0:10

Hey everyone, welcome to the DRIVE

0:13

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If you want to learn

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more about the benefits of

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our premium membership, head over

1:01

to peteratiamd.com/subscribe. My

1:04

guest this week is Courtney Connelly.

1:07

Courtney is an internationally renowned foot

1:09

and gait specialist who teaches globally

1:11

on topics related to foot function,

1:13

gait mechanics, and strategies to combat

1:15

foot and ankle pain. She

1:17

is the founder of Gait

1:19

Happens, a group of clinicians

1:21

providing high-quality online cutting-edge foot

1:23

education. She is also the

1:26

owner and operator of Total Health Solutions

1:28

Clinic and gym in Golden, Colorado, where

1:30

she heads patient care with a

1:32

focus on restoring gait mechanics and helping

1:35

people resolve their foot problems. She

1:37

holds a BA in kinesiology and a

1:39

BA in human biology and a doctorate

1:41

in chiropractic medicine. In this

1:43

episode, we speak about all things related

1:45

to the foot. We talk in great

1:48

detail about the anatomy and complexity of

1:50

the foot. Unfortunately, you do need to

1:52

understand this if you want to understand

1:54

why things go wrong in the foot

1:56

as they so often do. Now, I

1:58

should mention at this point, that

2:00

I know many of you listen to this podcast in

2:02

audio only and that's fine. This

2:04

again might be one of those episodes

2:07

that is worth watching on video

2:09

and the reason for that is that

2:11

Courtney uses a model of the foot

2:13

quite a bit when we're talking about

2:15

anatomy and even when we come back

2:17

to some of the pathology of the

2:20

foot because it's just easier to actually

2:22

see for example why you end up

2:24

getting a bunion if you understand the

2:27

biomechanics and anatomy of the foot.

2:30

So with that said we speak

2:32

about loading, balance, falls, control, range

2:34

of motion, posture. We talk about

2:37

the common injuries again including what

2:39

I just mentioned bunions, tendon issues,

2:41

toe weakness, Achilles injuries, hammertoes, plantar

2:44

fasciitis and much more. Through

2:46

this conversation we do a deep dive

2:48

into all the various shoes that people

2:51

should be looking at not only as

2:53

adults but potentially as children. In addition

2:56

to this interview that you're about to

2:58

hear we also recorded a

3:00

video in the gym to better explain

3:02

a number of the concepts that we

3:04

spoke about. So in this video we

3:07

break it down into diagnostic tests

3:10

that are used to determine mobility,

3:13

strength, etc. And

3:15

then we cover the exercises that you

3:17

should do to improve the

3:20

outcomes based on the diagnostics. So

3:22

this interview will be available to everyone. The

3:24

videos from the gym will only be available

3:26

to our paid subscribers and they can be

3:28

found on the show notes page. So

3:31

without further delay, please enjoy my

3:33

conversation with Courtney. Courtney

3:41

awesome to see you. Thank you for making the

3:43

trip to Austin. It's much better to be doing

3:45

this in person I think than by video given

3:47

all the content we're gonna cover. Thank

3:49

you so much. I'm very excited. So before we

3:51

kind of get into the foot help me understand

3:53

your personal obsession with this

3:55

part of the body. Where did that begin? I

3:58

grew up as a ballet dancer. And

4:00

pretty much all through grade school and high school, I

4:02

spent a lot of time on my feet, a

4:05

lot of time in ballet pointe shoes, which as you

4:07

know are very rigid, stiff, you're up on your toes.

4:10

And I kind of always battled foot pain.

4:14

And then when I decided to choose this as

4:16

a career, I was my self-exploration.

4:18

I thought I was going to learn all of

4:20

this stuff about the foot. And

4:22

that just didn't happen. I really didn't

4:24

get a lot of education in regards

4:27

to how the foot actually functions. Because you're

4:29

a chiropractor by training. Why did you choose

4:31

that over, say, podiatry or something that was

4:33

purely focused on the foot? My

4:36

father and I have had this conversation so many times. I

4:38

first was going to go down the physical therapy route and

4:40

then I was like, I want to create my own treatment

4:43

protocols. And my dad has

4:45

always been a big fan of chiropractic, so we just

4:47

had a lot of conversations and that's where it went.

4:50

I was always been interested in exercise and movement. It

4:53

just seemed like a good fit. So as

4:55

you said, you go to school and you're probably not spending

4:57

that much time on the foot. I think we had like

4:59

half a semester. That much.

5:01

Right? That's actually a lot. I would have

5:03

guessed less but okay. I just

5:05

became fascinated by it because it just always intrigued

5:07

me. It's a very complex part of the body.

5:11

And I think with our education, it was

5:13

always viewed as if something hurts in the

5:15

foot, we're either going to put

5:17

an orthotic under it or refer

5:19

them for some type of surgery. And

5:22

I was blessed enough to have some really

5:24

good mentors around me that increased my appetite

5:26

for learning about that and that's kind of

5:29

how it started. I ended up graduating from

5:31

school and working in a couple

5:33

of orthotic labs. I see. So

5:36

you went straight from school directly

5:38

into specializing effectively in the foot.

5:40

Yeah. It's changed a lot. Yeah. So

5:43

orthotic labs. So this is presumably a place where people

5:45

come and have custom orthotics made. Yes.

5:49

So I would work in the front of

5:51

these offices and there'd be grinders in the

5:53

back and they'd be making the orthotics. So

5:55

I was just constantly surrounded by all of that. And

5:57

that's what we knew. we

6:00

see patients, they have foot pain and we would

6:02

cast them for orthotics and make the orthotics. Interesting.

6:05

So even when you came out of

6:07

school, your knowledge and your

6:09

practice was largely still based on

6:11

the conventional way of putting

6:14

support under the foot, hoping for the best. Yes.

6:17

All right. So with that background, we

6:19

can evolve to where you are today which is obviously

6:21

leaps and bounds ahead of that. But

6:23

let's give folks a bit of a sense of the complexity

6:25

of the foot. I think most people look

6:27

at their hands and because of

6:30

our dexterity, I think people

6:32

understand the intricacies of the hand. I know once

6:34

in a while when I'm trying to communicate that

6:36

to a patient, I'll even show them a picture

6:38

of the homunculus which is the

6:40

image of the, I know you know

6:42

what this is but just for the

6:44

listener, the image of the cerebral cortex

6:47

where it graphically represents the size of

6:49

the anatomic features in proportion to how

6:51

much motor and sensory control they have.

6:54

And our superpowers as a species is

6:56

what we can do with these things. It

6:58

differentiates us from all other species. So

7:01

how does the complexity of the foot

7:04

fit into the equation of the human

7:06

body? Well, I think another one

7:08

of our superpowers actually is that we're a

7:10

biped. So we have

7:12

so many cutaneous receptors, muscle

7:15

spindles, joint proprioceptors on

7:17

and in our feet that

7:19

communicate with our vestibular system so

7:22

we can become upright and bipedal.

7:25

When you take away those functions, it

7:28

really alters how you're moving, how you're interacting

7:31

with your environment. I mean, it's always so

7:33

wild to me because when we think about

7:35

it from a rehabilitation perspective, we

7:37

are very good at rehabbing the low backs. We

7:40

do a lot of core strength. We do a lot of

7:42

glute strength. We do a lot of hip strength. But

7:45

you don't hear many people saying, I'm doing

7:47

a lot of foot strength. And it's literally

7:49

our first interface with the ground. It's

7:52

how we contact the ground. It's how everything

7:54

starts. So when

7:56

we take that away, you're really making

7:58

it much more challenging. for yourself and

8:00

I think it really can alter our survival as

8:02

well as decrease our quality of life. Yeah,

8:05

it's funny, you can probably tell looking around

8:07

how obsessed I am with race cars and

8:09

I've made this analogy before but basically there

8:11

were four things that determine the speed of

8:13

a car. Obvious things,

8:15

the engine, the chassis, the aerodynamics, the

8:17

stiffness, the driver's capabilities, what they can

8:20

do in the car but of course

8:22

the tires. And the analogy

8:24

here of course is clearly that the tires are

8:26

the feet and you can have

8:28

the greatest car in the world, the most

8:30

powerful engine, the most remarkable chassis and the

8:32

best driver. If the tires are shot, none

8:35

of it matters. You simply can't get the

8:37

power to the ground and back. So I

8:39

think there's a lot to be said for

8:42

how it is imperative. In

8:45

fact, I would even go one step further. I

8:47

think feet are even a more important part of

8:49

the human body than tires are to the car

8:51

and here's the reason why. As

8:53

we'll discuss, the feet play a role in

8:55

the suspension more than the tires

8:57

play a role in the suspension of a

9:00

car. So when you now talk about force

9:02

absorption, the feet are even more of

9:04

a priority and if you can't absorb force in the

9:06

feet, I think we're going to hear that we're going

9:08

to translate that inability to translate force all the way

9:10

through the body. Yeah, a good friend of mine, Jay

9:13

DeCheri, he always says that you can't build a jet

9:15

engine on a paper airplane and I

9:17

just love that. We're building all of the

9:19

strength and we're focusing on everything above the knee

9:22

when in reality, so much

9:24

of this force, I mean, gait is

9:27

shock absorption, it's stance stability, it's propulsion

9:30

and all of those things enable us

9:32

to become efficient with movement. Now we'll talk about

9:34

a lot of this stuff when we get into

9:36

the gym later today and go through some of

9:38

these things but on a personal level, my interest

9:40

in this probably didn't start

9:42

until a couple of years ago when I

9:45

began to, for the very first time in

9:47

my life, experience pain in

9:49

my feet that wasn't just fleeting.

9:52

Obviously, like every other knucklehead, I

9:54

had the odd bout of plantar

9:56

fasciitis in my youth that got

9:58

better with traditional. means. But

10:01

it was really only when my

10:04

volume of rucking started to get really

10:06

high and the poundage started to

10:08

get really high that I

10:10

was starting to experience pains in

10:12

my feet that I now believe

10:14

could be attributed to weakness. So

10:17

Courtney, I think it would be much easier

10:19

for everyone to kind of understand the

10:21

complexity of the foot if we had

10:23

a better understanding of the anatomy, myself

10:25

included. So I noticed you brought

10:28

your friend here. What's his name again? Eddie.

10:30

Named after... Eddie Vedder. Very

10:32

well. Pro-dam is one of my favorites.

10:34

As we have both been to the same concert recently. Okay,

10:37

so walk us through the anatomy of the foot.

10:40

So, very important. I think

10:42

especially when it comes to understanding how we're

10:44

treating the foot and foot pain to understand

10:46

the anatomy of the foot. So there's basically

10:48

three parts to the foot. You have a

10:50

rear foot, a mid foot and a forefoot.

10:53

How many bones here? 36

10:55

bones, 33 joints. It's

10:57

a complex part of our bodies

10:59

and I think that's why a

11:02

lot of rehab treatments and protocols

11:04

have veered away from really understanding

11:06

what's happening here.

11:08

So starting in the rear foot, the calcaneus, it's

11:10

one of my favorite bones and here's a fun

11:12

fact. A 100-pound female actually

11:15

has a larger calcaneus than a

11:17

350-pound gorilla. Wow.

11:20

Fun fact. Some other fun facts

11:22

about this. The actual bone itself, there's two

11:25

layers to the bone. So there's a thin

11:27

cortical layer, outer layer and

11:29

then there's a spongy inner layer. So

11:32

the way the calcaneus is actually designed,

11:34

think of like a rubber ball bouncing,

11:37

it was designed to absorb

11:39

shock. The other thing

11:41

about the calcaneus is there's a fat

11:44

pad that sits outside

11:46

the calcaneus. So

11:48

there's also two chambers. So there's

11:51

a thin microchamber that is

11:53

not easily deformable because

11:56

when we walk, most of

11:58

us as in a walking gate we

12:00

graze the heel. So that outer chamber

12:02

is not designed to deform. But

12:05

there's a macro chamber on the

12:08

inside of the fat pad that

12:10

is highly deformable. So

12:12

again, we have a fat pad and

12:14

we have the way the bone has been

12:16

designed to absorb shock. That

12:19

fat pad, by the way, is

12:21

two times a better

12:23

shock absorber than sorbacine. It's

12:26

a material. It's a synthetic material. Like a rubber?

12:28

Mm-hmm. A lot of performance

12:32

orthotics, for example, are

12:34

made of, designed to

12:37

dampen vibration and

12:39

absorb shock. And so when I'm talking to my patients,

12:41

I'm like, we have a beautifully

12:43

designed calcaneus that was designed to

12:46

handle all of this shock, to handle

12:48

what happens when our heel strikes the

12:50

ground when we walk. So

12:53

very important structure there. Now

12:56

the calcaneus looks like it

12:58

interacts with another major

13:00

bone there that sits right

13:03

under the fibula and the

13:05

tibia. The talus. Yeah.

13:07

One of the few I remember. Yes. And

13:10

fun fact about the talus, there is

13:12

zero muscle attachment to that

13:14

bone. It's all ligaments. Mm-hmm. So

13:17

there was a study, Ben O'Nig, who's done a lot of

13:19

research in our work, they looked

13:21

at sectioning the anterior talofibular

13:23

ligament. So that's also a

13:25

very common ligament when we sprain our

13:28

ankle. Mm-hmm. If

13:30

those ligaments on the outside of the ankle get

13:33

completely torn, you now

13:35

have this talus that has

13:37

nothing attached to it. So

13:40

what can happen is the

13:42

talus can migrate, it can adduct.

