Socialized Medicine Impact On My PT Practice

For 20 years I practiced in Socialized Medicine as a Physical Therapist in the Army.  What is the thought process of a Socialized Medicine Clinician?

….I get paid the same whether I see you for 30 visits or 3 visits…so it behooves me to heal you in as few visits as possible, so I can see the next patient and the next patient as quickly as possible.  So, every skill as a clinician is aimed to heal my patients in as few visits as possible.

  1. In 20 years of becoming as skilled as possible at healing my patients in the fewest visits, which skills attributed to that outcome?

    Manual Therapy.  I average 3-4 visits from evaluation to resolution of symptoms and that’s because I put my hands on my patients.  My hands tell me what systems need to be treated, my hands do the treatment and the patient’s body is able to complete the healing with typically one exercise or activity modification.

  2. As a socialized medicine clinician, you eliminate those aspects of your practice that don’t lend to your patients’ healing or at least don’t give you optimal bang (results) for your buck (time).  What did 20 years of practice in that setting teach me was fairly useless for the time invested by myself, my staff and my patient?
    1. Modalities… Time and time again, studies have shown that things like ice, heat, ultrasound, electrical stimulation and use of a LASER are of very limited value to the patients’ healing.  Guess what… Bare Necessities doesn’t own a single modality.
    2. Exercise… A lot of physical therapy practices provide a lot of supervised exercise time as it’s reimbursed well by insurance carriers and doesn’t require a lot of “work” on the part of the clinician.  However, in my experience the more exercises involved in a rehab program, the less likely a patient will be inclined to do any of them once discharged, especially if they involve equipment like a stationary bike or weight machines.  Once again, Bare Necessities owns no exercise equipment.  Typically, I’ll prescribe at most one exercise and that exercise typically involves no equipment that a patient wouldn’t already have access to in his or her home.
  3. Three visits/week… When I first left the Army, I worked for a civilian clinic and it always bothered my boss that I wouldn’t schedule my patients 3 visits/week x 4 weeks.  That’s how a lot of insurance based clinics operate: get the patient to commit to as many visits as possible.  Part of the reason they need so many visits is that these Physical Therapy practices offer very little manual therapy and fill the time with a lot of fluff such as modalities and supervised exercise.  I typically see my patients at MOST 1 visit/week and the course of care is usually complete sometime around the 3-4 visit range around the 6-8th

I’m not blaming civilian physical therapists for their practice philosophy. they are practicing as they were trained and to some extent doing what they need to do to survive with a very poor insurance industry reimbursement rate.

Lastly, in a medical setting with the foundation of healing the patient in as few visits as possible.  I was blessed to receive the Surgeon General’s award for clinical expertise as best of the best, an award that was given to the top 4-5% of military clinicians.  Come to Bare Necessities…it’s physical therapy like you have never experienced before.  There is hope for healing!!


Palpate:  Pal-pate

pal-pat-ed, pal-pat-ing, pal-pates

To examine by feeling with hands and fingers; used by some archaic physical therapists, who (Bless their Hearts) just don’t know any better.


As many of you know, I’m currently fortunate enough to be on an APTA board tasked with developing a definition for a new Board Certification which will fall along the lines of:  Primary Care or Family Practice or Family Health (or whatever title meets consensus).    Well as we flushed out what exam skills should be included in this specialty we fleshed out a solid 2-3 paragraphs on behavioral testing and under palpation?  Nothing.  The Palpate bullet stood alone.  When I suggested it needed some description the other members of the group (all senior and experienced clinicians) didn’t show a lot of excitement to elaborate on the “palpation” bullet.

A little about me….my exam is MOSTLY palpation…the more experienced I become as a clinician the MORE I rely on palpation.  I was an Army Physical Therapist for 20 years and I was awarded the Surgeon General’s award for clinical expertise.  In one year of a cash-based clinical practice with 0$ spent on advertising I had a 4-week waiting list.  I’m only mentioning this to underscore that I must be doing something right as a clinician and palpation is the cornerstone of my practice.

I always tell my students that “your eyes can be fooled, your ears misled, but your hands will perceive a true reflection of what is happening in your patient’s body.”  If my clinical experience has any validity to it at all…and I’m inclined to believe it does based on my patient success rate…then why has the profession of physical therapy turned away from palpation?  I feel that as the pendulum has swung towards Evidence Based Practice, it has at the same time swung away from Intuition and Feeling of which palpation is a tool.  Our research based institutions have a hard time “measuring” palpation for validity or reliability and so it’s been shunned to a great extent.

