly. And it makes sense. It’s an evolutionary thing, we’re wired to stick to what we believe. Because if we had to rethink something every time we encountered it, we’d be dead. Something would’ve eaten us by now. So do you remember, I want to pick this apart for the fun of it… I’m thinking about slowing the film down, frame by frame. So your mom says, “Hey, you got to try these out,” and she’s talking about all these things where she was in the right direction, but not necessarily for the right reason. When you said your spider sense was tingling, can you, A, say more about that, and B, tell me what you started researching, what you found when you actually dove in, where’d you look and what’d you discover?
Rafi Salazar:
Sure. Yeah. So I think the thing that she said that I was like, “Oh, no,” she said, “Oh, I’ve had plantar fasciitis for years, and now I wear these shoes and I don’t have plantar fasciitis.” And I was like, “Okay. Are you doing anything?” And she’s like, “Well, I’m exercising and stuff, but the shoes took away my plantar fasciitis.” And I was like, “We’re going to dig into this.” And being the research nerd that I am, and having access to PubMed and some of those peer-reviewed research journals through the university, I just did a search. And the research that was being published back then, and probably still being published right now, compares quote, unquote, “shod” runners to barefoot or minimalist runners. And I didn’t know anything about any of these terms when I was digging into it. And what I was looking at was, I was trying to look at injury rates, but I was really looking at the impact forces, of running efficiency, and things of that nature.
So it’s funny because even on the surface, there’s one study, I can’t remember where it was published, probably the Journal of Orthopedic and Sports Medicine, or something like that, and they compared shod runners to barefoot runners and over, I think it was a six-week program or something, six weeks running on a treadmill, and they were testing stability of the ankle. And at the end of that research study, the conclusion was, well, the people that were started running conventional shoes, they put them in into barefoot shoes, and then they tested them for six weeks, they had more instability in their ankles than before. And so we should be, whatever, cautious about encouraging people to do minimal shoes or something like that. And being, at the time, doing research or teaching evidence-based practice, I was like, “Okay, if I was to appraise this article, the conclusion that you’re coming to obviously is a no-brainer.”
If you take somebody from stabilizing, anti-pronation shoes, and you put them in basically no shoes or very flexible shoes, well, no, duh, they’re going to end up pronating more probably, they’re going to have some more instability. But they never made the connection, for me, of, because they have instability, they will have more injuries. They couldn’t make that connection. So I began digging a little bit more, and a little bit more, and ended up coming up with… it was a study published, I think it was in 2018, and it was in Foot & Ankle Orthopaedics, and it basically discussed foot exercises to transition people into barefoot to improve function, muscle size, foot pressure, distribution, all kinds of stuff like that, with the ultimate goal of reducing injuries. And what they showed was these, we call them the core four exercises in the book, but the core forefoot exercises, which are basically seated doming, standing doming, you’re trying to just work the intrinsic muscles of the foot and toe spreading.
They equated that to increased endurance and ability, like heel raises and heel lifts, decreased instances of plantar fasciitis, actually increasing the natural arch of the foot. And that got me down that rabbit hole of, okay, so obviously, there’s a connection here between the footwear that you choose and what that means for the function of your feet. Very similarly, my background as a clinician is upper extremity hands, and we talk about all the time splinting people in the wrist or the hand. And one of the big things we’re worried about is intrinsic muscle wasting, losing the ability to grasp or to do fine motor things because you’re splinting or immobilizing the muscles over long periods of time. And it’s the same basic of principle in the feet.
So that got me down the rabbit hole, and then I was like, “Okay, so now, there’s obviously some merit here to the idea of allowing the feet to move more and then doing it in a targeted way to intentionally build strength, to decrease the risk of injury in the long term.” Because really, it’s the strength and the foundation, like you said, of your body’s movement that dictates whether or not you’re going to get injured in the long run or not.
Steven Sashen:
Well, I want to highlight something else that you said you did that most people don’t do and can’t do, and that is you looked at the research and then took a bit of a deeper dive into it. And what I’m saying that is, almost any of the research that’s comparing shod runners to barefoot runners, where they say, “Hey, we took some runners and we had them run barefoot,” it’s like… well, two things. One, if you just put them in a brand new shoe, their running gait would change. In fact, I was in the lab with Dr. Bill Sands, and this is a thing he would do, is you’d come into his lab with every shoe you owned, and he would show that each shoe you wore changed your gait.