13:46

So the tibia will internally rotate,

13:49

the talus adducts and

13:51

then what happens is it kind of bangs

13:54

into the medial malleolus there.

13:57

So patients will often present

13:59

with pain. along the inside

14:01

of their ankle and it will

14:03

be diagnosed as say tendon dysfunction

14:05

posterior tibialis when

14:07

it is an instability at the

14:09

rear foot because that talus is

14:11

shifting. And would

14:13

that patient have necessarily suffered

14:16

something traumatic to have torn

14:18

the AF ligament? I

14:20

mean typically when you look at ankle

14:22

sprains for example, mild ankle sprains over

14:25

and over again actually pose

14:27

more of a problem from a

14:29

gait perspective or a rehab perspective

14:31

because people will typically sprain their

14:34

ankle, shake it off and

14:36

then continue to walk or play on it. And

14:39

in that situation, the ligament

14:41

is just getting longer and longer and looser

14:43

and looser. And when you

14:45

have these continuous sprains, you have changes

14:47

to the ligament but here's the cool part. The

14:50

ligament actually heals. More of

14:52

what the issue is is that the

14:54

superficial peroneal nerve, so the nerve on the outside

14:56

of the foot. Show where that would be

14:58

there. So that would come on the outside of

15:01

the ankle. Those nerves get stretched. Sometimes

15:04

those nerves get torn. And once

15:06

you start changing the neurological

15:09

input, that's the issue. The

15:12

ligament will heal. It's when

15:14

you lose the sensory input. Yes.

15:17

So you're walking down a curb. You

15:19

lose sensory input and you say, oh. And

15:22

there's no cue saying don't do that anymore.

15:25

And then you keep doing it over and over again.

15:27

I had a patient this week

15:30

that had had multiple ankle

15:32

sprains when he was a kid. In

15:34

the last couple of sprains that he had,

15:36

he couldn't feel anything. And

15:39

that's when they were like, okay, we need to take

15:41

care of this because he lost all

15:43

sensory input. I kind of wonder how

15:45

much of that I have going on from all my frequent

15:47

ankle sprains growing up. But we'll probably

15:50

figure that out when we do some of the interesting

15:52

diagnostic stuff. So what

15:54

is that bone that the

15:56

talus and the calcaneus look

15:58

like they're both touching? Is that the

16:00

navicular? This is the navicular right on the inside.

16:03

Yeah. So this is the

16:05

highest point of the

16:07

medial arch and also an

16:09

important bone here. Posture

16:11

tibialis, so a very important inverter

16:13

of the foot. So it inverts

16:15

the foot. It helps stabilizes the

16:17

arch. Comes down,

16:19

wraps around the navicular and

16:21

inserts on the bottom of the navicular. It also

16:24

has eight plus insertion points on the bottom of

16:26

the foot. I'm sure you've

16:28

seen people that have an accessory navicular. So

16:31

it's almost an extra bone that

16:33

sticks off that navicular.

16:35

And you can see it when you're looking at

16:37

someone. It looks like they have a protrusion. Because

16:41

the posterior tib has to come

16:43

down and wrap around the navicular,

16:46

if you have an extra bone there,

16:48

the vector of force is

16:51

longer. So the way I'll

16:53

describe this to my patients is if you were doing

16:55

a chest press, for example, when you're starting here, imagine

16:58

having to start all the way back here. It'd

17:00

be more difficult. So that's

17:02

where with those patients when you

17:04

see that or you see that they have

17:07

an arch that doesn't want to recoil

17:09

or function, you have to consider, hey,

17:11

we really need to go after strengthening

17:14

posterior tibialis and or some of these

17:16

patients if there's too much

17:18

of a structural variant, that's when you

17:20

implement things like an orthotic, for example.

17:23

So is the navicular considered then part of

17:25

the midfoot? Is the calcaneus

17:27

the only thing that makes up the posterior foot?

17:29

The rear foot. The rear

17:31

foot. And those distinctions, I'll let you

17:34

finish talking about the forefoot, but presumably

17:36

those distinctions are based on not just

17:38

their location but that they have some

17:40

functional significance. Yeah, I think when you

17:42

look at the gait cycle, so when

17:44

we talk about the gait cycle, we look at

17:47

different rockers of the foot. So

17:50

when we're initially walking and our

17:52

heel strikes the ground, that rear

17:54

foot, the calcaneus starts

17:56

or initiates pronation. So

17:59

then we go into eversion. And then you have

18:01

the mid such an unlocked. And because we're

18:03

going to use these words so much today,

18:05

let's make sure people understand a version. Pro

18:07

Nation: Super Nation of the Foot? Absolutely yeah.

18:09

Petition with maybe with your hands. So.

18:12

It inversions. Would.

18:14

Be going out. Let's. Also

18:16

a super nation. Pro.

18:18

Nation is and unlocking of the site. To

18:21

this is where the slits flattens and widens.

18:24

And I think we've kind of demonized

18:26

pernicious. Definitely. And will talk. I know

18:28

we're going to go through a couple of drills today. the

18:30

you've had me doing. To. Really work

18:32

on relaxing the foot and letting

18:35

it pro name without tensing up.

18:37

He version same cells the cow teeny

18:40

as to when you eve or it's

18:42

basically. Allowing that per nations

18:44

to begin. And. Is

18:46

that movement? All of those

18:48

movements? Are they facilitated by

18:51

muscles or or the ligaments

18:53

themselves Actually deforming? I think

18:55

it's ever since. When.

18:57

You're seal hits the ground,

18:59

you have. Bodyweight:

19:02

Then. You're dealing with ground reaction force.

19:05

I. Think the beautiful saying about Gates

19:07

is that we need to have adequate

19:09

range of motion. But. You also

19:11

have to be able to control that range of

19:13

motion. And. That's when things

19:15

get sticky. Is when we

19:18

see people speeding through the gates

19:20

cycle or their speeding through pro

19:22

Nation and they can't control it.

19:24

Then you have the system guy

19:26

at slow down and presumably that

19:28

comes back to he centric weakness.

19:30

I mean certainly few look at.

19:33

I'm sure we'll get into specific

19:35

muscle talk. But. There's

19:37

a lot of essential to control this

19:40

required when our foot hits the ground.

19:43

Or. I'd so three massive bones their we've

19:45

covered. Massive certainly on the scale of

19:47

the foot. Let's. Keep going

19:49

down the path there. Are. Some zoc about

19:51

one more quick area of that I think is really

19:53

cool. This sustained tactile

19:55

intel I. As. A

19:57

medium lip us the cow, Kenya's. It's

20:00

fully ossified by the time or seven years

20:02

old, There. Is a research

20:04

study around Joseph looked at twenty

20:06

three hundred. This children. And.

20:09

They looked at static footprints

20:11

and house for were. Affected

20:14

the development of their medial

20:16

arch. Which. I thought that's a

20:18

pretty large. Cohort: first study. So what

20:20

they sound is by the age of thirteen

20:22

these are kids for to thirteen. By.

20:25

The age of thirteen, those who

20:27

did not wear shoes less than

20:29

three of them. Presented.

20:31

With what they considered flux. The

20:34

ones that wore shoes. Nine

20:37

percent. Were. Considered having

20:40

such seat sorry three percent or

20:42

three in total three percent of

20:44

three percent said the ones that

20:46

wore shoes. They also notice that

20:48

type of shoes so the ones

20:50

that more closed toe box shoes

20:52

had a higher prevalence for. I

20:54

always say with research let a

20:56

guy do not shakily. So.

20:59

I thought it was interesting so with a close. To

21:01

shoe, there was more of a prevalence than

21:03

even the kids that were sandals. So.

21:05

Why is that? You know? Did they take their shoes

21:07

off and run around barefoot? Do they have more toast?

21:10

Play with the foot? Able to function in a better

21:12

position? What this conclusion of

21:14

the study was. The researchers said

21:16

that this sensory information. That was

21:18

gained. By. Their seat. Somehow.

21:22

Gave them a protective tone.

21:24

An increase in protective muscular

21:26

tone that was in a

21:29

billings the arch to elevate.

21:31

Their how is that accomplish? Because I know that

21:33

there's going to be many people listening to those

21:35

who are going to immediately wanna think about their

21:37

kids. The reality of it is most

21:40

of our kids are in school for me

21:42

pretty young age and therefore they have to

21:44

kind to be in shoes. You live in

21:46

Colorado so you're gonna have your kid to

21:48

school and sandals now the winter so. you

21:51

get a sense of the

21:53

time requirement being out of

21:55

shoes if indeed there's causality

21:57

between time away from shoes

21:59

and improved foot health at a young

22:01

age? I think we have

22:03

the opportunity with the kids. I

22:06

mean, when they're at home, just take their

22:08

shoes off, different sand, grass. I mean, this doesn't

22:10

have to be all the time, but

22:12

even just a little bit. I mean, every

22:14

kid on the planet, the first thing they do is take their

22:17

shoes and socks off because they're

22:19

wanting to gain that sensory input.

22:21

So I think even a little bit can go a very

22:23

long way and then we'll get into footwear because that's a

22:25

big one for the kids. Yep, we definitely want to talk

22:28

about that for both kids and adults. Totally. And

22:30

then getting back to the development of this

22:32

guy, the Sussetaculum Tila. So

22:35

if we know that it ossifies by age seven,

22:38

and we have this window where

22:40

we know that between these ages, three,

22:42

four, five, six, that the arch is

22:44

developing, and we can start

22:47

to allow sensory input and

22:49

start to begin muscle strength, the

22:51

way he develops, there's a little

22:53

lip. You see how it lips

22:55

up? So it positions

22:57

the talus almost with a lateral tilt.

23:00

So it's very important from

23:02

a bony architecture perspective on

23:04

how stable that foot is. There

23:07

are cases where this will develop

23:09

in a downward slope and then

23:11

you predispose, you can predispose for

23:13

some type of flatfoot deformity in

23:15

the future. Okay,

23:17

carry on. So that's the

23:20

rear foot, midfoot if you will. Moving

23:22

into the forefoot. The

23:24

forefoot is where we will see

23:27

most of our injuries because when

23:29

we're walking, there's eight

23:31

times our body weight that goes through

23:33

the forefoot with propulsion. That

23:35

is so hard to fathom. Well,

23:39

how about some other numbers here? Your

23:41

Achilles tendon is about four times your

23:43

body weight when you walk. Meaning

23:45

it experiences four times your

23:47

body weight with each step? With force,

23:49

yes. And the

23:52

Achilles is the tendon

23:54

of only the gastroc or

23:57

the gastroc and the soleus? Gastroc and

23:59

soleus. Okay, we should just

24:01

also clarify. I'm sure many people

24:03

know this but when we are

24:05

referring to tendons We're talking about

24:07

the attachments of muscles to bones

24:09

earlier We referred to ligaments which

24:11

are the attachments between bones So

24:13

folks understand that and the Achilles

24:15

tendon which everybody is familiar with

24:18

is obviously and massive tendon I mean

24:20

I've seen the size of these things

24:22

when they're injured when they're severed I

24:25

don't know where it ranks in tendon size

24:27

for the body But it is certainly one

24:29

of the largest I would have to believe.

24:31

I love talking about the Achilles tendon. It's

24:33

beautiful I mean you have the gastroc and

24:35

the soleus they twist on each other It

24:38

can become a very robust tendon

24:40

in the soleus actually makes up

24:42

larger fibers of the Achilles tendon

24:44

Than the gastroc the soleus is a powerhouse But

24:47

getting back to that load when we're walking Four

24:50

times when you start running those

24:53

numbers double So the

24:55

inside of the arch so

24:57

the calcaneonevicular area Experiences

25:00

loads of up to 11 times your body

25:02

weight when you're running I mean it's

25:04

massive, but here's the very cool thing is our

25:06

foot was designed to handle it I mean we

25:08

have all bone structure muscle Tendon

25:11

that was designed to handle that load

25:13

the problem is if you don't use

25:15

it you will lose it It's

25:17

interesting you said that the majority of

25:19

foot injuries are going to occur in

25:22

the forefoot now by my math There's

25:24

about what 15 in the forefoot lots

25:26

of bones in the forefoot metatarsals

25:29

Phalanx distal phalanx proximal phalanx distal and

25:31

proximal there. Yeah, that's for the big

25:34

toe. Yeah, okay eight times our body

25:36

weight at propulsion The

25:39

forefoot has to be incredibly

25:41

stable at push-ups Because

25:43

it handles so much load So

25:46

when we're walking for example One

25:49

of the most common injuries at the

25:51

forefoot will be a generic diagnosis of

25:53

metatarsalgia or stress fractures

25:56

so two and three typically

25:59

will be your metatarsalgia area. And one

26:01

being the big toe. One is the big

26:03

toe. Five being the pinky toe. Yeah, we'll

26:06

get to that favorite guy right there.

26:09

Three and four typically your where you'll see a

26:11

lot of stress fractures. Tell

26:13

people what a stress fracture is. A

26:15

stress fracture basically can be caused by two

26:17

different things. Tensile

26:19

strain or compressive loading.

