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Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and letโs begin your run smarter journey.
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On today's episode, we are diving into the latest running research. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who just like you have been through vicious injury cycles and when searching for answers, struggled to decipher between common myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. Back from Smarter Scholars, I have three really interesting papers that have been released in the last month in our folder. Well, in my particular folder that I've gathered over the month, there has been 14 papers that has sort of made it into the Google Drive that you can go check out. But yeah, there have been three really interesting standouts. I try my best not to do too many rehab focused ones around like uh specific injuries, especially if they're quite niche, because I want to try to tailor it to the biggest audience that I do have or relevant to the biggest audience. So um things like, ah I guess, shin splints and proximal hamstring tendinopathy, while the PhD stuff I tend to just launch on my second podcast, but uh other kinds of smaller injuries. um you can definitely learn more about if you want access to the Google drive. I do have one today around plantar fasciitis though. I decided to scrap one on uh knee pain because I've done a couple on knee pain in the past, but I really try to gravitate towards injury prevention and performance because I know that's what the vast majority of you guys are after. And yeah, if there's any interesting injury focused ones, um they need to be really, really good for me to. have it appear on this episode. uh yeah, I'll dive into that shortly. But the first paper that I want to talk about is titled a systematic review of factors associated with performance in non elite runners. So big topic, um systematic review. a large comprehensive uh data set, but with the subject being performance for non elite runners, that's like and a lot of factorials. So was just really curious to see where this paper in particular uh took it and what results came of it. The introduction sets up the stage and says that performance in long distance running is a multifactorial phenomenon. In general, anthropometric training and physiological variables have been considered to be important predictors of performance for runners at different competitive levels. For example, a negative association between body fat, body mass, body mass index and performance has been shown. While training and physiological determinants have shown a positive association. Additionally, physiological determinants and training experience have been found to influence marathoners with increased maximal oxygen uptake or VO2 max, anaerobic threshold, improved running economy, weekly training volume and intensity leading to reduced time. In ultra, Trail runners, performances have been associated with mental toughness, resilience, and obsessive passion. Additionally, environmental factors such as wind, temperature, and humidity, as well as race course characteristics exert an influence on athletes competing in marathon and ultra marathon events. Gaining clarity on these gaps is the first step to designing interventions to improve running performance while respecting the characteristics and needs of runners. Given how widespread running is among the general population and given the increased popularity of ultra marathons in the recent decades, we aim to identify the factors associated with performance in non elite runners competing in distances ranging from 5K to ultra marathons. So sometimes when we come across these studies, they'll narrow their population and say, let's just focus on the elites or let's just focus on the highly trained and let's just focus on a half marathon or a 10K. But this is, like I say, a wide scope. We're looking at anywhere from 5K to ultra marathons and in the population of non-elite. And so let's see what they found. Firstly, when looking at shorter raced distances, they found that it was more the physiology that matters. So for 5K and 10K runners, the biggest predictors of performance were things like VO2 max, lactate threshold, running economy, neuromuscular power. what your running speed is at your VO2 max and strength and explosive ability. So in other words, like the runners who could use oxygen better, tolerate harder efforts, produce more force more efficiently, they tended to run faster. Really, ah no surprises there. Reinforce is something that we've been talking about for a long time. It's that you want to boost your running efficiency. Strength training is uh big proponent of this podcast and what I talk about a lot and strength training will help boost some of these will help you become well, it will help your running economy that has been shown. But looking at your training in particular, we need to look at your threshold work, your intervals, any heel repeats, any speed sessions, all of those on top of some good robust strength training will help you adapt to meet those demands are required for those shorter distances. One