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Part 1 of 2: Brodie Chats with Podiatrist, researcher & podcast host Ian Griffiths all about Plantar Fasciitis. We talk about the harsh reality of this heel pain and why is it so common, along with the confusion involving treatment. Some topics that we cover: Why is plantar fasciitis so prevalent? Why is so it hard to seek effective treatment? What are some common mistakes running with PF make? What does the evidence indicate regarding treatment? We also answer all your patron questions. Apple users: Click 'Episode Website' to.. Find Ian's podcast by searching 'Podchat Live' Visit his website at https://sportspodiatryinfo.co.uk/ Twitter: @sports_pod & @podchatlive Instagram: @sportspodiatryinfo Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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 let’s begin your run smarter journey.
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On today's episode, persistent plantar fasciitis troubleshooting with Ian Griffiths. 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. to today's episode. Thank you for joining me on the Run Smarter podcast. Today we have Ian Griffiths and he is a podiatrist from the UK. He is a clinician and is also a researcher as you'll talk about in a second. He's also the podcast host of PodChat Live. He co-hosts that. And it's one of my favorite podcasts. Been listening to it for a very, very long time. It's kind of like the podiatrist version of RunChat Live. If you're interested in Matt Phillips and what he does with his podcast, it's very, very similar format. Um, like I said, Ian, um, and Matt, they're both very charismatic, very chatty. And it's very evident in today's episode because we, um, had a chat for such a long time, he now holds the record for the longest chat I've had with a, um, on this podcast. And I had to break it into two parts. It was unplanned at the time, but had to make the judgment call halfway through the interview. And usually when I'm chatting to someone. and let's say it gets to 40, 45 minutes, I just pick within my list of questions what to ask next and kind of have it wrap up around the 60 minute mark. So I'll kind of pre-plan that or I guess modify the questions in a way that it wraps up in a nice time. But it was such an engaging conversation and Ian was so passionate and everything he spoke about I just had to add a couple of different things and we just had a good chat around plantar fasciitis because something that I'm really interested in, I see a lot of my patients with it. I know a lot of people, a lot of listeners are very interested in this topic. And so we just continued and we went for such a long time. And so it's definitely going to have to be a two-parter. So maybe the cutoff at the end of today's episode is a bit abrupt. But like I said, we need to absorb this information and digest it in smaller chunks. So today we talk about Uh, like what plantar fasciitis actually is, we talk about why it is such a persistent troubling condition. Uh, what are some, uh, what are some effective treatments? What are some mistakes that people make? And we delve into some of the research that, uh, Ian was involved in regarding the most effective treatment. Uh, he was involved in a systematic review regarding plantar fasciitis treatment. And he also touched base on other treatments that aren't as effective in the literature, but can still be effective to relieve pain as well. So we cover a lot. Hope you enjoy this episode and we'll dive into part two next episode. Ian Griffiths, welcome to the podcast. Thanks for joining us today. Thanks so much for having me. So it's an honor. Well, it's an honor for me as well, because I've been following your stuff for a very long time. I'm a very regular listener of, um, pot chat live and yeah, I've been following your stuff very closely for a very long time. So it's a pleasure to have you on. I appreciate that plug actually. I didn't, I didn't ask for that. I promise. Well, we'll do, we'll do the plugs at the end as well, but I love, um, plugging podcasts. I really believe in the ones I listen to regularly. So we'll do it more often throughout this interview. Great. All right. So, um, if people aren't familiar with you, can you maybe just, um, give us a summary of who you are, what you do and, um, where you spend most of your time these days? Yeah, of course. Um, so I'm, um, my name is Ian Griffiths. I am a, uh, sports podiatrist and I'm based in the UK, in private practice in London, two days a week. And I need to stop and think here because this is my sort of a pandemic modified week, which is still, as you know, we haven't quite got on top of the pandemic here in the UK as well as you guys have in Australia. So I'm trying to think what we do now. It used to be three days in clinic, I'm two days in private practice in London. Um, I do some lecturing at, um, QMUL on the master's, uh, degree there, the sports, uh, sports, podiatry master's degree there. And, um, Ultimately, other than then, you know, dabbling with, with social media and podcasts and nowhere near to the level you do, of course. Um, I, um, Oversee the, the homeschooling and the school running of my two children as well. Fantastic. Brilliant. I love the, um, the combination of clinic. and research kind of lecturer sort of thing at the same time. It's, it keeps your clinic skills up to scratch and also keeps like, you know, up to date with the available research, which is a really, really nice combination to have. And I'm excited to dive in today because plantar fasciitis is probably something you talk about a lot and you're very familiar with, but something that I've done a couple of episodes on the podcast before, but it's a condition that so many people have and it can become, as you know, very chronic, very persistent and just very irritable very easily. My first question that I had written down sparks my curiosity because if I'm active on say Facebook groups and if I see people posting or if I'm talking to people who have large running Facebook groups, they always say it's plantar fasciitis posts that come up all the time and that get the most engagement. People just always comment, yes, this is me, this is me. What's helped you everyone's like constantly looking for the solution, constantly looking for ways to settle down their pain. Um, why do you think out of all the conditions that runners can have, why do you think plantar fasciitis is one that is so, um, prevalent and one that can just stem into something that's so nasty and so chronic? Yeah, my experience is exactly the same as yours with, with regard to, you know, dipping into social media groups and, and seeing this being spoken about almost more than anything you could argue and, and clinically as well, you know, a bit like yourself, almost all of our clients tell our sports people and large, large proportion of those are runners. And it seems to be the chat we have more often than not. Um, I think the, the last literature I saw had it at, um, had plant a heel pain at being essentially 8% of all running related injury, which It actually doesn't sound as high as it probably should in my mind, the amount I'm talking about it. But then when you look slightly outside the running literature, the sort of, I guess, society or community level, depending on the literature you read, it could be anywhere, plant a hill, paint anywhere between four and 10% of any community can get it any moment in time. And I think when we consider the demographics or the sort of cluster of people that are more likely to suffer, certainly going all the way back to when I trained, I was always taught that it's the condition of the older or the middle age, I say middle age because I'm of this age group now, but the middle aged and sedentary person, that you know, possibly slightly overweight. That was kind of the classic plantar heel pain patient that we would talk. But what we now know is, as we've just been alluding to, that the younger and the active are very much getting this as well. So when we think about it, spanning the young. and the middle age or the old and the thin and the underweight or the overweight, the different body masses and the active in the sedentary. Well, that kind of covers it. We've kind of just described every single person on the planet in some way, shape or form there. So it doesn't seem to discriminate in the way it used to. And I think it's sometimes confusing when you think how is something, how does something get young runners who are very, very active, but also it gets sedentary, less active sort of older people. How can something And I think ultimately it's to my mind probably a very similar mechanism, which as you know is this fine balance between load and capacity. So essentially how much we're how much demand we're placing on a tissue, how much we're asking a tissue to cope with and how much that tissue is able to cope with. So obviously, the more active you are, the more you're putting load onto a tissue, the more sort of sedentary you are, you could