Today we have Lizzie Marlow, a specialist physiotherapist from the UK to share her expertise on tibialis posterior tendinopathy. We answer some listener questions along with: Tib post anatomy & function Likely causes for this condition in running Role of pronation & orthotics in tib post tendon pain Early & late stage strengthening exercises Running considerations & prevention tips You can find Lizzie on Twitter here If you would like to support the podcast and participate in future Q&As sign up for $5US per month at our patreon page For Brodie's running blogs, podcast episodes and online courses visit our Run Smarter Website To follow the podcast joint the facebook group Becoming a smarter runner To find Brodie's running information on instagram @runsmarterseries
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On today's episode, Tip Post Tendonopathy Rehab and Prevention with Lizzy Marlowe. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission to bring clarity and control to every runner. My name is Brodie Sharp. I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. This has been a long time coming, our TibPost Tendonopathy. I think I received a fair bit of feedback from Facebook groups saying, when are you going to do a TibPost episode? I think it's been going on for the last couple of months. So sorry for my delay, but I am so happy that I have Lizzie Marlowe presenting rather than just me talking about it. She's done an excellent job. She'll introduce herself in a second. Before we get into today's episode. Thanks to everyone who submitted their questions. I'll give you a shout out now. First to Sam Todd, sorry, during the interview, I had a bit of a blank and couldn't remember if it was male or female, but sorry, Sam, I did answer your question and had to look back in the Facebook group and apologies for that. But we have, Sam had asked, she asks, have you, she's been having um, flare ups and wondering, uh, are flare ups expected. Catherine, who asks, um, uh, her Lizzie's advice to prescribe orthotics. We have Jill talking about plyometrics during to post rehab and Danny who asked, what are some strengthening exercises to strengthen the tendon? I'll answer all your questions, um, within today's episode, but thank you so much for submitting your questions. And yet we cover so much today. We cover, um, what are some running considerations. What is the anatomy and function of the tip post or tibialis posterior? What would be the likely cause of this tendinopathy? What we can do in early stage rehab? We talk about orthotics, we talk about pronation, we talk about late stage, we talk about prevention. So much to cover today and Lizzie was so generous with her time and loved hearing everything that she had to say. Really sound advice, really evidence-based advice and yeah, just loved talking to her. So... I was actually worried about my voice, not last in the distance, but like I said, last episode I just finished attending a four day Tony Robbins seminar where me and my brother were just in the living room. It was a virtual seminar and we were just dancing in the living room, changing our life, yelling at the TV and it was just a party for four days straight for 13, 14 hours a day and yesterday lost my voice in the morning. And luckily it had recovered, but I was wondering how to go throughout the interview. So I held up well, thank God. Um, and the result was just an amazing interview. So without further ado, here is Lizzie. Lizzie, thanks for coming onto the podcast. This whole topic around to post tendinopathy, uh, is a long time coming because I get a lot of feedback from, um, my Facebook group and, uh, every time I like, I think this is probably the condition where people are like, when are you going to do an episode on to post tendinopathy because I haven't done. one yet and as soon as I saw you on Benoit's course I'm like this is the person, this is the time, we're going to do this now and so I really appreciate your time and thanks for coming onto the podcast. Hi Brody, thank you so much for having me. I'm really excited about talking about this topic, it's something I'm really interested in so yeah it should be a good talk. Absolutely me too, maybe we dive into your career at the moment, like who you are, where you're from and why this particular interest. Yeah, so I am a lower limb and running physio based in London. And I also do a little bit of part-time lecturing on various lower limb and running courses as well. So I work in both the public and the private sector. So I guess this has meant I've had exposure to a variety of different patients, including runners, but also patients who are a little bit less active. And I've had some amazing opportunities working in various different lower limb, various different central London teaching hospitals. And this has allowed me to work in a few different specialist lower limb and foot and ankle clinics. I guess I've always loved the complexity of the foot and ankle and became particularly interested in TibPost while working in a specialist clinic in London with a specialist physio called Nolene Davie, who actually trained in Sydney and is one of the founders of the Association of Foot and Ankle Physios. So through that, I got to assess and treat loads of patients with TibPost tendon problems. and just found it a really interesting condition to assess and treat. Great, all right. So for those who aren't too familiar, and I know the tip post, I guess anatomy is a little bit hard to visualize, and that's when like the downfall of a audio podcast, but could you maybe like as simplistically as you can for like a runner to understand, maybe describe the anatomy and the function of the tip post tendon? Yeah, so I'll definitely give it a go. As you mentioned, it is quite complex, but the tibialis posterior is a muscle that sits in the lower leg. So it attaches on to the back part of the top of the tibia or the shin bone. So it's essentially behind the back of the underneath of the knee. And it runs down the lower leg. So it sits underneath the calf. So it's quite deep in the lower leg. and it passes behind the inside of the ankle, so on the inside of the foot, and then it attaches onto a number of bones around the medial arch and the underside of the foot. So it has a pretty broad insertion underneath the foot around the medial arch, and one of its main functions is basically to stabilize the medial arch. It also plays a really important role in running and walking. So, when you're running, as your foot contacts the ground, your tip-post muscle essentially lengthens or works eccentrically, and this allows the middle part of your foot to drop down, and essentially the foot pronates. This means that the foot can become a mobile platform to allow it to adapt to different terrain. Does it make sense so far? It does, yes, absolutely. Okay, good. The other really important thing that it does is during the later stages of running, as you push off, the foot then has to