I’m not arrogant or foolish enough to think that the ramblings of an “old” clinician will affect any change of teaching in any physical therapy program, I’m just mentioning it here to plant the seed for younger clinicians.  These younger clinicians who at some point in their career may become “burned out” or disillusioned with their profession because patient after patient just doesn’t seem to be making spectacular improvement in spite of following the Clinical Practice Guidelines to the letter.  I’d advise these younger clinicians to take a moment…close their eyes, screen their ears, turn ON their intuition and really “feel” what their hands and fingers are palpating.

Shin Splints



The most common cause of shin splint pain is excessive (in magnitude or duration) of tension on the tibia by the Posterior Tibialis muscle.  The reason the pain is so extreme is that the Posterior Tibialis muscle fibers blend with the skin of the Tibia which is called the periosteum.  The periosteum has the majority of all sensory nerve endings in the entire bone…so if you are having shin splints, you are having “bone pain” as if the periosteum is tearing…that can be excruciating


Once you understand the job of the Posterior Tibialis you will understand why it hurts and how to facilitate healing.  When you walk or run the arch on the inside of your foot lowers with shock absorption impact in a motion termed pronation

shin 3

The Posterior Tibialis resists this pronation motion much like a shock on a car. So, the more the foot and leg roll inward in both the magnitude and duration…the more “work” demands are placed on the Posterior Tibialis as it resists this collapse of the inside of your foot.  The more the Posterior Tibialis works, the more it pulls on the periosteum and the more likely you will have shin pain.

Treatment for Posterior Tibial Shin pain.

  1.   Ice will work as an analgesic…it treats the pain, but doesn’t address the pathology.
  2. Heat is also an analgesic…it treats the pain, but it may improve circulation to the injured tissue which can bring nutrients needed for healing.
  3. Anti-inflammatories. They also work as an analgesic and if taken as prescribed will in time reduce inflammation, so once again they do not address the actual pathology.
  4. Reducing the demand on Tibialis Posterior will lead to true healing of the pathology.  Rest can come in several magnitudes…
    1. Reduce pronation… limit wearing shoes that offer little or no support to the inside of your feet and time walking barefoot.
    2. Reduce pronation… limit walking on unstable surfaces like sand or gravel.
    3. Reduce pronation… you can purchase shoes that offer a higher level of motion control and any reputable running shoe store can help you select those.
    4. Reduce pronation… you can add an arch support to further limit pronation. Feel free to come to Bare Necessities for a free gait analysis to give you advice on both shoe and potential arch support prescription…if you don’t live near Laramie, WY…we are still happy to give you free advice if you can send us video of you walking barefoot on a treadmill.  Email to or send larger files to Anthony.Bare on facebook.
    5. Reduce Impact… decrease minutes of running or walking. Consider non-impact activities like biking and swimming.
    6. Reduce Impact… do your walking or running on a treadmill. A good treadmill provides a level and supportive surface.
    7. Reduce Impact… Reduce running downhill and consider increasing running uphill (once again made easier on a treadmill).
  5. There is no significant role for strengthening for this pathology… Tibialis Posterior is already over worked…more work is not the answer.
  6. There is no significant role for stretching for this pathology… the Tibialis Posterior is as tight as it “needs” to be to do it’s job.
  7. Manual therapy. There is a role for manual therapy to facilitate healing of the Tibialis Posterior and the Tibial periosteum, but if you haven’t addressed #4 above the manual therapy will be much less effective.

While Tibialis Posterior is the most common cause of shin pain, there are other causes and if your symptoms aren’t located on the lower inside of your shin or your pain doesn’t rapidly respond to the treatments suggested above, then it is time to seek medical evaluation.

The Fallacy of Plantar Fasciitis



Plantar fasciitis is such a problem that you can hardly conduct an image search for plantar fascia without returning mostly images of the plantar fascia with a big angry red splotch on the plantar fascia near the heel.