argue that you know why am I getting heel pain when I walk to the shops well because of the. potentially the age-related changes in the tissues, but also the deconditioning that occurs with being sedentary. You know, someone running, someone very, very young, running a hundred kilometers a week, can overload their plantar fascia, but someone who's 55 and just walks to the shop for some milk every morning, that can be an overload. It's all relative. And I think that probably speaks, in my mind at least, my interpretation is that speaks to why this is so common across all populations that we've talked about. And with regard to its persistence, The way I would always describe this to people in a very simplistic term would be that sensitive tissues can either be kept sensitive by activity or they can be desensitized. And one of the first things I don't need to tell you as a physio, one of the first things we do with sensitive tissues is say, okay, what initial things should we put in place to sort of try and lower sensitivity before we then gradually reintroduce some kind of loading protocol? And ultimately... when you've got a sore heel, it's easy to keep it sore. It's not like a thumb where you think, my thumb's pretty sore, I'll dull back on those 10,000 texts I'm sending, or perhaps I'll switch hands and I'll scroll Instagram with my other thumb today. You can't suddenly decide, I'm going to hop just on my asymptomatic foot today. You can modify your activity. And again, if you're willing to do so, we know we have challenges with people doing that as well. But even when you modify your activity, you can, it's very easy to keep a sore heel sore, which I think probably speaks to these, these depressing and frustrating timelines that we see plantar heel pain exist upon. It's a perfect answer. It's one that's makes what makes me think about what I call this pain rest weakness downward spiral where the sensitivity of the tissues themselves can be spiraled out of control where every day sort of activities your normal day-to-day stuff starts to interfere with that tissue sensitivity. And now we're not just talking about running because people are totally backed off running altogether, but they have to work, they have to, they have duties throughout the day, they have to go shopping. And that can start to, if you've passed this chasm where that activities of daily living are now stirring up that Achilles or stirring up that plantar fascia, it's very hard to control that. And then by the time you've sort of realized a case supportive shoes or trying to de-load it as best you can, maybe with an orthotic, maybe with some taping, maybe with something usually by that stage, everything irritates it. Like walking for half an hour irritates it. And when I was back in clinics, I was seeing a lot of people with plantar fascia. You could just get a sense of their career. Like you could get a sense of their injury path for the last six months where, you know, running 5Ks would stir it up and then running for 1K would stir it up and then walking for two hours would stir it up and then walking for half an hour would stir it up and now standing still for 15 minutes stirs it up and there's this like steady decline of tissue tolerance and this steady increase of tissue sensitivity, which it's hard to say, but I think the first couple of weeks that then trickles onto the first months of mismanagement is like a real, Sticky point really creates that downward spiral, which people are often really stuck in. They're often all the way down that spiral and they're trying to work their way back up, which is very, very tricky to do once they're in that state. Would you agree with that? Would you agree with kind of that timeline and those examples? Yes, I would. That's my experience completely. And I think it's why if we do catch it early, We seem to the prognosis, the timelines, everything just seems to just be a bit easier for everyone involved. The fact of course is that we certainly within podiatry and the way we're set up in the UK, we rarely catch it early. For a number of reasons, it may well be they've been, I don't know, we'll probably come on to talk about this, but they may well have been around the houses and seen a few people, seen their GP, tried a few things from the internet. If we see someone and their opening gambit to me Oh, you know that they've had it in the, you know, it developed in the last three months. That's, that's we're lucky. You know, most of the time we're looking at six months plus and they've sort of, uh, finally made their way around and like you say, unfortunately, how far they are then down that spiral. I love that by the way, I might steal that for clinic immediately. Um, how far they are down that spiral definitely seems to feed into their, um, how they feel about it and their mental state. And then we know how important those things are with, with regard to the pain experience, but also, you know, the options left available to us and the kind of timelines we're on and, uh, all things sort of linked to prognosis. Yeah. Well, then let me ask you this question. Why is it so hard for someone who has had plantar fasciitis for a couple of weeks or a couple of months to find effective treatments? It's if, if it's so prevalent and we've got a ton of evidence on what some effective treatments are, um, why are we not finding Why is it not the first thing that people seek and why are they mismanaged for weeks and months? Yeah, it's a great question, isn't it? And I guess for me, when I hear that question, it almost immediately in my mind separated into two things, which is why is it hard for them to actually find effective treatment, as you said, but then this ill voice in my head said, what is effective treatment? Do we know? And that might be a bigger question to answer. There was a lovely... qualitative bit of research done not long ago, sort of like a thematic analysis of, a guy called Matthew Kotchett, who's a podiatrist at Latrobe in Melbourne. And he's done some amazing work around the realms of some of the non-mechanical factors considerations with regards to plantar heel pain. And essentially it was, I can't remember the, I'm embarrassed to say I can't remember the title, it was something along the lines of, lived experiences of people with plantar heel pain. So essentially took people and sort of just really kind of got to the nuts and bolts of what they wanted from treatment and how they felt about treatment. And ultimately the strong themes that emerged were that there were suggestions that when people had gone to their GPs, their GPs, I think one comment verbatim was my GP wasn't interested. And I do think you sometimes have to get... lucky with the person you're sitting in front of or whether they're, whether they're into feet, so to speak. Um, certainly when it comes to sort of GPs. And I think the second strong thing was that, and it might speak to the actual original question here is that internet searches were referred to as being confusing, conflicting, and unuseful. And I think we're fooling ourselves to think that the first time a runner develops discomfort, they come up, they book straight in to see one of us. We know that they're straight, you know, they're on their phone as we all are, you know, the other day I had a plumbing problem. probably should have called a plumber, ended up doing that ultimately anyway, but why would I do that when I can take 10 minutes on YouTube and watch some videos first? This is just the way we're now wired in 2021. And you get onto the internet and like we say, we've got this confusing, conflicting, borderline, unuseful information coming from all angles, anecdote. We have lots of evidence, as you say, but there's an awful lot of anecdote out there as well. And you layer on top of that the mentality of a runner, are they willing to seek help? How long have they ignored this for? I know as a runner when something hurts, if I ignore it, perhaps it will go away and it won't interfere with that week's training. But then the more I don't ignore it, the more it sort of makes itself known to me. And I get through those almost stages of denial before I decide, okay, I better see someone. And then I go on the internet and I try a few things there. Now I'm confused because things haven't worked. And this is probably why people end up seeing us six months down the line, because you know, this is the journey they've been on. With regard to what's effective, that's the big question, because I think the problem here is the one thing, of all the things we do know and some of the things we don't know, the one thing I suspect most of us agree on is that there isn't a one size fits all. I mean, this is true of any pathology, isn't it? Any condition. There isn't a one size fits all. There isn't a blanket approach. And I think that's the problem when you... when you see runners or hear runners speak to each other about I had this problem and I did X, I did Y, I did Z. Well, firstly, you know, we're looking at different people that may not have had the exact