change from a mobile platform into a more rigid lever. This allows the calf to become more efficient as you push off. If the foot was still mobile and flexible during this stage, then the calf wouldn't be able to generate so much momentum or power as you push off. So essentially during the different stages of the running cycle, the tip post helps the foot to switch between a mobile platform and then a rigid lever, depending on what it needs to do at that particular time. Very beautifully said. So if someone's just sitting there now, if they can like feel their shin and kind of feel the inside of their shin, that's kind of the region, like the deep part is where the muscle might be. But if you can kind of trace further down, keep following your shin further down, you see that bump on the inside of your ankle, the tendon actually passes behind that bone as you're saying and then will attach onto the arch of the foot or around the arch of the foot. And that's kind of where it's placed. And what you're saying is when a runner makes first contact with the ground, what the body needs to do is absorb that load. Otherwise, there's a huge shock that goes through your body. So Um, what the foot does is, uh, roll in or pronate in, in order to slowly absorb those loads, cause we don't want to a big fast slap into the ground. Otherwise we're going to get a lot of damage. So what the tendon is responsible for or the muscle is responsible for is slowly kind of controlling that action so that we absorb that load over a period of time. So it doesn't like become like a sudden impact force. And that's very important for us. So we don't get injured. But then what you're saying is later in the phase, we do need to switch to a more of a rigid lever so that we can propel off because we can't push off a very flat flexible surface. So what it does is create a really rigid lever in order to propel forward further in that running cycle. And the Tibialis posterior, what it does is go from that platform, like you said, that mobile platform of absorbing load, and then switching on and kind of creating that lever for momentum and propulsion. Yeah, exactly. So it's a really, really important tendon in terms of walking and running in gait. Yeah. Yeah, fantastic. I think you explained that perfectly. And I think for someone who doesn't have much of a physio background, it's nice for like repetition to like explain it in a few different things and maybe one little explanation, like finally. catches on for someone, they're like, oh, now I get it. So hopefully we're all on top of that now. And realizing the anatomy and the function of things, when it comes to a tendinopathy, what might be the primary cause of a developing pain? So I guess the first thing to think about is with tibialis posterior tendinopathy or posterior tibial tendon dysfunction, as it's sometimes described, is that it's essentially an overload of the tib post tendon. Perhaps it's working too hard to stabilise the foot for various reasons when you're running and when it's asked to do too much too soon, it can become a bit grumbly and angry. And there are various different causes. So as with many running injuries, there are often multiple things going on. So it's very difficult to just attribute it to one thing. usually there are a combination of different triggers that perhaps might be intrinsic, so things going on inside the body, or extrinsic, so things going on outside the body. So if we think specific to Tib post, some of the intrinsic factors that might be going on could be potentially some strength deficits, in particular the Tib post and the calf complex. But also the whole of the kinetic chain. So the whole of the lower leg muscles, the quads, the hamstrings, the glutes. If you're globally quite weak, it might be that you're putting a bit more demand through the foot and ankle. Some of the other intrinsic factors might actually be the structure and the shape of your foot. So this can mean that your tip post has to work a little bit harder to stabilize the arch when you're running. and then it might be more likely to become overloaded. So for example, if you have a naturally flat foot or dropped arches, this might put your tib post at a little bit of a disadvantage because it has to work in a slightly stretched position. This doesn't mean that all runners who have flat feet will develop tib post problems. And in fact, there are probably loads of experienced runners out there that have flat feet and have no problems at all. So it's likely that foot shape is only a small part of the puzzle and it might be relevant for some people. I think one of the other things that's particularly important with runners is mobility restrictions. So in particular some restriction around the ankle joint. So a reduced ankle dorsiflexion range of motion can be particularly important in tib post tendon problems. So dorsiflexion is essentially when the top of the foot moves closer to the shin. So it's the opposite of going onto your tip toes. And this might be a result of perhaps some stiffness around the ankle joint or some tightness in the calf muscles. And this movement is actually really important during the later stages of running when your foot is in contact with the ground. And if it's restricted, sometimes this can cause the foot to go into pronation to compensate. for that stiffness. And that might actually put some load through the structures on the inside of the foot, including the tip post. I think the last intrinsic factor to be aware of is probably BMI, so body mass index, how heavy you are for your height. So if you have a high BMI, generally you're gonna put a little bit more mechanical load through your foot and ankle tendons, and this might put more stress through the tip post which has to work a bit harder to stabilise the arch. Now, interestingly, as well as having a mechanical effect, fat cells, especially around the abdomen, can lead to more inflammation in your body. And this can affect the health of all tendons, including the tidpost. And it generally promotes this widespread inflammatory environment, which makes tendons more susceptible to inflammation. I'll go on to the extrinsic factors but I wanted to check if you had any questions on that first. Yeah, there might be a few things that we can unpack there. When you first start, you answered this really, really nicely and it covered so much. There's, first of all, you talked about the overload, which hopefully the listeners are like, oh, fantastic, that fits the pattern of every other tendinopathy, every other lower limb tendinopathy that's out there for runners. So doing too much too soon is definitely a key factor for the cause for this. Um, over the last couple of episodes, I've kind of been explaining that if you, if you, uh, have do too much too soon, or if you over train and like they'll, uh, an injury would develop at almost at your weak link and let's just say, um, you do have a foot shape or an arch that's lower than