I recently watched a video on Facebook posted by one of my Physical Therapy peers on the topic of plantar fasciitis. I privately messaged him to let him know that I thought his presentation had missed some key points and his reply cited the Clinical Practice Guidelines for plantar fasciitis. There are some issues with that response from my standpoint:
1. The Clinical Practice Guidelines for plantar fasciitis are fairly useless in regards to “what to do” to treat plantar fasciitis and of some limited value in “what not to do”. They very accurately reflect current available research which is of little clinical value in this instance.
2. I’m concerned that my profession is so entranced by Evidence Based Practice (EBP) that they have stopped seeking information or guidance outside of what research has generated, and as a result their patients often suffer through suboptimal care and (pun intended) limp down the clinical plank of failed conservative care, injection and ill-advised surgery. I know this not what the developers of EBP-theory intended, but I’ve seen it just about daily on social media.
3. The research available on this topic is doing very little to help clinicians truly heal their patients of their foot pain. I would dearly love to pitch research ideas for anyone who has faculty connections.
Now off the Soap Box and on to clinical guidance…
– Plantar fasciitis is a misnomer, most of these patients don’t use their plantar fascia at all. A more appropriate term would be “Mechanical Heel Pain”. Typically, the origin of Mechanical Heel Pain is a poor initial contact in stance phase in which the contact is too medial in magnitude and/or duration. The medial aspect of the midtarsal joint, subtalar joint and calcaneus are very neural dense and do not tolerate this increased pressure well and eventually leads to heel/foot pain.


– Unfortunately, a bad initial contact (as described above), has consequences throughout the foot and lower extremity that further perpetuate an inefficient gait cycle. Here are some examples: hallux abductovalgus (painful bunion), metatarsalgia, achilles tendinitis, medial knee pain (pes anserine, plica, etc), lateral hip pain (trochanteric bursitis, piriformis syndrome, etc) and SI dysfunction.
– The good news is that when you treat the cause (improve foot mechanics) and treat the tissue (manual therapy), the patients’ symptoms resolve very quickly…1-4 visits.
If you are a clinician reading this blog and you didn’t delete it from your feed after reading #2 above,  you have practiced long enough to be frustrated at heel and foot pain patients’ poor prognoses. Please consider attending a lower extremity biomechanical course, it will completely change your practice. I teach a 2 day course called Thinking on Your Feet. Of course, I’m biased and think mine is best, but there are some other good courses out there. Give one of them a chance and it will elevate your practice above the limitations of the current Clinical Practice Guidelines.
If you are a patient reading this blog, you may have had “mainstream” care for your foot pain which probably included: activity modification, exercises (strengthening/stretching), modalities (heat, ice, ultrasound), massage, shoe inserts, dry needling, injections or surgery. You have probably been nodding your head the whole time, because you know your foot pain isn’t completely (or any) better. Find a clinician with biomechanical training in this topic or contact me directly for advice at or find out more about my unique practice and skill set at

LTC Tony Bare (ret) DPT, ATC, OCS

Laramie, WY

The Fallacy of Leg Length Correction


For many years I was honored to be the Military’s expert in lower extremity biomechanics and I’ve made tens of thousands of orthotics in my career and yet I’ve only added a leg length correction in maybe 10-20 instances.  The reason this came to mind is that I recently assessed a patient s/p TKA who became one of the very rare patients to add her name to that list.  I thought I would share my thoughts on the subject because I certainly have run into no shortage of patients (and providers) who strongly believe in correcting for leg length difference.

  1.  Since Jesus ascended to heaven there hasn’t been another person on the planet whose legs are symmetrical and really how could we be symmetrical?  The obvious is the actual length of the femur and tibia, but functional leg length difference is more often due to asymmetry of Coxa, femoral, genu, and tibial varus/valgus alignment

        2. Leg length asymmetry is just one part of the picture of frontal plane function…the real culprit is often what’s happening below the ankle and understanding those biomechanics will help you go a long way to deciphering the potential effect of leg length difference on functional biomechanics.

       3. The body has numerous mechanisms to cope or compensate for frontal plane deviations and typically it’s been coping well for years or decades.

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How do I decide whether or not to correct for a leg length asymmetry?  

  1. Has something changed in the bone?  Most of my leg length corrections followed a TKA, THA, or Femur/Tibial fracture.  Some change in bone length that the patient’s body hasn’t lived with for decades.
  2. Is there an observable frontal plane gait deviation?  Look for a drop in the pelvis on one side that would indicate an uncompensated leg length difference that might need intervention.
  3. Does the patient present with chronic or recurrent frontal plane pathology?   Unilateral sacroiliac/trochanteric symptoms (bursitis, piriformis, etc), lateral thigh/knee pain (ITB, Vastus Lateralis, and patellofemoral pain).
  4. You’ve balanced the frontal plane issues below the ankle (typically: rearfoot varus, forefoot varus, and/or unstable midtarsal joint) and the patient’s symptoms have not improved.  The foot has so much more leverage to impact the pelvis, you will be amazed how quickly your posterior and lateral hip pain patients recover when you address frontal plane issues below the ankle.

