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Part 2 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.
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On today's episode, I continue my chat with podiatrist 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. No idea why you would, but if you haven't listened to part one already, please do so. Um, last episode, we started our conversation with Ian Griffiths to talk about plantar fasciitis, why it's so persistent, um, what mistakes a lot of runners make and what some effective treatment can be, and we continue our conversation today, um, making it a bit more digestible by breaking into two parts and talk, we answer more of your patron questions. We talk about. Um, concurrent diagnoses, having two conditions at once. And also what are some hallmark plantar fasciitis symptoms so that we know that it is an accurate diagnosis or where, um, a little bit more confident that is plantar fasciitis instead of masquerading as something else. And so let's dive straight back into our chat with Ian. Michelle asks around like, um, diagnoses or differential diagnoses. She's had a, a couple of years of foot pain and then had a diagnosis of Baxter's nerve neuroma or entrapment and then moved on. And I think the diagnosis changed to like a collapsed fat pad. And now they're suggesting maybe something else. I guess to form this into a question, is there common signs and symptoms for plantar fascia? And then if someone's displaying other symptoms, would you maybe suspect there's another pathological involvement? Yeah, I'm glad Michelle's asked this question because I'm conscious that we have been very much talking about, you know, plantar fascia or plantar heel pain. And you could be forgiven for us thinking that it's the only thing that can affect the heel. And as Michelle is experiencing, it's far from the case. There's a lot of anatomy in the area. There's a lot of differential potential differential diagnoses. I'm not sure what a collapsed fat pad is. That's a different terminology to perhaps what we use here. Like we could get fat pad atrophy. Yeah, I think it might be the same thing. I read the same. I read it and I thought maybe it's an atrophy of the fat pad. Yeah, or fat pad irritation. But yeah, you know, she's mentioned two differentials there fat pad irritation, Baxter's nerve, which anyone that doesn't know, it's just a small nerve that sort of sits in between a couple of the intrinsic muscles and can get kind of compressed or pinched and give you very, very similar presentation symptoms to plantar. old school, what we would refer to as plantar fasciitis, probably I would say the neural component of heel pain, easily the one that's missed the most. So there's an awful lot of differentials. The reality is if you develop plantar heel, pain on the under surface of your heel, and you go and see someone, and regardless of who they are and how much they actually see heel pain, whether they know what they're talking about or not, the chances are you probably leave with the diagnosis of air quotes, plantar fasciitis. And even though that's far from the only diagnosis there, there's many, as we've mentioned, the reality is if someone just indiscriminately gives you a diagnosis of it being the plantar fascia, they're probably gonna be right more than they're wrong, because as we've already mentioned, just how common, how prevalent this problem is. But it is important to exclude other things in that area, things like, you know, like we say, The reason you want to know what you're dealing with is because you may manage them slightly differently. So you also want to exclude things like a stress fracture of the calcaneum, obviously. That's gonna be a very different management. There are other things in that region that are more sinister, of course. Things like tumors, God forbid, luckily, very rare, but these are the things that you want to make sure you're not dealing with. Not to mention, of course, when we talked about nerve, it can't... not just a local or whatever, we can get ridiculous sort of leg pain, we can get pain that manifests in the foot that isn't really a foot problem per se. So I think the most important thing, and it sounds like Michelle's had a journey that unfortunately we hear quite commonly is you bounce around a couple of diagnoses. And the thing that's kind of most upsetting about that is it's quite clear that until you're really, really confident what you're dealing with, can good management ever therefore commence? And the argument is if we keep changing our diagnoses, why is that diagnosis changing? Is it changing because we've given it a diagnosis, we've managed that accordingly, it hasn't responded, therefore it must be something else, we bumped onto a different diagnosis. And that just sounds like a really frustrating journey. And unfortunately, I feel for Michelle because we hear that story a lot. There were definitely hallmarks that raise our suspicion of it being the plantar fascia. And I would say the most common one, isn't, you know, it's not just where it hurts. Cause like we say, a lot of heel pain can hurt in the same area, but the thing that really raises our suspicion is that, that first step pain, or we refer to as post-static dyskinesia. So a transient short, so short period of time where you feel stiff and sore and sensitive after a period of rest, most common in the morning, cause you've had six, seven, eight hours of rest. But in some scenarios, if you're sitting at your desk, you know, working away for a