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Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, Flat Feet, the deformity or healthy variant. Welcome to the podcast helping you train, rehab and run smarter. When I first started running in my twenties, I knew it would be something I'd be passionate about for the rest of my life. But, unfortunately, developing injury after injury disrupted my progress and left me under trained at the start line on race day. Even with my knowledge as a physio, I still fell victim to the vicious injury cycle and when searching for answers, struggled to decipher between common running myths and evidence-based guidance. That's what this podcast is here to help you with. So join me as a run smarter scholar and let's break the injury cycle by raising your running IQ and achieving running feats you never thought possible. The name sounds familiar. We have Ian Griffiths back on the podcast. He is a podiatrist who last time talked about plantar fasciitis. We had to do a two-parter because he's such a talker, so charismatic and a wealth of knowledge that he just kept talking and went for about an hour and 25 minutes. And so I had to split up into two episodes. Now he is back on with his colleague, Gabriel, to talk about their paper that they've just released about I came across it on Twitter and I reached out to Ian and I'm like, can I have the, um, kind of the paper and went through it. And I'm like, man, this would be a great podcast episode to chat about. So we talk about flat feet. We talk about, um, is it normal, natural, okay to have flat feet? Um, and where these narratives come from about flat feet and If you are asymptomatic, if you don't have any symptoms, do you need to do anything about it? If you are symptomatic, what can you do about it? And so, um, I, it was really tough coordinating this because Gabriel lives in Canada, Ian in the UK, me in Australia, trying to get a reasonable time for all of us to sit down for an hour and have a chat. There was like one slot in. My day that was realistic for everyone. So it was 7 AM for me and it was late at night, I think 10 PM for Ian and like 2 PM for Gabriel. So we managed to come together. I knew this would be a little bit longer because having an extra guest, you know, it's kind of a bit more back and forth a little bit more, getting everyone's perspectives and so that takes a little bit more time, but it was just more value, more knowledge. You're going to love both of these. guests as we interview and also come up with like just the topic itself is very, very interesting. You'll quickly learn that they're full of knowledge. Ian kept me on my toes with the show notes and he sort of ran it off a whole bunch of papers and said, Oh, Brody can just add those into the show notes later. So I did my best and I hope you enjoy. So let's bring on Gabriel and Ian. Okay. Welcome back everyone to the run smarter podcast. I have two guests with me today, which I'll introduce individually. So first of all, we have Ian, welcome back to the podcast. Thanks for having me, Brody. Delighted to be in, I hope this means I didn't do too badly last time. Yes. Uh, from memory, you, you were quite a talker and you delivered so much valuable information that I had to split the episode into two episodes. Cause I went for. quite a long time, but you know, just a wealth of information. So I'm very, very glad to have you back on. If people aren't familiar with those previous episodes, would you mind just giving an introduction into yourself and who you are? Absolutely. Yeah. My name is Ian Griffiths. I'm a podiatrist based in London in the UK. Spread my time across working in private practice, elite sports. And I'm also a lecturer in sport and exercise medicine at Queen Mary University of London as well. Excellent. And Gabriel, welcome to the podcast for the first time. Thank you very much. Thank you for having me. If, well, people won't be familiar with you. So could you mind giving a similar, um, intro into who you are and your, uh, your background in terms of your academic background? Yeah, perfect. So, uh, My name is Gabriel Moisin. As you may notice by the accent, I'm a French-Canadian researcher. I'm a licensed podiatrist since 2014, but I decided that I didn't want to go into clinical work. I wanted to do research, so I did a master's and a PhD on biomechanics for tortuosis and musculoskeletal disorders. And I don't know how it works for you in Australia and in the UK, but here in Canada, if we want a job as an associate professor, we need one or two postdocs. So I went to the UK. I went to the University of Salford to work with Chris Nestor and Kristen Allens for a few months, working on challenging population stroke survivors and Canada working with lower limb amputees. And since 2020, I'm an associate professor at the UQTR, mainly working on foot artosis, biomechanics, musculoskeletal disorders. Well done. Wow, what a background. And we're talking about a paper about flat feet, which caught my attention to scrolling on Twitter. And as luck would have it, Ian was one of the authors on the car. Great. Let me reach out to him. And he was grateful enough to hand me the paper and have a read through it. But Gabriel, I'll start with you. Why the, why the need or did you feel compelled to do a paper on this certain topic? What, what generated that idea? First, as stated earlier, I'm a pediatrist, so I work with patients, let's say one day a week, and on a daily basis I have patients, adults, children complaining about having flat feet. And the problem with this is I spend hours a year just explaining to them that having flat feet is not a problem. And I got tired of this. And the second part is, as a researcher, I often review scientific articles for journals. And let's say one out of four or three papers I review, I must explain to authors that flat feet is not a problem. It's not correlated with MSK disorders. So again, I got tired of this. And the final nail in the coffin was when I read a paper in, I think it was in frontiers in pediatrics in 2021. And the paper was about why pediatric flat feet was a was catastrophic. we needed to correct all of them so I read that and I said okay I need to write something on this so I contacted Ian just to see if he wasn't bored to write something he told me yes so we had a research project ongoing so we had a lot of fun I said, why not do a second paper together? And I reached out to my good friends, Dominique Chiquan. He is a lecturer in pediatric medicine here in UQTR. He is also a speaker for the running clinic. So I asked him, do you wanna join? He said yes, and the rest is... I wouldn't say history, but the rest is the paper. Yeah, excellent. So the paper we're talking about, I had to just pull it up now is flat feet, deformities or healthy anatomical variants. And so Ian, when Gabriel reached out to you, did you see or have a similar experience like with your frustration about the narratives behind flat feet? Yeah, absolutely. Um, when, you know, as Gabriel said, we, we just finished working on another paper and we'd had loads of fun. We clearly had really similar thought processes, our philosophies were well aligned. So when he sent an email saying, what do you think about this? I said, yeah, I'm completely on board with this. This is a discussion I'm having daily, weekly, monthly, and have been having for 20 years. My only concern, I think it's OK to say, is that I said to Gabriel, we both know this is needed. But I... I hope you won't mind me saying I remained unconvinced that the BJSM would publish it. I'm delighted they did, but you know because it shows you know BJSM isn't a podiatry journal, it's a sports medicine journal, so I was delighted that we could. you know, a wider audience because perhaps not everyone's having these conversations on a daily basis like we are. And as we know, you know, people get their information from different sources, the internet, friends, you know, colleagues at the running club. So unfortunately, that noise often drowns out a small editorial in a journal. So, um, Yeah, I was delighted to jump in and try and do our bit and fight, fight the good fight, so to speak. Yeah. Well, the podcast listeners will be glad that, you know, they're keeping their finger on the pulse in terms of what's