So that’s one thing. And for the things about, quote, “running efficiency,” which is not about how well you run, it’s measuring VO2 max, or something, how much energy you’re expending when you’re running, there’s two things that are interesting about that. One, again, if you’re just switching to something radically new, it’s a new movement pattern that’s unfamiliar, that’s going to make a change and it’s going to be more difficult. Basically, what I’m saying is, that very rarely can you actually find out more about the cohorts, about the people that they’re using in the studies, that’s one thing, and the other is, whether they paid any attention to form.
Because even if you switch someone barefoot, especially on a treadmill, they can have shitty running form. They can still be overstriding, heels striking, do all these things, and no one ever seems to look at that or measure that. This is like in the early days, when doctors would say, “Oh, I love this barefoot running thing, I’m getting more patients than ever.” It’s like, “Well, first of all, you said that in the early ’70s when running shoes came out, and secondly, when someone came in and said they got injured running barefoot, did you ask them if they were actually running in bare feet or not?”
“Well, no.” “And did you look at any video of them running and do you know how to analyze their running form?” “No.” I said, “Well, it’s not about the footwear, it’s about the form. And if you don’t know what you’re looking at, then you’re just making up a whole story.” But there’s a guy here in town, I’m usually reluctant to mention his name, but I will, I think he might’ve retired, Rodger Kram. And Rodger, he would say that he was using accomplished barefoot runners to compare in his studies. And I called him on it. I said, “I know all the barefoot runners in this town. You didn’t have any of them in your study. You had people who do some barefoot training as part of their long distance training, but they’re not barefoot runners. They’ve never run a mile on pavement, for example.” Not knowing who is actually being studied, and not looking at the critical thing, like we both mentioned, form not footwear, these things are massively misunderstood. And most human beings don’t have the resources or the will to really dive in and see, is this study done well or not?
Rafi Salazar:
Yeah. Well, and I think it’s one of those things, like I had an edge because I was teaching this in the university, I went to grad school for this. Evidence-based practice is what clinicians at least should be, on the surface, doing. So being able to look at a study and pick it apart more critically. To your point, most of studies out there comparing barefoot runners to non-barefoot runners, they basically take a cohort of conventional runners and then randomly assign them, one way or the other. So if you take somebody who’s run the last 20 years in regular cushion, pronating, limiting shoes, and then you put them in barefoot shoes, of course, they haven’t learned how to run in those shoes yet. So it just leaves a little bit to be desired.
Steven Sashen:
So I want to slow the film down one more time. So you got a pair of shoes, and what was your experience when you put them on… I mean, what’d you do the moment you got them, and what was your experience of that?
Rafi Salazar:
Sure. So the first time I put some shoes on, and I won’t mention them because they’re a competitor of yours, and I know you speak-
Steven Sashen:
It’s okay. We’re all friends.
Rafi Salazar:
Yeah. So I put them on, and I actually ran backwards for 20 paces so that I could feel… Someone, I think it was a marathon training academy podcast I’d listened to before then, was talking about form. They said the best way to get good running form is to run backwards because you’re going to naturally land on your midfoot or your forefoot, you’re going to be upright, your elbows are going to be behind your body, you’re just going to get in good running form doing that. And then so you run backwards 15, 20 pace, and then you run forward a little bit, trying to maintain that form, and what I noticed very quickly was that, I went backwards, it felt good, and then I went forward and started to heel striking a lot, and it hurt my feet, because I was on pavement. And after probably about a block, my first run in minimalist shoes really lasted maybe a quarter of a mile. And that is because I had read some of this research and was like, “Listen, there are people getting injured. I don’t want to run four miles and injure myself.”
So I ran about a quarter of a mile or so, and what I noticed was, initially, like most people, I was overstriding, I was striking on my heel, it was hurting me. And probably in the first, I don’t know, 150 yards or so, I noticed that I began altering my gait pattern, I was changing, and I was landing more on that midfoot, forefoot, and reducing some of those impacts on my heel. And that was my first go at this. And so what I tried to do was then build up… So I was doing cross-training so I wouldn’t lose just functional capacity in the off days.
