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Brodie Chats with Podiatrist, researcher & podcast host Ian Griffiths about different running foot conditions and answers your patron questions: 1.) Big toe OA: Patron question: Any tips for managing great toe arthritis? Also, can the loss of function due to this condition create problems elsewhere? 2.) Sinus Tarsi syndrome: Patron question: Are there any management recommendations for sinus tarsi syndrome? 3.) Plantar plate: Patron question: What is your take on strengthening/rehab for plantar plate injuries? 4.) Fat Pad pain: Patron question: Is it possible to increase the thickness of fat pads on feet or at least prevent a decrease with age? 5.) Morton's neuroma: Patron question: Are there any exercises that are likely to aggravate Morton's neuroma? Other patron Qs: "I have a couple of distinct pains in my feet. When I am running there is no pain, post-run - hours later, I have a strong burning to the side of each foot and heels. "What foot exercises, if any does Ian recommend for persistent Achilles Tendinopathy?" "What does Ian recommend for footwear outside of running from an injury prevention standpoint" "I constantly get sore toes (aching). I have plenty of toe room, shoes are good length/width, I have changed shoes with the same outcome". 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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In today's episode, Understanding Common Running Foot Conditions 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 Ian Griffiths at the end of this interview because I just, I understood that this was a quite a tough challenge for him, for anyone to take on such a, to try and answer a lot of these questions because I've got a lot of patron questions come through with a lot of foot conditions and while it's nice to have a deep dive into certain conditions. Cause today we talk about big toe arthritis. We talk about Morton's neuroma, sinus Tarsi syndrome, plantar plate injuries. We talk about having like sore toes, burning feet, all these sorts of things, fat pads as well. And sometimes it's nice to just do a deep dive into a certain topic, but I sort of just had, all right, Ian, we've got these nine questions, whole bunch of different conditions. Can we try and limit to an hour if we can? And that's just an incredibly tough task. And a lot of these conditions are quite hard to explain, um, purely through an audio format and a lot of these questions did require a little bit of extra information, um, for Ian to answer it with a little bit more detail, but he did it in such a professional fashion and with the same enthusiasm he has, um, last time he was on, which was. talking about plantar fasciitis, we had such an in-depth conversation and we were enjoying ourselves way too much. We had to split it up into two episodes because it went for about an hour 15, an hour 20, something along those lines. But we'll take it away. Really happy with how this episode turned out. Big thanks to Ian for coming on again. Please check out his social medias. We've got Sports per Dietary info, which has lots of really in-depth information, really simple information for runners about foot conditions. And please check out his podcast, PodChat Live, one of the few running podcasts that actually listened to because it's got such good high quality information. And you can just tell just by the caliber of the answers Ian provides on this interview, like I said, really happy. And I know you'll love it. Ian, welcome back to the Run Smarter podcast. Thank you. Thank you for having me. Yeah, it was a pleasure having you on last time. And you know, people could sense the, the amount of passion that you have with these working with runners and, you know, just trying to educate people as much as possible. So I had a, um, an episode on foot strength and asked the patrons about some questions they want to submit. And a lot of them were about foot conditions. And while it wasn't necessarily foot strength specific, I thought I'd have. someone of your caliber onto the podcast to talk about all these conditions. So I have a whole list of patron questions submitted and thought we would dive into all of them. Um, how does that sound? That sounds fun. I, you'll have, you know, I'll talk about feet as long as you'll have me. So that's no problem. Yes. Good. Well, I am conscious that it is, you know, 10 PM and your local time over there. So I'll be conscious of that. We've got the first one from Holly. And Holly asks any tips for managing big toe arthritis? Um, first of all, do you want to just dive into big toe arthritis for runners? Maybe talk about that a little bit before we dive into Holly's question. Yeah, yeah, sure. Um, we'll, we'll keep it brief and sort of not go too technical, but essentially it's, it's an incredibly common thing we see, um, not just in runners, in humans really, um, traditionally, I think, uh, osteoarthritis was referred to as being wear and tear. I don't think we like that term too much anymore. I don't think it's a great term to hear if it's your toe that's being talked about. Also, we now know that it isn't just wearing out of the cartilage like we once thought it was. The whole joint is involved, the bones, the cartilage, the synovium, the fluid in there. Essentially, what you end up with is a joint that... is more painful and more stiff than we would like it to be. Now when it comes to the big toe, that can sometimes be problematic, given that it's one of the joints of the foot that has a fair amount of repetitive load and work placed through it, particularly with running, but with walking as well. Essentially, when it comes to managing it, and again, forgive me, I'll probably be the same with all the conditions we speak about in the... some things depend on context and the individual and the severity. So forgive me if I'm sounding a bit vague and a bit gray, but essentially we'd always try and manage them conservatively first. So, you know, conservative management sometimes looks like using foot orthoses. A lot of the time now, we are very fortunate that we've got these carbon plated running shoes that again, are very much marketed for performance gains, you know, being certain percent faster, but actually they're a godsend when it comes to sort of limited range, stiff, painful big toes. They can really sort of allow someone to continue running and essentially immobilize that area while it desensitizes a bit. And we've also got other, I think they still come under the umbrella of conservative, but we've got things like steroid injections as well. And all of these, I would encourage people to... to consider, to talk to people about before they end up in front of a surgeon having that chat. Not that isn't sometimes where you need to be, it really just depends on the severity. And again, when I say severity, I'm constantly having to remind myself that the severity of someone's arthritis doesn't necessarily correlate with their pain. So we see, as I'm sure you do Brodie, we see an awful lot of toes that are. radiologically considered to be quite severe, but these people are pain-free and they are performing functional tasks to a level that they are happy with. So, you know, always remember that you are not your x-ray, but ultimately if things are painful or stiff, if things are inhibiting your ability or your joy of running, then, you know, think carbon plated shoes, think foot orthoses, think injections. That's where I'd start with it. Nice and I have had some episodes in the past about knee and also hip OA and it seems like the advice for that is exactly the same you know it's not just a wear and tear pathology it shouldn't be considered that anymore it should be considered more if we're talking about the big toe