really interesting point was found that strength and plyometric measures were linked to better 10K performances. And like I said, I've talked about the strength training quite a lot on this podcast. I don't feel like I need to repeat myself, but that's what they found when it comes to the shorter distances. They looked at body composition. It did matter. ah They did say that ah the review consistently found higher body fat percentages and skin fold measurements were associated with slower run times, especially in the 5k to half marathon runners. uh But it doesn't just mean that less mass or BMI, but I don't want you just to, you know, listen to this and think lighter is always better. It's more that carrying excess non-functional mass may reduce efficiency. That's probably how we should sum it up. That distinction matters because recreational runners can easily fall into the under-fuelling, chronic dieting, unhealthy body image kind of thinking, what we call the red S relative energy deficiency in sports, essentially just under fueling yourself. And we know that that has injury implications. And so for injury prevention, having energy availability still matters enormously. And a runner who is lean and under recovered, under fueled or constantly injured, you know, that's not going to lead to performance. The half marathon performance came down to a few things. The half marathon findings were actually very practical. The better runners tended to have higher VO2 max, yet again, higher speed at VO2 max, greater weekly volume and faster average training pace. Nothing revolutionary there, but it does reinforce that consistent training volume still matters. So if we can... string together some several good months of training without breaking down without injury that we're accumulating ah weekly training volumes quite nicely. So there's no shortcut around that and building aerobic development. They found that the Cooper test which is a pretty classic uh performance based test where you pretty much just try to run as far as you can for 12 minutes. That particular Cooper test predicts was really strong at predicting your half marathon performance. So if you get really well at that test or meeting those conditions and fit enough to outperform your old self in that particular test, then you're doing pretty well at carrying over to half marathon performance. So you don't necessarily need expensive lactate testing or fancy lab equipment to estimate your fitness trends. You can just do some old school field testing if you so want to, because that's what the research. showed in this paper. uh There was something that I found was unexpected and kind of interesting. They looked at the emotional intelligence and running performance. This systematic review found one study that showed runners with higher emotional intelligence tended to perform better in the half marathon. And so, you know, he might say, okay, what is that? Is that just an incidental finding but uh Think about what emotional intelligence probably helps with during these endurance races. They're probably more disciplined when it comes to pacing. They're not overthinking things. They're not catastrophizing. They're good at staying calm, under fatigue. They can regulate their emotions better and making smarter decisions mid-race. I guess more rational decisions mid-race. And that can be very, very relevant when it comes to recreational runners. I mean, how many... people freak out at the site or like the feeling of being fatigued too early in a race or like, you know, there have been some challenging races where you're like, yep, this is way too much. Let me pull the break. And it's only like several days later when you're like, oh, I probably could have pushed on if I was more resilient. I think I just talked myself out of it. It's a big, big mental game with a lot of these races. a huge. number of runners sort of sabotage their races by oh going out too hard or panicking or interpreting fatigue as danger and mentally kind of spiraling. And so the psychological side of performance is probably underappreciated and hence very interesting that they've actually found a correlation between that emotional intelligence and actual performance. When it comes to the marathon distance, they found that it's mostly about training consistency. For marathon runners, the strongest predictions weren't necessarily the physiological markers, but the biggest themes were weekly mileage, frequency of running, the quality sessions that were included, long-term consistency and the years of sport participation. One of the strongest practical findings were that runners doing more than 10 hours per week and maintaining consistent quality sessions tended to perform better. So whatever you can do in your training to sort of execute on those points, we'll start getting you more superior results. The marathon rewards durability and consistency more than almost anything else, which also ties directly to injury prevention because a runner who can string together uninterrupted training months, less like boom bust, less injuries and just slow patient progressive loading, long run consistency, stable training blocks are usually