FYI: Understanding Where Foot Pain Begins

Article reprinted with permission from Neil J Feldman, DPM. For more information, visit Dr. Feldman online at

The key to running form, and running injury free, starts with a stable base. While most people would think that the base is a stable foot or a stable shoe, the truth is that the base is NOT the foot! The base is the pelvis. Though the feet are what lands on the ground, the pelvis is where all movement is initiated. Our legs (and feet by extension) attach to the pelvis from below and provide the motion initiated from above. The spine connects to the pelvis from above and provides holding control while the torso rotates and counterbalances leg movement. When running, and performing most sports, the pelvis is where it all begins. To highlight this point, think of which weight bearing activities are tolerated when you have an injured foot. People who can’t run due to injury are often able to ride a bicycle or use an elliptical machine. Having less pressure and load on the foot helps, but the real reason lies in the pelvis.

From a professional standpoint, there are certainly times when I recommend a bike or an elliptical machine for my injured patients. A bicycle seat stabilizes the pelvis. The body is able to leverage against the seat and keep leg motion consistent. To discourage bad habits, it’s important to maintain a cadence that is in the proper run range (greater than 85 rpm). Below 85 rpm, athletes and patients tend to push the pedal with each stroke rather than lift with the opposite leg. You wouldn’t want to rely on one leg to carry all the effort when you have two that can do the job. Pedaling efficiency is no different than running efficiency: wasted motion costs energy. Above a cadence of 85 rpm, you’re much more likely to engage your hip flexors (front of hip) to create lift on the pulling leg and move through the classic dead spot in the top of the pedal stroke (between 10 and 2 o’ clock).

When the cadence (and efficiency) drops, and the push greatly outweighs the pull, there is increased force placed through the ball of the foot. Many triathletes who have not developed proper cycling skills present with a complaint of forefoot pain precisely due to this phenomenon.

The elliptical machine, with its absence of foot strike, has an advantage with the injured athlete. It reduces stress on the pelvis by “pushing” one leg up, and removes the need for the athlete to lift the leg. Athletes can then “run” without pelvic stability. This can be beneficial with certain injuries, however, the body can adapt to not using the hip flexors to create leg lift. The act of moving one leg down automatically brings the other leg up. It’s as though we are allowing our body to walk or run while only stepping down and never having to lift the other leg. This is bad as we would now have to rely entirely on the feet to move us forward. By spending a lot of time on the elliptical machine, you “run” the risk of developing very bad habits.

The role of the hips

In Chi Running (Danny Dreyer, 2009), the pelvic position is the key to maintaining posture and form during running. Anatomically, there are many muscular attachments on the pelvis, but I will highlight four main groups. When your pelvis is in neutral (not tilted forward, back, or rotated), the transverse abdominus, (deepest abdominal layer), the multifidi (low back muscles), psoas (hip flexors) and hamstrings are all in harmony. The transverse abdominus functions as a primary pelvic stabilizer. This takes tension off the other muscles that attach the pelvis. Because most of us sit, and started to do so at a young age, most of us have a pelvis that is tilted forward. (The best guess as to why this occurs is due to the relative shortening of the psoas in a sitting position, the adaptation it makes over time as well as the adaptive weakening of the posterior hip.) The abdominals are a thin, sheet-like muscle that is unable to contract or relax like a bicep muscle. When it is stretched, it can no longer stabilize the pelvis. With forward tilt of the pelvis, the abdominals and the hamstrings are placed into relative stretch, while the psoas and multifidi are shortened. Shortened muscles quickly become dysfunctional when they adapt to the new position. This leaves the hamstrings as the only major group that can stabilize the pelvis, though the hamstrings should have a distinctly different role (hip extension and knee flexion). This is precisely why patients and athletes complain of chronically tight hamstrings. In many instances, the hamstrings aren’t tight. They are just being “flexed.”

What does this have to do with the feet?

In normal function, our hip flexors should be able to provide leg lift on the up (swinging) leg, and the hip stabilizers should be able to stabilize the body on the down (standing) leg. Pelvic dysfunction can be defined as improper or inadequate stabilization (holding).