emerging and it doesn't just get hidden behind one editorial that they'll never read, um, and, and instead be flooded by the blog posts and articles and Instagram stuff, all explaining. the poor narratives around flat feet. Um, but you know, this has a, it all generates from somewhere. It always has a premise. So I might start with you Ian, like how did this initial idea or concept around flat feet causes injuries and is so catastrophic? How did that come about in the first place? Yeah, it's a great question. And I wish I had a great answer. I've looked into this a few times. Um, just out of interest really, just where are the origins of any discussion point or myth as we're now referring to it. And yeah, the honest answer is I can't find exactly how far back it goes. Now, there was a paper published just two months ago, two, three months ago, May this year, lovely paper and it was called, I can't remember the exact title, I think it was called Flatfoot Over the Centuries. And it was a lovely historical piece and I'm not, I'm not a historian or anthropologist of any kind, but it talked about how flat feet as a concept they've been identified throughout all timelines of history. Tutankhamun is documented to have had flat feet. Do you remember the partial skeleton Lucy that was found in Ethiopia that was apparently over 2.5 million years old, suggestions that she had flat feet. So it's not a new thing. I guess the question is when did we decide this was a bad thing? and I can't quite work that out either. You know, we've got pictures that Da Vinci drew in the 15th century, you know, anatomical drawings showing flat feet. The first research I can find talking about surgery for flat feet, so I think that suggests to me a time when people decided they needed correcting or that they needed treating. That's like in the late 1800s. So this isn't a modern day, you know, we talk about some myths, like running shoe myths. and we're often referring to the 1970s, the 1980s. We're going back 2,000 years minimum here. So it's really difficult to tease out exactly who and when decided this is a flat foot and this is a bad thing. But we know that surgery's been discussed since 1884. We know that orthoses have been used for several thousand years, although our modern-day orthoses, what you and I would know as orthoses, probably not. probably the early 1900s. But again, none of this is particularly new. But this paper, and I'll send it to you, Brodie, because I think it'll be of interest to you and maybe to your listeners as well. There was a lovely sentence at the end of it which essentially said, after more than 2,000 years of history, there's no consensus regarding the best way to treat flat feet. And it went on to say, which I think is really pertinent to Gabriel and my. And I wish we'd known about this when we wrote it. I think we'd have probably included it, but it said um Many authors I'm reading this verbatim by the way There was no way I could memorize it so it's in front of me Many many authors seem to have spent more time trying to identify the best corrective method Rather than answer a crucial question is flatfoot a pathology an anatomical condition or a mere phenotypic feature of the human body so you know Pretty much what the point we were making I think Yeah. Wow. I, when I asked the question, I didn't expect an answer like that. That's, uh, extremely thorough and the direction I never expected to take. Um, but yeah, exactly. Um, but I think like, you know, all these theories, like this podcast is, uh, I do like trying to identify any theories or narratives that are quite poor and are in there like this tons for runners that are out there. Um, and. I think a lot of these theories intuitively make sense. Like if you just look at it, you're like, you know what? It looks like if it's a flat foot and, or if it's a heel strike, or if there's like, you know, a knee caving in or something visually, it just looks really like wrong and you would imagine that something that is perfectly aligned would be, would make more sense why it's more anatomically advantageous to have that. You know, more I guess, structurally, a bit more sound. And I guess the theory just builds off that. It's a, it's a very easy to buy in to say that flat feet, you know, you need to correct flat feet because it realigns you and it does all these sorts of things. And, um, that buying is really, really easy because it just looks like it should be fixed, but if we look at the research in terms of injury rates and those sorts of things, um, my guess is we're not really seeing those conclusions. Um, Gabriel, I guess we're with, um, that. side of things like what does the research show? Do we, do we know how compelling is it when we stack up the evidence? Yeah, when you look at each individual studies, you can find studies reporting that flat feet are a risk factor for something, for a heel pain or for forefoot pain, but there's a problem with that because science doesn't work that way. To have a more precise response to a question, you need to look at all the evidence. And in science, it's called systematic review or meta-analysis. So when we look at these reviews, and Ian published two of those. Which are cited in our editorial when we take all the available evidence We see that having flat feet is not a risk factor for many things. So we create a weak risk factor for Pathopharmal pain syndrome Yeah, I see Ian nodding Medial stress syndrome and I think overuse injuries and you found So that's not a lot of disorders And the truth is, there are so many more important factors than when you treat the patient. Allow me an example. So I have a PhD in chronic ankle instability. So let's talk a little bit about chronic ankle instability if you allow. It's a topic I know well. But the literature is not that strong, but let's say that foot morphology is a risk factor of sustaining a sprain. Let's say, I say maybe, having cavus feet. the opposite of flat feet is a risk factor of sustaining a sprain. Let's say it increases your chances of having an ankle sprain by 5%. But the most important risk factor of sustaining an ankle sprain is prior ankle sprain injuries. And when you have an history of ankle sprain, you are two to eight times more likely to sustain another one. So it's 200 to 800% more chances. It's way more than five or 10% more likely. So it's way more important to focus on that than to focus on foot morphology. So as a clinician, should I focus on foot morphology? Of course not. I should focus on modifiable factors such as previous injuries, strength, proprioception, all that stuff. So in my opinion, focusing on foot morphology doesn't make much sense. Okay. Yeah. Ian, much to add on that in terms of what the research shows and how compelling is the evidence linking flat feet to injury or non injury? No, not much bad. Um, other than to echo that, you know, the research is equivocal. Um, and this is why we, you know, Gabriel, you mentioned we do systematic reviews, meta-analyses, they're fancy words for saying here's a study and here's a study and over many, many years there are many, many studies and we bring them all together and see what the totality of them looks like because, you know, they all, it's kind of level one evidence, it gives us the best understanding of where we are on any given topic and we did, as you said, two of those, I think it was in... 2014, so actually probably needs a redo now by someone else. There's a work, but one of them was we looked at static foot posture. So just what your foot looks like when you stand still, how pronated you are, how flat your foot is. And the second one was dynamic foot dynamics. So what your foot does when you're moving and as Gabriel already said, you know. nothing was a particularly strong predictor for the myriad of injuries that we often see listed as consequences of having a flat foot. And I think that's the important thing. To your point, Brody, you're absolutely spot on that it makes sense that good alignment should be better because that's all around us. We have the mechanics telling us that our steering needs to be tracking perfectly and and our wheels need to be set on our car straight. And we have the engineers and the architects building all of the city lines you see. The buildings are vertical, you know, because