outperforming runners. that are executing on, you know, quote unquote perfect workouts, but just inconsistent throughout the year. Moving ahead to ultras, ultramarathons, that was treated kind like a different sport. And the paper says that as the distance increased into ultramarathons, traditional physiology became less predictive. Instead, the biggest performance predictors became pace or pacing strategies, previous marathon experience, longest training runs. terrain familiarity, nutrition, environmental conditions, and race tactics. In other words, the ultras became less about raw fitness and more about energy management, decision-making, and survival skills, those sorts of things. They found that a higher carbohydrate intake was associated with better ultra marathon performance, which lines up with what we're currently seeing in the research with more carbs during races. fueling earlier higher carb tolerance with training. And for recreational runners, that's important because there may still be people who are under fueling during their longer runs and trying to fat adapted without trying the higher carb and seeing if that actually has a benefit for them. So when it comes to long, long races, carbohydrate availability becomes critical. Looking at the Environmental conditions, I don't think this really surprised me too much, but the review also found that heat, sunshine duration, wind, hilly terrain and trail surfaces all impaired performance. Sounds obvious, but runners often blame themselves like too much, like they'll run a slower race than their PB or they'll set sites on a race pace and then not hold it and you know, it sort of all comes apart after that, but it might've just been a slightly hotter or windier marathon. that's you're just comparing yourself to a marathon that was a lot cooler. ah And you know, with a ultra, a hilly ultra is not equal to a flat ultra, all those sorts of things. So terrain does matter. So in other words, like don't interpret slower performances as like a fitness loss when the environment had simply changed and changes the demands on the body. Okay, just quickly, they did mention lifestyle habits. just thought I'd just mention in here. So they found that there was an association with poor performance included when with smoking, alcohol consumption, sedentary time, higher BMI. Again, nothing groundbreaking, but does reinforce that performance isn't isolated to the 60 minutes you spend training. It's more to do with your overall lifestyle as well. And so guess my biggest takeaway from this paper is that performance changes depending on the event. The things that predict the fast 5Ks are not necessarily the same as predictions for an ultra marathon. And if you decide to go from 5k, 10k half marathon marathon ultra, which, you know, a lot of people tend to have that progression, you know, things need to change. And if you want to perform uh those shifts in demand, and from physiological to mental need to develop as well. So just be very aware of that. Think of recreational runners sometimes make the mistake of copying elite runners or influencers or you know what they might see. uh But you know, I think we take away these and kind of relates, like I say, to the non elite runners rather than the elite runners you may follow and try to replicate what they're doing. I think it's really nice to fall back on this sort of advice as well. The next paper I stumbled across and was really interested in is around shockwave therapy. The title is shockwave therapy for mid portion and insertion of Achilles tendonopathy. It is a systematic review and meta analysis. I'm like, Ooh, excellent. But Turns out it wasn't open access. I'm like, ah, damn, tried to get access to it. Couldn't, but found in the author list. Dr. Peter Maliaris was in there and I'm like, Oh, excellent. Let me just email him. Cause you know, we've converse back and forth over the years. He is the guru, one of the world's leading gurus in tendon treatment and tendon management. So uh emailed him and kindly next day I got the PDF in front of me. So reviewed this and I think you'll find it really interesting. know shockwave is very popular. um Is it overhyped? Let's find out. In the introduction, they start off by saying, among numerous treatment modalities, shockwave therapy has gained popularity in treating Achilles tendinopathy, despite conflicting evidence. While shockwave can be applied as a monotherapy, or just by itself, it is typically incorporated into a multimodal treatment approach, including... exercise, eccentric loading, stretching, medication, heel lift, orthoses, dietary supplements, et cetera. Clinical trials have reported inconsistent outcomes potentially due to the variations in shockwave parameters. You can have radial shockwave, you can have focused shockwave, and different treatment protocols and patient selection criteria. Shockwave can be delivered as focused or radial energy. i.e. sound waves, the focused shockwave targets deeper structures while radial shockwave generates lower amplitude pressure waves that mainly affect superficial tissues. The precise mechanisms of shockwave action in tendinopathy is still uncertain. Like even when