specifically it's you know the symptoms and it can be irritated from overload and there may be something structurally going on but could be well managed if you know taken into consideration and I do like the advice around the kind of bigger stiffer shoes or orthoses to help I guess what you said decrease the sensitivity of it in that particular period of time because it doesn't necessarily mean your pathology is getting worse it's just in a little particular sensitive state and we can do things to help settle it down with injections and footwear and those sort of things until it calms down then you slowly build your way back up and I've had my experience, I actually had some foot pain last year and queried a stress fracture. So when God an MRI and they said, okay, no stress fracture, but you also have mild to moderate big toe osteoarthritis. And I was so disappointed that they put that in the scans because it has nothing to do with my presentation. I have had no, um, big toe pain in the past and was really disappointed that they decided to throw that out there. So. Um, I'd be like a, an example of someone who has mild to moderate a way that has perfectly functioning toes and no pain whatsoever. So that's a little case study, um, to come forth with, but, uh, Holly also asked, can this condition cause problems elsewhere? So if someone does have a painful. Toe, um, can that start to produce some sort of other pathologies or other issues? further up the chain? Yeah, it's a valid question. I was just taking a second here to be mindful of the way I answer this because the answer is it could, but I also want to be clear that, you know, the concept of, I know that when we look out there in the wide world, we go on places like Instagram, there's all sorts of skeletons with red lines that are bad and green lines that are good. The body is not a machine. I know I'm sp- preaching to the converted here when I talk to you about this Brody, but I see people that say, well, if your big toe doesn't move properly, then that causes X, Y and Z, and that's probably what's causing your mandibular slash jaw pain. I don't want that to be the message here, but it is fair to say that the big toe joint is fairly fundamental to what we would call sagittal plane mechanics, which is a fancy way of saying when we're running, we're normally going in a straight line. We're moving from somewhere behind us to somewhere in front of us. And the way we pass over our planted foot on the ground is initially via our ankle joint and then laterally via our big toe joint. So if that joint is stiff, painful, restricted, we may not go through it or use it as well as we could or should, either because we can't use it mechanically because it's too stiff, or we may well find ourselves avoiding it. Our central nervous system will do this for us. We will always avoid something that's sensitive. So when we then start moving in a different way, it is not unreasonable to assume that may load different tissues in different ways. Now whether that means we could be so bold as to say, if you've got big toe osteoarthritis, it will cause you knee pain or hip pain. I don't know that I'd be too comfortable sort of being too definitive about what it may cause, but we've certainly seen scenarios where people move differently, pain avoidant strategies, et cetera. And that may well load tissues more proximal to the big toe. So higher, you know, higher up, um, in a different way. So it's, it's a very reasonable thought process, but I think we need to be careful not to catastrophize things too much and get too caught up on, you know, my big toes not moving, therefore I'm, I'm doomed. Hmm. Yeah. It's, um, it's a fear that a lot of people have, especially if someone starts having say like. two conditions or three conditions all on one side, they assume that like that one side is, you know, moving differently, or it's going to cause more issues in the future, just, and they're unsure of why it's happening. But they just attribute to if injuries are on one side, there must be something seriously going on with the mechanics and not necessarily the case. But like you say, take it on an individual basis, because it could, but could not also. We do. We do it for reasons, don't we? We do like, you know, it's very easy for, if someone had a arthritic big toe on the left side and their left hip started hurting, we want to know why that left hip's hurting. And we know that it can be complex and multifactorial, but we're much more reassured if a health professional tells us, well, actually that's probably problematic because the big toe on that side isn't working. And again, it's an easy link to make, and it doesn't mean it's right, but I'd also, quite rightly, you could have... a big, a stiff saw big toe on the left and hip pain on the right, and you could see a different specialist who'd tell you that was the cause because it was compensatory. So we've got to be careful because it's a bit boggy and engraved. Again, these really stiff rocker sole shoes, they really help facilitate that progression through the sagittal plane, which hopefully not just keeps that big toe, as we already mentioned, a bit less sensitive, but it facilitates better sagittal plane movement, straight line mechanics. without some of the potential compensatory or change loading patterns elsewhere. Yeah, very well said. Jesse asks, are there any recommendations for sinus tarsi syndrome? And curious to get your thoughts on first of all, what sinus tarsi syndrome is? Yeah, it's probably, you know, When we're speaking to a group of runners and we talk about certain conditions like big toe arthritis or plantar fasciitis, like we spoke about at length last time, every runner in a room nods along because they've either had it or they've spoken to someone that's got it. And sinus tarsal is something that may not come under that umbrella. It may be something runners are like, what the devil does this mean? just realized actually I've got a foot model here and I can hold it up and show you, but this is a podcast, not a video, isn't it? So you probably- Yeah, you can teach me if you want. You probably won't do any good, but essentially if you take a look on Google images at the foot skeleton, what you'll see if you look on the lateral side to the outside of the ankle, the side that your little toe is essentially, it's sort of front outside edge. You've got this little aperture or it's sometimes referred to as a canal. So where your sort of talus sits on top of your calcaneus. So this is a terrible use of podcast video I'm doing here. I'm showing Brody on the video here. You've got this, you know, you've got the bone of your ankle sits on top of your heel bone. And basically, there's a little canal or passageway between the two. And that's referred to as the sinus, that is anatomically referred to as the sinus tarsal. Now within this canal, there are ligaments, there are nerves, there are vessels. And some of these can, we can get irritation in this area. So it's usually either post-traumatic, so we can see sinus tarsal irritation after an ankle inversion or similar, or we sometimes see a more gradual, slow, insidious onset and it's thought to be secondary to biomechanics, so the way your foot dynamics, so your foot behaving in a certain way. We see more pronated feet, we tend to see more compression. in the sinus tarsi, at least mechanically speaking, it makes sense that would occur. Now we tend to find, you know, if people report pain on the sort of front outside of their ankle, they report real difficulty on uneven surfaces. It raises our suspicion that it may be sinus tarsi syndrome, but it's important to note that it does have some differentials that manifest or present in really similar ways. mentioned an ankle sprain. Ankle