26:22

So when you have force going through

26:25

the bone and the system just can't

26:27

handle it so it starts to irritate the

26:29

tissue if you will. When

26:31

you look at the foot and I think this is important from

26:34

a rehab perspective is depending upon

26:36

where the fracture is, you'll

26:39

know what type of stress

26:41

fracture it is. So for example, if

26:43

you have patients that are hitting their heel

26:46

very hot and heavy so they

26:48

might have a rigid foot, they might have one

26:50

that doesn't have good mobility and

26:52

they hit the heel heavy, they

26:55

can get a stress fracture in the

26:57

calcaneus. The fifth

26:59

metatarsal also very common

27:01

location for these compressive loading

27:04

stress fractures because they can't

27:06

handle that compression. But

27:09

on the other side of the foot, remember

27:11

we talked about the navicular. That

27:14

guy technically should never hit the ground. It's

27:16

the highest part of the medial arch

27:18

but he can get a stress fracture.

27:21

So you're saying to yourself, well how is that

27:23

possible? If they're caused by compressive loading, not that

27:25

guy. He's caused by

27:28

tensile strain. When

27:30

you can't handle the foot

27:32

pronating and rotating and

27:34

you can't handle the movement of the

27:36

foot, the tendon will start to

27:39

tug and you'll start to

27:41

get that strain at the navicular stress

27:43

reaction leading to stress fracture. So

27:46

interesting, we think about bones as

27:48

having this great capacity for contractile

27:50

force right so axial loading. We

27:52

don't think of them as requiring

27:54

as much tensile force but of

27:56

course they're under tremendous tensile force

27:58

in the opposite. We think of

28:01

our skeleton as needed to support

28:03

compressive load, but of course,

28:05

they have to do both, which actually

28:07

is a pretty remarkable material. Like, concrete,

28:09

for example, is only strong under compression.

28:11

It's so weak under tension. I think

28:13

I mentioned this once before in the

28:16

podcast. Without rebar, concrete would

28:18

be useless. Yet, our bones have to do

28:20

both. So you're

28:22

saying that you can tell,

28:24

I mean, not to oversimplify, but

28:27

lateral injuries are likely to be more

28:29

compressive. Medial injuries might be more likely

28:31

to be tensile. And again, I don't

28:33

know that that matters necessarily other than

28:35

it explains what caused the

28:38

injury. Yes, but also

28:40

with treatment because when

28:42

you look at compressive loaded stress fractures,

28:44

so at the heel, at the fifth

28:47

metatarsal, you have to cushion those. Obviously,

28:49

let the tissue heal. But

28:52

that person might need something that's

28:54

going to give a little bit. The

28:56

navicular stress fractures, the metatarsal

28:59

stress fractures, the sesamoid stress

29:02

fractures, because

29:04

they happened due

29:06

to an instability, to

29:08

a tensile strain, you can

29:10

boot them, but your follow-up with

29:12

them better be rehabbing the strength of

29:15

their foot because it's not that they

29:17

landed too heavy. It's because they

29:19

couldn't control their motion. That's

29:21

why people with sesamoid injuries, for

29:23

example. So the sesamoids are the two

29:25

little bones under the big toe. They're

29:29

similar to the patella. Sesamoid

29:31

refers to, if I recall, a bone

29:33

that is completely surrounded by tendon. Yes,

29:36

it's like a little joint capsule. Yeah,

29:38

nothing is exposed of the bone. It's

29:40

completely embedded within the tendons, correct? Yes.

29:43

When you get those stress fractures there,

29:46

they can be extremely painful and

29:48

people stop using the big toe, which I'm sure we'll talk

29:50

about. But if you offload it,

29:53

these people will be in boots for three months. And

29:55

they'll say, okay, the bone's healed. Go

29:58

back to your activity. The

30:00

were like that because even though the

30:02

bone is healed, the muscles are now

30:04

even weaker. You are more susceptible to

30:07

the injury because you've lost whatever strength

30:09

he once had. Their. Had it happen

30:11

in the first place. Okay,

30:13

so. Let's. Talk

30:15

a little bit about the muscles in the

30:18

foot as well, because. It

30:20

is a very muscular structure. We don't

30:22

think of it that way cause we

30:24

look at it and we can sort

30:27

of see the bones through the skin,

30:29

but especially on the bottom. The musculature

30:31

is incredibly complicated and. It

30:33

is really related to what's happening in

30:36

the lower leg as well. Oh yeah,

30:38

Who. I think we talk about muscles of

30:40

the site. We can talk about intrinsic

30:43

muscles vs. Extrinsic. So intrinsic muscles. they

30:45

live in the site. They. Start in

30:47

the end in sight. We. Have sore

30:49

layers of muscles that. Is. Just

30:51

unbelievable. It is. And I think

30:53

the beautiful thing about the size. Is.

30:56

You can look at the site. it's the only

30:58

place in the body. Where. You can look

31:00

at it. In. Same. Something.

31:03

Is going awry here. Because.

31:06

You're form things like Burundians and

31:08

hammer tears in Taylor's Burundians and

31:10

you'll be able to look. At

31:13

your finger? This isn't the way it's has to look.

31:15

Maybe I should pay attention to it. He

31:17

can't do that is near hip unless you take an extra.

31:20

In. When you can get your hands

31:22

on a foot research to see these

31:24

deformities in their flexible you really think

31:26

about a from muscular imbalance. So.

31:29

If we wanted to look at some. Of the intrinsic

31:31

muscles of the foot, So. if

31:33

we were to start with the big

31:35

one abductor how assess so he sits

31:37

along the big tell and he's responsible

31:39

for straightening the big tell and i

31:41

think the other thing that will be

31:43

helpful when we go through this is

31:45

every medical student and what as to

31:47

learn what an abductor versus an abductor

31:49

is and since they're always embedded within

31:51

the names of the muscles we always

31:53

remembered this is abductors abduct they take

31:55

things away like a person's being abducted

31:57

they pull away from the body base

32:00

basically. Yes. Adductor

32:02

pulls back towards the body. So with

32:04

that said, hopefully people will have an

32:06

easier time remembering some of these terms.

32:09

So we have our forefoot here. Here's

32:12

the big toe. So abductor

32:14

hallucis is going to straighten

32:17

the big toe. There's also a

32:19

muscle. Pulls it to the middle. Pulls it towards

32:21

the middle. Yep. There's an adductor

32:24

hallucis. It's kind of like a backwards

32:26

seven. So when

32:29

these guys get out of balance, for

32:31

example, if I'm in a

32:34

shoe, which we'll talk about later, that's

32:36

going to squeeze my toes together. Such

32:39

as your ballet shoes. Yes. Or

32:41

most dress shoes. Yep. I

32:44

have adductor now that's shortened and

32:46

I have ABductor. It's lengthened.

32:49

It's lengthened. So you start to

32:51

get this imbalance at the foot and

32:53

then you start to see

32:55

changes in the foot. Bunions

32:58

are a result of an instability

33:00

in the foot. Yeah. What exactly is a

33:02

bunion? Everybody's heard of them. A lot of people have

33:04

them. It's a

33:06

transverse instability, not where you

33:08

see the bunion. Here.

33:12

At the metatarsal medial

33:14

cuneiform when someone can't

33:16

control motion at

33:18

the foot. Sort of the

33:20

junction between the midfoot and the forefoot. Correct.

33:23

Then they will start to have this

33:25

instability. All a bunion is by the

33:27

way is this bone basically shifting

33:29

to the outside. Yeah. So

33:32

anybody who's seen it, what you

33:34

notice is you're looking down at

33:36

a person's foot and you'll see

33:38

this huge outpouching in what's

33:40

otherwise the widest part of the foot. Looks like

33:42

it just got a whole bunch wider and it's

33:44

pointing out. But when you see the skeleton, it's

33:47

much easier to understand why that's happening. Yeah. So

33:49

it's this guy going that way. A

33:51

lot of people have these surgically repaired. What

33:54

are they doing surgically to repair that? We

33:56

could talk about this for a long time. with

34:00

those surgeries. A lot of

34:02

them are to

34:23

the cuneiform so they stabilize where

34:25

most people have that instability.

34:28

Once you start pinning things together,

34:31

you might take care of alignment. But

34:33

you've done nothing to strengthen the muscle

34:35

that allowed this to get there. The

34:38

conversation of my mom has a bunion, my grandma

34:40

has a bunion and my response to that is

34:42

you don't come out of the womb with a

34:44

bunion. You might inherit connective tissue

34:47

laxity for example or there might be

34:49

hypermobility issues but if we know that,

34:51

just like we talked about with the kids earlier,

34:54

the earlier interventions, you get them in the right

34:56

footwear, you make sure they're in shoes,

34:59

right, that have a

35:01

toe box where the toes can

35:03

actually splay especially if you know that your

35:06

mother has a bunion. I think

35:08

what's fascinating about the big toes, if you look

35:10

at your nail bed, some

35:12

people that have bunions, the nail bed

35:14

will be flat and it'll

35:16

just look like it's adducting.

35:20

Here's the bunion. Oh, I see what you mean. Yeah.

35:22

But the nail bed is flat.

35:25

When you see that, it's typically

35:28

from footwear. When

35:31

you see the nail bed and it's actually rotated,

35:33

because you see some of those people right where

35:35

the nail bed's kind of turned in and there's

35:38

a looks like it's a rotational issue, you know

35:40

for certain they can't control rotation. Which

35:42

is cool because now you're like, okay, one

35:44

of the reasons I got into all of

35:47

this was I have bilateral bunions on both

35:49

of my feet due to the

35:51

fact that I was constantly in pointe shoes

35:53

and then my solution to that was I'm

35:55

just gonna start bracing my feet because they

35:57

hurt. So they just got weaker.

36:00

and weaker and then I was

36:02

like this is not right. So

36:04

we started strengthening them getting us

36:06

in the right shoes and different ballgame. And

36:09

what's a hammer toe while we're at

36:11

the topic of common pathology? So banyan

36:13

very common. Hammer toes are basically when

36:15

the toes start to hammer the ground.

36:17

All of them are just two through

36:19

five. Two through five. The big toe

36:22

can hammer it's just not as common as two through

36:24

five. This is why when

36:26

you look at hammer toes so

36:28

this would be the top of my foot. We

36:31

have extensors, short toe extensors

36:33

but we also have long

36:36

toe extensors. So on

36:38

the top of the foot the short

36:40

toe extensors are doing a lot of

36:42

work and the long toe extensors are

36:44

not. Yeah this is one of

36:46

those things where if you're listening to us this

36:48

is very difficult to understand. It's

36:50

why watching what you're saying makes

36:52

a lot of sense and again just

36:55

so folks understand the extensors would

36:57

be pulling back. The flexors would curl

36:59

forward and so it seems

37:01

counterintuitive to say how can a

37:04

hammer toe be in

37:06

part driven by this extensor phenomenon.

37:09

Well if the short extensors the

37:11

ones that attach with a

37:13

shorter moment arm are fired up

37:15

and the long ones are relaxed

37:17

it actually looks like a hyper flexion.

37:19

Yes and for people who have

37:21

pain along the bottom of their

37:23

foot so along their

37:25

metatarsals if you take out

37:28

your insert of your shoe and

37:30

you see a lot of wear underneath

37:32

the second or third metatarsal

37:35

you know you're probably walking around with

37:37

too much pressure going through there. So

37:40

on the bottom of the foot it's

37:42

the exact opposite. I have

37:44

my short flexors that

37:48

aren't doing anything in my long

37:50

flexors who are. So

37:53

hammer toes is a muscle imbalance due

37:55

to a weakness in the foot

37:57

and what do you attribute the root

38:00

of that too. If the

38:02

bunion seems predisposed, not

38:04

putting aside genetics and other things like

38:06

that, but just environmentally, if the predisposing

38:09

feature of a bunion is shoes that

38:11

are pushing the big

38:13

toe in, what is the

38:15

environmental trigger that is most commonly driving

38:17

a hammer toe? I think it's the

38:20

same thing. I think that we

38:22

have not been paying attention to our feet for

38:24

a very long period of time. And

38:28

if you were to walk around with

38:30

your hands in mittens for

38:33

20 years, you shouldn't be surprised

38:35

when your hands don't function. It's

38:37

the same concept at the foot,

38:40

really, that it is everywhere else in the body. I

38:42

think we just don't think about it. Well,

38:44

it's not even mittens, right? If you really think about it,

38:46

for most people, if you think back to being a kid,

38:48

like you could still move your fingers in mittens. It's actually

38:51

mittens that don't allow you to move

38:53

your fingers. That's the better analogy. And

38:55

yeah, if you were to spend 12

38:57

hours a day in that

38:59

situation, it would be obviously

39:02

cumbersome. So let's go

39:04

back to the intrinsic musculature of the

39:06

foot. I know we're going to talk

39:08

more about intrinsic and extrinsic foot stabilizers

39:10

when we get into the gym. There's

39:13

a couple key muscles. I

39:15

think they're all key, but we don't have time to go into all of them,

39:18

but that are responsible

39:20

for a lot of our foot function. So

39:22

for example, flexor digitorum

39:25

brevis is one of my favorites. So

39:28

this guy runs from the heel

39:30

and inserts up into the

39:32

failing. So into the toes. It's

39:35

a big muscle. It runs parallel to the plantar

39:37

fascia. He's responsible for decelerating

39:39

toe extension when we walk. Remember,

39:41

it's all about slowing things down.