same problem, which is another point to mention, but you're really just hearing what worked for me sort of in quotations. And I think as soon as you try a few things and they don't work, that just feeds into that downward spiral of, okay, well, I'm stuck. I'm stuck with this forever. I mean, I see people in their late 20s, early 30s, real athletics specimens. And one of their own, at the start of a consultation, when you sort of ask them, tell me your story, tell me what you're worried about, tell me what you want to achieve today, tell me, give me the backdrop. And more often than not, more often than I would like to hear, I hear young, healthy people say, do I just have to live with this forever? because their experience over the previous months has suggested to them that may be the trajectory they're on. So it's really messy out there. It's the Wild West, you know, and you go onto social media and, you know, in our clinical academic sort of silos, we live in the gray. So we are comfortable being uncomfortable. We're happy to acknowledge what the... meta-analyses and systematic reviews, tell us we're happy to hold our hands up with the limitations of such research. We are happy to say we don't have the answers to everything. But runners don't like that. And why would they? Because they can go on Instagram and some guy or girl with 120,000 followers can tell them in nice big thumbnail and bold letters, cure your plantar fasciitis. And they're like, well, I prefer what this guy or girl is saying. So this is kind of the whole messy business. Every time you're talking, you're answering my question. I'm coming back with, I'm thinking of maybe like five or different ideas or five different questions to ask you. Cause it's such a fascinating topic. When you're talking about Facebook or like searching Google and searching Facebook groups and things, um, you're exactly right. Cause you'll never see a post where someone says, I have plantar fasciitis, I've had it for 12 months. What's helped everyone else. If you will always come across conflicting stuff. It's like. orthotics didn't work for me. Orthotics was magnificent. That's all I needed. Taping, strengthening, stretching, um, you know, shock wave, all these sorts of things. And like you were saying, it's almost like what has helped you. The individual is very different from what will help me as the individual. And I guess that's why the, you do get so many questions, so many different replies and why it's so hard for the individual to choose. a treatment, because some of it's not only just puzzling and confusing, because there's so many different options, but some of it is very conflicting. It's contradictory to like, you know, sometimes stretching made things worse. Sometimes running actually made it better. Sometimes running made it worse and sometimes complete rest made it worse. And it's, it's very, very tricky, very hard to navigate. But, um, one idea that sort of struck to me while you're talking was when you're mentioning that a runner. Um, can sometimes ignore this for such a long period of time. And often think when runners are injured, they don't, they don't seek help. Once it's painful running, they get to the point where it's so painful that they're unable to run and then their motivation levels go through the roof because, you know, they love running. It's what they do. And as soon as that's why, when they have these minor injuries that they just keep running and they just ignore it and they, they hope that it'll get better on its own. And once it gets so aggravated, so irritated, so sensitive that they're unable to run, that's when they're booking in the next day. Um, just cause motivation level shoot the route through the roof and plantar fasciitis or this plant to heal pain is something that can for some people really creep up on them. It can all of a sudden the only, you first notice it when you've had it for five weeks, it's one of those really thing that is really, um, very subtle, like, oh yeah, there's been a bit of stiffness with my first few steps in the morning, but it goes away. And you. Forget about the rest of the day. And it's not until you'd be like, Oh, I've had stiffness every morning for the first couple of minutes for the last two weeks, maybe I should get it sorted out, but everything else throughout the day is fine. And then all of a sudden, when you finally decide to get treatment, it's been there for two months and it's, they just like, I don't know where the time went, I don't know why it's been there for so long. I usually am so proactive with these things, but it's just, it just crept up on me. So that can be a very clear experience. You've hit the nail on the head, hearing the word crept up on me. If someone comes in with an ankle sprain and you say to them, tell me what happened, they'll pretty much say, well, it was April the 22nd. I was at my brother-in-law's wedding. I was on the dance floor. When someone presents with planta hill pain, you say, tell me the story. They're not gonna give you a date. Whereas at ankle sprain, they'll say it was Saturday, it was three Saturdays ago, plant a hill pan. They say, it was springtime. They'll give you like a three month window. For the exact reason you say it's so gradual and insidious. And I think your point about pain not stopping runners, but pain which stops running, you know, really being the motivator is key as well, because it is something you can usually run through for quite some time. Like you say, you wake up in the morning, you walk to the bathroom. you feel older than your years for the first four or five minutes. And then you kind of, by the time you've pootled around, made some coffee and had some breakfast, you kind of think, oh, I'm good to go again. You run that day, you then wake up the next morning, it's Bill Murray and Groundhog Day, you know, essentially, but you kind of go, well, you know what? But by midday, when I go for my lunchtime run, it feels okay. So it can't be that bad. And like you say, it's only when it starts trickling into daily life, all that pain in the morning starts hanging around for longer. I think you're absolutely right. I think your comments are beautiful. And I think coming back to, you know, what works for some doesn't work for others. I mean, it's what we refer to scientifically as subject specificity. I mean, it shouldn't surprise any of us. And it's not unique to plantar heel pain or unique to stretching or foot orthoses or taping. It's, you know, if you took 10 people with a headache and gave them all the same dose of paracetamol, you'd probably get, you would get subject specific responses. And this is one of the limitations of research. When we say shockwave works or corticosteroid injections work, what we tend to find is the data has been mean pulled. So, you know, here's 30 people that all had plantar heel pain that affected, you know, function to this degree. They all had, here's that number represented as a mean of 30 people. We gave them all shockwave and, you know, for three weeks, six weeks, and then at the end. here's that mean and once again, it's gone down. Well, you pull a couple of people out of that study, there'll be someone in that study that had no improvements in pain or function whatsoever, but they got lost in the mean pooling of the data. So I think, yeah, you go on the internet and just bear in mind your reading what worked for someone else. And let's not forget, of course, the huge flaw that we all have as humans, which is making spurious correlations and sort of doing things. and committing the post-hoc fallacy, which is I did X and then something happened, therefore X caused something to happen. And I think sometimes when you see things on the internet, you certainly don't want to illegitimize someone's very real outcome. Like if a runner is on the internet telling other runners that they rubbed a mixture of toothpaste and horse urine onto their plantar heel pain, and the next morning their plantar heel pain was gone, I'm not saying I don't believe them. I'm not saying that isn't an outcome that happened. I'm questioning the mechanism behind what's happened here and whether we are dealing with some incredibly strong contextual effect or placebo type scenario, or whether something else that was going on at the time was contributing, whether it just happened to regress to the mean that next morning. I mean, with some of these stories we see on the internet, we need to bear in mind what worked for someone else won't work for me and also. what they're saying helped might not be what actually helped because we, we are, um, very, very easily misled with regard to timelines and correlation causation. Yeah. None of us are nothing. Yeah. We're all guilty of that. And when it also comes to Facebook posts where someone said, Oh, I just did stretching and it went away, but you're not, they're not posting all the other stuff that they might've done or incidentally done, like have time off or reduce their running mileage or change their footwear or, um, they're they're drawing these