sprain and sinus carcice syndrome can present in a fairly similar way. You can get pain and sensitivity in the same location and you don't tend to like uneven surfaces, but also actual arthritic arthritis or synovitis in the subtailer joint itself. So the most important thing is to know you're definitely dealing with sinus carcice syndrome because it's got a couple of really, really similar differentials. So usually an MRI, if suspected... sinus tarsal you'd normally confirm or refute with an MRI. Now again, I think depending on why you've got it, so if it's sort of post-traumatic, you'd sort of treat it a bit similar to an ankle sprain. So the order of the day is good physiotherapy, alongside usually footwear, sensible footwear and good physiotherapy. But if it's been one of those more gradual, bit of a closer look at your foot's biomechanics, how the foot's behaving. Do we think there's this high levels of load going through the sinus tarsal, through the subtalia joint in that region? So a bit similar to what I've just said, sensible footwear, foot orthoses, good physio. And once again, if it's not responding to those conservative things, it is something that it's fairly easy to inject. and much easier to inject than an arthritic big toe joint because it's like you say if you look on an image it's like a really big canal that you can just ultrasound guide a needle in there, dump a load of corticoid steroid and that tends to respond quite well. So yeah, it's probably not a particularly common thing. I mean we see it quite commonly but it's not a common thing when you're talking to a group of injured runners but it can be persistent, it can bother people. A bit like post ankle sprains they can... They don't necessarily prohibit people running, but they grumble. You know, they all make people, I speak to runners that say, it's like a three out of 10, but I can't remember, I haven't run without thinking about it or without it grumbling a little bit for like the last three, four, five months. So it's, it's one of those low irritability, low severity, but really long frustrating persistent type problems. Hmm. Yeah. I think, um, one of the major takeaways there is to when to seek. advice or went to seek an assessment or went to seek scans or treatment. Um, because like you say, it can behave like if you roll your ankle or sprain your ankle, um, it can be caused by that. And some people might just think it's a persistent rolled ankle when in fact, it might be the sinus tyce that's, um, you know, being involved and particularly. And you also said like with insidious onset and something that wasn't that traumatic and I guess the overall takeaway is if it's not getting better in a couple of weeks and you're still noticing that grumbling within a couple of weeks, because in most cases with an ankle sprain, it just gets better. And if one to two weeks, usually back to, you know, your normal functioning, if it does persist, then it definitely is warranted to get assessed and then query whether you think it might just be an ankle sprain or whether it might just be something else or this sinus tarsus. So very good advice there. Anything else that we might need to include in this condition before moving on? No, I think your point's really valid that, you know, if you sprained your ankle, if you've, if you've undergone an inversion mechanism, you usually know, like you say, you remember doing it. So, um, you don't have to necessarily rush off and see someone, you know, for every time you turn your ankle, but if after a few weeks, these things are grumbling on, um, definitely worth booking in to see someone cause you know, is it, is it an ATFL, you know, sprain? is it the sinus tarsal or is it, you know, neural irritation? Is it the perineal? All these things can sometimes then manifest further down the line after inversion. So knowing what you're dealing, as with all things, knowing what you're dealing with gives you the best chance of being as efficient with your time and your energy, you know, put into getting it to recover and getting back running, you know, sooner rather than later. I want to dive into plantar plate injuries. And we'll start by talking about that because Aidan asks, what's your take on strengthening or rehab for plantar plate injuries? But let's dive into the condition first. What is it? And like, you know, is it common amongst runners? So yeah, let's start with what it is. So the plantar plate is this sort of deep. fibrocalf lich which again I've got my foot model here but unconsciously it doesn't seem to be. Essentially, plantar means on the sole of the foot. So essentially the best way to describe it to runners who may not be medical who are listening and don't have the video and they can't see my foot model, if you go up, if you're standing barefoot and you go up onto your tiptoes, where you bend across the foot, the ball of your foot that's touching the floor, they're your metatarsal heads. And essentially what keeps your toes... attached to your metatarsals and in good alignment and stable are the capsular structures that attach from the metatarsal to the proximal phalanx and on the underneath the plantar aspect you've got this deep fibrocartilage which is referred to as the plantar plate and it's a lot of I've seen a lot of texts that actually refer to it as almost a functional extension of the plantar fascia because obviously the plantar fascia has goes along the sole put in as slips into every single digit. So probably helpful I think for people to think of it as a functional extension of the plantar fascia. So anything you do that places load or tension in your plantar fascia probably does the same to the plantar plate. That's a good way I think to sometimes have a think about where it's located and the kind of things that might place demand on it. Now we see a lot of it. Do I see a lot in runners? And again we can get plantar plate like anything, like any soft tissue you can get a strain. You can get tears, you can get ruptures. Do I see a lot of plantar plate injury in runners? I see some. Most commonly second metatarsal phalangeal joint, so second toe joint seems to be the most common. I've read some work that suggests if someone presents with pain in the second toe joint, it should always be on the list of differentials because it's one of the most commonly missed diagnoses. and there are certain tests you can perform for it. I would say if you've got pain in any of the toe joints associated with you looking down at your foot and you suddenly think the toes look like they're changing position, drifting up, floating up or drifting to the side, that's a pretty good indication that the structures that normally hold the toe in a good position may have some kind of deficit. So it doesn't necessarily have to be, again, it can be traumatic or it can be sort of repetitive micro trauma. So it feels like it's insidious and it's crept up on you, but metatarsal phalangeal joint, ball of the foot pain with a change in toe position. We should probably be really thinking that the plantar plate may be involved. We see a lot in the last, I look after a couple of professional rugby teams, the last three I've seen have all been in rugby forwards. And if you think about the demands of scrumaging. It will make sense as to why there's an awful and these are these are big bigger big men as well It will make sense as to why the plant plate is placed under significant load. So that's what the That's what the plant to plate is and when we see it I guess Non elite sports people we anything that places high Dorsiflexion demands across those metatarsals. So People have switched to forefoot running and we go back 10 years, 2010, 2011 when we know we had a little boom, Ball To Run came out and there was the paper