And then I was just trying to extend longer and longer. And what I was trying to do is make sure that my form was good while I did the transition. And as soon as my form started breaking down, it was a sign to me of weakness. So I would just stop running then, I would go back, I’d do whatever exercise I was doing at the time, because I looked at it as a long-term transition. It took me, ultimately, about eight weeks or so before I was back up to running a 5K or something like that, and feeling good about it. But I was a spaz about the form, so I was not going to let myself run in poor form, especially after feeling it on my heel that first time. I was like, “Okay, there’s a way to do this,” and obviously, it’s a repetitive movement. I don’t want to injure myself over a long period of time doing heel striking for two miles in bare feet. So that’s what I did.
Steven Sashen:
I’ve seen a number of people, when they hear about this whole idea, and they hear that you’re supposed to land midfoot or forefoot, they’ll continue to overstride and then just point their toes, plantar flex. When you were making that transition in that first 100, 150 meters, were you noticing any other changes in your gait and others? Were you still overstriding and plantar flexing, or could you tell that you were getting your feet underneath you?
Rafi Salazar:
Initially, I was overstriding and just plantar flexing. After a while, and part of this was reading and listening, and really listening to my body too, I was landing more under me, and then what also happened was cadence picked up as well. So the faster your cadence is, at least the research supports this as well, the faster your cadence is, the harder it’s to overstride.
Steven Sashen:
Yeah. There’s a chart that I didn’t save, and even if I did save, organization is not my skillset, where it was showing the relationship between cadence and force. And for most people, as your cadence was picking up, the amount of force is reduced until you start picking up significantly. And then basically, once you start sprinting, you’re putting a lot of force in the ground. But it was a nice U-shaped curve between cadence and force, and I wish I could find that piece of research again.
Rafi Salazar:
Yeah. So it’s about finding that balance, and that’s what I did. I just tried to build up… Going from having run half a marathon and just having the capacity to run 10 miles, it was maybe humbling a little bit, I was trying to fight the urge to run more because I knew I could run more, but I went into it with the vision that it was going to be a long game and that it was going to take some time to build up to that in the new… I was changing my running technique, I was changing my running form, and that takes time.
Steven Sashen:
Well, here’s a personal question, not deeply probing or anything, but what you’re describing is my favorite thing, which is, you basically became your own coach. You were using the feedback you were getting to make these adjustments in real time. Did you have any sense what’s actually happening for you? Is that just the way you’re built anyway and you didn’t notice?
Rafi Salazar:
No, I realized that what I was… Again, because of my background in the clinic, I realized what I was going to be doing involved learning new motor patterns. So I nerded out a little bit and was like, okay, these are the movements that we want to do. If I’m going to be landing on my forefoot, on my midfoot, I need to get my feet up under my body, I need to get on my back up, I need to worry about the posture. I can’t be over reaching with my arms. And it was a matter of, I was having to be very cognizant of it while I was running for those first several weeks or months, making sure that, okay, my form is good, I’m feeling it, this is what it feels like when I get out of sync, whether it be overstriding, or get reaching too far with my body, or hunching over, whatever it happened to be. And it just took learning what right feels like.
Steven Sashen:
Well, I love that you pointed out that you paid attention to what wrong feels like, because that’s something that if we’re not really aware of that, it’s harder to learn what the right is. Sometimes when I’m teaching people, I’ll say, “Exaggerate this thing you’re doing badly,” because it’s just so ingrained, you don’t know what you’re doing right or wrong, so you need to do something on either end of that spectrum to wake up your brain enough to go, “Oh, okay, now I know where I’m starting at least.” So that’s a good one. I want to lead to a couple of things, but you mentioned something else that I really like… actually, there’s two things. One is, think about the counterfactuals, thinking about when people are presented with this idea of running barefoot or minimalist footwear. No one ever seems to talk about the various places in the world where this is what they do without a problem for years, and years, and years, they never used that as an example of, “Hey, this is possible.”
The excuse is always, “Yeah, but they grew up doing that.” So as if it’s impossible to learn some new movement pattern at any point in your life. You can’t learn to play the guitar once you’re past the age of seven, is the analogy for that one that makes no sense. And the other one that I love, and I’m dying to hear what your thoughts on this one, is, I hear this one a lot from people, they go, “Yeah, but we didn’t evolve to run, let’s say, barefoot, or whatever, on hard surfaces like this.” What’s your response to that? And I don’t even know if there’s actually been research, but I have thoughts about this one. I’m curious if you do.