So you might be asking, why not correct for the apparent leg length asymmetry? What’s to lose?

  1. As noted above, of all the things that could lend to the appearance of a leg length difference, most of them are more variations of angulation (varus or valgus) than a true difference in length of either the femur or tibia (unless something has changed in the bone, see #1 above).
  2. You might actually be creating a leg length asymmetry. (Whatever the patient has going on, they may have been coping well with it for decades and changing that may cause more problems than it improves).
  3. Correcting for a leg length difference inside the shoe can significantly change the fit of a shoe far more than treating the frontal plane issues in angulation below the ankle…and if the patient doesn’t like how his/her shoe is fitting, she won’t wear the correction.   Typically the most correction you can fit inside a shoe before shoe fit becomes an issue is ¼”, so the picture below is for your entertainment purposes.  I was stationed at Brooke Army Medical Center in 1998 when I ordered a “custom shoe modification” for a 2” leg length difference secondary to femur fracture and instead of doing the hard work of adding the correction to the sole of my patient’s shoe, the Orthotist did the ridiculous work of constructing the biggest heel lift I’ve ever seen.  I’ve kept it as a souvenir.

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Postpartum Journal of a Manual Therapist


  1. Prenatal: There is a whole blog written about Amy’s first two births, but I’ll summarize. Graham was a traumatic inverted “T” C-section and Stella was a home birth VBAC (Vaginal birth after C-section). Both Graham and Stella were well past 41 weeks gestation and over 40 hours of hard labor and 4 hours of pushing during the VBAC birth. I treated Amy’s c-section scar and uterus extensively before conception and during the final trimester I did several sacrotuberous and sacrospinous ligament releases. Juliet was born at 39 weeks 6 days after only 5-6 hours of active labor and less than 20 minutes of pushing. I’m not claiming responsibility for the vastly easier birth, but as a manual therapist it sure makes sense that I contributed.  From Amy: I feel like the work that Tony did prenatally made a huge difference. Juliet also engaged in my pelvis prior to labor which was a first for me.  My first two births were difficult due to baby’s potitioning and presentation. The assumption (by several medical and  birth professionals) is that I had soft tissue restrictions in my pelvis and also scar tissue that prevented optimal fetal positioning and vaginal birth or easy vaginal birth. Having my husband treat both the soft pelvis and scar tissue allowed the baby to get into my pelvis properly and to rotate and descend more easily in labor. As a former doula I have extensive knowledge in optimal fetal positioning, I made it a point to learn as much as I could after my own experiences and I have a great understanding of how the pelvis and baby work during birth. I actually did less to prepare for my third baby than I did my second one as far as optimal fetal positioning techniques are concerned, the biggest difference was the body work that my husband did. One thing that I really appreciated was that Tony and I could speak the same language when discussing the pelvis concerning pregnancy and birth and then he was able to take it farther with his visceral treatment knowledge. 
  1. Mastitis: Amy started running a fever a few days after birth and sure enough I palpated a rigid quadrant in her right breast. I treated the area 5 times over the next 2 days and combined with Ibuprofen, ice packs and cabbage leaf compresses she had complete resolution of her symptoms in 48 hours without having to drag Juliet and herself to the acute care clinic for antibiotics.  From Amy: On the 3rd day postpartum I started feeling feverish and having chills. I didn’t notice any hardness or swelling in my breast right away but when Tony palpated he felt the blockage and soon it was hard, engorged, red, warm and very painful. I felt as though I had the flu. We gave ourselves  a deadline of 48 hours for improvement or we’d go in. After Tony treated my breast the first time I could tell it was better. The pain was less and it was less engorged. Treatment the first time was pretty painful but each time after it felt better. By our 48 hour deadline it was as if I had never had mastitis at all. My fever peaked at 102.7 (while taking Tylenol) but I was able to stop taking Tylenol completely and it didn’t return. The engorgement and redness was gone and there was no pain. I took ibuprofen for an additional 24 hours. 