by Daniel Lieberman in Nature, it was the perfect storm. And for the following year, we saw a lot of people suddenly switch to running with more minimal shoes, less cushioning, less stiffness in their shoes, which I'm not saying that's a bad thing, but I'm saying it can be a bad thing for certain tissues when they're not used to it. And then they also switched to barefoot running, which again is more forefoot dorsiflexion. Um, I think I probably saw more plantar plate tears in 2011 than, than I had done in the previous decade. Um, so I would say, uh, coming back to the second question and just correct me if I misremembered, but you said, what, what do we think about rehab for it? Was that the question? Yeah. Like is there strengthening that's warranted? Uh, what sort of rehab? management is, is it worth when we have this injury? Yeah, I think, um, this is one of the things that intrinsic foot muscle strength is, is probably, um, an incredibly sensible thing to consider. Which we know the, what we're essentially looking at here is a structure that tries to maintain a good function and stability of one of the metatarsal phalangeal joints. So, um, if it's lacking in some way, um, then, you know, asking some of its neighbouring colleagues to pick up some slack and it's probably a smart idea. Again, if we're talking about a complete plant to plate tear, the horse may have bolted and strength may be not going to cut the mustard and we may be looking at surgical options, but that would be with a complete tear or rupture. Generally speaking, I think intrinsic muscle strength. Basically, what you've got to try and do is get strong. I think I should probably mention calf flexibility. probably sensible to target, particularly if we think there's problems there. Because calf inflexibility, you know, tight posterior muscle group, one of the most common causes when we're moving of having a slightly early heel lift or, you know, loading our forefoot a bit earlier during the gait cycle. And that again is going to place demand on the plantar plate as well. So again, if we consider it the functional extension of the plantar fascia, we can sort of think what sort of things would we do to rehab the... know, what would rehab for plantar fascia pain look like? It should probably look quite similar, but we've got to try and avoid positions of loaded flexion at the metatarsal phalangeal joints when we are acutely sensitive. So it's one of those, I guess, double-edged swords where we say, okay, let's get some calf or some soleil strength. But actually one of the main ways we tend to do that is with standing or seated heel raises. And heel raises... are going to load you through the ball of the foot and that there may be a good time to do that, but it's not normally going to be fairly early on. And would you say like in the early phases when it is quite irritated and you know, struggling to come up onto the balls of the toes that becomes quite irritated, is there a phase of similar to, you know, that rigid footwear that we're talking about before? Is it worth? trying to limit that amount of toe extension to allow that particular structure to rest? Yeah, I think that's a really smart idea. Again, not as a life sentence, but early on to try and desensitize things. Rigid, stiff, rocker style footwear, if you've got them. It's almost getting to the point where I think every runner should have a pair of carbon plated, stiff, rocker style footwear with a big toe spring, if not for race day to try and get PBs, then there are multiple niggles, aches and pains where this shoe is a great tool to reach for early on and we already mentioned big toe arthritis and this is definitely another one. We also do something called digital plantar flexion taping. So you just loop a bit of tape around the digit, plantar flex the digit, pull the toe down and then cross it over on the sole of the foot just to limit some of that toe extension as well. And some people report that foot orthoses with a cutaway underneath the the metatarsal head of the, of the, well, I was going to say second, but it may not be the second, of course, but that tends to be where we see it most commonly. A cutaway for the sensitive metatarsal head region is, is often reported as being quite useful as well. Yeah. And I'm glad that you highlighted the, um, abrupt changes that could happen. Like if we're not playing rugby, cause we're mainly runners, um, that like, say minimalist footwear, um, forefoot running. can be okay as long as you adapt to it. And as long as the rest of the body has enough time to adapt to those conditions. But if you do have an abrupt change in like sprinting or a hill sprints or footwear that's like really flexible and requires a lot of demand through those particular structures, then you could be running into a little bit of trouble. And if that shift is too abrupt, then that's when we start might, then we could be raising some issues. Yeah, totally agree. I always say to my athletes, my patients, there's no shoe that is inherently good or bad. There's no running technique that's inherently good or bad. It's change that gets us. Human tissues are sensitive to change. They don't like things too quickly. They like time to adapt. They don't like holidays. They don't like surprises. They don't like novel loading. Well said. Okay, we have Joanne's question. Is it possible to increase the thickness of fat pads on the feet or at least prevent a decrease with age? First of all, what are we referring to when talking about fat pads of the feet? I'll make an assumption here because we've got two main fat pads of the feet. Obviously fat is one of those things, you know, throughout most people's lives they spend... the majority of the time sort of demonizing or trying to get rid of it around in certain body locations, but actually on the feet, on the underside of the feet, you don't want to get rid of it. Not that you can, but it's an incredibly good cushion. It's an incredibly good anatomical cushion. So the two main fat pads are the calcaneal fat pad, so that the squidgy fatty lump you have under the heel bone. and you've got the forefoot fat pad, or the plantar metatarsal area fat pad. So essentially, you've got a thick pad of fat under the heel and under all of those toe joints that we've just been talking about. So I'm not too sure which one is being referred to here, but with regards to sort of their sort of thinning or wasting away, or what we would refer to medically, as you know, as atrophy, Essentially that is something that is going to happen with age and that's something that's essentially to all intents purposes normal you know and To my mind there's not really too much you can do to decelerate it now That's not to say there isn't there aren't things you can necessarily do about it. But you know as far as kind of Decelerating the natural gradual process of the fat under our feet sort of thinning out That's a bit like saying can we? can we stop our skin from wrinkling as we age? I mean, some people might sell us things that promise they can, but the reality is at some point, we're all gonna be wrinkly, and that's okay. There's nothing abnormal about that. The other way I've heard it described is, think of the pads of fat on your feet, like the cushions on your sofa. And with every, we take 10,000 steps a day, hopefully for 18, 90 plus years. If we sat on a sofa, for 80, 90 years, what would the cushions look like? They wouldn't be nice and thick and full and they wouldn't be new. We'd need to get them restaffed. So I'm not saying we can restaff the fat pad, but certainly, this isn't my area, I'm not a surgeon, and I know it's also much more popular in the United States than it is here in the UK, and I'm not too sure, forgive me, what the status is in Australia