Rafi Salazar:
Yeah. I am not one of those wear or go barefoot or wear minimal shoes all the time no matter what, because there are times like, “Shoot, when I’m standing up on a concrete surface for a very long time, it’s nice to have a little cushion.” I think the reality is, if you look at the way our feet, our body really is designed to move and all that, we evolved to run on uneven surfaces. Yeah, that makes sense on principle, but the reality is, once you learn the appropriate motor patterns, whether you’re doing it on uneven surfaces or flat surfaces, the impact force is still being reduced if you’re running appropriately. So I don’t know, I feel like… I’m not too convinced.
Steven Sashen:
Well, my version is, you got to go to these places that we evolved on and in because there’s a lot of hard packed mud, which may as well be concrete, with stuff sticking out of it that you don’t want to step on or in. I also love to say, look, as a former gymnast, we did not evolve to do double twisting, double back flips, but we can do them. We didn’t evolve to fly fighter jets, but we can do it. I don’t even know what this fallacy is called. It’s like the reverse naturalistic fallacy, which is, if it’s natural, it’s good. This one is, I don’t know what it is, but it’s a misunderstanding of history and what we can do. There’s got to be a name for that one somewhere.
Rafi Salazar:
Yeah. And the reality is, neuroplasticity, our brains as such, because our brains control our body and our motor patterns, our brains change from the day we’re born to the day we die. So there’s no reason to think that you can’t learn a new motor pattern or you can’t generalize a skill from, say, uneven surfaces to flat hard surfaces if given the right time and training.
Steven Sashen:
Great feedback. I will add to that, since you brought up neuroplasticity in your experience, it took you about eight weeks. For me, it was much faster. And for some people, it’s longer, because people do have different propensities for neuroplastic change, for learning a new movement pattern, for adopting that, for feeling it. And of course, people will be better or worse at different things. So you might find that if you’re running, you’re not going to be as elegant as some guy who’s a two hour, five minute marathoner who’s just wired for that. But that doesn’t mean that you can’t find a way to do this that’s enjoyable and works for you.
I also like reminding people that there’s lots of different ways you can run. There’s different distances. So I’m a sprinter, I run as fast as I can in a straight line for really short distance. I don’t take turns around the track because I don’t have a GPS watch and I don’t like to get lost. But there are other people who, the idea of what I’m doing just is completely absurd and they’ll run 100-mile races and everything between. So not only is there that thing of finding that, taking your time to become your own coach, to listen and find this new optimal form, but then figure out what you want to do with it. It was a whole other piece of the puzzle.
Rafi Salazar:
Yeah, absolutely. Yeah. And I think part of it too with the taking the eight weeks was more strength-based than anything. The reality was, I had been running in shoes that had limited the intrinsic muscle strength of my feet, so taking the time to really strengthen the right muscles in the kinetic chain. And it’s been one of those things that, even now, I’m still working… I had an injury maybe three, four months ago, six months ago, in my glute med, and it was probably because of the way I was running. So now, one of the PTs in the clinic here has been working with me, and I’ve been strengthening that right muscle, that left side of that left glute, and working on it to address really in the context of running.
So I think it’s one of those things too, it’s not only the neuroplasticity piece, but it’s really the strength of the underlying muscles too. And you’re going to find stuff like, okay, now that my feet is strong, the problem just moves up the kinetic chain, and now that my knee is strong, now is my hip, and now that my hip is strong… So you’ll play whack-a-mole probably your whole life. I think that the reality is, just approaching it from this motor control strength-based approach as opposed to trying to stabilize-
Steven Sashen:
Well, and I think it can go the other way around too. And what you just pointed out, glute medius, which most people don’t even know they have, is, when I was with Bill Sands, he was saying, “This is the number one thing that we do with runners, is they just don’t have any strength in their glute medius.” And for anyone listening, just look that up and look up… And we can talk about strengthening exercise for that as well. I saw something on the trail the other day that blew my mind. This woman ran by me and her left leg looked totally fine. Everything was in alignment, looked great. Her right leg, her knee was pointed inward, vastus valgus, and her right foot was still pointed outward. It was averted in a way that I’ve never seen, it was like cork screwed.