39:44

We want to control it. If

39:47

I don't have good strength of that

39:49

muscle, he shares load,

39:51

if you will, with the plantar fascia. So

39:54

one of the biggest predictors for

39:57

patients that have plantar fascitis,

39:59

it is would be an acute

40:01

plantar fascial pain is

40:03

a weakness of flexor digitorum brevis.

40:06

When you look at treatment protocols on how

40:08

to get people better with plantar fasciitis, it's

40:11

like stretching their calves and I'm not saying

40:13

that's bad but you also have to look

40:15

at the strength and the stability at the

40:17

foot and he is a very big player,

40:20

very big player in the stability

40:22

of the foot in decelerating pronation.

40:26

You just referred to plantar fasciitis, we talked

40:28

about it a second ago. It's clearly something

40:30

many people listening will understand. They will also

40:32

probably have a ballpark sense of what it

40:34

feels like and how there's a real tenderness

40:37

in the arch but can you explain the

40:39

anatomic structures that make up the plantar fascia?

40:42

So the plantar fascia is going to start

40:44

at the calcaneus and it's

40:46

going to insert into

40:49

the deep transverse metatarsal ligament up

40:51

at the forefoot. The

40:54

plantar fascia has a very key role by

40:56

the way in stability of the

40:58

foot. I'm going to explain

41:01

something called a tie bar mechanism. So

41:03

the tie bar mechanism of the foot is

41:05

this, I like to call free because we

41:07

need to take advantage of it where

41:10

we have a ligament that runs across

41:12

the metatarsals. When

41:15

our foot, when we're walking and

41:17

we go into mid-foot loading so

41:19

when all the pressure comes

41:21

in, our arch starts to flatten and

41:24

widen, when the

41:26

forefoot splays, it

41:28

triggers receptors in

41:30

that deep transverse metatarsal ligament.

41:33

The plantar fascia inserts

41:37

into that ligament so it's kind of like

41:39

this P. So

41:42

when the foot splays, it

41:44

triggers this mechanism of

41:46

horizontal stability as

41:49

well as vertical stability. Because

41:51

the plantar fascia like a triangle

41:54

at the forefoot now begins to

41:56

spread under tension while it's also

41:58

being elongated vertically. It's like a

42:00

fan. So that's the beautiful

42:02

thing about forefoot splay is it's

42:04

this free mechanism that's basically telling our brains,

42:07

hey, you're about to push off. You

42:09

better get real strong and you better get

42:12

real stable because we're about to take on

42:14

eight times your body weight. It gets

42:16

me excited. You take that away,

42:18

you take away forefoot splay, you

42:21

can forget about the receptors talking to you

42:24

because you're not getting the tug on

42:26

them from the deep transverse metatarsal ligament

42:28

display and you're also not signaling the

42:31

plantar fascia. What would

42:33

oppose that? How much compression needs to be

42:35

on the foot, presumably in the form of

42:37

a narrow shoe that would

42:39

prevent sufficient splaying to activate

42:41

the plantar fascia in that

42:44

regard? There's numbers out there.

42:46

You say three to five millimeters. I don't expect

42:48

people to get out and start measuring this. But

42:51

a good way to look at this is if

42:53

you were to take out the factory insert of

42:55

your shoe and you place

42:57

your foot on it and then

42:59

stand on top of the factory insert. If

43:02

your forefoot expands over... Wider

43:05

than the insert. Wider

43:07

than the insert. It's too narrow. You can

43:09

be pretty certain that those toes are

43:11

getting squeezed. That's a great

43:13

rule of thumb. I

43:15

would bet that many of my shoes don't

43:19

pass that test. Is

43:21

it safe to say that it

43:23

might be tolerable if it's a fashion shoe you're

43:26

wearing but you certainly wouldn't want

43:28

that in an athletic shoe where you're running

43:31

or rucking or doing something under load?

43:34

You would argue never be in a shoe of that nature. My

43:37

daughter is 12 so she always tells me, mom,

43:39

why do you make me wear these platypus shoes?

43:42

Everybody else gets to wear Nikes. I get it. But

43:44

yes, the more time we can spend

43:47

allowing our foot to be in a position where

43:49

it can function like it's supposed to, the better off

43:51

we're going to be. It's very

43:53

interesting though, Courtney, because this

43:55

is not conspiratorial but there's clearly

43:57

nothing in the shoe industry that

43:59

is... aligned with that. I mean,

44:01

shoes are not typically designed to

44:03

have that degree of width, are

44:06

they? No, they're not.

44:08

And what's interesting, Nike just came

44:10

out with a baby shoe. This

44:12

is a couple months ago. And in

44:14

their report of the shoe, they

44:17

said, we've done the research. This

44:20

shoe will help your child's development of

44:22

their foot. When you say baby shoe,

44:25

what age? Toddler. First start walking.

44:28

Okay. Technically, you would argue maybe they shouldn't be

44:30

in shoes at all though, right? Right. At

44:32

that age. I mean, they don't need to be if they're walking. Most of their walking is

44:35

not outdoors, but okay. In

44:37

the article, they said, we've done the research

44:40

and we've created a shoe that has a wide

44:42

toe box, a flexible thin

44:44

sole, because we want your

44:46

child's foot to do what it was designed

44:48

to do. And I'm sitting there going, yes,

44:51

like, but why? Why would you not carry

44:53

that through to adulthood? Exactly. But they're starting

44:55

to realize it. And I think when

44:57

you look at research from a shoe perspective,

44:59

at the end of the day, we want

45:01

something comfortable on our feet. And

45:04

I would argue that every single one of

45:06

my patients, once I simply put them in

45:08

a shoe that allows their toes to sway,

45:11

they will always say, it feels more

45:13

comfortable. Anything about it from

45:16

balance. Are you going to balance better like this?

45:18

Are you going to balance better like that? It's

45:20

just not a hard sell. So

45:22

plantar fasciitis, itis of course

45:24

refers to inflammation of the

45:27

plantar fascia. What are

45:29

the most common causes of it? And

45:32

how do you think about treating

45:34

it in the acute sense?

45:36

So somebody shows up for the first time and

45:38

they've got it. What are your thoughts on the

45:40

differential diagnosis for what led to it? And how

45:42

do you go about rehabbing it with an eye

45:44

towards preventing it in the future? First

45:47

you have to make sure that's what it is. There's a

45:49

differential diagnosis of heel pain. I mean you have to rule

45:51

out calcaneal stress fractures for

45:53

example. There's back stairs neuropathy. So

45:55

people will have googled and

45:58

they'll just immediately say, I have plantar fascia. So

46:00

first and foremost, you just have to be certain

46:02

that's what it is. And it's

46:04

a clinical diagnosis. It's not like you've

46:06

got an imaging study that confirms it.

46:08

You have to sort of exclude other

46:10

things as you said. Yeah, and you

46:12

can see a thickening of the plantar

46:14

fascia. Okay. Although rarely I assume

46:16

that's done, correct? You're not likely going to

46:18

put somebody in an MRI for that. No,

46:20

and we'll talk about imaging later with all

46:22

that but there's a difference between anitis, plantar

46:25

fasciitis and plantar fasciopas or

46:28

fasciosis I should say. By

46:30

the time most people get into my

46:33

office, it's no longer in

46:35

an acute stage because in an

46:37

acute stage, this is your initial injury. So

46:40

it is treated very differently. Orthotics

46:43

often can help in those

46:45

initial stages of an acute

46:47

injury because you are offloading. Let's

46:50

just explain to people again, I'm sorry I'm all

46:52

over the place but the anatomy here is so

46:54

complicated that I think it helps to talk about

46:57

pathology to explain it. The

46:59

reason an orthotic can be acutely

47:01

helpful is because it prevents

47:03

the full collapse of the arch, therefore it

47:05

takes some of the stretch off the plantar

47:07

fascia, is that why? Yeah, and when you

47:10

talk about what exactly an orthotic does, the

47:12

jury is still out on that but we

47:14

know it has something to do with force.

47:17

So when the foot starts

47:19

to unlock, it's

47:22

a load modifier. An orthotic

47:24

is a load modifier. So it's going to

47:26

modify the load that's occurring at the heel.

47:30

So in an acute situation, that's great

47:32

but if I had a penny for

47:35

every time one of my patients came in with

47:38

their orthotics that they got

47:40

20 years ago for their

47:43

plantar fasciitis, I mean I'd be a rich

47:45

woman because they're like, well it

47:47

helped acutely but

47:50

research will say two weeks and at the most

47:52

up to a year and then it's time to get

47:54

out of those things. There has

47:56

to be an exit strategy and

47:58

while you're planning this exit

48:01

strategy, you need to be strengthening

48:03

the foot. You have to

48:05

be strengthening things like flexor digitorum brevis

48:07

to be able to share the load

48:10

with the plantar fascia. So

48:12

in an acute setting, they're treated very differently.

48:15

When it's more of a chronic

48:18

heel pain, this is degenerative. This

48:20

is repetitive load. They've been

48:23

walking around on a foot that can't handle

48:25

load, then the tissue starts

48:27

to break down. And in those cases,

48:30

for me, it is all strength.

48:33

It's load. It's not deload. Even

48:35

for a period of time. I mean, I

48:38

tend not to go that route. And

48:41

we have conversations. I mean, there's a lot of

48:43

education that goes behind this. Irene

48:45

Davis, who I know you know, she's... I've had

48:48

Irene on the podcast, yeah. Her and Sarah Ridge

48:50

are looking at research right now where they're looking

48:52

at patients with chronic heel pain. So chronic plantar

48:55

fasciosis at implementing

48:58

minimal footwear in getting these patients

49:00

and seeing what happens with them.

49:03

If you think of the plantar fascia as

49:06

a connection to the Achilles tendon.

49:08

And it is connected, I assume. Yes. Yep.

49:12

The calcaneus, think of it like floats in between

49:14

the plantar fascia and the Achilles tendon. We

49:17

know that tendons need

49:19

load. So think about

49:21

that from the plantar fascia perspective. You

49:24

have to load it. You have to

49:27

load the tissue in order for the

49:29

tissue to get stronger. And

49:31

is the load also necessary to heal

49:33

the tissue, assuming it's not cut?

49:36

Yeah. I mean, if we wanted

49:38

to jump into loading with tendons,

49:41

it's not that anybody who's had

49:43

a tendinopathy, we always say

49:45

rest is not good for tendons. It's not that

49:47

rest is bad. Talk to anybody who's had an

49:50

Achilles tendinopathy, if they rest for a week, they're like,

49:52

yeah, it feels great. The problem is

49:54

that when they go to return to sport or

49:57

they go to return to walk without

50:00

without having loaded the tendon, they're

50:02

gonna be right back where they started from. So

50:05

when we talk about loading the tendons, it's

50:08

a mechanotransduction. So

50:10

when I load a tendon, there's

50:13

a fascial gliding that occurs. So

50:16

this mechanical stimulus that

50:18

then gets converted to a

50:21

chemical stimulus. And

50:23

then we start to see tendon

50:25

healing. In that sense, it's

50:27

very similar to bones. I mean,

50:29

we've talked a lot about this on the podcast

50:31

where the most important thing

50:34

for strengthening bones is force on the

50:36

bone. And that's why weight

50:38

training and grappling, believe it or

50:40

not, are the two best exercises

50:42

for bone density, because they put

50:44

the most stress on the bone,

50:46

both compressive and tensile. And

50:49

the mechanoreceptors in the bones,

50:52

which sense the deformation, use

50:54

estrogen as the chemical signal

50:56

to signal bone building. So

50:59

of course, why estrogen is arguably the

51:01

most important hormone here. So it's the

51:04

same thing. It sounds like in tendons,

51:06

presumably different chemical transduction systems, but it's

51:09

mechanical deformation signals a chemical

51:11

to build. Yeah,

51:14

there's the tenocytes that kind of live

51:16

within the fascicles of the tendon. Exactly

51:18

what you just said. This mechanical gliding

51:20

kind of shears the

51:23

cells. You get a chemical stimulus, and then

51:25

you start to get the changes

51:27

within the tendon, which I think is really fascinating.

51:31

So let's go back to the person

51:33

who shows up. So you've excluded other

51:35

things. You've diagnosed them with indeed plantar

51:38

fasciitis. What are the

51:40

most typical reasons for that presentation

51:42

in, let's start within

51:44

a young person, a young active person? Weakness

51:47

to the foot for certain. And

51:49

when you say weakness, specifically within

51:51

which muscles? Which are the prime

51:54

examples of the muscular? So

51:56

when they come in, I'll always, I have a

51:58

toe dynamometer. So it's this. little device. Did

52:00

you bring it today? I did. Okay,

52:03

good. I always wanted to try one of these. Yes. It

52:07

tests the strength of your toes. So

52:09

it's a little device, you put a card underneath

52:12

your big toe and

52:14

I'll have the patient press their big toe into

52:16

the card. You should

52:18

be able to produce 10% of

52:22

your body weight through your big toe. That's

52:25

Flexerhouse's longest. When

52:28

you put the card underneath 2 through

52:31

5, you

52:33

should be able to produce about 7 to

52:38

8% of your body weight. When

52:40

they're pressing their toes

52:42

down, there's a couple rules. They

52:45

can't lift up their heel and

52:47

they can't hammer the toes.