a vertical column is the most stable. So I think we take all of that and we just assume it applies to the human body. But it's not a building, not a machine. It's an ecosystem, a complex ecosystem with a central nervous system driving it. And I think the reason that these myths and again, underpinning why we wanted to encourage people to think about different foot shapes being normal, rather than one foot shape being normal, is that the myth persists because of how easy it is to buy in. It's easy to understand, it makes intuitive sense, and that's why it won't go away, because the truth is muddy, and people don't really like muddy. So all I would say is, you know, I often say this to my patients, not everyone with flat feet has pain. and not everyone with pain has flat feet. So, you know, it's clearly more, pain is always going to be more complex than what your foot looks like. Yeah, I'm curious to get both your thoughts on this because Gabriel, if you're like seeing patients and they're convinced that their pain is because of flat feet and they need orthotics and those sorts of things, how are you explaining to them? Or what's your reasoning of why people with flat feet aren't getting in general, why it's not a large risk factor. Like you said, there are more greater risk factors for developing pain. But if someone is already bought into flat feet equals pain, how you rationally explain to them otherwise? Yeah, that's a good question. I think the there's an important concept is the concept of causation and correlation. It doesn't mean that you have two variables at the same time that one will cause the other. So in other words, if you have flat feet and a plantar heel pain, it doesn't mean that flat feet will cause... plantile heel pain. And I think that the problem originated a lot from this. So clinicians saw heel pain and the patients had flat feet, but they thought, okay, perfect, the flat feet caused heel pain, but that's not true. And most people with flat feet have developed natural adaptations, compensation over time. So the human body is able to adapt if you give it time. And when you're born with flat feet, you have a lifetime of adaptation. So when you're adults, your body is a lot, is able to dampen the extra impacts, for example, in the medial angle structures, uh, a similar concept in running. For example, if you want to start running, you won't start with a 10k. You'll start with one and then two, three K. And then after a couple of months, couple of weeks, you'll be able to run for 10k. It will be easy. Uh, so if you develop a flat, a flat foot, for example, yesterday I had the erectus foot and today I have a flat foot. That would be a problem. But when, when you're born with it, it doesn't matter. Yep. Ian, much to add on that in terms of how you would talk to your patients or explain exactly why people with flat feet aren't getting injured. I often take an angle of trying to just trying to help them understand that. across the human species, across any given population, variation is normal. And that's to be... I think once you've got your head around the fact that we're not all... we don't all look the same, and we're not all supposed to look the same, and we seem to be accepting of that with other physical features, you know, if you can get your head around that and you apply it to feet, you might have them buying in, okay, well, things vary, and to give a clinical example to make it more easy to understand, Discussions are having clinic. I'm sure we all do is the runner the patient who says All my feet that or maybe they were the are my art is normal because there's very There's a very kind of strong myth out there that there's a normal foot and therefore any deviation from that would be considered abnormal So they want to know do I have normal arches or do I have high arches or low arches? and I'll often sort of use the analogy of why we're talking about arch height, I thought, well, what about the human height? So for example, we walk out into the street and we're not all the same height. There isn't a normal height, not in the optimal sense anyway. There might be a normal in the distribution sense, i.e. a mean, but if someone who walks past me is seven foot five, I look and I think that is one small person. If someone walks past me, an adult male who was, you know, four foot eleven. Sorry to go if I'm mixing my metric and imperial for you. I think to myself, that's a short person. But those aren't abnormal people. That's just a tall person and a short person. And they are within our species. And if someone walked past me who was 5'11", 6' in the UK, they're neither tall nor short to me, because that's population average. It doesn't mean they're normal and the other people are abnormal. It's just that people are different heights. That may come with certain consequences, No matter how good you are at basketball, if you're four foot 11, you're probably not gonna make it in the NBA. But that said, you know, if we embrace that feet have different types, that, you know, we talk about the, that paper talked about the phenotype, fancy word for saying the physical expression of our genetic code. So the hands that our parents have dealt with and that we're playing for the rest of our lives, whether we like it or not. Some of us have high arches, some of us have low arches, and some of us have arches. in the middle, which we might call normal, but we're referring to that in the distribution sense, rather than the optimal sense. I think once people get their head around that, there are a lot more understanding of okay, great, I don't need to worry about that quite so much. And then we can focus on, you know, more pressing matters as Gabriel was mentioning. Yeah, it's a good one to punch you both because you've come up with two different approaches to this. We've got the Ian saying that, you know, okay, variation is normal within our species. and Gabriel saying, okay, within these variants, people just adapt. Like if you are born with it, your body will get used to it. And you, you know, as long as you train and do things within acceptable limits and make sure that the body slowly adapts over time, your body can do amazing things. There's a YouTube video by Kevin Maggs and it was load versus capacity and something else in the title, but does a really good job of explaining that people are quite amazing and they will adapt to a wide array of circumstances. And they have just a quick clip of the Paralympics and people like limping up to the start line or like a high jumper who limps, limps and builds up speed and then jumps over the, jumps over the, the thing. And, you know, we see this all the time. We see people can really in extreme anatomical variance, just get on and they don't get injured as long as their trainings within acceptable limits. And it's you just look at that and think, all I need to do is just make sure I don't have these abrupt changes. Yes, like Gabriel saying, if you have high arches and all of a sudden tomorrow you have flat feet and you have to and you decide to go for a run, you know, that's a pretty dire situation. I would imagine that, you know, the body would get overloaded very quickly. but you know, give it time, the body does amazing things. And I think in the paper, it mentioned something along the lines of unnecessary interventions for asymptomatic feet and how like you both work in clinics, you may have someone who doesn't really necessarily have much of a physical issue or pain, but may be concerned about the structure of their feet. What would... be a typical in other clinics, not necessarily you both, but for industries and whether it's podiatry or physios and those sorts of things, what would be your typical unnecessary intervention for asymptomatic fever? So not in pain. Ian, can we can I start off with you? Yeah, absolutely. I think I'm very lucky in my clinic that I don't tend to see just demographics and logistics really. I don't tend to see too many people myself who aren't in pain. It happens now and then but really quite rarely but your point is valid in that if people are coming in who are pain free, they're still coming in for a reason and normally that reason is a worry or concern they have and it may well be about their mechanics, their movement patterns, their foot