few hours and then you get up to go for a sandwich, you can get a slightly sort of diluted or lower level version of it in the day as well. So any kind of transient sensitivity or soreness on weight bearing after a period of non-weight bearing, usually raises our suspicion. That's very, very typical, I would say, of the plantar fascia. But the one thing to say is, you know, our clinical tests are all well and good. We... We take a good history. We listen to the nature and the location of the symptoms. We make a best guess, but we don't always get it right. But I would say pain in that sort of inferior aspect of the heel, post-actus cranesia, so that first step pain after rest, they are the big two. And the pain can, some people refer to it as a dull ache. Some people refer to it as a bruise. Some people refer to it as a burning. In that region, if you've got burning and tingling, in that region without that first step pain in the morning, then you're kind of going, this sounds more like a Baxter's nerve than it does a plant to fascia. You know, these are the things that we hopefully that help us sort of guide us on the right path. Yeah. Unfortunately, all these diagnoses don't fit a very fine categorized line and it's very hard to, we know that life doesn't work that way. And sometimes, you know, you kind of do a thorough assessment. You think like 70% of it, sounds like plantar fasciitis, but then, you know, there's this other 20, 30%, that just doesn't make sense. It just doesn't fit this common characteristics. And then you think, maybe let's just try to treat it like plantar fasciitis and then see if it's, see if that's effective. But we know in the back of our mind that there's just something that's not fitting the pattern. And sometimes it'd be 50-50, sometimes it could just be a whole bunch of different things. And like you said, there's getting an accurate diagnosis or getting someone to actually assess it is the best first step because then they can actually have an accurate assessment rather than just assuming that it's plantar fasciitis. And I like to use plantar fasciitis and I'll start the terminology that's very accurate when it comes to this actual pathology, but it's so commonly used. I just thought we'd just use it anyway. But the, yeah, I think just to add. Sorry, just to dive in, just because of something you said there, I'm the same with you with terminology. I used to be a stickler for fasciitis, fasciopathy. I can plant a heel plant. I don't tend to get too worried about it now because we're all talking about the same thing. But yeah, just to piggyback on what you said. We see common things commonly. So I think what we probably assume when we see these things and it ticks a few of the boxes is this, this is more likely to be, you know, a plantar fascia problem than not. So we treat it accordingly. And then when it doesn't respond. we may recalibrate our diagnosis. And that sounds like the journey that Michelle's been on. And I think when something comes in, this is the benefit of seeing someone who sees a lot of heel pain, seeing a specialist rather than asking strangers on the internet, so to speak, is that when things come into us, because we see the common things commonly, if something suddenly jumps out at us during the history taking or the examination as immediately quite atypical, then we can front foot that and get on top of that. bit early. So I've certainly seen people that have come in and said, I've had plantar fasciitis for six months, seven months, I've tried XYZ and I say, okay, let's have a look. And it's been a flexor, luceus, longus tendinopathy, which is a very different condition. You know, I've seen all sorts of, I've seen TIP post tendinopathies, I've seen posterior ankle impingements all present as, I have plantar fasciitis. So there really is no substitute for physically getting in front of have I got what I think I've got and am I doing the right things? Because that'll just get you on track a bit quicker. Yeah, extending for that or kind of just like, yeah, moving on to that question slightly, I had a cluster of patron questions come in around these kind of co-diagnoses or like two presentations or three presentations at once around that particular area. So Steve and Holly were saying they both have Achilles tendinopathy as well as plantar fasciitis and Holly having big toe arthritis as well. And just wondering, is there a correlation between those, um, those diagnoses? Like is it a, is it a correlation between training or is it when it comes to management, should they be managed differently or can they just be managed as two conditions effectively? Yeah. This is an interesting, this one really resonates with me because we see feet all day and foot problems, whether there's correlation, whether there's causation or whether they are just coexisting on the same foot, we see this a lot. So if someone comes in with, let's take, was it Holly who had the plantar fascia and the big toe problem? That's not, we can see those things and then we can sit there and we can rightly or wrongly. have a story if we wish, we could say, well, we know that the plantar fascia inserts into the big toe, you know, degenerative change in the big toe, whether it be slow and gradual or post-traumatic or whatever it may be, that's going to affect the way the big toe functions or moves. That's going to influence what we know as the windlass mechanism, and that may change the loading on the fascia. So you can, I'm not saying that's the right thing to do, but you can weave a