conclusions and thinking, yes, this helped me, but they're not really sharing everything that went on. And maybe it's a combination of all the things that went on that helped them as the individual. But then we're also tapping into the interesting topic of pain science. And if someone, their experience in like a clinic, if they're given an orthotic and they're showing all these, um, graphics of why it works and they're very, the clinician is very, um, well educated in communication and will say, this is why this is your pain. they get a lot of reassurance around it's okay to do certain things. And the overall experience is very positive for the individual. That's going to be a very real, very positive experience. And therefore whatever treatment the clinician chooses is more likely to work than if someone's just going out on a whim without really believing it to work and just give it a try and to see how it goes. That experience is going to be less effective because we know the brain is very powerful and I've had tons of episodes on pain science and most people will be very familiar with that similar effect or like the placebo effect and how, again, everyone's reaction, everyone's effectiveness to certain treatments will be extremely different because not only just the treatment that's effective for different people, but it's also the experience that they have around that treatment approach is very different as well. Yeah. And I'm already conscious that there may be runners, I know your audience is primarily runners and there may be runners that are suffering with this. they've seen the title on your feed and they've suddenly gone, oh great, I'm diving in here. Like finally someone's going to have the answers to how to, I can get rid of this problem. And now is the time for me to apologize that I'm not providing those. But I would also add to be wary of anyone who too confidently does. So that for the reasons we've just said. Yeah. And some people can be very confident like, because it's been magic for them, like they can swear by orthotics because it's helped them so miraculously. And so like you say, we're not discrediting anything that they're posting or the real benefits that they're having but we're just skeptical for it working for everyone else. So how about, we will talk about treatments in a second. We'll get to that. How about common mistakes that you see if someone does have morning stiffness for the first... you know, 10 minutes in their morning, that's happened for the last couple of weeks. We don't want this to spiral out of control. We don't want this spiral into a really sensitive state where everything is now producing pain. Do you see any common mistakes that these people with early stages plantar fasciitis have that really inhibits them down the track? Probably the things I see commonly done, and I wouldn't necessarily want to label them, maybe they are mistakes, but it feels, I don't want to be rude and tell people they're making mistakes, because you've got to do what feels right for you. But at the same time, the things that probably, you know what we talk about when we talk about, okay, what are the big wins? There's lots of things we can do, but we should probably do the big wins first. The analogy. that I've stolen from someone else shamelessly is, you know, if we've got a glass jar, we're gonna fill it with stones and we've got big stones, with big pebbles and tiny little stones. We don't wanna fill it too much with little stones because otherwise we won't get the big pebbles in. So let's get all the big pebbles in first and then what we can do is pour in all the little stones that will fill in the gaps around it. So if it's a case of what are the small stones that people are probably over-focusing on at the cost of ignoring some of the big stones, I hope I haven't milked that analogy too much. An over-reliance on passive interventions is probably the thing I would see the most. So people spend, and this isn't that these things cause harm, is that they cost time. Time, like you say, that could be better done, time, energy, or even you could argue money, that could be better directed elsewhere. So someone sort of over-relying on the phone roller, nothing against phone rollers, by the way, have one in my house, I should add. I don't wanna get into that. dogfight about sort of soft tissue manual therapy that I know you physios love so much, but if you're spending an hour a day on the foam roller, it's definitely an hour a day you could probably be spending somewhere else and other passive interventions that come under that umbrella as well. So I think what we tend to see is a huge over-reliance on passive interventions at the cost of probably, and also I would say the other thing I see is assigning too much blame to one specific thing, usually the footwear. The footwear gets blame a lot. It gets too much credit for stuff. Running shoes get way too much credit for some things and way too much blame for others, probably unfairly. So I think if you assign blame to a pair of shoes, and we hear this story that those shoes gave me my plantar heel pain. They're the ones that I was wearing the day that I first noticed this. Again, we know that doesn't necessarily mean anything, but if you assign blame to something, The problem then is you perhaps falsely think, well, as long as I change those, I've addressed the cause. And we know that may be erroneous. So, and at the cost of sort of blaming the footwear too much and spending too much time and energy on passive interventions, we definitely see a lack of reflection on someone's activity levels slash training habits. Because as you and I know, we can talk about some of the... the risk factors for developing plantar heel pain. And some of the literature might suggest that your foot posture is a factor and other literature might suggest that your ankle flexibility or range of motion is a risk factor. But I don't know what your experience is Brody, but certainly for me, nine times out of 10, if not 10, it's an error in load management. And it comes back to that mechanism we talked about with the young active or the sort of older with middle-aged sedentary youth. at that moment in time, you've asked something of the tissue, you've exceeded its top end, its ceiling, you've exceeded its capacity. And in a young runner, whether you like it or not, that's probably gonna be a training error. And we all make them, we all do things that we shouldn't, we all bump up our frequency or our volume or our intensity or combination of those things, particularly when we're training for events. And usually when we sort of, I love to sort of say to patients or athletes in clinic, Tell me what you think caused the problem and see what answers they come back with. And then I asked them if they'll open their phone and show me their Strava. And like I say, the answers are usually right there in front of them, but none of us want to admit that we perhaps overdid it a bit or that we trained like a bit of a maniac. We'd much rather blame the shoe and we'd much rather then switch that shoe in and out, phone roll the calves and we'll be back on track ready for the long run on Sunday. So I think it's just probably just where priorities are sort of, where someone sets their priorities and where they spend their time and energy. I don't know whether that's the, calling that a mistake is the right thing, but certainly that's my experience. I'm not sure if it mirrors what you've seen. Yeah, I think what you've said, like mirrors what I've seen exactly. And it's worth unpacking that, like in the initial phase or during any phase anyway, it's... you need to address the big things, like you're saying, you need to address the big things that would be the most effective for your management, rather than focus all your energy on those little things like passive treatment. So you mentioned foam rolling, I'm assuming. Well, we'll delve into those a little bit in a second, but pointing blame was a big, big thing because it can be a hindrance to your recovery. If you're blaming something that isn't really the cause or maybe only just be part of the cause because you need to have you need to have the right education around the mechanism of injury to be clear moving forward. And I think like once they're well educated on what's actually happened and they're educated on tissue capacity and overloading tissue capacity and what to do afterwards to restore that tissue capacity, the management just starts to make a whole lot more sense. And the little pebbles, the little passive treatments start to make more sense in terms of its relevance and the big. training errors like load management and building up the capacity becomes the most important thing which is like you say, is like the biggest factor when it comes to management. But if someone's listening to this and reflecting back on what we said earlier and said, but even if it's overload and it's training errors, it's maybe doing too much too soon, but you were just talking about, it also affects the sedentary population. It