posture etc. The lion's share of treatment should ideally look like education and reassurance. but we know that may not be the case. The clinicians, all of us, are sort of hardwired to try and help, and what help often means to us is doing something tangible. And for a lot of people, education and reassurance doesn't feel like they're doing something. We know that's not the case, but they feel like they need to physically do something. So I think if we're talking about what an unnecessary intervention may look like for an asymptomatic open quotations. flat foot, close rotations. It would certainly be the provision of foot orthosis. I don't think we have much data and I'm certainly, it's not a hill I'm going to die on that I would ever, you know, recommend foot orthosis for an asymptomatic foot. And beyond that, I've heard horror, I haven't just heard, I've seen horror stories of surgery as well. So subtailer joint stents or arteries is the high procure. More so, I believe, in North America. Doesn't happen as much in the UK, but surgery for an asymptomatic flat foot is horrifying. That's about inappropriate. You could argue all those things are inappropriate, but other than rob someone of a few hundreds, pounds, or dollars, they can't, shouldn't be able to do too much harm. And even if they did do some harm, you could always remove them. But to put a stent in, you know, a bit of a metal implant in someone's subtail joint when they were asymptomatic. I'm no surgeon but for me borders on, not just inappropriate, borders on negligent. Given what we know about the evidence that there's no guarantee this flat foot would have gone on to develop pain in the future. You're promising the prevention of something that you don't know whether it was going to happen. That's just about as inappropriate as it gets for me. And I don't see pediatrics either. Gabriel's already made reference to it. This is big in the pediatric world. Often parents worried about what they're doing. children's feet look like, whether it's going to hinder their development, their sporting performance. And that's a real tough, real tough discussion to have. It's education and reassurance, but as parents yourself, you know you want the best for your kids. And if you think someone in front of you isn't doing right by your kids based on the thing you read on the internet, you're going to push back. So those can be quite fruity discussions. But for me it's orthoses. surgery, they're the big two things that people will often try and reach for when I don't think they need to be. Yeah, I recall, I was probably working in a clinic for, that's probably my third or fourth year, I had a mum come in who has two kids, she thinks both of them have fat feet, they both are in orthotics and she thinks they need new orthotics because they've grown and now they need to. you know, more, they need new customizable orthotics. And my boss was like, Oh, well done. Like, you know, you go see her, give them orthotics because it's, it's money as well. It's like, you know, orthotics aren't cheap. And my boss wanted me to sort of just like, yep, go along with it. And I just felt really off. I, I tried to, I didn't really, I gave her the orthotics cause that's what she wanted. That's all she wanted. Just my kids just need new orthotics and I wasn't going to change her mind, but I was. kind of not confirming her sort of her opinions and her narratives at the same time. I was kind of just like sitting on the fence being like, Oh yeah, well, if they're comfortable, I guess, you know, you can, can wear them and those sorts of things. But I remember just walking away, just feeling like, you know, really icky about the approach. And to your point, Ian, the, I think about physios, um, when someone comes in, they might have foot pain, but they also might have knee pain and then say I have knee pain because I'm in marathon training, but I also have flat feet and like those sorts of things and like health professionals, like you said, they want to look for something and you want to do a good service. So you want to try and find the problem you want to try and find the solution to that problem and provide them with an answer like this is good, I guess kind of service and if you go looking for something if you go looking deep enough, you're going to You've got one leg longer than the other. You've got one, your glutes aren't activating. You've got your one, you've got your quads that are too tight and your hamstrings are too weak, or you've got this, you're going to find slight variance in a whole bunch of things. And sometimes if someone's injured and the physio doesn't know what the main cause might be, and it might just be like overload, they just go looking for other things and they find, you know, they find. these little variants and then they just sell that kind of narrative because the, the rationale for the, what they find and the treatment approach needs to have a rationale behind it. And so that's when you say, Oh, your glutes aren't activating. So that's causing your need to cave in and that's causing your knee pain. It's not the fact that they ran 20 K's a week and then went to 50 K's a week. It's, you know, they want to try and find this answer and they get a lot of buy-in because that is quite alarming for people. And it's quite, Usually if you talk in a language that is quite alarming, they get a bit more buy-in and they can stick to those interventions, those sorts of things. So it's definitely an industry kind of issue and it's very easy to go down that route as a health professional because like I said, it's quite effective, but even though it's not really helping people in the longterm. Anything to add Gabriel on this? conversation about, you know, unnecessary interventions and what you may or may not have seen. Yeah. In Canada, it's the same thing about foot orthosis. I've seen patients, young patients having one pair of foot orthosis a year for eight years. So it's $500 a year. It changes your Honda Civic into a Porsche, but that's pretty much what it does for the patients and doesn't, doesn't change anything. Another trend I see in the literature is giving foot exercises to correct flat feet. I've seen that a lot in the past couple of years. But why do exercises correct flat feet when it's not a problem? It's the same thing as foot orthosis. I'm a big advocate of exercises being in shape, working out. That's good. It's never a bad thing to be in shape. But why do foot exercises just go for a run and your feet will work just fine. And they will strengthen by just by the run. So why do specific exercises just for muscles, intrinsic foot muscles, in my opinion, doesn't make any sense as a prevention point of view. Yeah. Well, my understanding on like talking about runners, my understanding from The research that I've read and like my rationale is if you have a runner, if you look at them and they've got like a hip drop or like their knee caving in, and it doesn't really look that neat and tidy. Um, some people might say, Oh yeah, I have this hip drop and I have this knee collapsing in. So I'm working on a lot of glute strength and working on a lot of core strength, a lot of like quad strength to try and correct my running form, but to my understanding, you can find someone with a hip drop and all those sorts of things and do all the glute work that you can. And you can do that for six months, progress them to they're really, really strong. You put them back on the treadmill and they'll run exactly the same way. You won't correct a hip drop. You won't correct a sort of knee caving in. Yes, those structures will be really, really strong and their capacity will be a lot higher than what it was before. So their risk of developing some sort of overload has diminished, but it is this so much force going through the body at that moment that you can't just simply correct it. Um, that's my understanding anyway, but back to your point on flat feet, if you do strengthening for your foot, does it change the shape of your foot at all? From my understanding, no, not quite. There are a couple of studies out there just stating that it corrects a little bit. But when you look at the results, it's point, a decimal point of millimeters. So it doesn't make a significant difference. For example, if you increase your