If this involves a forward tilt of the pelvis, the psoas is unable to do its job as intended, and the body needs another strategy to complete forward movement. This strategy requires using our feet to push our body forward. The feet are made up of small bones, small joints and small muscles that weren’t designed to push the entire body forward with every step. Large bones, large joints and large muscles in our hips perform that job. Think of how much easier it would be to walk in place for hours on end rather than do calf raises for hours on end.

Change in center of gravity is another part of forward pelvic tilt that affects the feet. When our pelvis is in a neutral position, weight should be evenly balanced between the ball of the foot and the heel. As the pelvis tilts forward, the weight shifts back toward the heel, which causes our calf muscles to engage for balance purposes. Just as the hamstring is overworked and doing a job it’s not supposed to with forward pelvic tilt, so too is calf musculature. By turning calf muscles on (increasing load per step), their function becomes altered and they become limiters of ankle mobility rather than enablers of normal foot function.


Normal function starts with a neutral pelvis. Balanced posture is the key to running efficiently. We walk before we run for a reason, in much the same way as we have to learn how to stand before we walk. Just as the first time we learned to run in our lives (as toddlers), without balanced posture, it will be impossible to learn how to run properly as an adult if you don’t know how to stand with balanced posture. Good posture is the key to efficiency whereas bad posture must be overcome somehow. Most foot injuries from running result from asking our bodies to function beyond its capabilities by using our muscles and joints inappropriately.

With fatigue, the pelvis loses stability and the upper body leans forward. The hip angle and hip range of motion is reduced as a result. The foot will land in front of the body (think relative positions, as if the upper body is leaned forward, then the foot should be landing in line with the body, and thus behind the pelvis), and the toes will have to lift to allow the foot to clear the ground as the hip won’t be able to lift high enough. The leg muscles in the shin lift the toes and with time and fatigue lead to shin splints. The heel will hit the ground first and can lead to plantar fasciitis and achilles tendonitis (though this is not due specifically to the heel strike), among other ailments. The toes will grip the ground to stabilize the foot which can lead to bunions, hammertoes, metatarsal pain, stress fractures and neuroma’s. Those are just the foot related issues!

Creating a significant base of fitness is crucial to any training program. Without that base, we fatigue quicker and fall into bad movement habits quicker, increasing the risks of these injuries.

How do I put this all together?

Starting with good posture, run relaxed, lift the legs and lean slightly forward with the lean coming from the ankles (see Figures 1 and 2). Keep the hips stable and land more towards the ball of the foot, with every foot strike occurring underneath the body. Sounds simple, right? Reading articles like this, reading books, listening to coaches, friends and doctors can be confusing. Everybody seems to have an opinion and/or a solution. We are all unique individuals who bring different body types, with different strengths, weaknesses, levels of dysfunction, to the table. There is no cookie cutter approach to figuring things out and as such, it would be impossible to say what specific needs each of you reading this article would require. What’s presented here is the goal all runners should try to reach, but it may take time to get there. Be patient, and work with what your body allows.

Figure 1: Maintaining posture at foot strike. The yellow line indicates where alignment should be: ankle, hip, shoulder and ear. The image shows that the upper body is slightly forward of the posture line and thus there is too much bending from the hips. The blue arrow indicates where the elbow should be at foot strike, with an arm angle close to 90 degrees which is ideal. Also, the wrist is above the waist which is also positive. The red arrow indicates the how the stride extends behind the runner, as opposed to out in front.

Figure 2: At lift off, posture is maintained (head should be slightly forward an in line with the yellow line passing through the ankle, hip and shoulder), the bend comes from the right ankle (not marked here) and the left knee (red arrow) is driving up while the left foot remains neutral or relaxed.

(Gait analysis photos provided through Central Massachusetts Podiatry, PC utilizing Dartfish professional software).

Neil Feldman, DPM is the owner of Central Massachusetts Podiatry, a 3 physician practice located in Worcester, MA. Dr. Feldman is Board certified in foot surgery and a Fellow of the American College of Foot and Ankle Surgeons. He has completed numerous Marathons and 7 Ironman triathlons including the Ironman world championship in Kona twice. Last year Neil completed the Vermont 100 mile run in 21 hours, 34 minutes. More information about Dr. Feldman’s practice can be found at