we're talking about shockwave, shockwave, shockwave, it's still unsure of actually what's happening and why it's proposed to work. It's been argued that shockwave produces mechanical and biological effects through mechanotransduction and may improve tissue healing and alter pain responses through central or peripheral mechanisms. Until recently, no consensus has been established regarding the application or the procedure parameters directing shockwave in musculoskeletal and sports rehabilitation. Considerable differences across the literature, including differences in modality, the density, the flux density, I guess these are just the settings, the impulse number, the frequency, the overall treatment dose, as limited compatibility between studies and contributed to the inconsistent evidence regarding the effectiveness of musculoskeletal conditions. Although a recent guideline provides preliminary non-validated recommendations, meaningful standardization of clinical practice is yet to be achieved. While some systematic reviews suggest potential benefits of shockwave in Achilles tendonopathy, their conclusions are limited by methodological shortcomings, including the pooling of different tendonopathy subtypes and inadequate assessment of clinically meaningful outcomes. The primary objective was to estimate the effects of shockwave, whether as monotherapy or in co-interventions compared to no treatment. or sham shockwave on function and pain in patients with mid-portion Achilles tendinopathy or insertional Achilles tendinopathy. The secondary objective was to describe adverse events associated with shockwave. So mid-portion Achilles is more classic, more common, and it's sort of two inches above where the attachment of the Achilles is on the heel, whereas insertional Achilles tendinopathy is more at the insertion point around the heel region. Like I that is less common and a bit more stubborn, unfortunately. um So they're looking at both of those and seeing if shockwave has any benefit. um But as the introduction alludes to, there's been a lot of inconsistencies with, first of all, the understanding of shockwave, what's actually happening, but also how many sessions do you need? How intense does the... the shock waves need to be, how long does the session go for, do you do focal or radial pulses, all those sorts of things are just, ah it's disappointing and even shocking that we don't have the consistent results, because there's a lot of shockwave papers that do get published. ah So yeah, let's see what this paper shows. The systematic review pulled together nine randomized control trials. So in combination with all of those papers, a total of 557 patients were analyzed. Like I say, this is a meta analysis as well as a systematic review. So they need to have trials that are consistent enough to then pull all the data together and present it as one big finding. And like I said, good enough that they separated the insertional and mid portion Achilles tendinopathy because they are treated differently. They're treated as different conditions. The advice is overlapping, but yeah, some key differences. First, I guess it's important that I do explain what shockwave, I guess, kind of is. uh I was trained in this like back when I was working in clinics, we did get a shockwave machine in our clinic and we had these two, what I would call marketing guys. They weren't trained. therapists, but they were selling us this shockwave device and they're like, oh yeah, it's the best, you know, people need five to seven sessions this intensity for this long and I don't think they were going off much research, but shockwave essentially delivers sound waves into the tissue. And like the paper said, the focused shockwave tends to penetrate deeper, the radial more superficial and the proposed mechanisms are stimulating healing, don't know through what means, but improving blood flow, mechano transduction, like the paper suggested, and also altering pain sensitivity. tend to, whenever I have my various tendinopathies, respond really well to isometrics. Like I feel like my power returns and I feel less pain for several hours if I really load up with isometrics. I feel like the shockwave tended to have that same effect. uh But that being quite short lived, but that's just my personal experience. It does somewhat hurt during the shockwave. It's meant to hurt. You dial up the intensity so that you do feel uncomfortable during that session. um And then throughout the one session, if your pain reduces, which it was for me, then they just kept dialing it up until it became more more uncomfortable. um And then after the session, like I say, it felt better, but that was just my personal experience. and they're the proposed mechanisms. So let's dive into the findings of the paper. Biggest takeaway, shockwave probably doesn't do much. For insertional Achilles tendonopathy, the findings were remarkably consistent. Shockwave did not outperform sham treatment in a meaningful way. Not for pain, disability, function, short-term, medium-term, or long-term outcomes. And that was whether they used radial, focused, or both. radial and focused shockwave. And the differences were tiny. They