or other parts of the world, but there are people that will inject. inject dermal fillers essentially into those regions to sort of, it's a bit like adding a bit more foam into your old sofa cushions. I've even seen talk of, I guess it was fat grafting is what it was being referred to. But that's probably a bit extreme. I would say essentially if you are getting painful feet and we think that rightly or wrongly that's associated with this atrophy or thinning of the fat pad. just provide the cushioning that you don't, no longer have internally, just provide it externally. So this is where ensuring we've got good cushioned footwear. You know, we are going to be less comfortable when we're barefoot, but when we're in shoes, we can do something about it. We can have shoes or insoles that are incredibly cushioned. But like I say, it's a natural process. I wouldn't worry about it too much. It is gonna happen. I mean, there are some disease processes that will contribute to it. rheumatoid arthritis, diabetes, a couple of connective tissue issues like lupus, gliroderma, those kind of things, and body weight will be a factor as well. But I would say to anyone who had sore feet and they thought it was because they didn't have much fat on them, if appropriate, loose some body weight, wear really, really cushioned shoes, and we've got loads of really, really great options on the market currently. Um, and if that isn't bringing any kind of benefit, there are, there are things that can be injected, but again, I'm probably not the, you probably want to talk to a podiatric surgeon about that kind of stuff. They've probably got more day to day experience with it than I have. Hmm. Another kind of solution is the, those sort of maximal issues or cushioned shoes that you're sort of delivering for all, all these other questions that have been proposed. So, yep, I think it's a nice message to have. Everyone just needs to go shoe shopping, right? Yeah. And I'm sure there's a lot of listeners will be very happy to hear you say that. We can, we can move on to question five. Um, uh, this is Joanne again, asks, is there any exercises that are likely to aggravate Morton's neuroma now? We'll dive into that question in a second, but first of all, what is Morton's neuroma? What causes it? Poor Joanne. I hope she's asking these out of interest and she's not. So you're not suffering from all of these ailments concurrently, because that sounds miserable. Yeah, mortiduroma, like I say, we refer to them, I think, probably better to refer to them as intermetatarsal neuromas, because we can get them in any kind of space in between the metatarsals. So again, we've got those, worth looking up a sort of image of the foot skeleton, and basically anywhere that there's a gap between the metatarsals. So... the gap in between one and two, the gap in between two and three, the gap in between three and four, and the gap in between four and five. So, you know, four potential locations where we can get an intermetatarsal neuroma. Intermetatarsal just means in between the metatarsals, and then neuroma is essentially an irritated, swollen, painful nerve. You know, we have these nerves that run through here that innovate the digits and the web spaces, and they can get a little bit, a little bit. a little bit swollen, a little bit irritated and uncomfortable. And when they are, it's fairly classic to be described as burning, classic kind of nerve pain symptoms, really burning, tingling, often sometimes some numbness in the toes or the web spaces between the toes. Some people report really strange sensations like there's a pebble under their foot or like their sock is bunched up. So any of those kind of feelings that you're getting. it's possible that you may have a neuroma. Morton is the eponymous sort of name that's given to it, particularly when it's in web space three, four, which is the most common location, if we're being honest. And painting the intermetatarsal regions elsewhere, we could probably consider other things before we consider a neuroma, so to speak. So that's what it is, an incredibly common thing. The question I think was... what, what exercises would aggravate it? Was that the question? Correct. I'd probably extend the question to say what does aggravate it? Are there any things that are likely to cause an irritation? Yeah, it's, it's particularly, um, it's particularly sensitive to compression like any nerve can be. So essentially compression can be a sort of transverse compression. So I want us to imagine your foot's being squeezed side to side, which is why people may say that when they're wearing their running shoes, commute to work, it's much more comfortable than when they're wearing their Oxfords or their Brogues. So stiff, narrow, tight leather kind of dress shoes traditionally would be something that we would expect to be provocative because of the side to side compression. But I've also spoken to a few people that report prolonged compression from beneath as well. So if you think about people who cycle can sometimes complain about this for two reasons. I think quite narrow and quite tight fitting anyway, but also where the interface is between the pedal and the cleat is normally right where the problem lay. I've also had a few people that have talked about bothering me when I'm running, so I went on the cross trainer, or the elliptical trainer in the gym, and actually the elliptical trainer can often annoy them more, because with the elliptical trainer, you don't have a flight phase or a float phase, as you do when you're running. Your feet are just constantly in contact with that. with that plate. So essentially you just get prolonged compression and it just continues to intensify as you exercise. So they don't like compression nerves in particular. Everyone, I'm certain everyone has woken up one more, you know, in the middle of the night because they've been sleeping awkwardly on their arm. They've been compressing, you know, compressing a nerve in their arm and it just feels miserable. And as soon as you remove the compression, take your body weight off that arm, things kind of settle down. The problem with the foot is there's just this constant repetitive... cyclical compression, either from shoes or from the ground or from the way the foot's performing mechanically, that just keeps this in a, in this perpetual state of irritability and annoyance. Um, so again, exercise wise, I would say anything that, um, contributes to that compression, um, is probably to be avoided. Well said. Yeah. Um, I've also seen, I don't know if you've seen as well, some runners that have like a narrow. or like a crossover step width, and they sort of their right foot as it's about to make contact with the ground like reaches over to the left-hand side and makes contact over on the other side of the midline and can essentially what happens is when they do that cutting action, the outside of the foot makes contact with the ground first and then when you have that ground reaction force in combination with that tends to kind of create a little bit of compression and so there might be a little bit of irritation. Have you seen like a similar pattern? with Morton's neuroma in that particular gait cycle? I must admit, it's not something that immediately, I think, yes, I've seen lots of, but it makes totally, you know, hearing you say it, makes total mechanical sense if we load that lateral column as we often do, if we've got a big tibial vario, if you've got very bowed shins, or indeed if we're very narrow in our step width, they're two of the main reasons that we would see a foot presented to the ground. when running in a very inverted position, so we'd land on the outside border of the shoe first. And then what we often have to do to avoid spraining our