And then she was a little overweight. And I noticed something that, like I said, blew my mind, she had no right glute. I don’t know if she had it removed, but I mean, literally, her left glute was a full looking thing in a slightly overweight woman, and her right glute was flat as a pancake.
Rafi Salazar:
Atrophied. Yeah.
Steven Sashen:
Yeah. And of course, that’s the thing, if you are not using your glutes at all, all of those things that happen downstream, and your femur being internally rotated, rotated your knee, all of that, it made total sense. And I was inches away from literally stopping her and saying, “Here’s some exercises that if you do this, I guarantee that’s going to straighten out your leg and you’re not going to be running like a dork.” But I was not that rude. But if I see her again-
Rafi Salazar:
I was going to say, probably the way the message is delivered has something to-
Steven Sashen:
Yeah, I don’t know what the right way to deliver that message is, because it’s certainly not, “Hey, when you ran by, I was staring at your ass.” And that’s definitely not the way to start that conversation. I don’t know what the right way is. So this took us a while just leading to where you started by saying you almost, at the beginning, said in the clinic. So talk about what you’re doing now and with whom you’re doing these things, and what you’re doing with these people?
Rafi Salazar:
Sure. Yeah. So we, at the clinic, have physical therapy obviously, we get people that are coming for all sorts of some ailments. On the running side of things, a lot of what we’re doing is, we don’t push this whole idea of minimalist footwear or anything like that, we talk about just natural running patterns really. So we wrote a book called The Natural Runner, it’s an eight-week plan, to transition from conventional heel striking, overstriding, to a more natural running gait. So a lot of that involves exercises, both corrective and then endurance building, and then obviously, running within the context of this program, to try to get you to the point where you could do this in thick cushion shoes if you want to.
I would argue that you probably need a little bit more proprioceptive feedback, but if that’s what you want to do, you want to keep your HOKAs, or whatever, with their 50 millimeter cushions, go for it. Or if you want to go all the way and go barefoot, this program works for that too. Really, the idea was just to reduce people’s injury by addressing the underlying strength component, the motor pattern, and the form. And that’s what we do with the natural running programs.
Steven Sashen:
Do you know about Isabel Sacco’s research on foot strengthening and people running in regular shoes?
Rafi Salazar:
No, I have not. I’ll probably look into it though.
Steven Sashen:
Isabel Sacco, S-A-C-C-O, she had people doing an eight-week foot strengthening exercise program. People in normal shoes split into two groups, one did this exercise program, the other didn’t. And over the course of the year long study, the ones who did just the initial eight-week exercise program had a 250% lower incidences of injury than those who didn’t, in regular shoes. Now, I add to that Sarah Ridge’s study, which showed that if you just walk in minimalist footwear like ours, you can build foot strength as much as doing an exercise program. Now, no one’s done the study yet showing you can just walk in minimalist shoes, run in regular shoes, and have a reduced injury rate. But do the math, if you’re walking in minimalist shoes that builds foot strength as much as the same exercise program that Isabel used to show a reduction in injury rate, if that makes sense to you with the transitive property of injury, then go for it.
So yeah, you’ll get a kick out of that study. So I know people are going to want to hear a bit more about what’s in your book without giving away the entirety of the book. So say more about what you’re actually doing, or give people some examples of things they can do. And then before I forget, because if I don’t ask this now, I’ll forget, have you thought about doing a study demonstrating the value of this program? Maybe you can-
Rafi Salazar:
We have thought about it. Being probably on the former academic institution side of things, I get a randomized control trial and all that, just costs a lot of money to do. So you can do… and I’ve been saying this for years, in healthcare, the value in healthcare, it’s tangent here, the value in healthcare is the data, the outcome’s data and what you can do with that and what you can demonstrate from that. So we’re definitely all about tracking data and outcomes and trying to equate that. We’re also dealing though with probably a bias sample size of people that are coming in because they know that they have a problem here, an injury, and they’re trying to fix it. They stay in the program as opposed to people who might come once or twice and then leave. So you don’t get those outcomes. So yeah, down the line, research would be cool if we could get funding or something, we’d be-
Steven Sashen:
I have a friend, I guess… how old is he now? He’s got to be, geez, almost 80. He’s a doctor who does prolotherapy. He’s actually the guy who taught prolotherapy to almost everyone in the country who knows it. And for people who don’t know prolotherapy, you basically take a needle and you jab it into the tendon or ligament that’s having some laxity problems, or some tendonosis or tendonitis, and it basically selectively injures your body so that your body recruits things to heal that.