archide by 0.5 millimeter, it's not clinically as significant. So in. Just to increase the arch height is not a good practice, but if you have weak, intrinsic foot muscles, you have pathology, that's a different thing. But we're talking about asymptomatic flat feet. Yeah. So similar concepts. So you can, um, do all the foot strengthening you can, might not change your arch too much, but you again built up the capacity of that foot to tolerate more and be more functional, I guess you could say. Andy, do you would you agree with Gabriel in terms of like, if we can ever change a flat foot or change the shape of a foot? Yeah, my understanding of the literature is that foot shape changes very little if at all with intrinsic exercise. I think Luke Kelly, and his team that they've published more on intrinsic foot muscles than most great, great scientists, great scientists, and I had a chat with him when I was over in Australia. I chat with him as much as I can because he's just so much smarter than me. So you've got to spend time with those people and try and get smarter by osmosis. And yeah, I think I land on the same side of the fence as you guys, which is I'm not against it. In fact, I think it's great if runners can do these things. But they're doing them to get stronger or to get better tissue capacity rather than with the goal of changing the shape of their foot. I think that's the most important. As with all things, runners do lots of things. Some have got science behind them, some haven't. We're never really saying to runners, you don't need to, you must not do X, Y or Z. What we're often saying is, what are you doing and why do you think you're doing it? Whether we're talking about intrinsic foot exercises or foam rolling or pheromones, are you doing this because you think you need to? Are you doing it because you want to? Are you doing this to get stronger? Or are you doing this to change your foot shape? And I just think as long as there's transparency from the outset. makes for a better onward journey for the runner. I just want my runners to reason through what they're doing rather than just parrot what they see in magazines or on blogs if that makes sense. Yeah, definitely. I guess another intervention might not be a clinical intervention but an intervention for someone who does have flat feet is the exploration of footwear, different shoes, different technologies and shapes and types of shoes and You know, this is almost, almost every runner is just like really obsessed with shoes. I have flat feet, so I need this type of shoe. I have a neutral foot, so I need this type of shoe. And, um, is there much evidence for the foot shape compared to shoe type or the shoe that they need or will thrive in or will reduce their risk of injury? Any correlation with that? Um, might start with you, Gabriel. No, the simple answer is no, it's not an evidence-based approach to injury prevention. The current literature does not support the use of, for example, motion-controlled shoes for people with flat feet. Actually, it's a lot more complicated than that. I'm not the best expert in running science, but I have two main rules. The first rule is don't change your shoe type unless you're injured. So, if you're not injured, just don't change your shoes. And the second is make sure your shoes are comfortable, they are well fitted and they are light. And to me it seems like the most evidence based approach. And then when you get injured you can change shoe type, you can try for example change your foot strike and all that stuff. But if you're not injured, just don't change the recipe, just stay with what you know, what you're good at. And you'll have fun and you won't... increase your chance of getting injured, because if you change your shoes, you can get injured just by changing your shoes. So that would be a big problem. Yeah. Ian, anything? No, not much to add as always. He gave us covering everything perfectly. And all I'd say is, um, I think what, what run, another reason why this one persists is that again, it's the low hanging fruit and it's the, it's the It's the path of least resistance. So a runner wants an easy, quick fix. Speaking as a runner myself, if you pick up niggles, what you want is to be back out running ASAP. So you'll throw everything at it. You'll throw money at the problem. But what you often want to throw is time and patience. Because we don't have, as humans, we don't have loads of time. We're very time poor. And as runners, we don't often have loads of patience. Because we've got races coming up, et cetera. So I think the myth here persists because runners love the idea of there being a shoe that can fix me. And as Gabriel said, the evidence of shoes ability to prevent injury is really quite poor, much poorer than I think a lot of runners appreciate. Whereas we look at other evidence, we look at the evidence for how many hours sleep you get tonight and your injury risk. That's actually quite strong evidence in that field. You look at recovery strategies, nutrition. stress levels, you know, other sort of psychosocial variables. And actually what you end up landing on is rather than buying a 200 pound shoe and cracking on and seeing how you go and hoping that fixes your problem, you'd probably be best served, sleeping better, reducing your stress levels, sorting out your diet, addressing recovery strategies. But which one of those do we feel like a runner is more willing to do? And unfortunately the evidence isn't, isn't really what the runner cares about in these situations. So this is the, the scenario we find ourselves in modern day. Yeah. I think as runners, we have one tool that we can use for the job. And the only tool that we have is your running shoes. And it's not, we don't have any other bits of equipment and those sorts of things. And as runners again, well, not, not everyone, um, but some runners are just, they just love getting new shoes and they love, you know, that. being their solution and yeah, ends putting up his hand. And, you know, sometimes when I see injured runners, they want permission to buy, go buy new shoes. I'll just, you know, convince my husband or convince my wife that I need new shoes just because it's something that they, they love doing, which is fine. I'm not going to be an advocate though, but, um, Gabriel, you might be familiar with, um, JFS schoolie, a, who is a good friend of the podcast is on the, the running clinic as well. And. Uh, when he was on the podcast, he was talking the same thing about changing shoes and he said that, you know, you want to say, um, okay, are you injured? Because if you are injured, maybe we can maybe change the qualities of your running or change the qualities of the shoes to, uh, I guess distribute the, the load elsewhere. Cause we can do that with certain shoes and like running types and that sort of stuff, and it might be more advantageous if you've had, uh, an Achilles tendinopathy for a very, very long time to then. redirect something maybe give a more of a stack height or a heel drop or something along those lines like we can do that and use it as a tool to sort of distribute but and the other thing is okay well do you want to increase your running performance as well maybe there's some merit to changing your shoe to increase your performance we know lighter shoes help we know super shoes are a thing now but the quality of the shoe like if it is If we do decide to put you in a shoe and you're not well suited to that, or you haven't adapted to the qualities of those shoes, then the risk of injuries starts to rise because it is something that you haven't adapted to and transitioning into that shoe would be necessary. And you have to be more patient, the more, the bigger the changes in that shoe. And give, you'll have to have more and more time to adapt. I just had a gentleman yesterday that I had. talk with who tried for six months transitioning to minimalist footwear, cause that's what he believed. He thought that would reduce his risk of injury. That would increase his running performance. All of his coaches and mates and they're all, um, convinced that minimalist shoes are the way to go. And he tried for six months transition and now he's ended up with six months of plantar fasciitis and he's trying desperately to get back to minimalist shoes while