52:50

Remember we talked about that hammering? That's

52:52

when you'll see people who love to

52:55

hammer their toes because it's a compensation

52:57

for weakness in

52:59

the foot. So that's how they walk.

53:01

It's like I'm clawing my way forward. So

53:04

when they do that, they have to press their

53:07

toes down. When

53:09

you do the big toe, the extensor hallis

53:11

is longest, are toes 2 through 5, do

53:13

they need to be off the ground or

53:15

are they on the ground just not hammered?

53:17

On the ground, not hammered but

53:19

you're pressing down 10% of body

53:21

weight. You know me Courtney, I

53:24

love metrics because what gets measured

53:26

gets managed. Is this something anybody

53:28

can go out and do or you can buy

53:30

these? Oh yeah, you can buy them. I think

53:32

the other thing that's also easy to measure first

53:34

if someone's going to do it at home is

53:36

I have a little laser scanning device, I also

53:38

brought this today, where you would stand

53:40

close to a wall and

53:43

you'd measure from your umbilicus

53:45

to the wall. Then

53:47

you keep your body straight so

53:50

your hips and shoulders are straight and you lean into

53:52

the wall as far as you can. It's

53:54

your toe strength that stops you from

53:57

smacking your face into the wall. distance

54:00

should be 4.5 inches or more. Got

54:04

it. So in other words, we

54:06

could do the trigonometry on that, but basically

54:08

there's an angle at which you're creating a

54:11

moment arm that you need to be able

54:13

to resist. Correct. It's called the

54:15

anterior fall envelope. Cool. We'll

54:18

test all these on you today. Oh boy. But

54:20

it's really fascinating, right? Toe weakness,

54:23

by the way, is the single biggest

54:25

predictor of falls when we age. Really?

54:28

So this is really cool. When

54:31

you think about falling, it typically occurs,

54:33

we're jumping all over the place, by the way here,

54:36

it's the initiation of gait. So

54:39

if I don't have that anterior fall

54:41

envelope, if my toes are weak, I'm

54:44

going to keep going. And so

54:47

not only can toe weakness be a predictor

54:49

of things like plantar fasciitis, fasciosis,

54:52

but also toe weakness can be,

54:54

and it is, researched by Karen

54:56

Merkle, one of the

54:58

single best predictors of falling,

55:01

which is, I mean, massive. Yeah.

55:04

I mean, I think we should spend a

55:06

few minutes on that in a moment because

55:09

obviously people who listen to this podcast are

55:11

no strangers to the importance of fall prevention.

55:13

We have talked about it typically through the

55:15

lens of bone density and muscle mass. So

55:17

low bone density, low muscle mass lead

55:20

to more catastrophic outcomes during falls.

55:23

Obviously the muscle mass is also a great way

55:25

to help prevent falling, but this is a very

55:28

specific muscle mass. So

55:31

athletic person shows up or active person

55:33

shows up, you've diagnosed the problem, you

55:35

have a culpable reason for it in

55:37

weakness. You've already alluded to

55:40

the fact which says, look, I'm probably not going

55:42

to rest you. What

55:44

drives you towards temporary orthotic versus no

55:46

orthotic and just get right to work?

55:48

So when I've had plantar fasciitis, we've

55:50

never done an orthotic. I've probably had

55:52

two bouts of it in my life.

55:55

It's just been a bit of

55:57

backing off some of the volume. some

56:00

manual therapy, ice and

56:03

more footwork. What's your

56:05

typical strategy? It's

56:07

very individual specific. You definitely have to meet

56:10

the patient where they are. What is their

56:12

activity level? What are they willing to do?

56:14

What age are they? Are they going to do this stuff? From

56:17

a passive perspective, I

56:19

do like shockwave into the bottom of

56:21

the foot. Medial gastroc.

56:25

The way the medial gastroc inserts

56:27

into the Achilles tendon, so we talked

56:29

about the gastroc, there's two muscle bellies.

56:31

The medial gastroc sits on the inside

56:34

and how it attaches into the Achilles

56:36

tendon will prevent ankle

56:39

dorsiflexion. Tell people what

56:41

dorsiflexion is. So ankle dorsiflexion

56:43

is basically this motion.

56:45

When I am walking... Pulling the

56:47

toes back basically. Pulling the foot

56:50

back. Yes. And plantar

56:52

flexion just for... Point the toes.

56:54

The other way. Point the toes, extend the foot.

56:57

That ankle dorsiflexion in a walking gait cycle, we

56:59

need about 10 to 15 degrees.

57:01

You'd be surprised how

57:03

people like to cheat the system there. So

57:06

when we get to medial gastroc, we look and

57:09

see how is their ankle mobility? Is it something

57:11

I need to address? How is

57:13

their foot strength? Is it something I need

57:15

to address? And then how is their capacity?

57:18

I always say it's never just a foot problem. I

57:21

wish it was. Make it easier for me anyway. But

57:23

when I'm watching someone walk, walking

57:26

is this internal rotation

57:29

when our foot hits the ground. So

57:31

I don't want the plantar fascia to be down

57:33

there like a dish rag. So

57:35

not only am I assessing what's happening at

57:37

the foot, but I'm looking at the knee. I'm

57:40

looking at the hip. Who's driving the car?

57:43

How well can my glute

57:45

max for example control the

57:47

rotation? Control my pronation so

57:49

that is that having an effect on

57:51

the structures of the foot?

57:53

So when I look at those cases,

57:55

especially with chronic heel pain, it's

57:57

never just a foot thing. I have to. carry

58:00

it up into the rest of the chain. As

58:02

you've sort of alluded to the plantar fascia because it's

58:04

so long, you can really have that

58:06

pain in many different places. The

58:08

real estate on the bottom of

58:10

the foot that is susceptible to

58:13

inflammation or irritation of the plantar fascia

58:15

is pretty long. Is it typically more

58:17

posterior and close to the heel? Most

58:20

of the fibers that were more commonly

58:23

irritated or that medial, there's a different

58:25

branches of it if you will. So

58:28

most patients will get that pain at

58:30

the heel, maybe more on the inside of the

58:32

heel. And it can be

58:34

pretty classic where it's really painful in

58:37

the morning and then as they walk on

58:39

it, it gets better. That can

58:41

change its space a little bit depending

58:43

upon how chronic it gets. Wow.

58:46

So it's a lot more complicated but I mean it seems

58:48

to me that all roads keep pointing

58:50

back to the plantar fasciitis is

58:52

a canary in the coal mine that your feet are

58:54

weak. Yes.

58:56

So the high bar mechanism that we spoke

58:59

of, that free mechanism of the vertical

59:01

and horizontal stability that we have

59:03

at the foot, take advantage of that. Allow

59:06

the foot and the toes to splay

59:08

and do a couple foot strengthening exercises

59:11

and it doesn't have to

59:13

be difficult. Yeah. And we're going

59:15

to give people a lot of those exercises to do

59:17

when we go to that section in the gym. Let's

59:20

talk a little bit about the extrinsic

59:22

stabilizers of the foot obviously as their

59:24

name implies. These are muscles

59:26

that originate out of the foot

59:28

but presumably have tendinous attachments within

59:30

the foot. Yes. So you

59:33

have the medial aspect and

59:35

you have the lateral aspect and then you have the

59:37

posterior aspect. So if we were

59:39

to start with posterior and we've talked about that

59:41

a little bit already. Right. Gastroc,

59:43

soleus communicating through the Achilles tendon

59:46

down around the calcaneus and attaching

59:48

right through the plantar fascia to

59:50

the forefoot. Yes. Very

59:52

big guys here. Soleus is the largest

59:54

muscle of the lower leg. He

59:57

is the one that produces a lot of that. force

1:00:01

at the forefoot when we walk. And

1:00:04

if I'm not mistaken, the Solius has

1:00:06

more type 1 fibers than the gastroc.

1:00:08

Slow twitch. Yeah. So

1:00:11

it's really the workhorse that can keep

1:00:13

going and going and going. Maybe not

1:00:15

generate as much force as the gastroc,

1:00:17

but far more endurance. It's

1:00:19

the powerhouse of the lower leg. It

1:00:21

does create a lot of force

1:00:24

at the forefoot. It's also very

1:00:26

important in the prevention

1:00:28

of ACL injuries, which

1:00:30

I think is counterintuitive given that it's below

1:00:33

the knee. I mean, when you look

1:00:35

at any ACL protocol, it's

1:00:37

always hamstrings. Biceps femoris, all

1:00:40

medial hamstrings, strengthen, strengthen, strengthen.

1:00:43

But the research will look

1:00:45

at and has shown that it's the strength

1:00:47

of the Solius that

1:00:50

prevents tibial progression.

1:00:53

I see. And if you can

1:00:56

resist the tibia moving forward, you

1:00:58

prevent the stretch on the

1:01:00

ACL in that hit. Interesting.

1:01:03

Never thought of that. It's fascinating. I know you

1:01:05

and I have talked about this before, but if

1:01:08

we look at capacity of the Solius,

1:01:11

there are numbers out there that in a seated

1:01:13

calf raise. So when you're

1:01:16

seated, the gastroc

1:01:18

is not your big player. Immobilized. Yeah.

1:01:21

So you're focusing on

1:01:23

Solius. Those numbers, 1.5 times your

1:01:25

body weight. For a single leg calf raise. You

1:01:27

realize I still haven't been able to do this.

1:01:30

I want people to understand how difficult that is because when

1:01:32

you told me that, I was like that

1:01:35

is insane. You need a Smith

1:01:37

machine to do the test. I don't have a Smith machine. So I

1:01:39

was at a friend's house who had a Smith machine and

1:01:42

I set up the apparatus. I actually had to download.

1:01:44

I was lucky. I had my phone. I

1:01:46

was able to download the paper you sent that walked through the

1:01:48

protocol and you're doing

1:01:51

a single leg calf raise where

1:01:53

one foot is doing all the work. Obviously the other

1:01:55

one is not. You've got a lot of padding on

1:01:57

top of the lower femur so that you can load.

1:02:00

the bar from the Smith machine directly over

1:02:02

the tibia and fibula. I think

1:02:04

it was six reps you had to do if I'm

1:02:06

not mistaken at 1.5 times your body weight. And

1:02:09

I think I got up to 1.3 times

1:02:11

my body weight and I was

1:02:13

like, is there any way a

1:02:15

human could do 1.5 times their body weight? And

1:02:17

clearly there is but I was

1:02:20

blown away at how difficult that

1:02:22

was. I generally pride myself

1:02:24

in being able to do the metrics that are

1:02:27

considered minimum metrics of

1:02:30

human performance. This was a fail. It's

1:02:34

shocking to me. It's one

1:02:36

of the biggest assessments we will do with our patients

1:02:38

because I want a baseline. I want to know where

1:02:40

we are. We have ultra runners, athletes,

1:02:42

they'll come in there and it's like wow.

1:02:45

Oh, I've had many people do this

1:02:47

test, everybody's failed it and they fail

1:02:49

it miserably. And so, Kyler Brown who's

1:02:52

talked to me about that because he works with some

1:02:54

of the best athletes. I mean he's

1:02:56

pointed this out as I think you have which is

1:02:58

sometimes the better an athlete you are, the better you

1:03:00

are at cheating. I'm not suggesting

1:03:02

that that's of my issue but I'm saying like

1:03:04

a lot of these times you'll see really good

1:03:07

athletes who can do amazing things and yet they

1:03:09

have very poor calf strength and you can't understand

1:03:11

how that's the case. So how is that the

1:03:13

case? I know we're jumping around. I want to

1:03:15

come back to the extrinsic stabilizers but again this

1:03:17

is such a fascinating topic when I see people

1:03:20

who can run and jump and do superhuman things

1:03:22

but when you isolate the soleus, it's

1:03:25

not even able to move their body weight. They

1:03:27

are the very good cheaters, they find a way. But

1:03:31

eventually, eventually something's

1:03:33

got to give. And whether

1:03:35

that's going to be today with the athlete or it's

1:03:37

going to be 10 years down the

1:03:39

road, when you are not using

1:03:42

your plantar flexors and I'm talking in a

1:03:44

walking gate cycle, when that strength capacity isn't

1:03:46

there, it's going to rear its head at

1:03:48

some point. And

1:03:50

you might be a fast runner

1:03:52

but imagine if you started to

1:03:55

actually strengthen the muscles that made

1:03:57

you fast. Some of

1:03:59

the best marathon runners in the world have

1:04:01

the longest Achilles tendons. We

1:04:03

have the spring of the tendon. We have

1:04:05

these gastroc and soleus that can isometrically contract

1:04:08

very strong and then transfer

1:04:10

this force. I mean, the

1:04:12

strength of the lower leg

1:04:15

is so powerful. To be able to

1:04:17

take advantage of that, we have to do it. All

1:04:19

right. So we'll obviously go through some of

1:04:21

those things. You mentioned now a

1:04:23

lateral and a medial set of muscles. What are

1:04:25

those large muscles as well? They seem to cause

1:04:28

a lot of pain. Let's

1:04:30

talk about lateral ankle stability. Pronials

1:04:32

are the big boys on the

1:04:34

outside. So, pronius brevis is going

1:04:36

to insert on the fifth metatarsal,

1:04:39

okay? Powerful everter of the foot. So

1:04:41

that's going to take us from this position

1:04:43

towards the big toe. Pronius

1:04:46

longus also on the

1:04:48

outside wraps underneath the foot and

1:04:51

inserts on the medial aspect

1:04:54

of the foot. Okay. So

1:04:56

down on the outside of the foot, around

1:04:58

and under to the medial. To the big

1:05:00

toe. Yeah. So when it contracts,

1:05:02

it flattens the arch. When pronius

1:05:05

longus contracts the foot. It pronates.