ankle is a very rapid sort of inward movement or very rapid pronation. So that is certainly a mechanism by which you would expect the metatarsals to sort of translate relative to each other. So we often think of, we often tell students to visualize the five metatarsals like piano keys. and the way they move kind of relative to each other, depending on how the foot's behaving. So I think that mechanism is certainly feasible. Yeah, I think that's a very valid point. There was another thing I was going to say about the, the burning kind of sensation. Anyway, I'll move on to Rachel's question and she has a bit of a story. She has a couple of distinct pains in her feet. When I'm running there is no pain, however hours later I have a strong burning on the side of each of my feet and heels. I have compartment syndrome and wonder if it is related. So I guess where we can sort of direct this question to you, if people are getting sort of burning sensations particularly on the outside of their feet or the outside of their heels, is there any cause or concern or any particular common pathology that might produce those symptoms? So, obviously, you know, pain is, we know, we know, and your listeners will know, because I know it's been on many of your episodes before, that pain is complex. And pain is whatever the sufferer says it is. And it's sometimes difficult to verbalize or articulate. So people, you know, it's like someone explaining to you what it feels like to be thirsty. It's not always easy. I know when I'm thirsty, I know what it feels like, but I couldn't necessarily really... well describe it. And I think pain is very similar. That said, whenever someone says burning, whenever someone describes, uses the word burning to me, until proven otherwise, my thought process is this could be neural, this could be nerve-related pain. And I think with this particular case, what raises my index of suspicion even further is the reference to compartmentalism. I'm assuming she means she has some sort of chronic exertional lower leg compartment type syndrome which we know we can get distal nerve changes, paresthesia, pins and needles associated with that. So with those two things combined, obviously, you know, with the huge caveat that with limited information and not seeing the individual in front of me, I'm just theorizing and hypothesizing but Someone says to me, I suffer with compartment syndrome and I'm getting burning in my feet after running. That sounds very neural to me. Would it's... Would it help your hypothesis if the runner is reporting that they're getting symptoms on both sides compared to just one side if they had some sort of bilateral symptoms with that particularly spark any change your answer or help you confirm a certain theory? Yeah, we do. We do sometimes, you know, we are always interested as to whether someone's got something bilateral on both sides or just one side. And again, one of the you know, this there's so many different causes of exercise-induced leg pain. I think one of the professors at the university I teach at has got a slide where every time he finds a differential, he adds to it. I think he's got like 45, 46, 47. Now, obviously, I'm not saying we see all of them commonly, but when we look at the big ones, things like stress fractures, medial tibial stress syndrome, or people may know as open quotations, shin splints, closed quotations. chronic exertional compartment syndrome, and nerve entrapment syndromes. So I think nerve entrapment syndromes and chronic exertional compartment syndromes can sometimes mirror each other. And certainly whether someone's got something bilateral or unilateral would be an important part of that discussion. And again, history taking is really, really key here. And obviously we don't have much more history than you've given us, but I would say, I mean, I hope that they are already seeing someone for this. I mean, I guess they must be, or they wouldn't. I would be highly surprised if they self-diagnosed compartment syndrome from the internet. It's not impossible, but I know runners do this, but I would say that I'd be very surprised if what they're experiencing at foot level isn't in some way part of that overall clinical picture. And add on to Rachel's scenario was, should I be changing my footwear because it seems like she's been running in minimalist footwear. And if I guess if we're kind of suspecting it's, it's likely due to the compartment syndrome, in most cases, like when people have minimalist footwear, it increases the demand on the calf complex. And so would increase the demand, the pressure, the compartment to actually, you know, produce like a lot of force and therefore have a lot more symptoms. Would you, if she were wearing this minimalist footwear, would you potentially recommend trying something else trying a different type of footwear? I guess we're still not too sure what compartment we're talking about either are we so if it was, you know, posterior compartment, and you know, calf, calf complex triceps, sure complex, then there is no doubt that being in more minimal footwear, more often than not, all other things being equal, will place a lot more demand and load on the calf. So if we do have a posterior compartment type syndrome and we're in minimal footwear, those two things don't seem like they are a particularly good marriage, if that makes sense. That said, if it's an anterior compartment syndrome, often switching to a more forefoot strike, a more, dare we use the word, you know, barefoot slash minimal running style, and that's not to say that if you go in minimal shoes, you will definitely run that way, it does seem to help facilitate that, then actually running more on the forefoot, being in a more minimal shoe for an anterior compartment syndrome, may well be very, very helpful. So it's difficult to know for sure without having more information, but I would certainly say that if, the other thing to mention of course, is if the thing you're currently doing isn't working for you, then you should always be open-minded to trying something different. And the one thing I would say is that, you know, changing shoes, playing around with shoes, although an expensive, expensive thing to do. Two things to say, firstly as a runner, you know, you shouldn't be too upset about having to buy new shoes, it's what we all love doing as we know. But definitely, you know, if you try shoes and they don't work, if you try shoes and they make things worse, there's no harm done, you just go back to what, you know, you can easily reverse the situation. When you're talking about compartment syndrome, often at some stage the discussion of surgery comes up. you know, fasciotomies and things. And again, not saying it isn't sometimes really useful and sometimes has really good outcomes, but it's a big day out. And the one thing I'd say about any surgery, and again, I'm conscious that I'm speaking from a position of bias as someone who is not a surgeon, but the one thing I've always said to people is whatever we try conservatively, it may help, it may not help, it may make things better, it may make things worse, but it's always completely reversible. And the one thing about surgery is once you've had it, you can't... unhabit. So when you're sort of having tests for compartment syndrome, being told you might need compartment pressure testing, being told, you know, here's the literature about a fasciotomy, the reality is that why would you not at least try changing things that are easy to change, like footwear, the low-hanging fruit, before you consider more invasive things? 