story if you wish. I think the fascinating thing for me is when we look how we might manage or the things we may do to manage one, are they going to help the other or are they going to be a problem for the other? So for example, I've seen a lot of people with who've gone onto loading programs. So, you know, calf raises for let's say an Achilles tendinopathy, or even for, you know, loading their plant to fascia. And that's absolutely the right thing to do for that tissue. But if you have a irritable or acute on chronic sort of degenerative big toe joint, then going through loads and loads of heel raises tends to flare that up. So what's really helping one problem doesn't help another. So these things are the real world pragmatic problems, I guess, that we all face. The one thing I will quickly say, and again, it sort of comes under the list of differentials that we probably should have said in the last question, but when Steve mentioned, I think it was Steve who said, I've got plantar fascia. plantar fasciitis, anachilles tendonopathy. We should never completely, we should always entertain the possibility as well that rather than just the mechanical overload of these tissues, we should always exclude that whether there's something more systemic or metabolic or inflammatory going on. Now I don't know Steve's age or anything about him, of course, but I would say, generally speaking, if someone came in to see me and they said, you know, if we've got multiple site pain, you know, the general rule for me is if we've got site, pain in three sites. If someone says to me, both my plant of fascia are sore, both my Achilles are sore, it could just be that there are crazy ultramarathenoids, we see an awful lot of those. But in a certain, certain other questions then may be asked about, okay, how is your general health? Do you get regular stomach upsets? Do you get regular eye infections or irritations? Do you have psoriasis or any dry, scaly kind of skin problems? And if there's a few yeses to some of those questions, and then we ask about family health as well. It might be that a rheumatological screening is appropriate. Um, just because as we know, um, multi-site unexplained joint pain, tendon pain, that's something else we need to exclude. Um, so I don't know if that's probably answered this question, but it just suddenly came to mind and I felt it was remiss not to mention that, that as well. Yeah, it's good point. It's good to cover all those, whether it's relevant to Steve or not. It's good to, especially when you start talking about, I'm like, yeah, let me chime in and say if things are bilateral as well, that raises a question because when it comes to overload, if it's usually a classic overload, for some reason, it always just happens on one side. It very rarely happens on both. And so if you're coming in with, um, patellar tendons on both sides, then yeah, it's very, very strange. And so it might lead you down another path. That's, that's very cool. I know that sometimes when I ask a lot of questions to guests and we start trailing off and time gets ahead of us, I wrap things up quite quickly. I might skip some questions and I might go over like quickly go over some questions, but I've just been so fascinated about every single answer that you've had, but I've just let you go. And sorry that I've kept so much of your time. No, no, not at all. I apologize if we've gone over your normal episode length. I ramble a bit, so apologies on my behalf. My solution to that is just to do two-parter. So we might break that up into a two-parter. But I do have another question. If someone has very chronic... plantar fasciitis, they've had it for two or three years. They've tried some of these basic things. They've tried say loading and it's just irritated them. They've tried say supportive footwear and they kind of get by, but any other sort of like loading through the day kind of aggravates them. Their, I guess their work habits are causing a flare up if they have to be on their feet all day, like nurses and chefs, a lot of those people. Is there a starting point for them? Is there somewhere that you'd be like, okay, let's make a start here to see if we can help settle down this irritation. As you were sort of describing that, you know, I was sort of assimilating it in my mind and I was thinking when I hear long timeline, that real persistent slash chronic long timeline plus non-response to intervention, plus still highly irritable, if that's the right way to describe the scenario you just set, a long timeline, non-responsive, highly irritable. Those for me alone are reason to say, rather than sort of look at what we do moving forward, let's go back one step. And do we need any deeper investigations? Do we need to, again, a bit like a previous question, do we need to ensure we have got the correct working diagnosis? Couple of things we also know with regard to that kind of scenario, there was some great work done by, all the great work is done by Ozzie's by the way, but great work done by Carl Landorf, who showed that that there's a quite high percentage of calcaneal bone marrow edema in people that present with plantar heel pain on these kind of timelines. So again, we'd want to exclude those kinds of things. Think of that for the runners listening to try and unjargon that, like think of it like a bone bruising. So we're not just dealing with the fascia itself, the bone has now become irritable and involved. And again, the heel bone, when that gets irritated itself, it's something that, you know, you might