Rafi Salazar:
Induced microtraumas. Yeah.
Steven Sashen:
Yeah. exactly. And I said to Tom once, I said, “Talk to me about the research on prolo.” He goes, “Here’s the research, I don’t take insurance, I charge a lot of money, and people come back.” Wait, sorry, “I don’t take insurance, I charge a lot of money, it’s really painful, and people come back and refer their friends.” So there’s a certain time where anecdotal information is actually valuable. But anyway, but backing up to what’s in the program, let’s walk through that or run through that.
Rafi Salazar:
Yeah, run through that. Yeah, I like it. So basically, it’s a seven-day workout plan or seven-day workout week, and we adapted it from a great book by… oh, man, it was published by Runner’s World. It was called Train Smart, Run Forever. And we basically took the idea of the seven-day workout week and adapted it for this specific thing. But his idea, the author’s idea, was basically, to be a lifelong runner, you obviously need to not just run, you need to work on all those things that break down over time, the right muscles, maybe it’s endurance and functional capacity. So we took that and adapted it for, okay, what does it mean for somebody transitioning from conventional running to natural running? What does that mean for their foot strength, their posture, all of that?
So it starts with basically understanding those forefoot exercises and then what they called weightless or barefoot weight-bearing. And this is based off of a study that was published in the Foot & Ankle Orthopaedics in 2018, but they basically outlined four exercises, two of them are similar. So there’s seated foot doming, which is trying to draw your feet up like that, like you’re arching your feet. You do that standing-
Steven Sashen:
Wait, for people who are just listening, can you describe that again?
Rafi Salazar:
Yeah. You’re basically putting your heel and your toes flat on the ground, and then you’re keeping them on the ground, you’re trying to pull them together, almost like you’re crunching your foot up, trying to arch your foot. It’s an isometric contraction, you’re trying to hold it three to five seconds. And you do that while you’re standing, so you’re weight-bearing and then you’re doing it, and then you’re doing it while you’re seated. And those are the first two exercises. The next one is plantar flexion and inversion. So plantar flexion is just pointing your toes, and then inversion is bringing the sole of your foot towards the midline of your body, so you’re pointing your toes and bringing them in. And then the last one is just spreading your toes, spreading them apart and closing them. And doing this in conjunction with what they call barefoot weight-bearing, which is just walking around in bare feet, for at least two hours a day, five days a week, increases the strength in your calves, your feet, obviously, your foot muscles, and can decrease injuries going forward.
So the title of that study is, Can Foot Exercises and Going Barefoot Improve Function, Muscle Size, Foot Pressure During Walking and Qualitative Reports of Function in People with Flat Foot? So what they actually did in this study was, they measured the arch of people’s feet over time during this program, and it was an eight-week program, and the majority of people who came in with flat foot deformity did these exercises. They didn’t do any other… they didn’t run, they didn’t do any other kind of exercise programs, they didn’t wear orthotics, they just did these exercises, and then they walked around in bare feet. And the majority of them, I think two thirds or so, ended up with actually a defined arch at the end of eight weeks.
So it builds the intrinsic foot muscles of your feet, the muscles of your feet, which is the platform for all of the running going forward. If you think about what a foot does biomechanically, you’ve got this arch, and that arch can spring and absorb some of the cushion, and then it’s also stabilizing you as well. So the first level is, every single day, you’re going to do these foot exercises and you’re going to walk around with bare feet. Regardless of whether or not you’re going to wear normal shoes when you’re running, or whatever, you’re going to work on the intrinsic muscles of your feet and improving the balance and then the strength, obviously going forward.
Steven Sashen:
That’s it?
Rafi Salazar:
No, that’s just the first part.
Steven Sashen:
That’s the beginning.
