Photo: Votography Images

By: John Fiore, PT, owner of Sapphire Physical Therapy

The function of the foot

There are many simple yet highly effective exercises to aid in foot function

The human foot is an evolutionary marvel. The human foot contains twenty-six bones, thirty-three joints, and one-hundred ligaments, muscles, and tendons. Humans have the unique ability to walk on two legs (bipedal walking), due in part to the ingenious balance of mobility, shock absorption, and propulsion found in our feet. Our ancestors climbed trees and traveled on all four extremities. As humans diverged from our primate ancestors, our toes shortened for push-off, our heel (calcaneus) mass increased for foot strike, and our mid-foot arch developed for shock absorption and recoil.

Why focus on foot function?

Most of us keep our feet covered in socks and shoes and rarely considering the important role our feet play in our daily lives and recreational activities. I have seen many feet in twenty-eight years of physical therapy practice, and I am confident that there is no such thing as the perfect foot. The take home message of this article is the importance of regularly addressing foot joint mobility, strength, and balance to allow your unique feet to function properly for a lifetime.

John Fiore helping a runner after the Snowbowl 15k. Photo: Votography Images

Foot stress increases when the ankle joints are stiff. When the lower leg and foot musculature (intrinsic muscles on the bottom of the foot) are weak, foot and ankle strain increases. In addition, foot and ankle joint impact increases when our foot is not capable of effectively absorbing and transferring impact force associated with landing, especially during running and jumping activities.

Next steps

While it is true that more impressive exercises exist (squats, lunges, deadlifts, planks), there are few exercises as important for living, working, playing, running, or jumping without pain than foot-specific exercises. I recommend being proactive in regard to your foot health, especially if you have recreational or competitive goals in 2021. Make an appointment with one of our physical therapists for a consultation, individualized exercise program, and training recommendations. Sapphire PT specializes in foot and ankle treatment. Our services range from preventative, to post-operative, to custom foot orthotics fabricated on-site for your unique foot issues.

Photo: Seth Orme

Evie Tate, PT, DPT
Sapphire Physical Therapy

Bone stress injuries (BSI) or “stress fractures” are one of the more common running-related injuries seen in female runners (1,2). These injuries occur when our bones are broken down faster than they can be rebuilt.  There are a few reasons why runners are more susceptible to BSIs, some of which being the repetitive, uniform loads applied through bones with each step and the perception that “lighter is faster” in regards to body weight.  This is where Relative Energy Deficit Syndrome (or RED-S) comes into play. RED-S looks at all the systems in the body that can be negatively impacted when we do not take in the same amount of energy (i.e. food) that we are expending (3).

One of the things that can happen when someone is experiencing RED-S is that they can develop low bone mineral density, which in turn can increase the risk of developing a BSI (3). As you can see in the graphic below, when someone is dealing with this energy imbalance, it can have major implications not just on bone, muscle and tendon health, but also on mental and emotional health (3). Common signs and symptoms of RED-S include disordered eating, amenorrhea in females, low testosterone in males, fatigue, and depression/anxiety (3). It is important to understand that RED-S can negatively impact you both athletically and in your day-to-day life.

Mountjoy, 2018


When working to improve bone mineral density and address signs of RED-S, it is important that you use a multi-disciplinary approach.  This means, you may work with a physical therapist, dietician, primary care physician, and/or a psychologist. It is also important that each member of your care team communicates and is working together. 

From a physical therapy perspective when combatting low bone mineral density, it is important to incorporate strength training and plyometrics, or jump training. In order for strength training exercises to be most beneficial for improving bone mineral density, you must be lifting heavy weights, not just performing body weight exercises (4). Heavy strength training has been shown to be more beneficial for improving bone mineral density than bodyweight exercises alone (4). Once your physical therapist feels you are ready, you should incorporate plyometrics into your routine.  Jumping, when added in conservatively and progressively, can aid in improving bone mineral density as well (5).  

A key takeaway is that while running is a wonderful sport, it can quickly move across the spectrum from helping your physical and mental health to hurting it.  Ensure you are taking the steps to protect yourself and incorporate strength training and plyometrics in your routine!