others. And like you said, it puts the tendon under more stretch. If you then overload your body. if you go from running 10K to doing 20K too quickly, it's more likely you're going to develop this tip post endopathy if you do have a lower arch because it is under more stretch compared to someone else who has a higher arch. But that's not to say that the collapsing foot is the direct cause. Direct cause is the overtraining. It's just... highlighting your weak points as soon as you do have those training errors. And if you were to adapt, if you do have flat feet and you do adapt carefully enough, then that tendon just gets stronger and stronger and stronger. But you might just be a little bit more of a, at a predisposition if you do have those training errors, what will arise. I think that's a really nice way of putting it. And like you said, it's only just a small part of the puzzle, but then you're also high BMI and that kind of thing. Yeah, absolutely. I couldn't agree more. And say you're a runner in your 40s, and you've started to develop this pain, well, you've probably had the same foot shape and the same running pattern for, you know, your whole life since you started running. And perhaps you've only just started to develop symptoms since you've upped your training, or you started training for an event. So it's not that necessarily your foot is the problem. It's perhaps your foot shape combined with the fact that you've had a sudden increase in training load and perhaps addressing the training errors is more relevant than trying to address the structural shape of your foot. Yeah. I'll never forget when I very first started running, I went to a park run and there was a lady there who was a bit overweight. She had like, it was cringe-worthy how flat her feet were and how much they collapsed in. And she was running 5k and she was actually doing it in like barefoot shoes or socks or something, and she had no support. She was just collapsing in. She had this external rotation that was just, it was cringe-worthy, but I was just watching it cause I was fascinated and she was just happily running, doing her 5k and I'm like, go you like a lot of people will say, why the hell are you running basing on mechanics, but I guess she's just developed enough tolerance and the body's adapted strong enough for it to tolerate that. And I'm just like, it's really fascinating how. the body can actually adapt and become accustomed to what you're putting it through. Yeah, it's amazing. She's probably been doing that for years, hasn't she? And she's allowed her body time to adapt to it. So yeah. Yeah, good to know. Okay, so we have some extrinsic factors that you want to discuss. Yeah, so I think the most important one there is training loads, which we've kind of touched on already. So I think this is an under-recognized cause of running related injuries, certainly amongst runners. And actually it's been suggested that it accounts for about 70% of running related injuries. And it's particularly relevant, I think, in TIP post problems. So as we've talked about, it's this doing too much too soon and not allowing the body time to adapt to it. So in particular things like increasing training volume or perhaps increasing the speed of your runs, cause you're trying to improve your performance or training for a specific event. or perhaps you've reduced your rest days or even started running on slightly different terrain. So an uneven route where your foot has to maybe adapt a little bit more and your tip post has to work a little bit harder to stabilize your foot. So if, as we've said, if these changes are introduced slowly, I think that the tip post can adapt, but the problem is when we're introducing these changes is too quickly. I think another important consideration, certainly with the foot and ankle is footwear. or perhaps more importantly, sudden changes in footwear. So a classic example would be switching from a nice supportive motion control shoe to a more minimalist shoe to perhaps try and improve your performance. And again, we know that this makes the tip post work much harder to stabilize the arch. And I think also whilst we're on the topic of footwear, it's also worth considering daily footwear habits. So not just while you're running, but perhaps what you're doing at work, what you're doing at home. Um, the classic example again might be, um, when the, the weather gets a bit nicer and you switch from a trainer to a flip flop, which I think you guys call thongs. Yes, we do. Yeah. So again, this will put, uh, obviously provide much less support to the arch of the foot and it combined with all the other things that we've talked about could potentially be enough to tip someone over the edge. Yeah, great. And you can say that, um, you can almost have a training load too much too soon outside of running. It's almost like that same concept, like you're saying, as soon as it goes to summer and you go from wearing shoes all the time to wearing, or just going in bare feet, walking around or, um, going to the beach and walking around on the beach, even though you're not running, this could be an overload in itself because the tendon works so hard to, like you said, the very start of the episode, it's one of its primary roles is controlling the foot. And if you take away all that support really suddenly then the load just might shoot up. And that's not to say that barefoot could be a good thing, but we just need to make sure that it's gradual and you're allowing that body enough time to get used to that sudden change in environment, sudden change in footwear, or the support that you're offering it. It's very key. And I love that you say that because I didn't really consider it too much because this is a running podcast, but... some people might just be like, I got this pain. I don't know why I've stuck to the same training schedule for the last six weeks and I just don't know why, but they're probably not considering things outside of running. So very, very good point that you highlighted there. Yeah, I think it's a little bit of detective work as well. You know, you do have to sort of tease these things out and runners often don't think that it's relevant. So it can be useful to just think about that. Yeah, I have the next question written down, but I think we've already covered it. It was, perhaps discussing the role of pronation and the importance of pronation in running. And I think we discussed it early enough, but is there anything you wanna add on before we move on to the next question? I think just that it's a really complex movement occurring across multiple joints, requires coordination of lots of muscles. I don't think you need to get bogged down with the mechanics of it. But as I mentioned previously, it well, I don't know if I have mentioned it actually, I think it's just got pronation has got a really bad reputation in the running industry. And I think that we get lots of runners coming in and they're really concerned that they've