Rafi Salazar:
Yeah, that’s the beginning. And then each other day, so you’ve got three days where you’re running, and then the other days you’re doing some kind of cross-training. And then one day a week is just a recovery stretch day. And basically, what you’re doing is some kind of cross-training. Now, we give you some examples in the book, like jump rope, cycling, rowing, and all those are really focused on the endurance, functional capacity side of things. We always recommend jump rope for the first eight weeks until you’re transitioning, because that’s really where you’re going to build some of that intrinsic foot strength while you’re actually jumping, but then you’re also getting eccentric contraction of the calf, which running and transitioning into a forefoot motion means you’re landing on the front or the middle of your foot, and then your heel is lowering down. And if you have not strengthened your calf or your gastroc, you’re going to end up with tightness, with soreness, possibly some injuries if you do it too long, too quickly.
So the jump rope, doing that as a cross-training, gives you the added benefit of that, you’re not losing any endurance, you’re building some of that functional capacity, but then you’re also training those foot muscles and the gastroc for what will eventually be a long run landing on your midfoot. So those are the cross-training days. And then there’s just various strength exercises, and you’re focused really on the posterior kinetic chain, which is, we’ve mentioned your glutes, your hams, your calf muscles, a little bit of core work. And basically, the idea there is that you’re building the strength foundation for all of your running.
So most runners, and really people in the US in general, because we sit at a desk all day, and because of the way we overstride a lot of times, you get strong anterior kinetic chains, your quads are very strong, your hip flexors are tight. Most people can’t extend their hip or kick their leg back very, very far because it gets tight up in the iliopsoas area, the quad area. So we work on stretching those as well. And then strengthening your butt, your glute, your hamstrings, because those are going to end up pushing you or driving you forward in a forefoot pattern instead of pulling forward with your quad.
Steven Sashen:
I heard something the other day. It was an interview with the author David Sedaris, who moved to France, and some people mentioned to him that he walked like an American. And he said, “What does that mean?” He says, “You throw your legs in front of you.” And that’s what we do. We don’t use our glutes and our hamstrings to extend, to push ourselves forward, we throw our leg forward and hop over it. We’re using the exact opposite muscles for what’s optimal.
Rafi Salazar:
Yeah. And from just a standard impact force of what that’s doing. When you overstride like that and you hit with your heel, not only you’re working those quads a little bit more, but the energy transfer is basically like, you’ve taken this straight rod and you’ve just jammed it into the ground. So the force is going right up the kinetic chain, up your ankles, knees, into your hips and into your lower back. So it’s not uncommon for runners to have back pain, or low back pain, or hip pain, and a lot of times, it’s just they’re striding and they’re smacking the ground super, super hard.
I was talking to a PT friend of mine the other day, he owns a PT clinic as well, and one of his guys is really into running. And he was running on the treadmill, this PT friend of mine, and his colleague came in and was like, “Dude, you are so loud on this machine. It sounds like you’re trying to bring down the building.” And a lot of it was from that overstriding. So a few things that he did was just he shortened his stride length, increase his cadence, and the sound went from like thunk, thunk, thunk, thunk to more like tap, tap, tap, tap, tap, tap, tap, and that’s what you want when you’re running. And we address that in the book as well, think about how fast your feet are moving. Because the less time your feet are in the ground, one, it means there’s less force coming up the back, but also means you’re running quicker, there’s less impact. It’s good for everybody.
So that’s the first phase is. We’re working on this cross-training, we’re working on strengthening the right muscles, every single day you’re doing these foot exercises and you’re walking around for at least two hours a day barefoot. Some of our folks will try to break it up like, “I did an hour in the morning, an hour in the evening.” Sure, the goal is just to increase over time. I always tell people like, “Unless you’re in public, there’s really no reason for you to wear shoes.”
Steven Sashen:
I would argue that even if you are in public, it’s totally cool. Depends on where you live. Obviously, if you’re in a beach community, then it’s really easy to do that. So there’s times where I’m in Costco in bare feet, and there’ll be parent and kids, and the kids will go, “Mommy, that man’s not wearing shoes.” And if the parents are nice, they’ll say, “Why don’t you ask them about that?” And they go, “Well, how come you don’t wear shoes?” I go, “Have you ever been to the beach?” And they say, “Yeah.” I go, “Do you wear shoes?” They say, “No.” I go, “Why don’t you just pretend we’re at the beach?” They go, “Okay.” They’re totally hip to it. It’s also-
Rafi Salazar:
…parental problems everywhere now.