affects like obese, inactive people. Why are they getting overloaded? Can you maybe just allay a lot of people's confusion when it comes to like the two different populations getting the same condition? Yeah, so ultimately it makes sense to us when someone who runs 50 kilometers a week suddenly puts in an 80 kilometer week and something usually a tendon because they don't like holidays and they don't like surprises. But it makes sense to us when you jump from 50K to 80K something starts to feel sensitive and sore. And maybe you reflect and you say, okay, I see what I did here, I overdid it. My graph on Strava is a bit too steep, when we look from week to week volumes. Completely understandable, like you say, that we say, well, hang on a minute, I'm 55 years old, I'm 60 years old. I took early retirement, I walk the dog every day, and I've still got this problem. I haven't suddenly, I haven't gone from walking the dog seven days a week to walking the dog. 14 days a week, which would be, you know, you could argue a weird way of looking at how they'd spike their load. And I think what it comes down to is like we said, we can either exceed our capacity by suddenly doing too much, or we can exceed our capacity by doing what we've always done, but our capacity has reduced. So the analogy, and once again, none of these are mine. I'm not smart enough to come up with my own. I steal them from everywhere and I can't even remember who I've stolen them from. So apologies to whoever. first came up with the water in the cup analogy, but ultimately what we're saying here is, if your cup is your capacity for, let's say your fascia, and the water that you're pouring into a cup is how much load or demand you're placing on it, basically always have more cup than you have water. As long as you don't overfill the cup, you're going to be okay. So if you've got a cup and you suddenly, you're putting in water almost up to the brim every week. and then you suddenly try and put in another 50% the next week, you overfill it. That's our runner that suddenly bumped their volume. Where the cup analogy needs slight explaining is that human tissues are very clever and that the more you do to them, the more they change and the less you do to them, the more they change in the opposite direction. Meaning if you were to slowly drip feed water into this cup in a slow and steady and sensible way, over time, the cup will grow in size. meaning at some point in the future, you can actually put 50% more water in, but it hasn't been a sudden overfill of the cup because the cup has grown with you. And that's essentially what we refer to as training. That's anyone who's been done a marathon knows that that's exactly the process. What they're doing at week 14 of their training would have broken them a week too, but their tissues have moved along the journey with them and adapted. The converse is true. And I think this is what we're talking about with the sedentary, which is, if you have a cup sitting there and you don't give it enough water, it starts to shrink. So if you've historically been filling up the cup to the brim, but you have, like you say, if you're not, if you are sedentary, if the only thing you're doing is walking the dog every day, if you're not doing any other kind of strength training, conditioning, cross training, if you're generally just enjoying retirement, then ultimately your cup will shrink. And walking the dog, which shouldn't overload a cup, the cup shrunk so much that now that amount of water overspills. So I think you're looking at the same mechanism just at the two ends of the spectrum, you're either putting way too much water into your cup, or you're putting water that the cup used to be able to contain, but the cup has shrunk, i.e. your tissues have, we're talking about deconditioning at this point. This episode is sponsored by the Run Smarter app. This includes all my free and paid content, along with housing the Patreon exclusive podcast episodes. You can download this free app by searching Run Smarter app in your app directory and start scrolling through past podcast episodes, blogs and videos. You'll find categories like injury prevention, running misconceptions, strength and performance, and of course, injury specific information. You've already learned a lot listening to the podcast. Why not kick it up one more gear through the Run Smarter app? A ton of sense. And I think I'll steal that one as well. Um, I think I can add to that analogy and say that if a runner is one of those fit and healthy people, their cup is quite large and they're filling in this water. If they. overdo things and they feel that water too much in that sensitive state while we've overloaded that, that cup itself becomes smaller in the short term, while it, while those tissues are experiencing a very sensitized state and you can't, um, what previously the week before you were filling it with a certain amount of water. Now you have to fill it with less because, uh, what was once tolerated is now can like stir it up and be quite sensitive. So in the short term. It's that cup itself is shrinking. We need to find how much water can currently hold without overflowing and then slowly build our way back up. And if done well, or if identified early enough, that's a very short process. That's a process of about a week or two to get it back to its pre-state. Um, but if mismanaged that cup continues to shrink because you keep over doing it, overdoing it, overdoing it. And that sensitized state just makes that cup shrink more and more. Would you agree? Yeah, absolutely. And the one thing you reminded me that on adding to that yet again is let's just let's we're talking about, you know, straight mechanical stress on the tissue, but let's not forget, the other things that feed into this process, which is that may well affect the size of your cup that may shrink the cup things like sleep deprivation, stress, anxiety, basically, every basically normal everyday life for a human being, there isn't there's almost nothing that doesn't have the ability to influence these scenarios as well. So I think when runners sometimes sit in front of us, looking at their Strava going, I don't understand, there isn't a big spike. I haven't overdone it. Or let you say that the retired dog walker says, well, I understand what you're saying, but I do go to the gym three times a week. And I play golf twice a week. There's nothing about that runner that suggests they suddenly dumped too much water. There's nothing about that retired person suggesting that their cup has shrunk. What are the answers? If we just looking at the mechanical loads, we're not looking at the whole person, the whole picture. So that's when all of the other sort of factors of being human come into play as well. So yeah, pretty complex, which is why we don't have wonderful solutions for these things. And why I have like 140 odd episodes now dedicate to so many different topics revolving around this. And I like how I have like the concepts you talk about do follow on with a couple of my previous. interviews, like I talked with Izzy Smith about over-training versus under recovery and the combination between the two and how stress, sleep, nutrition, hydration, all those things just contribute to how much you can bounce back or how much attributes to under recovery in a way. So it's a very similar concept and if those people who are unfamiliar with that can go back, I think it's around 90 odd, episode 90 something. But let's move on because we've got some patron questions that I would like to get through. So Janine asks, this is going to be a bit of a follow-on. Janine asks, is rolling a lacrosse ball through the plantar fascia effective or rolling it through the calf Achilles? And I'll extend that question to methods like the Theragun, the freezing over that water bottle and rolling that and just all those other kind of passive treatments. Is there a place for treatment? If so, how effective can it be? Yeah, this is, this sort of speaks to a couple of points we've already made, but I'll go back over them and full disclosure, I should say here, as a runner myself, around my house, if you did a walkthrough now, you would find various paraphernalia that we've just, that you've just mentioned in various rooms, foam rollers, lacrosse balls, TheraGuns, Normatech, it's all here. So that, I just want to make sure that I'm... I'm being as honest and transparent as possible. Is it effective? So again, the first thing that comes to mind is we need to define what effective means. So does it feel nice? As someone who does these things myself, the answer is usually yes. Do we have data to support the concept that it has profound effects or changes at a tissue level? I think the answer there is probably no. But like we say, then we need to ask our questions, is it doing any harm? So is it doing any harm to the tissues themselves? No, is it harmful? Is it influencing our beliefs in a negative way? And will that then hinder our long-term improvements progress? That's a very individual scenario as well. And