1:05:07

Mm-hmm. What he does is he's

1:05:10

going to evert the foot

1:05:12

and most importantly, this is why

1:05:14

the pronials are a very big

1:05:16

stabilizer of your big toe. Which

1:05:18

is counterintuitive because they're on the

1:05:20

opposite side of the foot. Yes.

1:05:23

So one pronius longus, this is the one

1:05:25

that goes underneath the foot. When

1:05:28

he's doing his job, we call it dropping

1:05:30

the head of the first metatarsal. So

1:05:33

basically what that means is it takes that

1:05:35

bone, the metatarsal, and it anchors him

1:05:37

to the floor so that we

1:05:39

have a stable position

1:05:41

at push off. Yeah.

1:05:43

So one of my favorite exercises is

1:05:47

putting a band, like an elastic

1:05:49

under huge tension on the floor,

1:05:51

pulling medially such that the only

1:05:53

part of myself I let contact

1:05:55

the floor is the base of

1:05:57

the big toe. Yes. balance

1:06:00

drills. So that's actually strengthening

1:06:02

outer leg. Yes, very

1:06:05

important. When

1:06:08

patients have ankle sprains for

1:06:10

example, remember we're losing sensation,

1:06:12

right? We have a sensory loss

1:06:14

if you will. You can have

1:06:16

dysfunction of your peroneals. When

1:06:20

I'm walking, because

1:06:22

peroneal is long as drops that first metatarsal

1:06:25

down, he's anchoring my big toe to the

1:06:27

ground. If he's

1:06:29

not doing his job, this

1:06:31

guy will stay elevated. So

1:06:33

he'll stay lifted a little bit. So

1:06:36

now when I'm walking, I don't have this

1:06:38

stability at my first ray and so I'm

1:06:40

either going to go to my outside again,

1:06:42

which means there's my other ankle sprain or

1:06:45

people will complain of a

1:06:47

pinching on the top of the

1:06:49

big toe. So there's

1:06:52

a difference between a

1:06:55

bunion, so this is when it goes into

1:06:57

this door. It comes out versus

1:06:59

people will see a bump on the

1:07:01

top of the toe. Those

1:07:04

are two different animals. So

1:07:06

if I'm walking and I don't

1:07:08

have that first metatarsal dropping, when

1:07:11

my big toe tries to extend, it doesn't

1:07:14

have this nice like rolling glide. It

1:07:17

kind of jams first and then

1:07:19

you get this irritation on the

1:07:21

dorsum aspect of the toe and it'll get

1:07:23

red and it'll get irritated and it's

1:07:26

what we would term a functional hallux

1:07:29

limitus. So a restriction

1:07:31

of motion at the big toe. And

1:07:34

it all stems because there is not

1:07:37

enough muscular force

1:07:39

from the lateral musculature

1:07:42

of the foot, the peroneals to

1:07:45

bring the toe down, the base of the toe

1:07:47

down. I mean, in my opinion, unless there's been

1:07:49

trauma, like you've dropped a weight on your toe

1:07:51

or you've had turf toe or things like that

1:07:53

where there's been an accelerated

1:07:56

inflammatory response, then

1:07:58

yes, it is a dysfunction. at

1:08:00

that first row, which is often

1:08:02

caused by a weak foot, there's

1:08:04

a common theme here, instability

1:08:07

of the outside of the ankle, ankle

1:08:09

sprains. And if those movement patterns are

1:08:12

not restored and

1:08:14

regained, then you start to

1:08:16

have this arthritic change

1:08:18

at the big toe and that is not fun

1:08:20

for anybody. It will alter gait,

1:08:23

it will alter movement. So

1:08:25

the big meaty muscle on

1:08:29

the outer part of your shin is

1:08:31

the tibialis anterior? Correct. And

1:08:33

does it attach, it

1:08:35

must go down around the lateral malleolus as

1:08:37

well? It's on the front of

1:08:39

the lateral malleolus, correct? Tib anterior comes down

1:08:42

and then tib anterior tendon, you'll

1:08:44

see it more on the medial aspect of

1:08:46

the foot, it's a dorsiflexor of the foot.

1:08:49

Biggest dorsiflexor, right? Yeah, okay.

1:08:52

So we were just talking lateral compartment. We

1:08:55

were going around the house. Yeah. So now

1:08:57

we're in the front of the lower leg. So this

1:08:59

is where tibialis anterior and all of

1:09:01

your extensors live. So they

1:09:03

extend the toes. Sorry to interrupt and

1:09:05

maybe you were just about to address this. Why

1:09:08

do we have toe extensors out of

1:09:10

the foot? When

1:09:12

you're walking, we always talk

1:09:14

about with gait what's happening in stance phase.

1:09:16

So there's stance phase when the foot is

1:09:18

on the ground and then swing phase when

1:09:21

the foot's in the air. The

1:09:23

reason why a lot of us give so much attention to

1:09:25

stance phase is because that's where all the magic happens, right?

1:09:28

All the load. But swing

1:09:30

phase, when we're walking, you

1:09:32

have to clear the ground. So

1:09:35

when I'm assessing gait, I will often close

1:09:37

my eyes and listen because

1:09:39

you'll hear the scuff

1:09:43

as I like to call it, where

1:09:45

they can't clear the ground. These will be your

1:09:48

runners that come in and tell you, I keep tripping

1:09:50

over, when I'm running, I keep tripping over rocks. I'm like,

1:09:52

are you really tripping over rocks or what's happening here? Because

1:09:55

if those tissues can't extend the

1:09:58

toes and extend the toes, extend

1:10:00

the foot, when they're

1:10:02

running or walking, they'll scuff

1:10:04

the ground and you can

1:10:06

hear it. So

1:10:08

they're responsible for a clearance and

1:10:10

swing phase, but then

1:10:12

also at heel strike,

1:10:16

here's that eccentric component. When

1:10:19

my heel strikes the ground, here's my

1:10:21

extensors, they have to

1:10:23

be very strong eccentrically because they're

1:10:25

going to decelerate my

1:10:28

foot hitting the ground. So

1:10:31

again, I'll close my eyes and I'll

1:10:33

listen because if they don't have good

1:10:35

control of those pre-tibial muscles,

1:10:38

tibialis anterior and your

1:10:41

extensors, it's like an elephant walking down

1:10:43

the hallway because it's foot slap

1:10:45

after foot slap. These

1:10:47

patients will tell you they have shin

1:10:49

spence, they have medial tibial

1:10:51

stress syndrome because

1:10:53

they just can't handle

1:10:56

the repetitive motion of their foot

1:10:58

slapping the ground without control of those

1:11:00

muscles. Very interesting.

1:11:03

Okay, so we've got these

1:11:06

three pockets of

1:11:08

extrinsic stabilizers, the intrinsic.

1:11:11

Let's talk a little bit more about the common pathology that

1:11:13

you see. So we've talked about a

1:11:15

handful of them already. What are

1:11:17

the most common pathologies you see due

1:11:20

to the anterior and lateral

1:11:22

compartment? We missed the medial

1:11:24

aspect too. Oh, let's go back to that.

1:11:26

From the big boy and the medial aspect

1:11:28

is where you'll see a lot of injuries

1:11:30

as opposed to your tibialis. So

1:11:33

posterior tibialis, like I mentioned earlier, comes

1:11:35

down along the medial aspect of the

1:11:37

foot and it's a very big stabilizer

1:11:40

of the inside of the foot. And

1:11:42

it's sort of as I'm feeling my own leg

1:11:44

under the table here, it's very difficult to disentangle

1:11:47

it from the gastroc, the medial head of the

1:11:49

gastroc, isn't it? They seem very close

1:11:51

to each other. If you were to

1:11:53

put your foot on your knee, point

1:11:56

your toe and bring

1:11:58

the sole of your foot toward the knee. towards the

1:12:00

ceiling, you'll see a

1:12:02

tendon that kind of pops up along the

1:12:04

medial aspect of the foot, that's post-tib. Yeah,

1:12:07

and that's the one that when we get

1:12:09

into the gym, we're going to work on

1:12:11

that exercise of

1:12:13

relaxing the post-tib while we

1:12:15

allow the arch to descend.

1:12:18

Yeah, I mean, posterior tibialis

1:12:22

decelerates prunation. Fun

1:12:25

fact, if you look at EMG activity, and

1:12:27

call it what you will, some people don't

1:12:29

love EMG activity just because there's a lot

1:12:31

of crossover. But posterior tib,

1:12:33

you will see activation from that guy from

1:12:35

the second the foot's on the ground until

1:12:37

propulsion. He's one of the only

1:12:40

tissues, muscles, where you'll

1:12:42

see this constant activation and

1:12:44

therefore we need to pay attention. Because

1:12:47

of its attachment, it rotates, so that

1:12:49

tendon has a 45-degree rotation

1:12:51

before it inserts. When

1:12:53

we talk about those energy storage tendons

1:12:56

of the Achilles and the post-tib, very,

1:12:59

very important for free

1:13:02

energy and propulsion. And

1:13:04

because of how it attaches, it has to be

1:13:06

trained in those planes,

1:13:09

in rotational or transverse planes. Let's

1:13:12

go back to pathology there. What else do you

1:13:14

see? So, I think probably

1:13:16

the most common diagnoses that

1:13:18

we will see, we've discussed one of them

1:13:20

already is heel pain. So

1:13:22

plantar fasciopathy. Lots

1:13:24

of tendinopathies, so your Achilles

1:13:26

tendinopathies and your posterior tibialis

1:13:29

tendinopathies. We know that

1:13:31

these tissues need movement. We know

1:13:33

that these tissues need load. And

1:13:35

I think it's important to understand, it's

1:13:37

not that we want necessarily, yes, we

1:13:40

want strong calves, but from a tendon

1:13:42

perspective, we want a tendon that is

1:13:44

healthy, which means you have to load it. And

1:13:47

that goes for both the Achilles as well as

1:13:49

post-tib, as well as your

1:13:51

peroneal. I mean, many people have

1:13:54

peroneal tendinitis as well. Interesting.

1:13:56

Is that predisposed by lots of ankle

1:13:58

sprains? It can be. more a function

1:14:00

of just weakness in the musculature? I

1:14:03

think there's a lot of factors you have to look at. Do

1:14:05

they have the integrity of the

1:14:08

musculature? Have they had a

1:14:10

history of ankle sprains that have just never

1:14:12

been rehabilitated appropriately? But think

1:14:14

of the post-tib and the peroneus longus

1:14:16

as like a sling. It's

1:14:18

this beautiful sling that stabilizes

1:14:20

the foot and they work

1:14:23

together. And when you have one

1:14:25

side that's not helping out the other side, you can

1:14:27

start to have these changes within

1:14:29

the foot. So you

1:14:31

alluded to imaging earlier. How

1:14:34

often does imaging play a

1:14:36

role in your diagnoses? Do

1:14:39

you tend to rely mostly

1:14:41

on the clinical history, the

1:14:44

physical exam? What fraction of the

1:14:46

time do you rely on imaging? I

1:14:48

think the biggest time and the

1:14:50

most important time at the foot, especially with

1:14:52

imaging, is rolling out stress fractures, especially

1:14:55

when you're dealing with runners and

1:14:58

things like that. But as far as everything

1:15:00

else, I mean, if you look at

1:15:02

research on doing MRIs,

1:15:04

for example, for tendinopathies and an achilles,

1:15:07

it really doesn't give

1:15:09

you all that much information that's valuable because

1:15:11

you can see a tendon on an image

1:15:13

and it would be like, wow, what's going

1:15:15

on here? And it doesn't correlate with subjective

1:15:17

or even – So it's not that different

1:15:20

from the back where the MRI – you

1:15:22

image a lot of people that feel nothing and you'll

1:15:24

see horrible looking backs. You image a lot of people

1:15:26

who feel fine and you could – the

1:15:29

reverse. So stress fractures make sense. MRI

1:15:32

probably better or CT. What's

1:15:35

the diagnostic test of choice for a stress fracture? I

1:15:38

mean, I like diagnostic ultrasound. Really?

1:15:41

Mm-hmm. I think it can be more accurate.

1:15:45

But yeah, the MRI, I just – I rarely will order

1:15:47

that just because it doesn't really give me the information that

1:15:49

I'm looking for. Interesting. Let's

1:15:51

go back to the achilles.