perhaps been told that they're a pronator or that they overpronate and I think we just need to move away from thinking that it's the root of all evil. Having feet that pronate more than perhaps someone else's doesn't necessarily mean that you'll develop an injury. And actually there's some research to say that having excessive pronation might even be protective against certain injuries. So I think that we just need to move away from thinking that it's harmful. There are certainly some scenarios where it might be relevant, but as with a lot of these things what we're discussing this evening. It's only a small piece of a very large puzzle. Yeah, I did release an article that was highlighting this and it's only just one article, take it with a pinch of salt, but they did follow a whole bunch of runners, new runners with their, and they put them into categories of their foot shape and saw how long it took for them to get their first injury. And the pronators like they... I think there was no difference between groups, whether you had a high arch, neutral arch, like a low collapsing foot arch, that kind of thing. And also it showed in there that potentially the ones who did pronate were less likely to get into a spench or had a longer time until their first point of their first injury. So it's interesting to know, but why do you think there's this misconception out there that, you know, if you're an over pronator, you're more likely to get injured, you need all this support, otherwise you shouldn't be running. Where do you think that's distilled and where do you think that's arisen from? I think it's very historic and it's certainly been around as long as I can remember. And I think part of it is probably to do with the running industry and perhaps making money out of expensive footwear and trainers that are designed to limit pronation. So it's in possibly their interests. to try and kind of explain to runners that it's harmful because they may be more likely to invest in the brand. The classic example, I guess, is when a runner goes to a specialist trainer store to ask for advice about the best trainers for their foot type and someone maybe gets them to stand on a pressure plate, maybe they get them to run barefoot on the treadmill, and they tell them that they're an overpronator as if this is the cause of all of their problems. And unfortunately, running injuries are just a little bit more complex than that. The relationship, as you've mentioned, between pronation and injuries still is something that is poorly understood. Um, and you know, we see so many runners with excessive pronation with no significant pain or injury history. So if it was the devil, as many, um, trainer shops probably, um, kind of explain, then, you know, everyone with this movement pattern would suck. with these particular injuries, but that's simply not the case. So yeah. Yeah. And I think if someone isn't aware of the current information, isn't aware of the current evidence, it kind of just like makes sense to them. It's kind of like you see a photo of collapsing feet, you're like, oh, that doesn't look good. And you look at someone who collapses in when they run there, you're like, oh, that doesn't look too good. And then you see a photo of an arch or like a posture, feet collapsing in, knees collapsing in, like hips are out of line. And then they have support under their feet where everything just magically aligns and it kind of just makes sense. It makes sense like visually for them. And then they're it's reinforced when they're being told by maybe health professionals or like you said, people at shoe stores and it kind of just reinforces that belief. Um, because I know if I didn't have any training that'd make a whole lot of sense that we want to be aligned. And if you are. over pronating will say if you are doing that then you're it doesn't look like a good thing and yeah like I said it makes sense but I do have a story I like to tell myself that if someone has an Achilles problem if someone develops an Achilles tendinopathy because they've been running too many heels like we or if they have less protection or less like a heel drop because that Achilles is put under more stretch. And what we call, like you said, dorsiflexion, like if someone's running up hills, your foot goes into more dorsiflexion, it's under more stretch. If they develop an Achilles injury, we don't call them like an overdorsiflexer and say, you shouldn't be overly dorsiflexing. No, that just make no sense at all. What you'd say is, okay, this is an overload. It's too much of an acute overload. What we can do is perhaps put you in some heel lifts to get you out of stretch in the short term, just to settle down some pain. And then once we get back, we need to make sure you're strong. We need to make sure that you don't overload with your training. We make sure we address all those training errors and things outside of running so that the tendon heals and gets stronger. It's exactly the same with this tip posting, you know, the injury might have been caused by a sudden load due to pronation, but that's not to say that you're an over pronator. We just need to educate people on that right topic. Is there anything you want to add with that? Yeah, no, absolutely. I completely agree. And it's a really nice way of explaining it because I think we're so sort of embedded in this belief that pro-nation is bad. But I think once you explain it in a slightly different way, it's much more easy for runners or patients to then think, Oh, actually, yeah, that makes sense. Maybe it's not such a terrible thing. Yeah, so we've moved into pain now we've moved into the tendon itself has started to become a bit irritated, perhaps we've had some training errors, what can we do in the early stages in order to settle down this irritated tendon? So I think the priority in the early stages is to try and reduce anything that might be overloading the tendon and of course, reduce any pain associated with that. So training modifications is a really important starting point. So as we've already mentioned, prioritizing things like reducing volume or speed of training. And I think a really, really key thing is adding in some rest days for adequate recovery. And I think this is something that can often be quite tricky for runners who've perhaps been used to running six days a week for a number of years, and then having to adjust to that, it can be quite tricky. But it really is an important strategy to try and reduce any overload and just allow things to settle down. And on those rest days, you could add in some cross training, perhaps swimming or some cycling. So you're kind of having some active recovery. And I think it's quite nice as well in that stage to stick to some sort of pain monitoring model. So when you're running or when you're doing your rehab exercises, or even when you're just doing your daily activities, be guided by your symptoms. So think about a score out of 10. And I think it's okay for your