again, is it taking the place of a big pebble? Because these things are absolutely fine to do, but they are, what I would conclude, the smaller stones in the jar. So again, I would say to any runner, Janine or otherwise, and this is the way I approach it myself, if you're doing all the things that we would consider should be front and center of a management plan for plantar heel pain, if you're doing all those things, and we can talk about what those are, I'm sure at some point, then when you've got the kids to bed and you're sitting down and you've popped on, you know, the football, and you decide to kick back and watch a bit of TV, is there any harm in foam rolling your calf, lacrosse balling your calf? I would always probably do that, rather than just lie on the sofa for an hour and watch TV. I could lie on the floor and lacrosse ball my calf for an hour. It's not robbing time or energy from the other bigger pebbles. So I would say, just be mindful of probably what we, don't place too much value on it. Do it because you... Do it because you want to, not because you think you have to. That's probably the way I would approach those kinds of things. Yeah. I think it's also worth knowing that like the, the foam rolls, the, the lacrosse balls, they would most likely just have a short term pain management, um, effectiveness. And so you would know it's working. You would know it's, if it's working for you, because your symptoms, like you'd feel better afterwards. And if it's for a couple of minutes or maybe half a day, or maybe a whole day, Like you would notice that difference. And so if someone were to ask you the question, should I do it? Well, you ask them like, do you feel better after doing it? Because it's not causing any harm. So if it's beneficial for you symptom wise, then yes, it should be a part of your management. And so that could easily be answered by someone who has that question, just try it out. And if it's beneficial, then go for it. But like you said, a key thing to note is making sure it's not replacing something that may be long-term of benefit and something that is the big key to long-term management. If you're saying no harm, have you found someone to use a little cross ball or maybe a theragun or something at that insertion site where it is particularly sore and irritated that way? It's interesting that would make sense to me, that if you've got something, we think about where the plantar fascia is sort of a... originates from the medial carcaneal tubercle, which is that inside, sort of underside, inside aspect of the heel, which most sufferers will know when they poke with their thumb, that's my sore spot. You'd think tumbling away at that with a therogun might make it more sensitive thereafter. And it's interesting that, you know, I see people that do this sort of stuff all the time, and it doesn't seem, in the majority of people, to be the case. And in fact, one gentleman not too long ago who had been through a course of shockwave therapy as well said he basically sort of in his own mind, they felt pretty similar. He said, I've had shockwave, I now use a Theragun at home. I basically treat it a bit, I mean, obviously it's not shockwave, it's just essentially percussion, but he said it kind of felt kind of similar. So I figured rather than just keep paying for shockwave, I'd spend a few hundred pounds on a Theragun and just do it myself at home. Not suggesting people do that, but you know, certainly haven't seen a strong trend for people that decide to do that, making it worse. And I think whether you decide to do it or not really comes down to, you know, whether you're the kind of person that says something hurts, I'm going to get stuck in there and push into it, or something hurts, I'm going to dial back from it. And that's probably, there's probably individual psychological profiles associated with those kinds of behaviors. Certainly, if I was very, very sore there, I know I'd be the sort of person that would leave it alone. But that's not to say we have data to support one over other. Yeah. And we've kind of been dancing around this for a long time around the most effective things that should be in everyone's or in most people's management plan. Load management, obviously being one of them, like finding that concept of the cup and the water and making sure that we don't overfill and making sure that we build up the size of your cup. what should be the most effective treatment for a runner, not necessarily the sedentary population, but what should be in most people's, if not all of someone's, everyone's management plan when it comes to overcoming plantar fasciitis? It's the big one, isn't it? There was a paper that was published and I was a very small part of the team. We published it in the British Journal of Sports Medicine just a few months back. It's open access. So anyone can... grab it and read it, whether they're a clinician or whether they're a runner. And it was essentially, it took us five years. It was a five year project. When I signed onto it, I was told it was a one year project but it just spiraled and spiraled and spiraled because of the size of this topic. And it's essentially what we're referring to as a best practice guide for treating and managing plantar heel pain. So it's directed at clinicians, so doctors, physios, podiatrists, and basically saying. here we are in 2021. This is this, we're not saying everyone that comes in with this problem follow this algorithm, because we already, as we've already said, that's not the way these things work, but it's a guide. And it essentially had a three pronged approach. The first was the systematic review meta-analysis where we basically collated all of the work that previously been done on modalities for treating plantar heel pain. Brought them all together. And for those that don't know what systematic review meta analysis is, you basically take all the work in one area, bring it together, people that are far cleverer than me run some, you know, statistics on it, and then we try and work out what does the totality of the science currently tell us about the things that work well, the things that work not so well, the things that don't work at all. So that was the first sort of stage of it that the you know, what does the evidence tell us works for plantar heel pain. The second part of this was we essentially interviewed world experts. All across the world, clinicians who essentially are experts in the field of plantar heel pain. So they treat an awful lot of it. They've done research in it, they've published it. And basically, essentially within the interview scenario, said to them, what's your experience of what works? What do you see work? What works best in your head? So we've got what the evidence tells us, but we've got what people are actually doing. And the third part, which... which is what I believe made this paper so unique, was we did that same kind of interview, but with the athletes and the patients, the patient voice as we're referring to it. And when you think about the paper I mentioned earlier in the podcast about the sort of thematic analysis of runners feeling like, you know, medical professionals weren't interested in that, you know, essentially that their expectations were not being met. It makes complete sense that you say, well, if we're going to study this thing, rather than just churn out another paper that says, this is what we think work. Let's ask the patients, what has worked for you? What doesn't work for you? What did you have success with? Where were your expectations met? Where were they unmet? And then what we tried to do was synthesize these three areas, the evidence and what it says, the specialists and what they say, the actual sufferers and what they say. And we brought it all together and essentially tried to provide, as best we could, a bit of a guide on where we're currently at with this. Now the results were kind of interesting and I'm certainly not sitting here saying anyone with plantar heel pain should therefore try what I'm about to say. But this was what emerged from all of that information when it got sort of bunched together. Plantar fascia stretching actually came out reasonably favorably and it was suggested that as a first line and the great thing I think about this is we're not saying it will work for everyone but what we know is it's something everyone can do. You don't need to spend money. You don't need to go and see something. You can be a runner who says, okay, where do I go with this? You can do something very cheaply, very easily at home and see if it works. Plantar fascia stretching came out as being quite favorable for something that should probably be tried as a first line alongside taping and also individualized education. They were probably the three things that initially we would say, you know what, If someone's suffering with plantar heel pain, and again, we wrote this more for the clinician than we did the runner, but I think the runners can take something from this. You know, let's have a think about what we're doing here. Let's