1:15:54

I don't know what it is in my

1:15:56

old age that has made me so paranoid

1:15:58

of an achilles injury. I've had

1:16:01

one bout of tendinopathy there

1:16:04

that took, God, probably like

1:16:06

three months to really resolve. Now, in that

1:16:08

three months, I didn't really have to do

1:16:10

anything different. I mean, I just did a

1:16:12

lot of training but

1:16:15

I would wake up every day in quite a bit

1:16:17

of pain. It got better as

1:16:19

the day went on but it was uncomfortable but

1:16:21

I had this huge panic that at

1:16:24

some point I was going to tear it, doing

1:16:26

some of the jumping exercises I do and things

1:16:28

like that. How much of that is,

1:16:31

I never want to say the inevitability of age but

1:16:33

how much of that is due

1:16:35

to tissue pliability of aging

1:16:37

as an additional predisposing factor.

1:16:40

Clearly there's a load component to this. There has

1:16:42

to be some insult.

1:16:45

Well, first let me say consider yourself lucky

1:16:47

at three months. These tendinopathies

1:16:50

at the Achilles, if you look at

1:16:52

research, I mean, you're talking years, five

1:16:55

years, ten years where people

1:16:57

will still experience symptom

1:16:59

at their Achilles tendon. So

1:17:02

a lot of my work in

1:17:04

talking to patients with Achilles tendinopathy is

1:17:06

just that. It's the education part of

1:17:08

it because most

1:17:10

people are afraid that they're

1:17:12

going to rupture their Achilles tendon and

1:17:15

I have to remind them it is one of the

1:17:17

most robust tendons that we have. There's

1:17:20

less of a chance of you rupturing it

1:17:22

but you have to be aware that

1:17:24

discomfort is probably going

1:17:26

to stick around for a lot longer than you

1:17:28

want it to. So

1:17:31

when we are rehabbing these, if

1:17:33

they wake up in the morning, that's a lot of the

1:17:35

times where you'll get feel that tendon stiffness. I

1:17:38

tell them if we're sitting at like a – and I'm

1:17:40

not a big fan of VAS scales. I don't like

1:17:42

to focus on how bad people are feeling but for

1:17:44

that measure, if they're sitting at

1:17:46

like a five out of ten, for example, that's

1:17:49

green light for us. That does

1:17:51

not rest. That does not stop. That

1:17:54

is still go. Yeah, and in fairness, I

1:17:56

was never above a five out of ten but

1:17:59

I'm a guy who's lived at a zero out of 10

1:18:01

in his Achilles. I've had a lot of pain in a lot

1:18:03

of other parts of my body but to

1:18:05

wake up and every day be out of

1:18:07

five out of 10, we're just walking to

1:18:09

the bathroom, I'm like, good lord. I

1:18:12

mean, that was very frightening

1:18:15

from the standpoint of is this a

1:18:17

harbinger of a catastrophic

1:18:20

injury? Dr. Patrick Seyfried There's really

1:18:22

three different types of

1:18:24

an Achilles tendinopathy or injury and

1:18:26

I think that's important to note because

1:18:29

they all are looked at very differently. So most

1:18:31

when people talk about an Achilles

1:18:34

tendinopathy, it's at the mid

1:18:36

tendon portion. So if you were to squeeze

1:18:38

your Achilles tendon, kind of right

1:18:41

in that mid portion, those

1:18:43

are typically the easier ones and

1:18:45

by easy, I still don't mean easy,

1:18:47

but easier ones to

1:18:49

treat. Then you have

1:18:51

an insertional Achilles tendinopathy

1:18:53

where that irritation is at

1:18:55

the calcaneus. So right where

1:18:58

it inserts, those can

1:19:00

be extremely difficult

1:19:02

because with those, the

1:19:05

Achilles tendon breaks down on

1:19:07

the front of the tendon.

1:19:10

We know that tendons need

1:19:12

load. So for those

1:19:15

guys, you have to make sure when

1:19:17

you're doing your calf work, for example,

1:19:19

that you're getting as high onto your

1:19:21

toes, end range plantar flexion so that

1:19:23

you can start to load that appropriately.

1:19:26

Those guys don't like to be stretched

1:19:28

all that much. So there's different things

1:19:30

that you do based on

1:19:32

the location of where

1:19:35

that tendinopathy occurs. Dr. John Ligato Sorry. In

1:19:37

that case, you would really minimize any dorsiflexion. Dr. Patrick

1:19:39

Seyfried And mild. Dr. John Ligato You wouldn't go on

1:19:41

a super deep dorsiflexion. Dr. Patrick Seyfried Yeah, like off

1:19:43

the stair. Everybody loves

1:19:45

to do off the stair stuff and

1:19:48

I'm like, can you do it without? How

1:19:50

does your form look without going into a negative? Because

1:19:53

when you drop that heel down into a negative, if

1:19:55

you don't have good midfoot stability and the whole thing

1:19:57

just looks floppy, I'm like, that's game over for me.

1:20:00

And let's again, I want to come

1:20:02

back to reinforce these terms, mid-foot stability.

1:20:05

We've talked about what the mid-foot is

1:20:07

anatomically. Now explaining exactly that

1:20:09

setting because that's a very common movement

1:20:12

which is, hey, I want to do a

1:20:14

negative when I'm doing a toe press of

1:20:16

some sort. What needs to be

1:20:18

true of the mid-foot for a person to be

1:20:20

able to do that going back to the anatomic

1:20:22

structures we've already discussed? When you

1:20:25

are looking at someone from the back, okay, and

1:20:27

if I was looking at them with their heels

1:20:29

off the back of a step, as

1:20:31

they go into that negative, if

1:20:34

they can maintain the integrity of their

1:20:37

foot, so in other words, when

1:20:39

they drop the heel down, I don't want to

1:20:41

see this collapse

1:20:44

or this excessive medial

1:20:47

drive where the whole foot

1:20:49

just looks like it can't even hold itself up.

1:20:52

Presumably those are more intrinsic failures or are

1:20:55

they potentially also extrinsic? It could be a

1:20:57

bunch of things, right? It could be everything

1:20:59

down to the ligaments. If they have poor

1:21:01

ankle dorsiflexion mobility, so

1:21:04

if they can't dorsiflex

1:21:06

here, they're going to

1:21:08

steal it. What's

1:21:11

the minimum angle of dorsiflexion you need to

1:21:13

be a functional human who can walk? Walking

1:21:17

gait, we need about 10 degrees.

1:21:20

Running? Running, you need a little bit more, but

1:21:24

if you think about when I'm training

1:21:26

someone, I don't want to train minimum.

1:21:28

No, of course not. Right? So

1:21:30

I want to give people movement variability. The

1:21:33

more movement variability someone has,

1:21:35

the less oh no moments we

1:21:37

have. So we

1:21:39

have to be able to

1:21:42

give people movement options. I

1:21:44

have assessments that we'll do and I'll

1:21:46

say, okay, we're at 10 degrees and it's actually really cool.

1:21:49

You can just use your iPhone. Because it has a

1:21:51

built-in little company. Right, there's utilities and it goes to

1:21:53

measure and I'll measure their dorsiflexion. And I like to

1:21:55

see about 35 degrees. Wow. You'd

1:21:58

be shocked. at what

1:22:01

people give you and they'll

1:22:03

say, well, I only need 10 degrees in order to walk. Well,

1:22:05

do you sit in a chair? Do you walk up and down

1:22:07

a stair? Because if

1:22:10

you do any of those other motions, you

1:22:12

have to be able to have ankle dorsiflexion and

1:22:15

ankle dorsiflexion is a

1:22:17

huge lack of range

1:22:19

in the foot and there's

1:22:21

three big compensations that you will see for

1:22:24

people that don't do that. The

1:22:26

first is when they're walking, they'll

1:22:28

lift their heel up early. So

1:22:31

it's an early heel rise. Now

1:22:33

remember we talked about with eight times your

1:22:35

body weight going through your forefoot, do I

1:22:37

want to increase that load? No. Do

1:22:39

I want to speed it up? No. So

1:22:42

problem number one there. Next

1:22:44

what people will do is they'll hyperextend

1:22:46

their knee. So

1:22:49

it's called a varus thrust gait. So

1:22:51

because they can't dorsiflex, the

1:22:55

knee goes, well, let me help you. Let

1:22:57

me hyperextend to

1:23:00

propel you forward. So

1:23:02

these patients will come in and tell you, my knee

1:23:04

feels lonky, the back of my knee feels

1:23:07

unstable and you have to look

1:23:09

at the ankle because it could be

1:23:11

feeding why they're doing it. That

1:23:13

hyperextension at their knee could be the reason. Now how do these

1:23:15

people find you? Because

1:23:18

you're famous through treating the foot. Are

1:23:20

they finding their way to you because

1:23:22

they're hearing you on a podcast talking

1:23:25

about just that or are there other

1:23:27

practitioners that are aware enough to recognize

1:23:29

knee pain and say actually your knee

1:23:32

pain is a compensation for your gait?

1:23:34

I've been teaching these courses now for

1:23:36

a while and I think a lot

1:23:38

of the referrals now are coming from

1:23:41

other physicians, other PTs, other doctors. I

1:23:44

work with a couple of clinics in Colorado.

1:23:47

It's been really awesome to see the medical

1:23:49

community really starting. We've had

1:23:52

patients who have hip replacements

1:23:54

and the feedback

1:23:56

on the other end of this sometimes is you don't

1:23:59

need to. retrain your gait

1:24:01

and now we're getting a lot of these referrals and

1:24:04

going yes you do. These are

1:24:06

all things you need to pay attention to. So

1:24:08

the word is spreading about the importance

1:24:10

of what happens at the foot and

1:24:12

how that can affect pretty much everything

1:24:14

else. Got it. Okay, so we were

1:24:16

back to the compensations for weak dorsiflexion.

1:24:18

Yeah, so we have early heel rise,

1:24:21

we have a hyper extension at the knee and then

1:24:24

the third strategy. Is that

1:24:26

collapse, right? Yes, but if

1:24:29

we're moving up the chain, the third

1:24:31

one that people will do is they'll

1:24:33

simply fall forward. They'll bend forward at

1:24:36

their hips. They'll use

1:24:38

forward momentum to carry them

1:24:40

forward. So now they're in your office with

1:24:42

low back pain. It's a

1:24:44

direct reason because they cannot dorsiflex

1:24:47

their ankle. I'm still a

1:24:49

bit confused by this. When

1:24:51

an individual comes in and let's say you

1:24:53

make the diagnosis and the diagnosis is that

1:24:55

their range of motion on dorsiflexion is

1:24:58

insufficient. They're at 8 degrees or even 10

1:25:00

degrees, which we've acknowledged is kind of the

1:25:02

bare minimum for walking. What is

1:25:05

preventing that person from being at 20 or 30

1:25:07

degrees? Is there

1:25:09

something within the bone or is

1:25:11

it neurologic where their body doesn't

1:25:13

trust itself enough to

1:25:15

appreciate a greater angle? When

1:25:18

you are assessing pretty

1:25:20

much any joint, you

1:25:22

want to see consistent patterns. So

1:25:25

if we were to take this with a squat,

1:25:27

for example, when people try

1:25:29

to deep squat, if

1:25:32

they can't do it, so they'll go down and

1:25:34

do a deep squat and they'll be like, I

1:25:36

just can't go any further. And I'll say, well, why

1:25:38

is that? So they won't,

1:25:40

it's my hip or my ankle. My ankles

1:25:42

just feel stiff and I'll say, okay,

1:25:45

I want you to go over to my squat rack and

1:25:47

you're gonna hold on to the squat rack and I

1:25:50

want you to deep squat again. If

1:25:53

they still can't do it, then

1:25:55

I know that there's got to be

1:25:57

some type of muscle or joint restructure.

1:26:00

restriction that's preventing them from

1:26:02

getting to that range. So

1:26:04

that could be muscles

1:26:07

that have shortened. We

1:26:09

might need to implement stretching

1:26:11

protocols. We might have

1:26:14

to implement joint mobilization. Sound at

1:26:16

the ankle, remember the talus, if

1:26:18

he kind of floats forward,

1:26:20

you can get a pinching. So there can be

1:26:22

a pinching in the front of the ankle when

1:26:25

people try to stretch. All

1:26:27

of those things would be a

1:26:29

consistent pattern because there's a muscle or

1:26:31

joint restriction. But if

1:26:34

they can't squat, but they

1:26:36

can go into a

1:26:38

deep squat and I would argue, Peter,

1:26:40

most people, as

1:26:43

soon as they hold on to something, they

1:26:45

go down into this beautiful squat.