symptoms to be less than a four, so around about a three out of 10 with any of the activities that you do. But when you stop those activities, your symptoms should settle down within a 24 hour period. So it shouldn't make your symptoms the next day any worse. And that's a really good way of trying to control the symptoms in the early stages and calm things down. We've talked already about footwear modifications. I think that can be useful as well in the early stages. So perhaps considering something like a motion control shoe, if you're in something more minimalist. And that's because it has a bit of stiffness in the midsole, and it might even have a little bit of a wedge under the inside of the heel, just to lift the inside of the heel up a little bit. And this could potentially reduce some of the forces acting on the foot and some of the loads on the tip post. Now just remember that making significant changes or sudden changes like this could potentially shift the load elsewhere. So you might want to introduce these changes more gradually over say a three month period. And you might need to even seek advice from say a podiatrist or physio who specializes in running injuries to just give you some guidance on that. And then the other thing in the early stages is to think about daily footwear habits as well. So with all of my patients who are, who perhaps have quite severe symptoms, I would always try and get them to wear some sort of supportive shoe, even just around the house. And then We've talked a little bit about orthoses already, and I'm sure we'll go into a bit more detail later on. But I think that these can be really useful to offload the tip post when running and walking. So the aim is not to put the foot into a perfectly aligned or neutral position, but rather to offload painful tissues so that things can settle down and become less irritable. Yeah, I don't know what your thoughts are on that, Brody. Yeah, brilliant. Cause that's the exact same scenario that we're talking about. We're talking about like an acute flare up where it is irritated and needs to settle down in order to start applying some load that it can start tolerating. So, um, there's some really nice strategies and it does, um, uh, tee up really well with a question came in from Katherine because she asks if you were to prescribe an orthosis in a young middle-aged adult, what would you prefer? Is there one that you might prefer over the other because there's a a wide range of variety of different orthoses that are out there in the market. Yeah. So I think it's really difficult to make that kind of decision. So, as we've talked about, orthoses are essentially just an external device that can change the internal forces that are acting on the foot. And it can be really useful in the early stages. It really depends on your particular symptoms. So if you've had fairly short lasting symptoms and you consider yourself to have a fairly neutral foot, or neutral foot type, then you might get away with a simple over the counter orthosis. So essentially you just want something with a little bit of a medial arch support, and you might even just need this temporarily until things settle down. If you've had symptoms for quite a while, so they're quite persistent, long lasting, and perhaps you have some concerns about the shape of your foot or the fact that you're pronating when you run, this is when I would probably consider speaking to a good podiatrist who specialises in running injuries because it might be that actually you need some custom-made orthoses and they can do a more thorough assessment. So I personally don't prescribe orthoses and so I would always refer my patients on to a podiatrist and there are a number of different variables that they have to consider like the stiffness or shape of the material, whether or not they put wedges underneath your heel. and the friction of the top of the fabric to reduce slipping between your foot and the orthosis. So yeah, it's a really complex process. And personally, I would get my runners to seek advice from a professional if they have any sort of concerns about it. Yeah, I totally agree with that one. And you mentioned two different things with that question. You said, one, it would depend on your symptoms. So it's not for everyone. It depends on your individual circumstances. And two, you said it's used just for the early stages and it might not be a permanent thing to, okay, you need orthotics for the rest of your life. You need to run in these orthotics. You need to run with this support issue. Keep in mind that if you choose to, that's fine, but you shouldn't be told to and the role of the orthosis in the early stages is just to offload that tendon or shift the load somewhere else away from that irritated tendon in order for time for it to heal in order for it to, in a day or two or maybe a week. start tolerating more loads and start applying more strength. And I think this is a really good time to ask Sam's question because he said, um, uh, Sam's recovering from, um, to post tendinopathy. I'm not too sure if it's male or female need to check that, but, um, been doing a lot of calf and footwork and experiencing a lot of ups and downs and a lot of flare ups when it comes to the, um, the rehab portion of the tip post tendons. So, um, should someone expect? these flare ups, well, they said forever, but should someone expect these flare ups throughout their rehab? First thing I think is important to understand that flare ups are very normal and common, especially when it comes to lower limb running injuries and overuse injuries like TIP post tendinopathy. It's a complex injury as we've already talked about and there are not often a lot of different factors associated with your symptoms. So it sounds like you've been doing some strength work already, which is great, because this is a really important variable to consider. But it might be that you want to consider some other factors too. So things like training loads that we've already talked about, or possibly some mobility issues. So we know that with running, it's really important that you have good mobility in your big toe, in your ankle joint, and also with your hip, so hip extension, which is bringing the leg back. And these are really key movements for running. And a good running physio will assess all of these in clinic as part of an assessment with you. And then another thing to consider as well is running mechanics. So we know that if you have prolonged or excessive pronation when you run, this may be relevant to your pain and the problems that you're having. So it might be worth getting someone to assess you running as well, and it might be worth considering an orthosis if you don't have one already. flare ups definitely shouldn't last forever. So you should expect to get some improvement within a few months and definitely some significant changes within six months. So if you're really not progressing, I'd definitely advise you seeking some help from