trying to manage this, um, plantar fasciitis. And it's, um, Because he thinks he thinks that once he gets there successfully that it will reduce his risk of injury, but he's been suffering with an injury that he hadn't had beforehand. So, um, it's interesting how we sort of convince ourselves or how other people can convince you of these certain things. And despite what your body's telling you, your body's telling you the complete opposite. It's, um, it's still people are still compelled to act that certain way. So, um, it's, it's an interesting take. Um, and I guess with. The other argument I hear when it comes to orthotics, not necessarily about injury reduction, but about increasing the mechanics of boosting the mechanics of your arch. You know, it would be more mechanically advantageous for there to be an arch to activate the windlass mechanism and sort of boost up the activation to because. injuries aside, we want to increase function. And if we're increasing function with a better shape, then that's going to help someone thrive. So asymptomatic or symptomatic aside, what do we have in terms of, you know, the mechanics and efficiency of and the use of orthotics and do you have much to on this topic? And not I don't have loads and certainly not my area of specialism when we're talking about performance because I'm primarily injury focused. But I guess the assumptions here, and I hear what you're saying because I, although I'm not an expert in this area, it's discussions that go on around me all the time. And I guess you have to adopt the philosophy that there's such a thing as an ideal foot. Because then the idea is when you've identified the suboptimal or the abnormal foot in clinic in an asymptomatic person, your cell, if you like, is here's some orthoses to optimize you. and we're talking about not just minimizing injury but maximizing performance and maximizing, you know, improve your running economy. But as soon as you embrace, as we're hoping people will begin to, as soon as you embrace anatomical variation and that there isn't such a thing as a normal foot, it's really difficult for that to have any, for that approach to have any foundation because what are you actually doing here? What are you trying to optimize if we accept that asymptomatic people all look different and their feet all look different? What are we trying to achieve with our orthoses? I think the assumptions here are that what we see in the first place is somehow predictive of performing poorly. And then when we give orthoses, we know that they have the ability to predictably change performance in every single individual. And what we know about critical focuses is that it's just not the way they work. They are incredibly unpredictable and subject-specific in the way they work. And that's a fancy way of saying if you give the same thing to 10 people. even if they've got the same looking foot, you give them, you know, the identical thing to 10 people, you'll get, you'll get 10 different responses. There's a systematic review, again, we keep talking about this, this is a big study that looks at all the studies done in there, this was published in 2019, so not that long ago. It looked at the effect of orthoses and shock absorbing insoles, so not orthoses, you know, black kind of cushioned insoles, performance in distance runners and actually shows that both autosies and shock absorber installs had a negative effect on running a car. So that's the only systematic view that I'm aware of. So not only do we not have justification for giving these things to people who are pain-free to prevent some injury we're allegedly predicting, but I think there's reasonable evidence to suggest that if we give them to runners, we may in the short term at least, and it was only, you know, I don't know what it would look like in the long term, but in the short term, negatively affect their performance or their running economy. Highly likely because we've been arrogant enough to assume we know better than that person's central nervous system, which on any given day will dictate the most metabolically efficient way to cover ground. Ken Van Alsenoy, who's a great podiatrist who I think he's still based in Aspitar, in Qatar, he's been doing some work on orthoses in economy and I don't... get you I can get you in touch with him because if that's an area you want to discuss more, he's probably better placed to answer questions because he's got some more sort of hot off the press stuff coming, I think. Excellent. Yeah, I think runners need to know that if you're an experienced runner, and you've been doing it for a couple of years, like your body has tried its best to be as economical as possible in your own, your own mechanics, your own anatomy, it's tried its best to be as efficient as possible. And I guess any change any subtle change here and there, you need to think comes at a metabolic cost. And yes, if you make that change and do it with enough repetition that then becomes autonomic or unconscious and becomes like more efficient. So maybe in the long term, but I guess that's where the theory might come in. Like if you put an orthotic or some sort of insole into a shoe, you're then having to change or deviate away from your, what your body has deemed the most economic way of moving. And it comes at a metabolic cost and therefore your running economy would suffer. Is that where the, I guess, did the paper sort of conclude that's why they see these results? Uh, so it was a systematic review. So it was looking at nine, nine from memory. It was nine studies that had been done in this area that had pulled together. Again, I'll send it over to you for your show notes and for your own interest as well. But yeah, my very amateur interpretation of it is exactly that, that when you introduce change in the short term, that will be more costly to you metabolically than it will be helpful. But in the medium to long term, I don't know, I suspect, because we know how adaptable the human body is, I suspect that may change again in the future. Yeah, Gabriel, you've been nodding away here listening very patiently. Anything to add on, on this particular topic? Yeah, I agree with you both. Uh, I think the movement, uh, the preferred movement pathway of, uh, theory of Benio Nigue is the one, is a good resource to understand all this. Uh, the only thing I would add is the, um, one explanation for the decreased performance with photorethosis is the mass of photorethosis themselves. So we know that if we add mass to the shoes, running economy will decrease. So how heavy are like your standard orthotic? I know there's different sizes and shapes, but like on average, how heavy would they be? That's a good question. Let me try. I want right here. Do you have a scale? No, I don't have a scale. Maybe a couple hundred, hundred grams. Maybe. I don't know. I'm not very good in. these small numbers. I think there's a, um, uh, this is like a blanket statement. Um, they say like every hundred grams, uh, negatively impacts your running economy by 1%. I think that's a, um, there was one paper that showed that I don't know if it's reproducible, but something along those lines and 1% significant when it comes to a distance runner or any, any sort of runoff of performance. Um, so yeah, another element. consider sorry, I'll cut you off anything else to add? Nope. Okay, excellent. Well, the I guess the overarching theme for what we've talked about so far has been asymptomatic feet if someone has a flat foot and they don't have pain. They don't necessarily need to worry they don't need to worry about orthotics or being at increased risk and the body will adapt and those sorts of things but I guess if someone does have flat feet and they do have pain. What's, what's our approach like now with our understanding of, we're sort of up to date on these narratives. What, what, what should we do for these feet as an intervention if they are a runner? Gabriel, we might start off with you. Yeah, I like the tissue stress approach. I know that this theory has its limits. We need to address the biopsychosocial and all that stuff, but if we stick to the tissue stress approach. It was published in, I think it was 1995 by two physio, R1MD and one physio, McPoyn and Conwell. They are US based. but even back then in 1995 it wasn't new in 