make sure this person understands what's going on. Because as we've already said, the more you understand what's going on, the more that will feed into whether you make good decisions or not. So individualized education about the problem, plantar fascia stretching and taping. So they're probably the things I would say, if you are listening and you're suffering from plantar heel pain and you think to yourself, actually, I've never been taped up and it's not something you could necessarily do yourself, although YouTube videos are available, but you could ask your physio to do it or your podiatrist to do it. If you think I've never tried stretching, if you think to yourself, I'm sitting here and truly ask yourself, do you understand what's going on? Do you, are you fully, if the test we do is, Kieran O'Sullivan test at the end of a consultation when we've explained to someone what was going on to test their understanding before they leave, we would often say, so just before you go, I want to ask you when you get home and your other half asks you, what did that person say? Tell me in your own words, how you're going to describe your understanding of what's going on to your other half over dinner tonight. And that's a really, I think a really nice way of understanding if as a runner with plantar heel pain, you think to yourself, could I explain this to my partner? And if the answer is you can't, it probably means that you need more education. And that's fine. Speak to the medical professional and they'll get you on board. But I would say stretching, taping, education. And the sort of second line after that, the things that then get to the point where you're probably needing these to be delivered by a healthcare professional, are shockwave therapy and custom foot orthoses. They were the next big two. Now, I'll be honest and I'll say, custom foot orthoses surprised me. They came out favorably over prefabricated devices. So it didn't surprise me that people did well with orthoses, given that we're giving them to people on and off for 20 years, but it surprised me that the off the shelf ones weren't as effective because a lot of our research prior to this had suggested, you know, you don't necessarily need to get something custom made. Now again, the limitations of, all this data may answer some of those things. But the one thing that we really noticed was interesting, and the one thing as a physio that I wonder whether you've already sort of flagged, where is it, where is it, is some kind of loading protocol or strength work. Yeah. And let me say from the off, I'm not saying that we shouldn't be doing those things. And when we come back to our load capacity, water cup analogy, what we know is that... you know, we're reducing our water by modifying our activity, but how do we get that cup bigger? We've already said it, we train, you know, we condition our tissues. So I'm not saying it should be omitted. I'm not saying it isn't useful. What I'm saying is at this moment in time, and it will change, I'm certain, the data to support it doesn't appear to be there. There was only one study at the time that we did this that really looked at it, which you'll be familiar with, which is the Michael Rathliff study, the sort of high load plantar fascia loading. and it didn't meet the level of quality it needed to for inclusion in the meta-analysis. So again, a meta-analysis can only really be as good as the studies that are in it. And there weren't any studies that had looked at strength with regard to plantar-heal pain that were of high enough quality. That doesn't say don't do it, but I just wanted to make sure you're aware of why that hadn't been mentioned there. But again, these would be what we've... we would call the big pebbles. And if you're doing all of these things, along with, like we say, and underneath the umbrella of education, individualized education comes load management, as you've said. So ultimately load management, understanding, and then if you look at all the other things, stretching, taping, shockwave, orthoses, they come under that umbrella of, we're trying to either trying to sort of modify loads on tissues in the short term and allow them in the medium to long term to become more tolerant of what will be what will be asked of them in future. Yeah, that's awesome. I'd love to have a look at that paper as well and have a read through it. Cause it's super, super interesting stuff. I love how you've taken the approach of asking the patients as well, as well as the clinicians. Cause I'm just thinking a scenario in my head of someone coming in to a consult with plantar fasciitis and the clinician being like, Oh, so is there any improvement? They say, Oh, you know, maybe. Yeah, I'd say so. And they're like, Oh, great. You know, like. How much is it like 50% or like 60%? They're like, oh, maybe, I don't know, 10%. And they're like, yes, it's working. Let's continue doing this. And like the patient walks out being like, I'm not really feeling that much better. And the clinicians sitting back in their chair being like, yes, what we're doing is working. Like those sort of like how you interpret what's going on, it can be totally different. You know, the patient's expectations is nowhere near met, but the clinicians like, oh, we're on the right track. We're doing the right thing. It's been effective. Um, so it's good that you get the story from both, both sides, because it can be totally different if you, um, just interview them individually. And, um, I do, I did have a deep dive doing the plantar fasciitis, um, episodes I did early in the podcast. I looked up the, um, relevant or the, the current literature that was available. And so to, surprisingly to me, like the stretching was almost, um, as if not more effective than this. strengthening in like, I think it was like six to 12 weeks, like within that kind of short to medium term. But then I think the strength down the tracks range superior, like, you know, three months, six months down the track. But I was surprised at how effective stretching could be. And when you're talking about stretching for someone who isn't that familiar, what would be some actual stretches like what would, what does the stretch look like that's been found effective while we're stretching calves, Achilles? How does it look? Yeah, so it was the stretch of the actual plant of fascia that came out favorable, which again, I'm exactly like you, surprised me. Because you go into these things as a scientist, hopefully with an open mind and unbiased, but the reality is you're still a human that has your own practices and beliefs. And you sort of think, well, we all stopped stretching the plant of fascia years ago. And there's debate about whether you can even stretch it, right, because fascia connected tissue isn't the same as different tissues. And... it comes out you're going to go okay well it surprises me but the science is the science I can't ignore it just because it doesn't fit my narrative or my bias. So it was a plantar fascia stretch which again will usually look a bit like the best way to describe it if I'm hopefully I'm doing a good enough job is if you if you knelt down on the floor but you sort of put your toes in, you know, you didn't kneel with your, the top of your foot flat with the floor, you sort of put your toe or your foot into like, almost like the position that we get in when you're in a plank or a press up. So you're kind of dorsiflexing or, you know, your big toe up and sort of leaning back slightly. Again, conscious of that, probably description hasn't worked well on a podcast, but if you just, if you Google plantar fascia stretch, the other way you could do it is just cross your leg over and just grab your big toe and pull it up into the air. You'll just feel that tension through the sole of the foot. But I think as part of that, you probably, most people are probably reasonably familiar with stretching the calf. Discussions within the literature about the calf complex and the Achilles tendon and the plantar fascia, actually, in some cadaver studies shown that they're almost one continuous tissue, so to speak. So I think it makes sense that if you're going to stretch, spend some time stretching your plantar fascia, throw the calf, throw the gastrocnemius, you know, the... the soleus, throw all of those kind of things into the mix. Although I did just see a paper that was published actually about two months ago, which questioned whether ankle range, it took people with and without plantar heel pain and looked at their ankle ranges. And the assumption would probably be, again, people with plantar heel pain might be a bit stiffer or might have limited range at the ankle. There were no difference between the two. So for every time you sort of feel you've got this stuff. you know, aligned well in your mind. A paper comes along to sort of poo it, which is kind of, I guess that's just the nature of what we do, isn't it? But yeah, stretching wise, I was hugely surprised. In clinic, what does clinic look like? Do we give more stretching than