were often like one point out of a hundred or two points out of a hundred, which is confounding considering the cost of shockwave, the marketing, the hype, like I say, all those sorts of things and how commonly it's recommended. I probably should have mentioned as well. It's very clever that some of these studies that they included had sham treatments because shockwave is one of those treatments where um The effects, the expected effects can be huge, but the effects can be a very powerful placebo as well, because you go into a clinic, there's a machine that looks pretty high tech. It's noisy, it hurts, it's, ah you you hear a lot of hype about it. So all of these can have a pretty powerful placebo effect and increase your belief or perception that this is going to help. And so that's where the... um placebo effect does come in. And the authors specifically discussed how difficult blinding is because you know, shockwave hurts. Whereas if you do fake shockwave, it doesn't hurt. So if the patients can tell it that they're in the treatment group, if you do have some sort of sham, ah it can be quite obvious that people do know what group they're in. So it can be hard. But they did try, they did try their best to, in some of these papers, create a sham condition, but purely based on the intervention and the circumstances around it means it is hard to completely rule out placebo. ah In fact, the only low risk of bias study that they had with the best quality showed no benefit of shockwave over sham. So that's important. What about mid-portion achilles and compare, because All that was just around the insertional stuff. What about the mid portion Achilles? Results are a bit muckier. So this is where there were a few studies showing benefit, particularly radial shockwave combined with exercise in some shorter term outcomes. But the evidence quality was extremely low and the results were inconsistent. Some studies showed good effects. Others showed absolutely nothing. So the authors basically concluded, we still can't confidently say it works, which I think is a fair interpretation. They can't say it doesn't work because there are some studies that are promising, but obviously vice versa. The exercise comparison is also interesting. So like one older study compared shockwave versus eccentric loading and found they performed about the same. But here's the key detail. When shockwave was added on top of the exercise, it usually didn't improve the outcomes further. So that's a pretty big clinical point because if exercise is already doing the heavy lifting, then what exactly are we paying for with all these shockwave sessions if it's not adding anything clinically significant or meaningful? uh So this paper repeatedly enforced exercise-based rehab remains the gold standard for mid-portion. tendinopathy treatment. The other thing that the paper found, so shockwave sometimes looked beneficial when compared to basically doing nothing, like the wait and see group, wait and see approaches. But when compared to sham treatment, proper exercise rehab, active management, the advantage just disappeared. Because it suggests maybe shockwave is better than no treatment, but not necessarily better than good rehab. And clinically, those are really different conclusions. As I mentioned, the secondary outcome of this study was to look at any adverse events. And so most people think shockwave is harmless, but two Achilles ruptures were actually reported after using the shockwave treatment. So the authors were careful with their wording here. They said that uh they can't prove that the shockwave caused the ruptures, but it's still worth mentioning, especially when the benefits are, as we mentioned, are uncertain. and the costs are high for these sessions. I know when I was in clinics, we did charge an additional fee on top of a standard, like the consult fee for doing shockwave. And as I talk with a lot of my clients, you know, they agree shockwave isn't cheap. So with those findings, it's probably worth helpful to remind you that Achilles tendinopathy along with a lot of tendinopathies is probably not just about damaged tissue. The authors discussed this and said that a lot of the outcomes are actually influenced by expectations, contextual effects, pain modulation, the nervous system changes. ah So this is what I took, like one of my big passions is around modern pain science and our understanding of pain science and how multifactorial it can be. um And so, Shockwave doesn't address any of those, I suppose in the benefits of the placebo effects, maybe there is some newly developed reassurance or confidence, but ah chronic tendinopsies do have nervous system changes, changes in the brain, changes the way we perceive pain and shockwave wouldn't necessarily deal with that. And so even though shockwave has become incredibly mainstream in tender rehab, we do need to... strip away the marketing and the machines and technology and all that sort of stuff. just have a look at what the evidence does show. And I think it's worth reminding ourselves that while there are some studies that are promising, there are just the equal amount of studies that show that it's not really that worth