1:26:48

And that's when you're saying to yourself, there

1:26:50

is a neurological inhibition here. This

1:26:52

person is screaming for stability and that's when we're

1:26:55

wasting a bunch of time going, I want you

1:26:57

to stretch your calves for the next 30 years

1:26:59

and you're not going to see anything because that's

1:27:01

not what they need. And then

1:27:03

it comes down to proximal stability. How

1:27:05

do we create stability? How do we

1:27:07

create a safe environment for their brain

1:27:10

and their body so that they want

1:27:12

to go into a deep squat because they need to go

1:27:14

into a deep squat? Yeah, I

1:27:16

mean, I've shared this story before

1:27:19

and it's worth sharing again, which

1:27:21

is that when a person is under

1:27:23

anesthesia, they can be stretched

1:27:25

into positions that they would

1:27:27

never imagine if they're not under

1:27:30

anesthesia. And you might say, well, okay,

1:27:32

so what? But they're probably going to get hurt,

1:27:34

but they don't. You can take a

1:27:36

person who can't touch their toes and

1:27:38

again, when they're under anesthesia, you could almost fold them in

1:27:40

half. You could get their palms

1:27:42

past their toes and when

1:27:44

they wake up from anesthesia, they will not have

1:27:46

torn a hamstring. And you ask the question, how

1:27:48

is that possible? And it's possible

1:27:51

because neurologically, they are being inhibited

1:27:53

from doing that because the body

1:27:55

says you are not stable in

1:27:57

that position. I'll give you an example

1:27:59

one more time. I had a guy that once when

1:28:01

I first was learning this I was in a lot

1:28:03

of back pain and I was

1:28:05

so stiff I couldn't touch my toes

1:28:08

and he took me through a 30-minute

1:28:10

exercise of increasing intra-abdominal pressure and

1:28:13

within 30 minutes the entire palm was past

1:28:15

my toes. Did I get

1:28:17

more flexible in 30 minutes? Of course not but

1:28:20

by generating high degrees of

1:28:22

intra-abdominal pressure my back relaxed

1:28:24

enough that it allowed my

1:28:26

body to move to that

1:28:28

spot. This to me is

1:28:30

one of the most difficult things to

1:28:32

both identify but more importantly to be

1:28:35

able to train because

1:28:37

in a way it is a light switch.

1:28:39

The circuit has to be grooved a lot

1:28:41

for that to become the new default. So

1:28:43

how do you go about doing that given

1:28:46

A, its ubiquity and

1:28:49

B, its complexity? I

1:28:51

think that assessing patients

1:28:53

for proximal stability is

1:28:56

mandatory. It's absolutely mandatory and

1:28:58

I'm a foot person. If I'm

1:29:00

far away from where we consider

1:29:03

proximal stability and creating intra-abdominal pressure

1:29:06

but if you were to look

1:29:08

at someone I'm always going to take

1:29:10

this down to the foot. If you think of

1:29:12

your pelvis as like a bowl of water, if

1:29:14

I were to stand and dump out

1:29:16

all the water, you have a

1:29:18

forward tilt to the pelvis. That

1:29:21

also can happen when the rib cage

1:29:23

would flare. We

1:29:26

call it an open scissor posture. So

1:29:28

when I'm assessing these patients I'm looking

1:29:31

at can they stack their rib cage

1:29:33

over their pelvis? Do

1:29:35

they have good breathing patterns? Can

1:29:39

they breathe 360 degrees around their belly? Can

1:29:43

they expand their rib cage? Because

1:29:46

if they cannot do those things and

1:29:48

they stay in this posture, if

1:29:51

you were to stand up and

1:29:53

dump all the water out, tell

1:29:55

me what would happen to your feet

1:29:58

because I'll tell you. You

1:30:00

will feel all of this

1:30:02

medial pressure along your big toes.

1:30:05

You'll feel your arches collapse if

1:30:07

you will. And this is

1:30:10

where pronation gets a bad name. Yes.

1:30:12

In Genu Valgham. Everybody's in, don't

1:30:14

let your knees not. I'm like, tell that to a

1:30:16

hockey goalie who stands there for

1:30:19

three periods in a valgus position

1:30:21

at the knee. I don't believe there's any

1:30:23

bad posture positions. It's

1:30:25

only bad if you can't control it and you can't get

1:30:27

out of it. You have to

1:30:29

be able to do these things. I have

1:30:32

to be able to protract my shoulder. I

1:30:34

have to be able to arch my back.

1:30:36

You just better control it and be able to

1:30:38

get in and out of it. Yeah,

1:30:40

I think this is worth maybe double clicking

1:30:43

on a bit, Courtney, because A, it's not

1:30:45

a conventional view. It's not a mainstream PT

1:30:47

view and I'm not throwing PT

1:30:49

under the bus. It's not a mainstream anybody

1:30:51

view. And yet I've heard

1:30:53

it enough from the people

1:30:55

who I think are hands down

1:30:57

the best at moving movement that

1:31:00

we should reiterate the point. There

1:31:02

isn't a bad posture per se,

1:31:05

but control is what matters. And

1:31:08

you could argue that the best movers

1:31:10

on the planet frequently

1:31:13

engage in what would be viewed

1:31:15

as quote unquote bad posture. Yes.

1:31:18

I mean, I don't think we

1:31:20

were all designed to look like these robots

1:31:23

and be in these like perfect postural positions.

1:31:25

It's just not realistic. I'm

1:31:27

just thinking of golf. My father's a big golfer

1:31:29

and we used to watch Arnold Palmer swing a

1:31:31

lot. And if you've ever watched Arnold Palmer swing,

1:31:33

you'd be like, how's this guy so good? Being

1:31:36

able to create this stability to

1:31:39

your system and to be able

1:31:41

to control these different postural positions

1:31:43

is key. It's key to

1:31:45

be able to get in and out of. And if you think

1:31:48

about that at the foot, it's

1:31:50

not that pronation is bad. We have

1:31:52

to do it. It's our

1:31:54

first opportunity for shock absorption when we

1:31:56

walk. We have to be

1:31:58

able to then. Get out of

1:32:01

it. Yeah and the person most

1:32:03

commonly who is in the open scissor

1:32:05

pattern, they're stuck in that

1:32:07

position. They aren't able to

1:32:10

get out of it and therefore they're

1:32:12

equally ineffective at shock absorption. Yes and

1:32:14

there's this disconnect Peter. When

1:32:16

I have patients stand in front of me, I'll have

1:32:19

them tilt their pelvis forward and I'll

1:32:21

ask them what do you feel at your feet? Half

1:32:23

the time I'll be like nothing. There's

1:32:26

this disconnect between my

1:32:29

pelvic motion and what my foot should be doing.

1:32:31

When my pelvis dumps forward, you

1:32:33

should feel the feet drop. When

1:32:36

you tuck the pelvis back, you should

1:32:39

feel the arches lift and that's this

1:32:41

motion, this dynamic motion

1:32:43

that the foot is capable of doing.

1:32:46

You said something earlier when we were

1:32:48

speaking about how our

1:32:51

proprioception and sensory appreciation

1:32:53

of the universe changes as we age.

1:32:56

Now that I'm over 50, what's

1:32:58

changed in my sensory apparatus of the

1:33:01

foot? We talked earlier about

1:33:03

how falls are prevalent and

1:33:06

how there's really factors that

1:33:08

contribute to these falls. We know one,

1:33:10

we've talked about this as a weakness

1:33:13

in toe strength. That

1:33:15

changes and I think the numbers are like a 35% decline

1:33:17

in strength. Over

1:33:20

what period of time? I'm not sure. In

1:33:23

presumably something young and something old.

1:33:25

Correct. Especially, there's a very big

1:33:27

change when you look at the

1:33:30

jump from 50 to 80 for example. We're

1:33:33

looking at the 35% decline right in

1:33:36

those ranges. Not

1:33:38

only does strength decrease but we

1:33:40

have four different types of receptors.

1:33:44

Couple fast adapting and some slow

1:33:46

adapting receptors. We're

1:33:49

responsible for gaining information so that

1:33:51

we can maintain our center

1:33:53

of mass for example. As

1:33:56

we get older, so let's start at

1:33:58

age 50. 20% it

1:34:00

takes 20% more pressure to Computing

1:34:08

the increased

1:34:39

circulation to the sensory nerves.

1:34:42

If we exercise, we're going to have increased

1:34:44

circulation to our sensory system. We

1:34:46

have increased nerve fiber branching when

1:34:49

that happens. With

1:34:51

increased nerve fiber branching, we

1:34:54

have increased sensation and

1:34:56

that has been found to

1:34:58

decrease pain and improve sensation

1:35:00

even in patients with peripheral neuropathies.

1:35:04

So maintaining strength in function

1:35:06

at your foot, I

1:35:09

think obviously will decrease the decline

1:35:11

of toe strength but also increase

1:35:14

the ability for us to

1:35:16

feel the ground which is imperative from

1:35:20

being able to walk upright and being

1:35:22

able to prevent us from falling. And

1:35:25

this sensory decline, how

1:35:28

much of it is superficial, meaning

1:35:30

you can test it and assess it

1:35:33

using the standard metrics of like take

1:35:35

an alcohol pad or a cotton swab

1:35:37

on the cutaneous branches and how much

1:35:39

of it is much deeper. I mean,

1:35:41

I'm guessing more of it is this

1:35:44

deep part that is dependent on significant

1:35:46

pressure but I don't really understand. I

1:35:48

did bring it to you. There's a

1:35:51

256 frequency vibration tool

1:35:54

and what you can do is

1:35:56

you'll have the patient laying down and you take this 256.

1:36:00

tool and I'll tap it on the ground

1:36:02

and I'll put it on the base of their heel. And

1:36:05

you get three chances, you're changing

1:36:07

what you're doing and

1:36:09

can they pick up the vibration? The

1:36:12

accuracy of that test has been

1:36:14

shown to be more accurate than

1:36:16

the nylon pricking of the

1:36:18

foot. Interesting. Vibrational

1:36:21

sensation, that makes sense

1:36:23

because that strikes me as a more

1:36:26

complete form of sensation than because

1:36:28

the nylon thing is mostly cutaneous.

1:36:31

Okay, well before we go to falls, I want to

1:36:34

round out a couple of other injuries. Okay. There

1:36:36

are a couple other toe injuries that are pretty common. Yes.

1:36:39

Let's talk about those. Okay, happy to. You want

1:36:41

to start with Halasis, restrict this? Yeah. We

1:36:44

will see this a lot and I think a lot of it has to

1:36:46

do with poor footwear selections. We've

1:36:48

talked about the chronic ankle sprains

1:36:50

and the inability to allow the

1:36:52

first metatarsal to drop. At

1:36:54

a functional Halix limitus, we need

1:36:56

about 40 to 45 degrees

1:36:59

of range of motion at the big toe in

1:37:02

order to have an efficient walking gait. Yeah.

1:37:05

This is my only superpower. I'm probably like

1:37:07

90 degrees at my Halix.

1:37:11

Excess range of motion is great as long as you can control

1:37:13

it. It remains to be seen. So

1:37:16

if I wanted to sprint though, I

1:37:18

would need 65 degrees, right? Because you're more

1:37:20

on your toes. Yeah. This

1:37:22

is where I've seen a lot of

1:37:24

former NFL players who get horrible

1:37:27

turf toe that have what

1:37:30

literally looks like 10 degrees. If

1:37:32

you can catch these patients, so

1:37:34

there's stages. So what will

1:37:37

start to happen is you'll get an inflammation on

1:37:39

the top of the big toe. Is the primary

1:37:41

pathology just the repeated jamming of that toe? Yeah.

1:37:44

The instability at the first ray. They can't drop

1:37:47

the first met down, so they start to irritate

1:37:49

the top of the joint. It'll be red. It'll

1:37:51

be swollen. Patients suffer. I'm on

1:37:53

a Facebook group for Halix Rigidus.

1:37:56

It's a support group. And the reason I'm on

1:37:58

it Is because. It's

1:38:00

a constant battle for these people for

1:38:02

footwear. They're. Like I need

1:38:05

issue. It's going to eliminate

1:38:07

me using my big toe.

1:38:09

Because. It hurts when they try

1:38:11

to extend it and have. These

1:38:13

patients all experienced trauma.

1:38:16

Know. If save had

1:38:18

like something fall on their toes save had

1:38:21

turf. Toe than yes, but a lot

1:38:23

of them. This is weakness. This is

1:38:25

poor footwear. That's why I think a

1:38:27

lot of these diagnoses. At the foot can

1:38:29

be prevented. This is pro active health care. I

1:38:31

mean you in a talked about your eggs in

1:38:33

your book. I love that story. There's.

1:38:35

No better way to stop the eggs

1:38:38

from being thrown in by taking care

1:38:40

of our feet from the ground up.

1:38:42

But I digress. So let's assume that.

1:38:45

The. Trauma was in the past. It's not

1:38:47

an acute issue. Is the treatment the

1:38:49

same where you have to get mobility

1:38:51

back by strengthening. I always say earlier

1:38:54

intervention is better. Even if

1:38:56

there's been trauma. You. Do not

1:38:58

want to immobilize something. We know

1:39:00

that when you immobilize, it starts

1:39:02

this cascade where you start to

1:39:05

change the neurological input to the

1:39:07

tissue. It just really will

1:39:09

create an environment where movement will be altered.

1:39:12

So even in those initial stages, Were.

1:39:14

Doing like big toe ranges of motion.

1:39:17

I always saw her patients have found

1:39:19

get excited about you exercising your big

1:39:21

toe but you have to be there

1:39:23

sometimes. Remember when I had my little

1:39:25

toe injury three months ago which still

1:39:27

hurts like. Not. As bad

1:39:29

but it's amazingly so are

1:39:31

still that first. Weekend The

1:39:33

thing was black. he has blue. You

1:39:35

still had me doing i some metrics.

1:39:37

I'm still doing them by the way.

1:39:40

Anytime I'm in pain. Five. Minutes

1:39:42

of ice and metrics actually makes me

1:39:44

feel better than why? Is that? I.

1:39:47

Call Isometric my pain meds for my patience.

1:39:49

He has a tell people we exercise you

1:39:51

had me do they always help with the

1:39:53