Steven Sashen:
Well, that’s my goal. It’s also really fun. If you haven’t been in a grocery store in bare feet, where the floors are nice and smooth and cold on a really hot summer day, and then you go to the produce section when the mister goes off and you just hang out there. Oh man, that’s the best.
Rafi Salazar:
Nice.
Steven Sashen:
So, so, so, as we bring things in for a landing, if people want to find out more, A, about you and what you’re doing, and the program in the book, let them know how they can do that.
Rafi Salazar:
Sure. Yeah. They can find us at pro-activehealth.com. We’ve got a tab there for running resources, but the book is called The Natural Runner, an eight-week training program to transition to barefoot or natural running without injuring yourself, I think.
Steven Sashen:
There we go. And I love that you’ve adopted natural running, because my favorite thing, I wanted to bring this up earlier, is you watch kids learning to run, and everything we’ve talked about is how they naturally do it, they don’t need any instruction. And there’s one other thing they do when they’re running this way, which is, a weird thing… Smiling, yeah, they have a good time. So, so Rafi, this has been an absolute pleasure and I’m thrilled to hear your story, and I’m hoping that more people inspired by it and understand just those little idiosyncratic differences as well. I like talking to people who have taken a dive into this, not just from their own experience, but also from the research side as well. But to highlight that it’s not… people always ask, “Is there a program?”
And while you’ve created a program, I’m sure your experience has been that for some people can go faster, some people takes more time, less time. And that thing that you described of basically becoming your own coach by listening and experimenting, that’s the best thing in my mind, because then you’re not swayed by people’s stories of they think that they can make you better with some magic technology that doesn’t really have any validity. And that’s another one of my goals, to make people immune to marketing bullshit.
Rafi Salazar:
Yeah. We quote this article in the book. The quote is something along the lines of like, “We’ve invested so many millions of dollars in running technology, but, quote, ‘the perceived benefits’ of injury reduction with this running technology has not borne out in the literature.”
Steven Sashen:
Not even in the literature, in the people who are doing the actual running. That’s the thing. In the early days with maximalist shoes, I was training with a handful of Olympians, and I said to them, “In two years, you won’t be able to run again.” And they’re like, “Yeah, I’m putting in more miles than ever with these things.” I went, “Yeah, yeah, I know. Your knees will be blown out in two years.” And two years later, they all switch to cycling. They literally couldn’t run. And ironically, they could now if they transitioned properly and got back into a natural form. But again, you tell people something that they don’t believe and their natural reaction is to disbelieve you, especially coming from somebody like me, where I’m not an academic, I’m not a researcher, I look the way I look, and I’m a sprinter, put it all together, and I own a footwear brand.
The irony is, I wrote this line down the other day, “I started a footwear company because I hate shoes so much,” which I think I have to make a video where that’s the opening line, just to see what happens because people don’t really get it. But anyway, do me a favor, give me your URLs one more time for everyone.
Rafi Salazar:
Sure. It’s pro-activehealth.com, and then the book is called The Natural Runner, an eight-week transition program, something or other.
Steven Sashen:
It’ll be obvious when you get there, that’s the point.
Rafi Salazar:
Exactly. Yeah.
Steven Sashen:
Yeah. Perfect. Well, A, thank you again, and B, we’ll have to talk offline because I’d love to help promote what you’re doing, since obviously, it’s what I believe in, and you’ve codified things in a way that we can add to our library of things for people to jump into. And by the way, speaking as a former competitive rope jumper, I love that you suggested that as well, because undeniably, that can help build strength better and faster than almost everything other than running, frankly. And for everybody else, thank you, thank you, thank you for joining us. A reminder, again, just head over to www.jointhemovementmovement.com. You’ll find all the previous episodes of which there are a bunch, and you’ll find ways you can find us on social media. And if you want to drop me an email with a suggestion, a comment, someone you think should be on the show, whatever you want to toss in my direction, just you can send that to move, M-O-V-E, at jointhemovementmovement.com. And until next time, go out, have fun, and live life feet first.