it. And so uh if you are considering shockwave and yet haven't executed on really nice load management, eccentric loading, functional restoration, ah I would definitely, definitely do that first. Another thing that I constantly remind myself of is shockwave isn't doing anything to rebuild the capacity of a tendon. know, strength training does that progressive strength training does that. And if the research is leaning towards progressive strength training is ah the gold standard and shockwave on top of strength training doesn't really show any additional benefit. Why not just give the strength training a really good go. and find a good clinician in your corner to help build that out for you. The next paper that caught my attention was Arch Supports and Plantar Fasciitis, a retrospective study incorporating patient reported outcomes and finite element analysis. Let's start with the introduction. Plantar fasciitis is a debilitating musculoskeletal condition causing heel pain, accounting for 1 million visits per year. It could be characterized by both inflammation and degeneration of the plantar fascia due to excessive strain or repetitive stress. Common non-invasive treatments include home-based stretching and strengthening programs, activity modification, taping, night splints, and non-steroidal anti-inflammatory drugs and physiotherapy. Arch support insoles include prefabricated and custom insoles, are also frequently prescribed as a non-invasive intervention. These insoles are designed to reduce strain on the plantar fascia by redistributing plantar pressure and providing structural support to the medial arch of the foot. However, despite their popularity, the effectiveness of arch support remains controversial. Some investigations report reductions in pain and improvements in functionality, often measured through a questionnaire such as the foot function index. Other studies indicate minimal or no added benefit of arch supports compared to placebo or alternative treatments. Since anatomical malalignment is also reported in plantar fasciitis, it is unclear whether the efficacy of arch support lies in realigning the foot structure. However, plantar pressure distribution seems to be altered in plantar fascia patients. However, the relationship between arch support induced alignment changes in their downstream effect on plantar pressure redistribution in plantar fasciitis remains poorly characterised. The study aims to provide possible mechanistic insight into the observed clinical effects of arch supports in the treatment of plantar fasciitis by evaluating pain interference, foot alignment through radiographs and plantar pressure distribution. This multifaceted approach will advance understanding of observed clinical results and generate a hypothesis regarding the biomechanical basis of orthotic interventions for future controlled investigations. So this paper essentially looked at foot alignment, the imaging radiographs, and also biomechanical remodeling, like they looked at heel pressures with and without these orthoses or support arch supports. And they tried to symptom involvement with a plausible mechanical explanation. Because while they do say, okay, so studies show that if I put on these arch supports, we reduce the pain, but what's actually going on? So this was a prospective single arm control trial, meaning that like everyone received the same intervention, there was no control group, there was no sham in soul, there's no comparison against exercise or other standard cares. So it's important to know that. Because while prospective studies are stronger than retrospective ones, without a control group, we can't confidently say how much improvement came from the insole versus, you know, people naturally get better, people heal. uh There are placebo and contextual factors. And as I mentioned later, there are other concurrent treatments that people are still allowed to do while wearing these supports. So the authors openly acknowledge this. It is a limitation, but This is more of a promising mechanistic evidence rather than proof that arch supports definitely work. It's like if they do work, why do they work? They're trying to answer that. So the participants they included, there's 29 participants aged between 18 and 65, all diagnosed with plantar fasciitis. The mean age was 36. There was 18 females, 11 males. The participants were fitted with a graded arch support system. They either had a high arch, moderate arch or a recovery slash relaxation support. And importantly, everyone was given the same shoe. They were all given the Brooks Ghost. uh taking out of the equation foot wear variability. And what outcome measures did they have? As I mentioned before, they looked at pain scores. They looked at imaging changes. So using weight bearing CT scans, x-rays and foot alignment measures. And they had this finite element analysis. This was, from what I read, sounds pretty cool. They built a computerized 3D model of the foot. And if you go to this particular paper, you can see on some of the pages, like what some of these images look like, but they can look at the heel stress, the force distribution, the pressure redistribution with the