someone who understands running injuries and who understands foot and ankle problems as well. Yeah. And I think, um, if Sam's like reflecting on this as well, earlier in the episode, reflecting on footwear outside of running as well, perhaps that might be something that might be triggering your flare ups that you're not realizing because you're focusing to maybe on the running component or maybe like the walking component or maybe the strength component and not realizing the standing and just daily life of footwear. So perhaps identifying all those factors and seeing if there's a certain pattern with the flare ups and changing the behavior or changing any predictability that might be occurring. Really, really nice. Since you're talking about some running considerations and you did mention the long or excessive pronation, are there any other running considerations like terrain or gait retraining that we might need to consider? I think it's a difficult one and unlike the knee, there's very little evidence or research on tidpost tendinopathy. So everything is really very much based on kind of... experience and chatting to other people. You could potentially have a go with increasing step rate or cadence, so the amount of steps you take per minute. So if you say increase this by 5%, you're going to be taking quicker steps, which means that you'll be spending less time in contact with the ground. And in theory, this should reduce loads on the tip post. And so it could potentially offload. anything that's causing or triggering the pain. I've had a couple of runners where I've tried it and actually it's flared them up a little bit. So I think you can definitely try it and explore it. And if it helps you fantastic, keep going. But if it doesn't work as a strategy, then you might want to move on to considering something else. Okay. What about terrain? What about uphill, downhill, trails, road, anything there to consider? I think the main thing is probably uneven surfaces just because the foot has to adapt so much more and the tip post has to work so much harder. I think with trails, I haven't really known that it's a massive issue, certainly not like it would be in an ITB related problem. And up and downhill as well, I don't think that's a major problem. I think speed work could potentially be an issue and that can generally be a problem in a lot of foot and ankle tendon problems. But yeah, now I haven't noticed it be particularly triggered by hills. I don't know what your experience is Brody. When I was working in clinics, there's a river that's near our clinic and people do a 5k loop around this river. There's a bridge that takes them over the top. Someone who was running around that river and came in with a tip-post tendinopathy, direction they were running in because even though they're either maybe the grass or the concrete path or something, there's a very gentle slope towards the water and everyone always, they're creatures of habit, I think they always travel in the same direction every single time that they run around that river. And so I could almost predict what direction clockwise, counterclockwise they're heading in because... if you were to run in one direction and there's a slope from left to right, one foot is going to pronate more, one foot is going to supernate more. And if they, they've obviously had an overload in training, but they're still running around that slope. And if, um, yeah, I think if, uh, there is a very gradual slope, then there would be an increased likelihood if the, uh, 10, uh, a tip post endopathy were to arise, it'd be on that foot that pronates more, um, towards the water. And sometimes, well, one of my best advice is just, okay, every second time you go to run around the river, I'll just go in the other direction and it just naturally balances things out. It loads things correctly. And I would consider that consider the direction of slope. If you're a trail runner that loves to run around a creek or a river, just keep an eye on the slope. If it's a consistent slope, um, because you will be subjecting your body to different loads, um, right to left. If you. one of those creatures that happen that do stick to the same trail, the same road the entire time. There might be one thing I'd add, but yeah, you answered that really, really nicely. Okay. Yeah, that's a really important point actually, running sort of along a slope. I can see how that would be relevant. Yeah. Yeah, it made a whole lot of sense to me. And even when I first started running around that river, I started developing a little bit of stuff on the inside of my foot as well. I don't know if it was Tidpost, it might have been, but. Recognize that and started running in the opposite direction just went away forever. So sometimes catching it early and recognizing it early Can all you need to do is just make one switch which is a really nice thing if you catch it early enough So I think there was there was a lot of questions around Strength work and if we're still on this topic of the early phase perhaps a little bit irritated we've settled it down with some supportive footwear and minimizing the running maybe where backing off the mileage and things are starting to calm down. What can be some early strength or rehab options that you would recommend? So I think that a lot of people like to go for theraband strengthening exercises and that can be a nice way of isolating strength in the early stages, but I would probably be more inclined to go for stuff in standing where it's a little bit more functional to running. So even just some single leg control work and some heel raise strengthening, which is sort of slowly graded, you can manipulate variables like the external load that you hold or the reps or the sets, or even the speed. I like to keep it quite simple. And I like to try and think of the different stages of running that you're trying to create. So thinking about that early heel strike that you get when you run. So you might want to work on the stepping and controlling and trying to keep a nice position of your midfoot and your heel. And then you can also place bands around the leg to just add a little bit of resistance to try and pull the foot into a slightly pronated position. So your foot has to work much harder to control that. I guess it's quite hard to explain over the podcast. It's usually useful to have some videos or pictures to describe it. Definitely. When you say single leg control work, are we talking about balance? Are we talking about walking? Are we talking about like calf raises, all the above? I think they're all probably going to have their place but I think you can start with even just stepping and holding and controlling with resistance from perhaps a band around the side of the leg. You can even do single leg balance, you can do like a single leg deadlift is quite a nice control exercise, even single leg squats where you're really thinking about the position of the midfoot and the heel so trying not to