say, okay, I'm in supportive trainers. Well, actually maybe we need to go into a boot for a few weeks or something like that. So you'd want to exclude those kinds of things. And the other thing, and again, we touched on it briefly with regard to the pain experience and how it's complex and individual and not just biological, but influenced by the, the psychosocial domains as well. You know better than me, Brody, I'm certain that when it comes to the persistence of symptoms, particularly my understanding of the back pain literature, and I know I'm swaying a bit. bit out of my lane here, I'm going a bit too far north in the body, but the longer that symptoms persist for, the more likely that there's strong factors from the psychological and sociological domains rather than just saying, okay, this is a tissue, tissue level problem. And because it's the foot and because it has such demand placed on it, mechanical demand on a daily basis, we are all guilty myself, certainly included in that, of someone coming in with a foot problem and us saying this is a mechanical problem. And as we know, no pain is ever truly mechanical. All pain is individual complex and influenced by biopsychosocial domains. But go back to the work of Matt Kotchett, there's some really, really good work on some of the, I guess, psychological contributors to, or psychological considerations to pain. And this bi-directional relationship, we're not saying, the key ones that come out of things like stress and depression. And again, I'm not saying if you're stressed and depressed, that causes heel pain. although we know that those scenarios do sort of influence pain, but heel pain can make you very stressed and depressed as well. So it's this bi-directional relationship. So when someone's got a really long timeline, it's highly irritable, it's non-responsive, I would say some investigations to make sure we're dealing with what we're actually dealing with and nothing more sinister. And we need to also at this point say, okay, all of the treatments we've talked about thus far. in this episode have been very, very mechanical. We do X, do Y, do Z. We need to think also at that point, I think outside the mechanical and start considering the psychosocial aspects. How well is this person sleeping? What are they worrying about? I'm not suggesting that we're being pseudo-psychologists here, but better than I with all your previous episodes that have covered pain science, way better than I'm rambling through right now. That is something at this point that I would say we would want to place emphasis on also. Did you know you can jump on a free 20 minute physio chat with me to see if you are on the right track with your rehab and running endeavours? This is a free service as part of today's sponsor, the Run Smarter Physiotherapy Clinic, which is my own clinic where I help treat runners both in person and all over the world with online physiotherapy packages. I always encourage runners to invest in their own knowledge first, but sometimes it's nice to have a helping hand and a second opinion. So I'd love to jump on board as your coach and physio if you require tailored assistance. Just head to runsmarter.online to see your available options. Once again, if you're still unsure if physiotherapy is right for you, we can schedule a free 20 minute injury chat with me, which you can find as a button on my website or in the podcast show notes. This will take you to my online calendar and you can book in a time. Yeah. And it needs its place in this interview as well, because some people just find plantar fasciitis in the title and then listen to this episode and not have listened to all the previous and they only need to go back about six weeks to, I did a two-part with Rachel Zofnus, who's a pain psychologist and explained it just exactly that. And my, um, my take on it is sometimes when people have had pain for a long time, you get them to kind of write down a pain diary when they get their flare ups, like, is there a rhyme or reason mechanically? And sometimes they say, look, I get a flare up when I'm more stressed. Like it's on a day where I'm just wound up and I'm just really like in a negative space, that's when I experienced like a heightened sensitivity and more pain. And it makes sense when you start to delve into what actual pain science is. And when it comes to plantar fasciitis, I know people really can spiral into like, it starts to affect their work. It starts to affect their ability to look after their family. it may start to impact maybe their income like there, and there may be like the primary income generator of their family. And if they can't stand to do their job, then there's a lot of stress around that. And so that would fuel a lot of this sensitivity. This will give a lot of relevance to the brain. And so if there is a little sparking pain that's sensitized, that's heightened, and that's like sparks a real trouble for a lot of people, it can be very, very hard to overcome. if they're in that cycle, yet we just give them taping, yet we just give them orthotics, or we just give them stretches. It's, it can only, it might only help a little bit. Whereas if we address the psychosocial component of it and really educate them around pain science, really educate them, we'll help them around the aspects they're worried about. And there's a lot of fear and address a lot of the anxieties and allay their fears a lot, then yeah, then treatment. subsequent to that can be very like can be more effective. And so very important that you do mention that