For more information regarding RED-S in endurance athletes, join us on Saturday, April 10th for our Women’s Running Clinic virtual seminar. We have speakers across the community discussing various topics related to all things running, including disordered eating and REDS in runners. Register here:



1 Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014;48(7):491-497. doi:10.1136/bjsports-2014-093502 

2 Wentz L, Liu P-Y, Haymes E, Ilich JZ. Females Have a Greater Incidence of Stress Fractures Than Males in Both Military and Athletic Populations: A Systemic Review. Military Medicine. 2011;176(4):420-430. doi:10.7205/milmed-d-10-00322 

3 Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. doi:10.1136/bjsports-2018-099193 

4 Mosti, Mats P, Trude Carlsen, Elisabeth Aas, Jan Hoff, Astrid K Stunes, and Unni Syversen. 2014. “Maximal strength training improves bone mineral density and neuromuscular performance in young adult women.”  The Journal of Strength & Conditioning Research 28 (10):2935-2945.

5 Vlachopoulos D, Barker AR, Ubago-Guisado E, Williams CA, Gracia-Marco L. The effect of a high-impact jumping intervention on bone mass, bone stiffness and fitness parameters in adolescent athletes. Archives of Osteoporosis. 2018;13(1). doi:10.1007/s11657-018-0543-4 




Photo: Seth Orme

By: Evie Tate, PT, DPT at Sapphire Physical Therapy

Have you ever had an overuse injury like a tendinopathy (also known as tendinitis)? A common misconception about this injury is that rest is the most important piece to recovery. Though rest is important, it is not the most important part of your recovery. While adjusting your training volume during a time of injury, you should also be progressively loading your tendon.  Tendon fibers become stronger when they are put to use in an intentional way.  

We know that tendon injuries for runners are typically due to overuse. Running can put up to eight times one’s body weight through the Achilles tendon with each step (1). We also know that a single, unweighted calf raise only puts around 3.5-3.9 times one’s body weight through the Achilles tendon (2). In order to withstand the demands of running, we must perform exercises that are heavier than just our body weight alone. 

When introducing exercise with heavier weights, it is important to start out with lighter weight and higher reps.  Every week or two, as your body adjusts and becomes stronger, you can increase the weight you are lifting and decrease the reps. This is what we mean by “progressive loading.” This is the best strategy to use when introducing heavier exercises into your workout routine.  Some excellent exercises for runners to start implementing into their routine include calf raises, squats, Romanian deadlifts (RDLs) and lunges (3).  Depending on the amount of running you are doing, you most likely only need to complete these lifts two to three times a week, with at least one rest day in between to ensure you are allowing your body optimal time to recover. 


1 Willy RW, Halsey L, Hayek A, Johnson H, Willson JD. Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. doi: 10.2519/jospt.2016.6494. Epub 2016 May 12. PMID: 27170525

2 Effects of minimalist and maximalist footwear on Achilles tendon load in recreational runners. ResearchGate. Accessed January 7, 2021.

3 Blagrove RC, Brown N, Howatson G, Hayes PR. Strength and Conditioning Habits of Competitive Distance Runners. J Strength Cond Res. 2020 May;34(5):1392-1399. doi: 10.1519/JSC.0000000000002261. PMID: 29023328.

Welcome to the Quarantine Q+A

Each week we interview members of our community to learn how the Corona Virus pandemic has impacted their lives, and how they are adapting in these challenging times. Our ‘Quarantine Interviewees’ are healthcare workers, small business owners, parents, service industry employees, and, of course, runners. We hope that by sharing the stories of our neighbors, we can find inspiration, solidarity, and connection as a community in the coming weeks and months. Please enjoy! 

For the first installment of the series we catch up with Sara Boughner. Sara is a licensed and practicing physical therapist at Sapphire PT in Missoula, a member of the Women’s Big Dipper Running Team, a dog lover, and most recently she won the Siuslaw Dunes 25K trail race in Oregon last month! Get to know Sara and how she is working hard to stay healthy, motivated, active, and connected amidst these wild times.

Thanks for joining the quarantine Q&A! First off, how long have you lived in Missoula?

I have lived in Missoula since September 2014, but it seems like forever since Missoula feels like home.


Are you training for an upcoming race? If so, which one? Has it been canceled or postponed?

I am training for the Scout Mountain 21 miler in June, and ultimately the High Lonesome 100 in July, but the word is still out about whether or not those will happen. I have been dreaming of alternative adventures in Montana in the event that my races get cancelled, but mostly I am taking it day by day and training for life!