  2. Uterinitis: I’m not sure what her diagnosis would have been, but her symptoms included a deep pressure and fullness and a “prolapse” sensation along with feeling “crampy”. On palpation I could definitely appreciate the fullness of the uterus which I treated using visceral therapy techniques with resolution of all symptoms following one treatment.  Amy: The only way I could describe what I was feeling was to use the word prolapse. It just felt heavy and full in my lower abdomen and even in the top of my vagina. I did look “down there” to see if I could see anything since sometimes prolapse after birth can happen and it can be bad enough for the cervix or even uterus to fall into the vagina but I’m happy to report that at 2 weeks postpartum I looked completely normal and pre-baby in the lady area. I didn’t tear during the birth and really had very little swelling so healing was fast externally but I was really glad to see nothing coming out either. I’ve been doing a ton of kegels every day but after the first time Tony treated my uterus that heavy feeling went away.   I did pass some small clots after that treatment but my bleeding is pretty minimal and after the second treatment I had no more clots. I didn’t really want to talk to him about this issue, I am still his wife and want to maintain some level of sexuality and since he had already watched me push the baby out I didn’t want to become “clinical” to him but I realized if I were going to talk to anyone about it, it should be him. He was the most likely to help me and he did. I’m still not 100% sure that I don’t have some prolapse. My pelvic floor is pretty weak and even before this pregnancy I had a lot of incontinence when I sneezed and especially when I run. I still want to do some pelvic floor rehab with a PT that specializes in it but I want to continue to have my husband treat me externally  until I start going. 
  3. Kidney Ptosis: Amy developed left flank pain which was worse when laying supine, with change of positions and breathing. I examined and did some treatment on her ribs, but they really felt fine. When I palpated her left kidney her symptoms were aggravated. The left kidney certainly makes sense for two reasons… 1.) In late term pregnancy the baby spends most of her time on the left side of her mom’s body 2.) There is a genitourinary vein that drains the uterus and ovaries to the left kidney that isn’t duplicated on the right side. This extra fascial structure would tend to drag the kidney inferiorly once the uterus retreats that direction after birth. I treated Amy’s kidney using visceral therapy and had complete resolution of her symptoms in one treatment. Amy: I had sharp shooting pains in my back that had me doubled over and in tears. I thought I’d broken a rib but I had done nothing to injure myself. The pain was so bad that I might have actually gone in for drugs but instead we got up and Tony treated me at 2am. It immediately felt better and I went from not being able to lay down comfortably to being able to go asleep. The next day it was a bit sore and the next day 100% better. This was about the time I started thinking my husband was a miracle worker. It’s not the first time I or someone else has thought that though. 


  4. Sigmoid dysfunction/constipation: Amy was having unusual pain and difficulty with bowel movements and on palpation the sigmoid colon was clearly the culprit. Once again complete resolution of symptoms following one visceral therapy treatment.  Amy: This is another one that I didn’t want to talk about. I don’t like “potty talk” and pretty  much avoid that topic with my husband but after two weeks of pretty intense bathroom pain I had to say something. I also felt like I couldn’t talk about the uterine stuff without mentioning this. Basically, every time I had been to the bathroom since I had the baby was super painful. If you’ve ever had a vaginal birth you know that first time going is pretty scary but it didn’t stop being scary. It got more scary because I knew it would hurt. Simple gas hurt. Laying on my back hurt. After two weeks I finally spoke up and things were better the next day after one treatment. He said my colon felt “ropey”.  I’m happy to report that all is well and I don’t have to talk about it any more! 

Why mention all this? I truly believe that moms are mostly expected to suffer through pregnancy and postpartum pains and difficulties as all part of “being a mom”. Pain and dysfunction are NOT natural states for the human body and I’m a firm believer in giving it a shot manual-therapy-wise. If you are a mom or know a mom recently postpartum, ask her how she’s doing. You may be able to alleviate so much of her pain and birth related difficulties. Trust your hands!  Amy: I do think he’s right that as moms we are just expected to have pain and suffer through it. We don’t have to. There’s so much that can be treated and that can feel better. 

Lastly, if you are one of those therapists who doesn’t believe in visceral therapy, please contact me! If you are open to the possibility, please attend a course and your practice will never be the same again and you will be able to help so many more people!!

The Fallacy of Calf Stretching


For decades physical therapists and physicians have been instructing their patients to stretch their calves for ALL manner of foot pain, heel pain, Achilles tendonitis, ankle pain and calf pain.