1995 I was pretty young but I think that they merely applied a concept that for example knee, hip or shoulder pain and they just applied the concept to foot and ankle pain so I try to use this approach so first I like to take a very good history. I believe that history is often more important than physical examination or clinical tests. So I would do a good history and then I would do a couple clinical tests, palpation, range of motion, gait analysis. And my goal is to identify the injured tissue. So that's my first step. and then I try to identify the pathological forces, the pathological movements that would cause the disorder and then I would address a problem. For example, if I have a symptomatic flat foot, for example a posterior tibialis tendon dysfunction I will palpate the tib post, I will evaluate the morphology to see if the foot got flatter following the initial symptoms functional tests, for example, ill raises. And then my treatment would be to temporarily reduce the pathological stresses, for example, with shoes, different types of shoes, for tartosis, and mostly education, education to patients. And then when the pain slowly decreases, I would add exercises to strengthen the muscle, the tendon, the ankle joint complex. So basically I want to treat the problem, and then prevent the problem from coming back after the other symptoms are done. Yeah. So that would be my approach. I think that like, it's, it's a very similar approach to any other. area of the body, if someone has knee pain, okay, well, let's reduce the things that are aggravating it. Let's identify the structures and then restore the capacity of those structures with strength once you're able to. But I think with the foot, what's hard about foot issues is, you know, most people, like you don't want to put someone in crutches or a cast or anything like that, and they have to stand throughout the day. And so they're loading an injured structure, which Um, can be quite tricky for someone, but I guess you're saying that's when you would use an orthosis or tape or shoes or something to potentially offload the structure or at least, yeah, offload a little bit to promote healing. But then once that healing subsides or the pain subsides, we can then start slowly introducing things to restore that strength and capacity, um, and strength exercises along those, those lines. Um. Exactly what we do for the knee. Yeah. And most of the time remove the orthosis. So for these patients, most of the time, after a couple of weeks, a couple of months, I just remove the orthosis because they don't need it anymore. Yeah. That's, that's a good, um, I guess I wanted to talk about misconceptions at the end, but I guess that's one that we should probably address is, um, some people think that when they put in orthosis, that's them for life, like you're locked into that, that. under your foot. And, you know, quite the opposite happens like people, they might get better. You know, you will see in clinics, people, some people get find it magnificent, they love orthotics, because they have it, they put on their foot, and they all of a sudden have a lot less pain. And, you know, that's an individual response to someone. But some people may be convinced that once they have orthotics that that's it locked in, I have to have this for life. Otherwise, I'm going to get injured, I'm going to get pain and those sorts of things. And what you're saying is we should use orthotics as a temporary approach to offload a tissue or settle things down and then wean off that orthotic to restore their original capacity and function the way they've been moving no matter what their foot shape. And let's chime in with you anything to add there in terms of interventions for symptomatic feet. that we haven't touched on? Not close to add close, close to perfect answer there. But just to reiterate, things you both already said, which is it's just it's just too darn easy to blame foot posture. And that's our problem. You know, someone comes in, patient comes patient is in pain and has flat feet. And therefore what evolves is patient is in pain because of flat feet and that correlation causation and it's just too easy to blame. So We just got to stress that patients and clinicians alike, that if someone comes in with black feet, don't immediately look to that as some kind of magical cause. They come in with pain, and like any other part of the body, and as you both said, take a history, take a physical, like try and identify what you think is going on. You know, there'll be individual contextual things to take into account. And again, clinical reasoning is key, is keen here. I think Gabriel said the history is key, and I totally agree. And often it's the history, I think, where you can tease out and really get the, tease out what's going on, and really get the patient on board, an opportunity to educate. I see so many people come in who say, oh, I've got pain, I think it's because of my flat feet. And then when you ask them some of the backstory, they've been running for 20 years with pain-free. And... you know, what happens is the plane developed a few weeks after they changed their volume or intensity or frequency, you know, those classic training errors because they started, they jumped up for an event and they really suddenly blame, you know, they seem to forget that they've been running plane three for 20 years for this, why did it not give you a problem for 20 years but then when you doubled your volume you got a problem, I mean, is it the volume that's the problem, is it, but couldn't cope with the volume, I think most people with... over their foot, they doubled their volume, they've increased their injury risk. So I think often when you really tease out the history you can kind of get to the bottom of what's going on and as you've already said I love foot postures as a tool to modify load and often if you do have foot pain it is one of the arrows in our quiver along with footwear that can modify load so we often say to people if you have a sore thumb you text with the other hand for a few weeks and your thumb would can't hop around for a few weeks. So these are times when we can use these or foci or footwear as tools, but the messaging is really, really crucial in that I'm not, you've come in with pain and flat feet. I don't think those two things are massively related. I think your pain has been caused by a training error. I'm going to give you something to offload your sore bit, and then it's gonna come out again. And you need to make sure they don't leave the room thinking, I can give you something to correct my flat feet. Because you can see how that can all get muddled up together. You know, you go in as a patient thinking you've got flat feet and pain. You leave with a pair of orthoses, thus validating what you thought was going on because you weren't listening and we know patients, you know, we sometimes bamboozle patients with too much inflammation. They don't retain everything we say. So the messaging is crucial, which is, don't worry about your feet. They're a normal anatomical variant. Your foot hurts because you train like a maniac. We're gonna give you something to offload it. We're gonna let you go. calm things down, build things back up, educate you about training habits in future, and you're going to be a stronger, more resilient, slightly less injury prone runner. Um, but the risk of injury is always greater than zero. Yeah. It'd be so tough to get that message across and make sure that message is across cause not only are you identifying while they have, or they already know they have flat feet and we're solving the issue temporarily with an orthotic. So that. that two will get paired together, I'm fixing my flat foot, but they're also probably coming in with a preconceived idea, or maybe their friends and family and runners or shoe stores are saying you have flat feet, you have flat feet, you're getting into because of this, this and so they've already coming in, not with a clean slate for you to just lay out a nice clear message, but they're probably Yeah, I've had clients when I used to work in clinics of saying to someone that you they might think they have arthritis in their knees and that running is detrimental to their, their arthritis. And you'll, you'll spend a good part of the