Amidst these uncertain times, what challenges are you facing and how are you maintaining motivation?

I imagine that I am facing similar challenges as many people right now. To name a few: uncertainty, consideration for how I can be the most helpful to my community, and how to stay mentally and physically healthy when routines and rhythms have gone awry. Maintaining motivation is multi-faceted for me. I start with recognition of gratitude for what I have: the ability to move my body; the ability to go outside (alone); a network of friends, family, and colleagues who support me in figuring out how to most responsibly navigate this ever-changing situation. It is a wild ride right now, and I am thankful to additionally lean on my running coach to not only get me out the door every day, but also make sure that I am not doing too much and putting myself at risk for injury.


In what ways are you staying active? 

I have been running solo on the roads and trails, trying to avoid crowds and also maintain stewardship of our trails by stepping off and waiting for others to pass. Walks and hiking with our dogs have remained a necessary part of the routine, as well. I keep thinking about dusting off my mountain bike, but the call of putting my feet on the ground is still too strong.


Are you doing workouts at home? If so, how are you getting creative?

I have been doing some workouts at home, though my usual routine is mostly running. For my running-specific strengthening I have been getting creative with weighted squats, step ups, and heel raises while wearing my loaded-up backpack. I have been motivated to keep up with core and push ups by staying accountable to friends on a text thread where we text “DONE!” to each other every day.


How are you investing in your mental health these days?

Mostly I pet my dogs. Running, deep breathing, lots of sleep, and remembering to take the pressure off everything I do has also been important for me. Taking moments to sit in the sunshine (when it makes an appearance), doing virtual hang outs with friends, and simply acknowledging my stress levels have also been helpful. Gratitude and perspective are always important for my mental health, though this is often easier said than done for me. At this point, my mantra has become, “smile through the suck.”


As a health care worker, what are some of the largest ways that the COVID crisis has changed your work life in recent weeks? 

I work as a physical therapist at Sapphire Physical Therapy, an outpatient orthopedic clinic in Missoula. The COVID pandemic has significantly impacted our caseload, and I have transitioned my patients to telehealth visits. We are currently adapting to a new reality in healthcare, and we are continually evaluating ways to safely offer the care that our patients need. Though I am not a healthcare worker on the “frontlines,” it is important to recognize that COVID-19 has impacted the healthcare system as a whole, and will likely transform how primary and secondary care is accessed for the time being.


Are there any silver linings or positive moments you have experienced due to the COVID crises you would like to share?

Appreciation for time spent with others has been a huge silver lining to see across the board. Seeing families out for hikes and walks fills my heart. In any time of crisis, it is always inspiring to see how others bring kindness to the table. Simple acts like making masks for healthcare workers and grocery shopping for others in higher-risk categories are some of the stories that will get us through this time.


Where are you finding inspiration right now? (books, music, podcasts, people, etc.)

The Physical Performance Show Podcast with Brad Beer, and NPR’s Hidden Brain Podcast. I just finished Where the Crawdads Sing as my fictional escape.


What does the Missoula running community mean to you in a time like this?

The Missoula running community has always served as an incredible support network. I look to Runner’s Edge, Run Wild Missoula, Missoula Parks and Rec, and Montana Trail Crew for leadership and guidance regarding how to maintain physical distancing while running and keep our trails from being negatively impacted. Most importantly, though, the running community in Missoula serves as family during a time like this. We understand and respect each other’s need to run for our health, and also know that we can lean on each other (metaphorically) if needed. Seth Swanson’s “Keep Your Distance Phatty” [virtual challenge and food bank fundraiser] was a great example of this.


Anything else you would like to share?

Of course, a big thank you to everyone who is working tirelessly to lessen the impact of this virus. Additionally, an appeal for kindness. Approach every situation, no matter how infuriating, with kindness to each other and yourself. It is a big task, but the last thing we need right now is unnecessary negativity. Stay safe, practice appropriate physical distancing for the greater good, and remember we are all in this together.


We enjoyed getting to hear from Sara and hope you did too! If you think this interview would add value to someone in your life, please consider forwarding this email to them.

Also, if you are enjoying the Quarantine Q&A series, or have a question you would like us to ask our interviewees, let us know! Email