it's very interesting with this topic. Yeah, I think, as we say, anxiety, stress, depression can dial up sensitivity. But likewise, increased sensitivity can increase stress, anxiety, depression. Like I said, I just encourage people to head towards the work of Matt Koch at the Trove. He's done lots of work, all in the context of plant to heal pain. and some of these non-mechanical, more psychological phenomena and how they can kind of influence things. And hopefully what, when we talked earlier about the big wins, the plantar fascia stretching, and we talked about individualized education, asking someone to explain to us in their own words what their understanding is, that comes into this discussion as well. Essentially, knowing that this may not just be a tissue level problem, like human tissues really. shouldn't be sore for two years, you know, or knowing that, you know, you're not damaging yourself. You're sensitive, you're sore, but safe. Again, I'm, I'm stealing these from the, the NOI guys, these, these sayings, but yeah, worth mentioning. I thought. Yeah, absolutely. And I'm always like you say, there seems to be a lot of researchers here in Australia that sort of make waves. I'm so proud to like, always have these international speakers. Yeah, I know. I'm like, it makes me so proud to be Australian because I talked to all these international guests and they're like, all these people are from Australia. Like it's weird. And I do know that like we do have a big vast kind of research center revolving around here. And there's obviously fantastic work in the UK and around Europe as well. But yeah, it always makes me proud to be Australian when I hear comments like that. I'm still trying to convince my wife to let us all listen. relocate our family to Australia, but I've not yet to win that debate. But one day maybe. We'd be happy to have you as we, um, as we wrap up, is there any other misconceptions or maybe, um, myths around like the cause of plantar fasciitis? I know you mentioned shoes is a lot of people like to blame the shoes, but anything that we haven't necessarily addressed today that you want people with plantar fasciitis or people want to be more aware of plantar fasciitis to know. There's probably just one. Um, And actually I wonder whether it's already dying out because 10 years ago I would hear this every day and present day, I don't think I hear it anywhere near as much and I'd love to hear if you still do. And that's this relationship or causation of correlation with heel spurs. I certainly remember going back 10, 15 years ago, like people would come in and they would, or they'd see their GP, they'd have plantar heel pain. The first thing they would do would be they'd have an x-ray ordered to see if there was a heel spur. this little project, you know, little bony projection on the heel. And then once that, if there was, and by the way, given that a quarter of the entire population, with, you know, have this spur, you know, as a sort of anatomical variant, you know, incidental finding, then you, you know, you, you develop heel pain, you have an X-ray, they find something, an X-ray, they, they marry the two sort of inappropriately. I think this is already dying out, but I wonder whether it's worth mentioning, but a lot of people link the heel spur to like, this little bony projection causing the plantar fascia irritation, or some people would say it's the pull of the fascia that causes the bone to model and develop in that way. The one thing I'd say is if that is a belief that anyone has out there, it's probably incorrect, given our current interpretation and understanding of this area, it's incorrect to assume this very simple causal relationship between heel spurs and plantar fascia or plantar heel pain. As we said, 25% of the population have this finding radiologically with no pain whatsoever. There's definitely been some really interesting studies. And I forget the authors now that have looked at where the spur actually sits relative to the fascia. And it actually sits higher than where the fascia attaches. So the concept of it annoying the fascia or the concept of the fascia pull developing it seems to be sketchy. It seems to sit a bit closer to... a couple of the intrinsic muscles, um, flexor, this is Sean Brevis to name but one of them. So all I would say is, uh, if you are a runner that has developed heel pain and you are of the belief or you've been told it's because you've got a heel spur, that, that probably is something that can be revisited. Yeah. Especially those beliefs that very disempowering. It's very little that you can do if they say you have a heel spur, like, well, it's always going to be that. This is the problem. If this heel spur is causing my pain, then you're quite right. How do I ever get out of pain while this heel spur remains? And therefore someone open me up and shave it off, do a bit of carpentry. And you're just like, like I say, it's so damaging to belief systems and to sort of therefore, it will influence the behavior you do. What is the point in doing X, Y or Z to help this problem if the heel spur will still be there? And the heel spurs, what's causing my problem, you know, the sort of a ability to, or the, the compliance with other instructions or other recommendations like our strength work, like taping, you know, why would someone do that if they truly believe the heel spur is the culprit? While we're there. Um, I swear, this is the last little bit we're talking about, but like, um, flat feet or like collapsed feet, like people have