let the midfoot and the heel drop down. and can be quite a nice exercise. Um, and kind of step ups with a bit of a knee drive is, is a really nice exercise to work on as well. And while you're doing these exercises, you've mentioned that we're trying to focus on control the foot and motion of the foot. Do you have any specific like cues that you like to give people if they are doing a single leg deadlift and maybe their awareness isn't like very strong around the foot. Do you have any cues that you like to use? I think just maybe trying to explain to not let the arch drop down, which I think is a really simple cue that can be quite effective. It might be that if they really struggle with that, you might wanna teach them how to do that in a seated position first and just give them some awareness of it. Obviously we don't want people to be terrified of doing that movement, because it's not harmful, it's not gonna cause damage. But what we do want to do is encourage the, the tip post muscle to activate while you're exercising and to do that, it probably good to have a nice neutral position of the, of the foot. Yeah. And would you have that same awareness for things like calf raises? Like if you're going up and down on your toes, you're trying to keep that arch engaged or making sure it doesn't, um, doesn't pronate. I think the main thing with the heel raises is as you push up onto your tiptoes and your heel leaves the ground, the back of your heel should sort of rotate inwards a little bit. And that essentially shows us that the tip post is doing its job. And if it stays really, really flat or in sort of a position where the heel is pointing outwards, it might be that we try and retrain that a little bit. So rather than focusing on the arch during be focusing more on the position of the heel as it lifts up. I've often seen people do double leg calf raises with like a small tennis ball sized ball like squeezing between the heels. Would you recommend that? I definitely use that in really, really early stage when they can't perhaps do a single leg exercise, a single leg heel raise. because I think that it's a nice, really well tolerated exercise that it's got someone on their feet and, you know, got them loading their foot. But I would try and progress quite quickly onto a single leg heel raise. And that's just because it's a little bit more specific to running. And I quite like an exercise where you get the runner to put their opposite foot perhaps on a chair. And then they're going to do a modified heel raise with the injured foot on the floor. And it just gives you the opportunity to load the foot a little bit more than you would do on a double leg. I don't really think that exercise has a name but I just call it a heel raise with the opposite foot on a chair. And you can add load to that so they can hold a weight or perhaps a dumbbell or a kettlebell and focus on that heel position as you lift. Yeah, I think I saw a photo of that during your presentation and the chair was a little bit more forward so it was kind of almost like a lunge, kind of distance away. Is that the one you're talking about? Yeah, and it's quite specific to that stage of running because when you push off your heel, your foot is quite far behind you so it's quite good to I think be lunging forwards onto something. Yeah, it's perfect to mimic that action of the running cycle. If we've lost some viewers just imagine if you do a lunch, most people can imagine what a lunch position would look like. But that front foot is up on a chair. You might not be that far forward, but that's the kind of position you can be in and then you can do calf raises with the leg behind you. I really like that and then you can add weights if you have you can maybe hold on to a dumbbell with one side or if you have like a Smith machine, then you can apply load with the across the shoulders. Um, so that's a really nice one. That's so functional and makes a whole lot of sense. So if you have the opportunity to do that, I'd highly recommend it. And then you're focusing on that, the control of the foot, the entire time, making sure the quality of the movement is, um, up to standard. Yeah, absolutely. Right. How about, well, I guess my next question would have been more advanced strengthening or like end stage. Stuff. Um, I guess this calf raise one can get pretty advanced and can be considered pretty end stage stuff. But do you have any other exercises you might recommend? Because I also think that end stage exercises can also be considered as prevention exercises as well, for those who have had to post tendinopathy in the past, or those who might think they're at a predisposition to getting this tip post stuff. So when it comes to end stage exercises, consider that as prevention type of exercise as well? Any tips? I think the first thing to be aware of is that the tip post, its main function is that it's a positional tendon. So this means it's designed to support and stabilize the arch of the foot. So it's very different from something like the Achilles, which is designed more for speed or power. And so during end stage rehab, Although it's really good to focus on heavy loads and plyometric drills to prime the runner for the demands of running, you don't wanna do specific heavy loads or plyometrics to isolate the tip post. You're more trying to work the whole lower leg to just prime it for getting ready for running. So yeah, as you mentioned, you could do heavy calf raises, single leg drills like single leg squats. You can increase the load on just squats and things like lunges. And then I think slowly progressing to more speed drills and plyometrics can be useful. So just standard lower limb plyometric exercises are pretty adequate. And you'd want to do one to two sessions a week for about two or three weeks to prime you for getting back to the full demands of running, probably alongside a return to running program. Yeah, and sorry, go on. I was just going to say it's really important when you do things like speed drills or plyometrics, um, to monitor your symptoms, uh, during and after, and just be guided by that pain monitoring model again, because you don't want to trigger a flare up if you, if you suddenly increase the speed or intensity of your training. I see that mistake, um, too often. So I'm glad you highlighted that because Um, people like, yeah, I need to start plyometrics. So they'll do three sets, four sets of a new exercise. And then it's just flared them up for a couple of days. So, um, be very careful when it comes to plyometrics for any rehab at any stage, making sure it's a gradual, uh, set. So you might want to do, if you're doing three sets of deadlifts or something, you might want to make sure that, um, if you're increasing speed or implementing some sort of plyometric movement, that you're only doing one set and then seeing how you feel. then if it's okay, you're then implementing the second set and see how you feel. And then you're slowly, gradually