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 learnt a lot listening to the podcast, why not kick it up one more gear through the Run Smarter App. Yeah, very well said. And some of my clients don't often like hearing this, but I kind of sometimes find it useful when it's worse, when you try something and it makes it worse. And I, you know, very particular or careful with what I say, but sometimes I say it's great because if we find out that we make a change and it makes it worse, well, then that's a little bit of evidence on understanding how it behaves. And we can actually now head in the other direction. and see if that makes it better. So sometimes that particular presentation or that reaction can be very helpful from a diagnostic point of view or like a behavior point of view in terms of like future management. So it can be a good thing as well. Yeah, I think that's a great point. You always learn something, don't you? And even if it makes it worse, then like you say, well, it shows it's receptive to change. So we've just changed things in the wrong direction. So yeah, we're always gonna learn something. Moving on, we have Steve who asks, what are some foot exercises that you might recommend for persistent Achilles tendonopathy? Oh my goodness, I'm conscious that I'm sitting in front of a physio here who knows this way more than I do. Yeah, I should say that I'm very spoiled where I work in that I work with great physios. So often when it comes to tendinopathies, I play minimal role in the prescription and overseeing of rehab. Let me give you a great example of how sort of basic... my knowledge and understanding of this is, my father-in-law, who's sort of in his mid-60s, multiple marathons under his belt, we were round there for Sunday dinner a few months ago now, and the dreaded discussion happens, you know, you're at the family dinner table, you're having a cup of tea afterwards, and oh, can I just ask you about my, oh no, here we go. And again, still going his mid-60s, still running very decent mileage, and classic kind of mid-portion pain, mid-portion swelling. You know, what should I do? And you know, my kids are running around and I'm not gonna fully assess, and you know, it's Sunday afternoon. So I'm almost embarrassed to say, certainly in front of you I'm embarrassed to say, Brody, I basically said to him, right, here's what I want you to do. For the next week, I want you to stand on the bottom step of your stairs. just with your heel hanging over, but just holding your ankle at a right angle. So I basically gave him isometrics. I said, do that for a week and let me know if it's any better and if not we'll work out what to do. And all I really wanted to do on that Sunday evening was, he'll never listen to this so I'm okay, but all I wanted to do was end the conversation and get on with my Sunday evening. And I thought it would buy me a week to work out, okay, what am I going to do? Who am I going to send in to see? It's a problem for future me, basically. He sent me a text on, that was on Sunday, he sent me a text on the Friday, five, six days later, and he was completely pain free. Wow, there you go. I was, and again, I know it's a very, very dated scenario where we essentially say, right, always start with isometrics. I'm fully aware that they're not as magical and pain relieving as as I know we once thought they were. I know some of the early data that suggested they were magical was brought into question, was a bit limited in its sample size. And I'm also conscious that having worked with Hakkan Alfredson in London for a few years, the Alfredson protocol of E-Centrics, it's no cookie cutter approach. There's no recipe book. There's no blanket approach here. Certainly the physios I work with, I know you'll be the same Brodie of- They essentially say, if I'd have said to one of them on Monday morning, oh, my father-in-law's got an Achilles tendonopathy, can you print off a rehab program for me? I know the look I'd have got. It would have quite rightly been, we don't just have a, here's rehab for Achilles tendonopathy. It's tailored and individualized. It isn't just three sets of 10. So apologies to Steve that I've not really answered his question, but I would say, if in doubt. basically start yourself on isometrics until you can get an appointment with the physio. Hopefully that isn't too out of keeping with what you'd say, Brody. It's a very safe question, or very safe answer. And I guess if the, if the response, just going back to your, your scenario, if the response is, oh, I feel a little bit better, well, then it's probably just trying to head more in that direction and say, okay, if that loading made things 15% better. How about if we try some more loading and that being possibly heavier rather than longer duration. And if that makes things better, then you continue heading in that same direction. But if it doesn't head in that direction, then you might try and look at other options and look at footwear or training loads or running intensities or anything that's outside, any loading that's inside or outside of running throughout the week to actually try and, adjust those dials to see if there's some sort of loading that could be had or other factors you could put a play but I'm sure you're very proud of yourself when he returned that message and said that he was pain free. I looked like a hero which is a problem it's a problem for next time isn't it because the expectation is inappropriately set now I just yes yeah all right we've got two more to go we have James who asks What's your recommendations for footwear outside of running? So like if during work or during summer, just outside footwear, do you recommend any type of footwear from an injury prevention standpoint in terms of any put in like stability or cushioning or something along those lines? Okay, so is this, is James asking day-to-day footwear that might reduce our chance of being injured? when we run, was that the question? Have I interpreted that correctly? I would interpret the same way. Yes. Um, I wish there were, I don't necessarily, you know, I'm always nervous when we use the term injury prevention. Um, I don't think we can prevent injury. Um, you know, as runners, we, we will cross paths with it, um, in our, in our lives, um, more than once, and that's just the nature of the beast. So prevention is, is it's the. It's the ideal, it's what we'd love to promise, but I think prevention is a very strong word. I think we can, you know, there are lots of things we can do that can reduce risk or mitigate risk, but even then, I think prevention is quite a strong term. Now, when it comes to footwear's ability, I think it gets too much, I'm sure we've spoken about this before, Brady, I think it gets too much credit sometimes with regard to its ability to have a significant influence on injury. when we really look into the data, and I guess we're talking about running shoes here primarily because there haven't really been many studies on non-running shoes in this regard, but when we look at different facets of running shoes, so we've looked at the stability or the dual density mid-soles, the pronation control shoes, when they've looked at whether high drop shoes versus low drop shoes, when they've looked at cushioning, so stack height, essentially there isn't really a strong overwhelming theme or conclusion that emerges from the totality of the literature that says, yep, this is what helps prevent injury. And there the shoes we're wearing when we run. So as far as day-to-day shoes that we could wear that would have some kind of injury prevention qualities, I'd say I would be surprised. I've certainly not seen any data to support it. The approach I take to life is one that I think many people do sort of intuitively anyway, which is wear things that are comfortable. Now that means different things to different people. So I know friends that are incredibly comfortable in Converse. Personally my hooves after an