these really disempowering, um, you're always going to be like this. You're always going to have these collapsed feet. It's like this, uh, The language that people use is very, um, it's very detrimental. And let's just say they're a runner and they've been running 20 Ks a week for the last year. And they haven't had any issues. Then all of a sudden they go to 30 Ks a week and they get this, um, stir up with the fascia. And then they're told you have this because you have flat feet or you overpronate in like these sort of really, you know, poor language, but they've been overpronating in quotations and they've had flat feet their entire life, but they haven't had this plantar fasciitis. It's only just been since they've increased their mileage, but now they go away with this belief that their feet collapse and that they need orthotics or they need to correct this pronation. And otherwise I'm going to keep getting this plantar fasciitis. Um, it's something that I see a lot in my, in like Facebook groups, people just say, you know, this is what I've been told. Um, and is there any solutions? Do you find? Um, can we allay those people's fears that the, like the correlation between the two, or if you do have flat feet and you do have plantar fascia, so there's hope for this type of population. Yeah. I get this a lot too, like yourself. Um, and it's one of those things that we're always trying to, as best we can sort of, um, push back against and educate people when it comes under that umbrella of education again. And all I would say to people is to runners is that when you go and see someone. what they're trying to do or they should be trying to do is identify the problem, exclude anything serious or sinister, reassure you accordingly, and then put in place some kind of plan that gets you back to what you love doing. That should really be how a consultation goes. Now as part of that process, and often with absolutely the best intentions in mind, us as clinicians can say, okay, what do we think is the quickest way to get this person back to doing what they love? How can we reduce the load on this sensitive tissue? And unfortunately, the foot posture is an easy target. It's the low hanging fruit as we refer to it because someone comes in and it's something that's very easy to observe, quantify in some way and then discuss. I always say to people, if I always lean on other literature and I go back to the back pain literature and sort of say, there's that. numerous studies that have taken people with no back pain, no current back pain and no previous back pain and they've MRI'd their backs and there's that graph and I know you know the one I'm talking about which shows all of the open quotations pathologies in these people with no current or no historic back pain, disc bulges and x-y, all of these problems on scan that look awful, that radiologically read horribly terrifying, but these are people with no back pain currently or yet if that same person who had those findings on image went bent over to pick up one of their children and suddenly felt a twinge and then had a couple of days of real immobility and sensitivity, went to a doctor and they said, with the best interest in mind, I better just exclude anything sinister, let's have an MRI. All of a sudden that MRI, which had no meaning whatsoever now falsely has, you've got a disc bulge or you've got X, Y, Z. And I think... although that's probably not the best analogy. This is what happens with the foot where someone lives their life on the foot of whatever posture they have. And again, your foot posture is an expression of many things, your genetic code, your bony architecture, your laxity of your ligaments. And I always say to people, it's the genetic hand that you've been dealt by your parents. So like you, I sit here and look at you, a beautiful head of dark hair. You got dealt that hand, I got dealt no hair. It is what it is. We play the hand we've been dealt. You know, when we're looking at foot postures, this is just another expression of our genetic code. We live our life happily most of the time with no problems. Like you're saying your example, a runner runs 20K, whatever their volume, problem free. They suddenly jump up to 30K, 40K, you know, 50%, 75% increase. Um, they In the presence of a story like that, I usually say to people, and they will have a worry because someone they'd have read or they'd have been told, it's your foot posture that's overloaded the plantar fascia. And I'll say to them, no, what overloaded your plantar fascia was 15 kilometers more this week. You know, your foot posture was doing just fine. You know, your tissues were doing just fine. You've just asked a bit too much, a bit too soon. You know, and we can go back into our water cup analogies or I'll often. borrow Tim Gabit's alcohol tolerance analogy of, you know, basically just doing too much too soon. It's pretty simple. That's obviously a really different story to someone who comes in with air quotes, flat feet, pronated foot posture, who says to us, all I want to do is run a park run. You know, I've never been, I don't identify as a runner per se, but I'm really starting to fall in love with it. But every time I've tried, every single time over the last three or four years, I get to 15 minutes of running and I get this real tightness, tension, pulling in the sole of my foot. That's, they could, you could have two people with identical foot postures, but really different stories. And one person, you could make a case that maybe their anatomy is one of the factors