implementing that explosive kind of movement. So Jill did ask a question about plyometrics and I think we answered it perfectly. A couple of plyometric examples would just be things like skipping, would be things like, you know, those drop squat jumps, like just anything that's quite explosive. Plyo lunges maybe. As long as the control is really good. I think you can probably YouTube plier lunges if you've, if you're not familiar with those, but like you said, all the time, making sure that the control is there, making sure that the, um, technique is there and making sure that it is gradual when you do implement it. And then when it comes to the preventative side of things, you're saying that this tendon is mainly designed for control. So a really nice prevention and priming or like a warmup kind of pre-activation thing would just make sure that you're. you have good control and making sure doing every exercise that you do have good control of the foot and ankle and the rest of the lower limb. And potentially before a run, if you're experiencing, or if you're like the end stage, maybe some pre-activation exercises could be things like a single leg deadlift or a single leg squat or a single leg calf raise, focusing on the control, making sure that's the key point of the exercise. And that's warming up and preparing the tendon for things like a run or a gym session. Is that... Is that kind of what you're getting across or am I? Yeah, a little bit. I think what's important is that a runner doesn't worry too much about then taking that into the run and thinking about every step and trying to control the situation. I think that that's something that just should happen naturally, but I think, yeah, some, some kind of warmup exercises are always useful. I will always get people to also really focus on an ankle range and ankle mobility before a run. So perhaps doing some calf stretches or ankle mobility work, just because we know that if the ankle is really restricted, that can put a little bit more load on the tip post. So that's a really nice way of offloading it pre-run. So yeah, that would be something I would also focus on. Lovely. I think, I see the same with people who have like glute problems and they try and run and activate their glutes while they're running and I think the same could be said for tip posts, like if people are worried about it and they're trying to engage their arch and they're trying to control their foot every time they step when they're running, I think that's just detrimental and shouldn't be happening. So yeah, I totally agree with that. Is there, as we're wrapping up, is there any other running considerations when it comes to rehab and prevention? I think we've covered so much, but anything else that comes to the top of your mind? No, I don't think so. I think just, you know, thinking about whole kinetic chain strength, as we've already talked about, making sure you get enough recovery between loading sessions. And that's not just running sessions, but also your rehab sessions as well, being guided by the symptoms throughout the rehab. And just thinking about your daily routine as well, and the impact that has. I think those are the key things. Yeah, great. Recovery is awesome. And I think the, like when it comes to recovery, things to consider are Like maybe barefoot walking or maybe like less supportive walking is a good thing. Just make sure it's not in huge amount of dosages because ideally if you want to strengthen the control of the foot, sometimes barefoot walking can be the best thing, sometimes minimalist shoes can be a good thing, but you just need to make sure that the body's strong enough to tolerate it and while you're building up that strength, yes, walking around in bare feet might strengthen the tendon, but if you do it every day, if you do it um, several hours in a day and it's too much, then, uh, it might be detrimental rather than helpful. And the same thing can be said with, uh, changing footwear for your running. And perhaps you have changed to a lighter shoe. Like we said, this top of the podcast, you might transition to a lighter shoe with less support that offers less support, which if you adapt it in the long run, it can be really helpful to make your foot resilient and, um, build up the muscles in your strength and strength around the foot and ankle. But if you. do it too quickly or if you do it too suddenly or if the for whatever particular reason at a particular time your foot and ankle can't contain that capacity, they don't have the tolerance to handle that load, then these sort of things are going to arise. So making sure that yes, when it comes to recovery, making sure that it might be every second day, you might do a minimalist shoe walk around. But then every second day, you're replacing that with a supportive shoe and you're allowing that tendon time to recover. and allowing like as symptoms allow, just follow that process. And if there is stiffness or pain, you might've overdone it. So let's respect the body and give it more time to recover, put in a little bit more supportive for a day. And then yeah, just working around with those variables to see what best works for you as the individual. Yeah, exactly. And as you mentioned as well, earlier in the podcast, maybe changing the route as well. So you're not always running on the same trail change the direction. So you're just loading different, different parts of the foot and the leg. I think variety is definitely the way forwards. Yeah, I think like, I don't have a tip post tendipity. But I think if I did, and I'll listen to this, I'd be like, yes, I'm ready to take action. I know I understand everything. And I've got a cool a few cool steps to take and We've covered so much. We've covered like outside of running, inside of running, early stage, late stage, you know, irritated, non-irritated. So it's been a wealth of knowledge this entire time. And I want to thank you for coming on and sharing your expertise. If there's anyone who wants to follow you or if you have any social media accounts, if people want to hear more, where can they be directed to? Yeah, so I'm fairly active on Twitter. So my Twitter handle is... at email 089 and I'm more than happy for people to contact me with questions or discussion points. So yeah, feel free to add or follow me. Brilliant. I will add that link into the show notes so if people want to reach out, contact you or just follow your content, they can just click on that and straight away they can start following you. Brilliant. Like I said, a lot of people that are listening to this podcast have been waiting a long I couldn't think of a better person to discuss this topic. So once again, thanks for coming on. Thank you so much, Brady. I had a really good time. It was great discussing it with you. Thanks for listening to another episode of the Run Smarter podcast. I hope you can see the impact this content has on your future running. 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