hour in Converse, that's not for me. If I'm going to be on my feet walking around, I need cushioning. So I generally, and again I'm middle aged now, so fashion has long passed me by, I generally favor comfort over what things look like, much to my wife's dismay. around the house, you know, at the weekend, if I'm in the garden with the kids, if it's sunny, on the three days a year that we have a barbecue here because the sun is out, I'll wear sliders or flip-flops, thongs, I think you probably refer to them as. So yeah, I tend to wear things that I find comfortable, that are fit for task, and I guess when I think about it, a bit of variation. So being barefoot a bit in the garden, being in flip-flops, being in Converse, I spend... I do the school run in running shoes on that guy, I'm afraid. Um, so yeah, just, I think variation and comfort are probably what we should favor, but not with the, not with too strong a promise that we're probably. Uh, preventing injury. Yeah. I think, I think the other, um, area to concentrate on, like I've, I've wrote down definitely the comfort side, definitely the the variety or at least adapting to variety you want to adapt to being barefoot being like you know having a whole bunch of different footwear that would that's probably going to help you know, broaden your scope. But also like you said earlier when in regards to the whole body, body doesn't really like surprises it doesn't really like you know too much abrupt changes in things. And so if you I used to when I was in clinics used to see a lot of plantar fasciitis come summer as soon as we start having warm weather and people were just spending a lot more time in less footwear, barefoot footwear, walking around the house, walking outside, going to the beach and like spending a lot more time just asking a huge demand of the feet. And then these reactions would start to play out. And that's a good example of surprises, just you know, a huge abrupt shift change in the body's just like what are you doing to me? I need time to adapt to this. I need time to strengthen up to you know, cope with what you're demanding. And so, yeah, I do think that footwear, like you said, footwear tends to, in terms of its marketing, promise a whole lot, but runners are also ones to quickly blame the footwear a lot of the times as well when they are injured. Um, but you answered that perfectly. So I think that's, um, just to add to your point, just to add to your story, to interrupt, just to add to your point, cause it's something I've noticed as well in, in London, um, sort of pre pandemic. obviously the lawyers, the solicitors, the accountants, the bankers, etc. would all be in, you know, Oxford's or Brogue's, stiff-soled, leather, you know, real formal shoes with suits, you know, double Windsor ties, the whole works. And then they, you know, we had a fairly long, as you know, prolonged, you know, lockdown. where they were sort of sitting on Zoom in their pajamas for most of the day and they were at home, probably barefoot or wearing slippers, flip-flops. Now we're back in the city. I speak to people now who've worn Oxford's and Brogue's for 20 years, but not for the last two years. And now they say when they put them on for a meeting, they can't wait to get them off again. They just not used to them anymore. They cannot wait. You know, they now say, I used to wear my... my number ones, as we refer to them here. I used to wear them 14 hours a day. Now I literally come in my trainers. If I don't have a meeting or a face to face with a client, I'll just leave them under my desk. So it just speaks again to, we like what we know and we know what we like. And again, if we want to get used to something, then we're gonna need to do that slowly and gradually over time. Yeah, that's a nice thing for people to self reflect on when it comes to lifestyle changes as well. Melody to finish off, she says, I constantly get a sore toes and some aching around the toes. I have plenty of toe room in the shoes. The shoes are a good length and the width and even changing the shoes produces the same outcome. Have you seen people with like the toes themselves becoming quite achy and like any sort of advice for Melody? So with the information we have, and this is something where, you know, normally in clinic, as I know you would, we'd delve a bit deeper and we'd want a bit more, more backstory here. So, you know, we hear that they're sore despite the toe width, toe box width, and we hear that they're sore despite changing shoes, but I guess I kind of want to know, are they only sore in footwear? Are they sore out of footwear? Are they sore at rest? Do they interrupt sleep? Do they have a predilection for being more sore first thing in the morning? You know, is there morning stiffness? And again, there's probably another barrage of questions I'd ask there, which would be around, are there any other unexplained joint pains anywhere else in the body? How are the joints of the hands feeling? Is there strong family history of this kind of thing? Do you have psoriasis? Do you have regular eye irritations, stomach upsets, IBS? It's kind of the... the questions that we, I guess we'd refer to as seeing if, you know, there are any inflammatory flags. Because this could just be, you know, hearing hooves and thinking horses rather than zebras, sore toes could just be, like we say, ill-fitting shoes, a narrow toe box, a shallow toe box, etc. But if changing shoes isn't changing symptoms at all, and if, you know, there's adequate toe box room and these toes are still... essentially unexplained, there's an unexplained aching within the joints of the toes, it's probably reasonable to start thinking more globally, potentially, or at least to exclude that right. So I don't want to terrify Maladie and suddenly make her sort of think that she's got lots of things wrong with her, but essentially at this point it's probably reasonable at the very least to meet with your GP and have a blood test and start some form of sort of investigative process, because there's lots of things that can make toes sore that essentially are more global or systemic and not anything to do with the toes, so to speak. If in doubt, back to the rocker sole, the stiff carbon plated rocker sole footwear, right? There you go. Well, add it as an answer to, I think, six of our nine questions that we've had on here. I'm not on commission, I promise, but I... As someone who has incredibly stiff, cavoid, high arched feet, very poor shock absorbing feet, I'm very limited in my range at the ankle, I'm very arthritic in both of my big toes, and I'm still at the moment at least maintaining between 70 and 80 kilometres a week of running. I wouldn't be able to do that were it not for these shoes that we currently have. I am a little bit biased, I am looking through my own lens because they really speak to me. They really suit my anatomy and my deficiencies, so to speak. And we're going to finish up there. Like that was amazing. I'm very conscious of the fact that this was a very hard. Task to, to come on as a guest and have these questions that have limited sort of information, very hard to explain, you know, just purely from an audio perspective, there's a lot of questions, a lot of different questions and I've, I've said that we, we sort of need to keep to around the hour, the hour 15 mark, and you've just taken that all on board and taken it like a champion and. You know, you've executed on all these questions with, you know, world-class knowledge and wisdom. So thank you very much for coming on, taking on the challenge and thanks for joining me once again. My pleasure. My pleasure. I hope it was useful. 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. recognise 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.