that is limiting their tissues ability to cope. And in the other, you just overdid it a bit, dial back on your training, et cetera. So I would always say to runners, you know, never ever. worry about your foot posture as an isolated observation. It is what it is, just the same way that we are all very different. You look at the human race and our variation is vast and that's the rich tapestry of life, so to speak. What we need to decide is in certain scenarios when we think that's a factor or not. And unfortunately out there, it's an easy thing for people to erroneously link to what the problem is. The final thing I would mention is that sometimes the foot posture isn't necessarily what the problem is. So let's take our pronated or flat foot that has been treating someone beautifully. They've doubled their volume. They've annoyed their plantar fascia. We could sit there and say your foot and the way it behaves isn't necessarily the cause of why your fascia is annoyed, but now your fascia is annoyed, this sort of, this may be something that we want to consider. And the way I've... heard this, you know, explained before is essentially if you're, you know, using an upper limit energy, if you're sensitive into extension at the elbow, whatever, you know, let's say you're walking, you're running down the street and you, you're listening to a podcast and you listen to this podcast, perhaps, and you, you know, you're, you're not paying attention. You catch your elbow on a lamppost and you really, really inflame it and it gets really sore. You can see, I don't know anything about the elbow here. I apologize in advance. Don't know why I picked the elbows and the energy, but if you really, really annoy your elbow. inflame, irritate, sensitize your elbow. What will probably happen for the next few weeks is it's sensitive into, you know, certain movements, maybe into end range extension, end range flexion. So those movements are now something to avoid, but they're not damaging movements. They're not movements that cause the problem. The problem was caused by the lamppost, but the lamppost has long gone. Almost what caused the problem is not really relevant now. What we need to do right now is avoid the things that are going to prohibit recovery. So I'd not often say to people like we've got the discussion of what caused the problem. And sometimes we might want to redefine the parameters within which someone pronates or supernates with tape, with orthoses, with footwear. But I'd always say to people, this is something we're doing to try and desensitize and get things to settle down. This is not a narrative on your foot posture being problematic, damaging, dangerous or causative in this problem. The lamp post in this scenario was you just doubling your training. We are now currently trying to get things to settle down. And I might, my aspiration is that when things have settled and you've gradually re-exposed yourself to load and you're tolerated and tolerant again, you can go back to the same shoe you're in and you can discard the orthosis. Great. I think like even that explanation, that education is so much more empowering to the person that has the pain. and they can see that and they can have a plan moving forward. And so it's just so much more proactive for both the clinician and the patient to sort of be on that same wavelength and kind of have that those next steps, because you can see with that explanation, what you can do, you know, in order to progress and then maybe some levels of discomfort or some levels of pain are okay. And then, yeah, there's, there's a lot more, positive belief around that. And before I have you like, you've been extremely generous of your time and like the further we've gone on, you've still been the same enthusiastic, passionate, answered it to the fullest extent the entire time. You're not just like, Oh, let's wrap this up. And I want to finish up now to, um, so we don't have a fear of me just turning this into three parts, but, um, Those people who want to learn more about you, I will include your Twitter. Um, I know you're, you're quite active on that. Um, I've got your podcast on Twitter as well. So PodChat live is the handle. You've got sports underscore pod for Twitter. You have sports podiatry info.co.uk as the, the website. Um, any other things you want me to include? I'll include the link to PodChat live, the podcast as well. Um, so people can go and have a listen. Anything else that you want me to include? Probably just pandemic experience for our own mental health. A lot of us are now just completely ignoring the news. And if you want to ignore the news, certainly I'm doing personally, just it's no good for my mental health. So I'm avoiding Twitter because as soon as something trends on Twitter, you find yourself down a rabbit hole. So I would say Instagram is where I hang out a bit more. At the moment, at least it just seems to be, healthier for the mind. So on Instagram, I'm sports podiatry info. Okay. You can look at all the like puppy videos on Instagram instead. Exactly. Life is better with puppy and kitten videos. Once again, thank you so much for your time. I mean, this has been a blast. I know this is going to help a lot of people who are listening to this. Um, thanks for coming on and sharing your wisdom. Not at all. Thank you for having me. And that concludes another run smarter lesson. I hope you walk away from this episode, feeling empowered 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. 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.