What if I told you that the underlying etiology of just about all musculoskeletal foot, ankle and leg pain is hypermobility (over flexible)?

You might reply, “But when I stretch I can feel how tight it is.”

I would counter with, “It’s tight because of an instability elsewhere in the foot-ankle-leg complex…which you are arguably making worse by stretching it.” EVEN THOUGH IT CAN FEEL BETTER SHORT-TERM following stretching. The most common place for hypermobility in the foot-ankle-leg structure is the oblique axis of the midtarsal joint. Every time you walk it is common to bend your foot at this joint instead of at your ankle joint…so the ankle joint/calf is stiff because your body does not make it move in normal gait.


When you stretch your calf, you are actually stretching everything on the bottom of your foot to the back of your knee. Those structures already hypermobile stretch first and most easily, then the structures that have normal flexibility and if you continue to stretch you will gradually make gains in the most “stiff” structures in the chain….but not until you’ve already stretched PLENTY of stuff that did not need it.

Yes, I’ll admit you will gain motion temporarily in the most “stiff” structures, but you won’t retain it, because your body will just continue to bend through the hypermobile joint because it’s easier. The underlying issue is INSTABILITY…you should just about NEVER stretch an unstable joint. You heal the stiffness in the calf, by stabilizing the foot.

How to stabilize the midtarsal joint…

TAPING: In my clinical experience, there has NEVER been a foot pain that didn’t feel better with a low-dye tape job. This rigid athletic tape application stabilizes the hypermobile components in the chain and the whole system feels better when stabilized…not when stretched. There are about a dozen elastic tape options as well.


STRENGTHENING: There is really no external lower extremity muscle that stabilizes the oblique axis of the midtarsal joint…so calf exercises and theraband exercises are fairly useless. There is value in strengthening the intrinsics, so proprioceptive exercises are very useful if symptoms allow.

ORTHOTICS: Arch supports custom and otherwise are of very limited value as they push up into the longitudinal axis of the midtarsal joint and if anything push the Center of Pressure laterally to the already unstable oblique axis. However, custom orthotics designed to specifically stabilize the oblique axis of the midtarsal joint will have a dramatic and immediate impact. If you have any questions about how to order this type of orthotic, please email me at or visit my webpage at

House Slippers for Orthortics

Friends, Amy found a house slipper that works perfectly with orthotics. You can put an orthotic in the slipper or I can put a permanent modification in the slippers for you. With winter coming we needed a good solution for hard floors, cold feet and wearing an orthotic because if you are like Amy, she needs that support when she’s home as much as when she’s not.

The brand is TOMS and the insole that comes with them easily comes out.


TOMS can be found easily online, just Google search it or at Journey’s, Nordstrom Rack and Dillard’s locally.

If you prefer to have the permanent modification the cost is $50 for one pair of slippers/shoes or $90 for two pair. You can also put your existing orthotics in them if you want to swap them out with your other shoes or you can order an extra pair for $85 to use exclusively in the slippers.




How to Avoid Foot Surgery



  Elective foot surgery is expensive, debilitating, time consuming, frequently unnecessary, and patients are often worse pain following surgery. Matter of fact, if you find anyone happy with an elective foot surgery you might also want to go ahead and buy yourself a lottery ticket…the odds are about the same. I always say, “there is NOTHING surgery can’t make worse”.   That is especially true in elective foot procedures.


Has your surgeon told you that you need surgery for the following?

  •  Neuroma
  •  Bunion
  •  Hammertoe
  • Plantar fasciitis
  • or maybe because you had advanced degenerative Osteoarthritis?

Trust me, the surgery will not address the cause of any of the above pathology.  If you fuse, remove, dissect, or realign something in the foot without addressing the cause, you are just kicking the can down the road until you need surgery #2, #3, etc.

A brief bio on me to provide credibility on this subject:  I became the Army’s expert in lower extremity biomechanics and foot/ankle treatment specialist in 2000 and was honored to hold that position until my retirement in 2013.  I’ve attended 120 hours of continuing education in biomechanics and have taught courses all over the country.  I have also successfully treated thousands of patients in my career, relieving their pain and in countless circumstances, avoided the above mentioned surgeries.