strengthening? Absolutely not. No, historically it's very much been the other way round. So I suspect like all research, if similar study is done five years down the line. things look different. I know that there's work being done. Henry Real is doing a lot of work on strength work in the context of plantar heel pain. So those studies are ongoing. So these things are always changing, always evolving. Ultimately, I don't know many runners that wouldn't benefit from doing some strength work if for no other reason, the links it has with performance, if that's what you're into. So if you're sort of thinking to yourself as a runner, well, I do my strength work because it improves my efficiency, my performance. And then, you know, if it, if it sort of increases tissue capacity and sort of helps as part of rehab of other things, then that's, that's just serendipitous. Isn't it? Yeah. I think I'm still thinking about this whole stretching thing and thinking of that, like, It's helped me in the past. I think when we're talking about the brain and how effective some treatments can be, and like I say, the whole experience around what a treatment effectiveness is, like you say, with the plantar fascia, we're not really doing a whole lot of stretching it, but we're noticing we're paying attention to it. It's like an, an effective treatment that everyone can do. And you kind of feel like, Oh yes, you get this kind of stretch where it produces a little bit of pain, but you know, it can be good for you. And so. doing that kind of makes people feel good. And we know that stretching in general makes people feel good, even though it's not really doing a lot, like maybe the ITB stretch, we know that doesn't do anything to change the length of the ITB, but people swear by it because it's so, um, because of the sensation it gives people and the feedback it gives people. And there can be a couple of injuries, say like proximal hamstring tendon, where we don't really suggest stretching cause that can irritate the tendon, like this insertional. um, tendinopathy that maybe one that we shy against, but stretching, I know I've had patellofemoral pain in the past slayers up every now and then. And I know that it's not malalignment of my kneecap. I know that it's not, you know, tight structures, weight structures, controlling the position of my kneecap. I know it's just overload, but I stretched my quad and it does wonders for my patellofemoral pain. It does, it just works like magic. And so, um, yeah, it's an interesting topic. It's interesting. Like how. what we know about anatomy and what we know about physiology sometimes doesn't directly correlate with patient experience and outcomes. And so it's good that you've highlighted the importance of stretching and how it can be very beneficial because it could be something that's very easy for someone to do and can have a lot of benefit. And so very good, very good point. I like that. I think when we think about what stretching is, we're essentially applying a load to the tissue, very low level load, of course. And certainly when we talk about one of the hallmark features of plantar heel pain, which is that first step pain on rising in the morning, you know, we often, there's been lots of theories about why that, why do we get that? Why does, you know, it's the classical sort of sign that raises our index of suspicion that the plantar fascia is involved here. But when we've been sitting for a few hours and we get up that first 10, 15 steps at the most sore, when we've been lying in bed for seven hours and we get up the first four, five minutes of sore, Lots of debate about why. I'm not sure we've ever really nailed the answer on that one, but certainly one theory I recall was that, you know, when you're lying in bed for seven hours and this plantar fascia is essentially having no load applied to it at all. It's essentially, and given the sleeping positions most of us adopt, you could argue with a slight plantar flexed ankle, there's even a shortening of the plantar fascia. you then suddenly go from seven hours of non-weight bearing to weight bearing. And we know as we weight there, we're gonna be applying a tensile load. So a load through the fascia that is trying to elongate it. Think of it like a stretch in loose terms. And that's provocative for the first few steps. But as anyone who's had this condition knows, this is part of the process. The more I walk actually, this is going to, as they would refer to open quotations, warm up close quotations. We might refer to it as motion is lotion fancy kind of phrase of someone smarter, but ultimately there may be something in the mechanism there by which, you know, tissues like to be loaded and the more you load them, generally, even if it's like it's a, in some scenarios, it'd be very sensitive, very irritable and to be avoided at that moment in time. But there aren't that many human tissues where the avoidance of load is ever going to be a medium to long-term consideration. So if you think of stretching as just applying small controlled dosages of load, Um, then you might be somewhere to explaining why people say it feels good. Um, but again, I'm, I'm theorizing. Yeah. And also in the research, I think night splints could be quite effective as well, which is along the same similar lines of, um, stretching. Absolutely. They just apply that prolonged, you know, tensile load or elongated force to the tissue. I don't know if you've ever worn one Brody. I put one on one. No, I've never had a touch wood. I've never had. Um, a reason, medical reason to wear one, but I always like to try and, if I'm going to ask anyone to do something, I like to have some personal experience of it, which is why I, that's how I justify my wide range of running shoes. Cause I, apparently I need to know what they feel like to talk to them about other people. But I put a night split on one night just to try. Again, I'm not, I wasn't pathological at the time. I wasn't, I didn't have a condition so that, you know, it's not a great study here. It's an anecdote, but. It was the most uncomfortable night's sleep I've ever had in my life. It really was. And it just, just testament to how all it was doing was, was holding my ankle at 90 degrees, which is a position I'm in when I stand up on a flat surface. It's a position I should be able to tolerate, but actually throughout the night, my ankle doesn't rest at 90 degrees. And I would, I would wager most of, most of the people listening, it doesn't even mean when you get into bed this evening, get comfy and then have a split second to think about what position your foot's in, I guarantee your ankles probably plantar flex. because you're either on your side in the fetal position, slightly pointing your toes down. If you're lying on your back, the weight of the duvet will push it down. If you're a front sleeper, again, the top, the dorsum of your foot will be on the, you know, you're going to be in a plantar flex position. So putting yourself to 90 degrees, which is a completely daily position that you're in for seven hours was wildly uncomfortable to me. And if nothing else, as you know, the looks my wife gave me when I put this thing on and got into bed. suggests to me if nothing else, it might be great for a plant to heal pain, but it's not going to do anything for your love life. It's going to be a, it's going to be a passion killer for sure. Good to know. Okay. It's good to, I think we'll wrap up there. I think that's a perfect way to finish and next episode, like we said at the start, it's going to be delved into part two. We're going to answer more of your patron questions around. dealing with multiple diagnoses at the same time, like plantar fasciitis, Achilles tendinopathy, et cetera. We're also gonna dive into asking your questions around other diagnoses. So perhaps you've been diagnosed with plantar fasciitis, but it's actually something else. So looking at some hallmark symptoms and getting just ways to understand a better accurate diagnosis. We also talk about maybe chronic symptoms. If you have something, if you have plantar fasciitis for two to three years, really inflamed, what are some things you'll do so we delve into the chronic side, the pain science side of things and we're also going to delve into Ian's take on plantar fasciitis regarding foot posture and pronation, over pronation, those structural influences and see how much of a link there is or how much of a correlation there is with plantar fasciitis. So hope you enjoyed part one and I look forward to bringing you part two next time. And that concludes another Run Smarter lesson. I hope you walk away from this episode feeling powered and proud to be a Run Smarter Scholar. Because when I think of runners like you who are listening, I think of runners who recognize the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated, active role in their rehab, who are looking for evidence-based, long-term solutions, and will not accept problematic quick fixes. And last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your Run Smarter path.