insoles. Essentially, they simulated how the force moves through the foot, very biomechanical engineering heavy. And so the main findings, pain improved very quickly. So when it came to the pain questionnaires, the pain improved significantly by week four. And those improvements were maintained through week eight and week 12. Importantly, the effect sizes were considered large and That means that the changes weren't just statistically significant, they were probably clinically meaningful too. And there was like, I'd say that the visuals on this particular paper are quite impressive as well, if you wanted to um go have a look at those in the Google Drive. But like I say, there is a caveat here, there was no control group. So because plantar fasciitis often improves naturally over time, we just don't know if that's what's happening in this cohort. And so that really matters. But like I say, the paper was trying to aim at like, if it does improve and if the orthoses are making people better, what is the biomechanical reason behind if there is any. So this is where the study became a bit more interesting. So the insoles changed the foot alignment in measurable ways, they found increased navicular height, increased calcaneal pitch. and changes in arch alignment. So in plain English, the arch support actually changed the shape and posture of the foot under load. That's important because, you know, critics often look at orthoses and argue they don't mechanically do anything. And this study suggests that they probably do. The heel pressure predictions were substantial. So like I say, they use that finite element modeling and it showed a 37 % reduction in peak heel stress and a 15 % reduction in average heel stress. That's probably pretty meaningful biomechanically when it comes to, you know, accumulating load throughout the day. But when it came to, I guess, the conclusions, the authors themselves didn't really oversell things or over promise. The authors throughout the paper repeatedly kind of stated that longer follow up is needed and control studies are needed and casual relationships. can't be confirmed because like I say, there's no uh placebo or control group to compare them against, which I appreciate that from the authors that immediately increases my trust in the paper. And like I mentioned earlier, these participants were actually allowed other treatments. They weren't restricted from stretching physio, know, activity modification, conservative management, all that sort of stuff. So this kind of reflects more of like the real world to put somebody in arch supports and have them do other things as well. So if someone improved, was it the insole, was it the shoes, was it the loading, stretching, exercises, all that sort of stuff, we don't know. But I guess it's worth me saying that ah we shouldn't listen to this and walk away saying everyone with plantar fasciitis needs arch supports. That would be overreaching because, you know, some people respond well, some people don't, some people prefer minimal shoes, some people hate orthotics, some people like it makes it worse. or makes their symptoms worse. So plantar fasciitis is multifactorial, we need to consider that. But after reading this, it does say like for most, uh this cohort does see that orthotics do seem to reduce pain and arch supports are relatively inexpensive. It's not like those expensive shockwaves that we're talking about in earlier studies um to am pretty practical just to whip into a shoe and just see if it really works for you. So the overall takeaway this paper provides sort of moderate quality supportive evidence that arch support insoles may help short-term plantar fasciitis symptoms. But like I said with the shockwave stuff, uh the arch support doesn't really do anything when it comes to restoring functional capacity of your plantar fascia. If it is a capacity issue and your running or time on feet or daily steps per day is exceeding the capacity of your plantar fascia and that's why you're sore and have that first step pain the next morning. Orthotics maybe help distribute the load so you can tolerate it a bit more but it's not doing anything to restore or rebuild and that's where strength training comes into it. And so I walk away from this being like okay first time if it's really stubborn and we want to settle down the pain let's try some orthotics but needs to be accompanied with really well structured progressive strength training in the ward. towards like restoring function. And so that would be my takeaway of that. Hopefully you enjoyed this episode, updating you on the latest research that's come out. I'll do another one like these in the last episode of June. Hope you have a lovely training week and we'll catch you in the next episode. If you are looking for more resources to run smarter, or you'd like to jump on a free 20 minute injury chat with me, then click on the resources link in the show notes. There you'll find a link to schedule a call. plus free resources like my very popular Injury Prevention 5 Day Course. You'll also find the Run Smarter book and ways you can access my ever-growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritising your running wisdom.