The BARE NECESSITIES Do’s and Don’ts of foot pain…

The Don’ts

  1. Don’t see a podiatrist. Podiatrists are foot surgeons and they have little knowledge or inclination toward conservative treatment options.
  2. Don’t let anyone inject your foot. Cortisone injections are somewhat effective in treating foot pain, BUT they do NOTHING to address the cause of foot pain. As a result, when the steroid wears off the foot pain often returns worse than before.
  3. Don’t let anyone sell you a hard plastic arch support. Your foot was designed to bend and flex during the stance phase of gait, and it can’t perform correctly with a hard piece of plastic wedged under the arch. These “custom” arch supports are also expensive and rarely covered by health insurance.
  4. Don’t let anyone convince you that you just need to “stretch” more. Typically the most common cause of foot pain is an underlying instability… instabilities get WORSE with stretching even though it can feel a bit better short term.

The Do’s

  1. Do try a change of shoe. Many times replacing a worn out, or poorly fit shoe will be enough to start the healing process. If possible get advice on footware from a reputable shoe dealership (none of the chains) or medical professional with significant foot/shoe experience or training. If you are on your feet a lot (work, home, sports), don’t skimp on your shoes. You don’t need to spend a fortune, but the shoe market is competitive and you do get what you pay for.
  2. Do try a full length off-the-shelf shoe insert that you can usually get in a running shoe store for $40-$70. This is a semi-rigid arch support and will still allow your foot to flex and bend as it’s intended to, but will still provide some support.
  3. Do find a good manual therapist (Massage or Physical Therapist) to break up the adhesions that are likely contributing to the pain in your foot. If your therapist tries pushing “exercise” as the cornerstone of treatment and does no or very little manual therapy, go find a different provider. This condition cannot be fixed with exercise, though exercise can be a component of recovery…the main emphasis should be on manual therapy (not dry needling) to both lower extremities.
  4. If all else fails…Do find a biomechanical specialist to construct a custom biomechanical corrective orthotic (shoe insert) to address the underlying cause of your foot pain. These professionals are few and far between. I noted above how I became a specialist in this field, and here is a link to my website. You will find information on the difference between arch supports and biomechanical orthotics as well as examples of what I would need to conduct an assessment on you (video and other) if you happen to not live close to Colorado Springs.

Lastly, if you happen to find this blog AFTER you already had a surgery (or 4)…there is still hope. Follow these same do’s and don’ts and you will be amazed at your recovery!!

By LTC Tony Bare (ret), DPT, OCS, ATC

The Calamity of the 1st MTP fusion…


MTP = MetaTarsoPhalangeal, the joint at the ball of your foot where your toe joins…also the joint where patients develop bunions.


I’m not even sure where to start with this blog, my heart breaks every time I see a patient with a 1st MTP fusion…usually they are fused bilaterally. It is a biomechanical disaster that should essentially never happen.

Why do patients have this debilitating procedure?

  • They have 1st MTP joint pain.
  • They have radiographic evidence of 1st MTP degeneration (osteoarthritis).
  • Failed conservative management (arch supports, physical therapy, and medications).

Surgeons motivated to help the patient with their only real tool: surgery and NOT understanding the consequences of fusing this MOST critical joint in ambulation.

What leads to 1st MTP degeneration? Unless you are a ballerina, you have earned a degenerative 1st MTP through bad biomechanics and physics. The most common cause I see for 1st MTP pain and degeneration is a collapse of the Metatarsal or Transverse Arch which is also frequently a victim of further biomechanical issues.

Treatment of 1st MTP pain?

  1. Fix the biomechanics…this usually entails an Orthotic…NOT AN ARCH SUPPORT. (See my post on the difference between a biomechanical orthotic and a “custom” arch support)
  2. Get the 1st MTP joint moving.
    1. Treat the soft tissue on the medial (inside) and plantar (bottom) of the joint.
    2. Mobilize the joint (1st MTP extension in sagittal alignment).
    3. If the 1st MTP has been dysfunction for a long time, there is likely restriction of the plantar fascia and that will need to be treated too.
    4. This is NOT a problem that can be fixed with patient stretching exercises, however use of a “Prostretch” device can be a helpful addition to manual therapy intervention.
  3. NEVER consider surgical fusion of this joint!!! 5 degrees of motion is a whole lot better than zero. It may make the 1st MTP joint feel better to be fused, but it doesn’t fix the problem that caused it to fail in the first place and it forces further compensations up the lower extremity chain of joints where the patient will likely begin to manifest other symptoms (hip/back most common).