session explained to them that it's perfectly fine. You know, um, running is actually going to be healthy for keeping, restoring the strength and keeping the strength and preserving a lot of the cartilage and, um, all that sort of stuff. And then, you know, just in passing at the very end that we like, Oh yeah, maybe I should stop running because I don't want it to get worse. Or like, I don't want to Um, surgery or some of that. And like, just in passing that they've completely missed the message and you're like, well, you don't have time to sit them back down and explain it all again. It's just like, it's so hard to, to break through some people and some people just, you say something and they, they hear something different, um, or interpret it in a different way and just based on what their narratives might be. So it can be extremely tricky. And talking about when you're saying it's too easy to blame the flat feet. I think when it comes to therapists in general. I sometimes have injured runners say, okay, training for a marathon doubled my mileage, got knee pain, went and saw a physio and they said my glutes aren't activating properly. And I'm like, oh my God, it's like such an easy blame to say your glutes aren't firing and like, that's a whole nother topic in itself. But yeah, pointing to something and it's just, it's too easy and you know, it's a big issue in the health professions in general. Okay, I think we've covered so much stuff. I just wanted to quickly cover because I just wanted to take advantage of two brilliant brains on the podcast. Any other misconceptions and things that we might not have covered around this topic? I think we ticked off the orthotics to be used as like a short term thing only, wean off it afterwards, you don't need it for life, that sort of stuff. We don't necessarily need to cover anything, but does anything come to mind when we're talking about misconceptions on this topic? Gabriel, anything to add? Yeah, maybe one thing. I see a lot of patients, clinicians, and sorry to say, but mostly physios, stating that wearing foot orthosis will weaken your feet. So I see that a lot. Maybe my experience is not representative of that. everyone but a couple of physios, a couple of researchers told me that and the answer is we don't know if it weakens your feet. The current literature is not that strong. We have a couple studies saying that it won't weaken your feet. I think we have one with only five people saying that it could atrophy your intrinsic foot muscles. But my take on that is if you have foot orthosis and you are in pain, it will increase your physical function. You will be more active and your intrinsic foot muscle will likely increase. You will have an hypertrophy, not an atrophy. But if you wear foot orthosis and you don't need them. And then perhaps it will cause an atrophy, but the, the answer is it's not that simple. So saying that foot orthosis will weaken your feet in a few weeks. It's simply not true. Yeah, that's good. Can I, I think I might've been guilty of that in the past. I think my messaging would it be fair to say that if you use orthotics. too often not you wouldn't weaken your feet, but you might become more accustomed to those orthotics and then harder to, to operate and function without those orthotics. I think, like I used to have a client that you could see her level of functioning, she got foot pain whenever she played tennis. And then she got put in orthotics and she could play tennis without pain. But then all of a sudden, long walks. or like time on feet, long days, she would then get that foot pain. So then she put orthotics whenever she went for long walks. And then all of a sudden she, that was fine. Then a couple of months later, she got pain with short walks. So then now she wears orthotics with her short walks. And you could just see like the level of capacity continue to reduce and her need for orthotics continue to increase as that level of. as she'd get more and more adapted to those orthotics. So one could imagine that, this is just one case, let's just take that, but one could imagine that she could be getting weaker, but the foot muscle strength might not be getting weaker, but she might become more accustomed and more adapted to the orthotics and harder to operate and function without the orthotics. Would that be fair to say? Yeah, yeah, and I agree with you. If you don't need full orthosis, just don't wear them. But it's not as catastrophic as some people say. So that was my point. That's a, that's a fair point as well. People might have the fear of if they encase or have an orthotic or encase their feet in maximalist supportive shoes that they're weakening their feet. Um, and yeah, it just doesn't happen that way. Muscles don't atrophy if you're continuing to use them, even though if there is a bit of support. Um, okay. Excellent point. What about you, Ian? Anything, any misconceptions or final takeaways or anything like that? Yeah, I'll piggyback on the concept of fear and I'll just loop back to our overriding message here, which is people's inability to accept or embrace human variation And thus label something, you know inherently bad The biggest issue for me remains this narrative that a flat foot is either the cause of someone's previous problems or the cause of someone's current problems, or if they're asymptomatic, the promise, almost, you know, well, you're going to get problems in the future. So... How is that not fear inducing when you're effectively telling someone their foot is just like a volcano? It's either erupting or it's dormant, but it's always something It is never something that we can ignore or not worry about and that really bothers me because No human should be made to feel like that about any part of their body And if we look at runners, we all see runners in clinic, you know most of the time and almost every runner if they've been running long enough, if you ask them about to look back at their history, have you had any injuries in the past? Most have got some tales to tell, some war stories. If you sort of look at any runner and say, are they gonna get injured at some point in the future, statistically speaking, yeah, probably, because the biggest risk of running injury is running. So unfortunately, it's too easy to blame the foot. You tell the runner it's what caused that problem back there. You tell them. they're uninjured, it's going to give you a problem in the future. And then when they inevitably develop one, or because of training error, they go, oh, that guy did tell me this was about my feet. And so it just snowballs and snowballs. And I just can't shake my annoyance humans like us clinicians making other humans feel like that. It's inappropriate. They deserve better. Yeah. Well said gentlemen. Um, and it's been a pleasure talking to you both. Um, congratulations on the paper. And I know these things are hard to, to write and then get published and approved. And I know it's a, an arduous task and I'm glad that I can share it, share it with runners, share it with as many people as I can, cause it's a, it's a great conversation and a message that people need to hear. Um, I think it's. been a miracle, we've been able to coordinate a time for everyone on spending across three continents. Um, I'm ready for breakfast and you're ready for bed and Gabriel, you're probably ready for a beer or something like that. But, um, I think, yeah, I want to thank you both for coming on sharing your wisdom, people can clearly, uh, hear that you have an extended knowledge on this topic and very well versed in the research and trying to come at it with an unbiased approach and, you know, people would, it would just ring true to a lot of people and hopefully, you know, get the message across because the message is important and the narratives that are attached to a lot of these interventions are really unhelpful, very disempowering, very fearful, anxiety provoking. And so hopefully this allays a lot of people's fears and they can have better control of their situations. So thanks lads, thanks for coming on and joining me on the podcast. If you are struggling to overcome an injury, you can jump on a free 20 minute injury chat with me, which you can book through my calendar in the show notes. 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