Podiatry: “We’re trained in biomechanics and biomechanics kind of forms the basis of our thinking… we’re trained in this kinematic model of the really older model of you have a foot, the foot rolls in, this is bad, this is faulty mechanics, we need to correct that with an insert.”
“Even if you do treat that way [kinematic model] and believe that, it still helps people.”
“I call it arts and crafts. I get to play around with foot orthoses and footwear and really dramatically unload these tendons. Now the Achilles is a bit different because it inserts onto the calcaneus, but the tib post on the inside, the peroneals on the outside, I can dramatically unload those tendons every step that you take with a simple insert while we’re getting you strong.”
“Half the people that I see, the reason that they haven’t been able get back to running is just no one’s given them a program. They’ve got all the right other stuff.”
Peroneal/Tib Post Tendinopathy: “In the clinic, we treat them very similar to the Achilles. Now, of course, Achilles, it’s a bigger, thicker tendon. We look at what load is going to be most provocative for a tendon. We’re talking max ⁓ dorsiflexion with high magnitude. It’s very similar with the tib post and the peroneals because they basically run next to each other. The only difference is the insertion. The Achilles comes down and inserts, and let’s just say for argument’s sake, the middle of the foot. So it’s not going to do a whole lot of supination and pronation, muscle contracts, the tendon pulls. Whereas the tib post comes down on the inside. So if you just imagine it, you’re pulling on the tendon, you’re going to get some plantar flexion with the tip pose, but you’re also going to get some inversion. So it does have more than just one load that it’s responsible for. And the same thing for the peroneals. So they are in opposite, the tib post is mainly an inverter and a plantar flexor, whereas the peroneus brevis, inserts onto the base of the fifth, and then the peroneus longus wraps around underneath to the base of the big toe.”
“If we want to de-load an Achilles tendon, as you come into mid stance, your foot will hit the ground, your tibia will move over the foot, and you’ll have ankle dorsiflexion, which will load the tendon.”
“With Achilles, simple heel raises and heel lifts can really unload that compression of the insertion and the tensile force. And even high-pitched shoes can do that as well.”
“I haven’t given a foot orthotic for an achilles tendinopathy. I’ve given like two and that was because patients wanted them.”
“If I’m talking about using an insert, or I don’t want to say an arch support, but using something that contours the arch, I should be able to apply a supinator force underneath the inside of the foot. That’s going to reduce how far and how quickly I pronate and that’s going to significantly unload the tib post.”
“I love this three phase approach: phase one is the pain phase. We just need to calm it down. The rehab is important, don’t get me wrong, but we just need to calm it down. We might use tape, anti-inflammatories, maybe injection, shoes, relative rest, deloading, whatever it may be. Then we move into the capacity phase and that’s where the rehab comes in. You’re comfortable to start the loading. We’re talking about calf raises. Maybe we’re talking about some meaningful activity return, maybe to return to run program. And then we move to the minimum effective dose.”
“If someone’s got metabolic disease, they’ve had chronic tendinopathy and they just wanna play a round of golf. How harmful is it for that person to wear a high-pitched shoe and a heel lift for all of their golf games? They’ve done all the rehab, all the right things. Do we need to tell everybody to get out of these things? Because they can certainly try, but maybe they won’t.”
“Yes, the rehab is important, but sometimes the unloading is just as important and sometimes even more important. So that’s how I think about those tendons [peroneal and tib post].”
“We talk about inserts and heel raises, I call them unloading therapies.”
“Patients always come to see me and say, listen Blake, I don’t want you to put me in an orthotic or a heel raise. I don’t want you to do anything. I just want to start the rehab. I say, well, you’re walking around day to day with your job with a 5 out of 10 pain. We can’t just add more load and expect you to get better. We just need to calm it down first. And all I want you to think of as these therapies, whether it be shoes, insole, taping, heel raises, they’re just to calm it down.”
“If you’re taking 50,000 steps throughout the week, that’s an opportunity for us to unload this painful tendon.”
“Let’s say someone’s got patellofemoral pain… We know that knee flexion is gonna load the patellofemoral joint. We might get them spending more time barefoot or in their flat shoes, so we get more ankle dorsiflexion and less knee flexion and then vice versa for the Achilles tendon.”
Achilles tendinopathy: “I see people, I’m like, you’ve already got high-pitched shoes, wear them as much as you can, because it’s gonna unload your Achilles every single step. That’s gonna make you feel better. It’s also gonna help us get to the point where you can start to do this heavy loading sooner.”
“Flat feet and high arches are not diagnoses at all. And I hate when people get told that they have this because you’re just describing someone’s anatomy. It’s like saying you’ve got long fingers and I’ve got short fingers. It doesn’t really mean that much and you can’t change it. And we know that you don’t need to change it to get better.”
“If someone has a flat foot posture, what we can hypothesize is you’ve got more mobility through your subtler joint. Well, then when you pronate, you’re probably gonna pronate further and a little bit quicker. So yes, you load the tib post more, but as you know, what we can’t understand with human bodies is how much it takes until that tendon or that tissue is gonna fail. So you can pronate a heck of a lot but not have any pain and people can pronate a little bit and have pain… What we say is the biomechanics gives us a clue as to where the load comes from.”
“And the same for the peroneals as well. You see a really laterally loading high arch foot type and you see some people, they walk on the lateral border of their foot and they have a peroneal tendinopathy.”
“If I feel great in shoes, it might be more likely to be the Achilles. But if I’m barefoot, that should load the Achilles more. And people come in and say, Blake, I’ve had these Achilles for six months. I hate wearing shoes. It feels better when I’m barefoot. That doesn’t fit the bill of Achilles tendon.”
“I am surprised time and time again, while I’m pushing into their tendon and they’re saying it’s sore. the diagnosis on the MRI, the tendon’s pristine and it’s the joint, or it’s the nerve or some surrounding tissue.”
“If you treat this like a tendon and it’s a peritendon or the sheath, it’s going to hate you. It’s just going to get stirred up and painful and people go through this rehab time and time again. And it’s just the wrong diagnosis.”
Paratenonitis/Peritendonitis: “I’ve tried to manage and I usually give them about four weeks that I try to calm it down as much as I can really deal with it. And I basically treat it like a bone stress, like no loading, complete rest, cause you’ve got that fluid around the tendon. And the theory is when the muscle contracts, the tendon will shorten and all the fluid around the tendon gets compressed and irritated. And so many of them, they get a corticoid steroid injection between the tendon and the sheath and they just completely settle down. It’s amazing. I’m not saying that people need to go out and have injections. This is for the medical doctor, but my previous years, when I first started, I would have held onto that person and tried to rehab them for months and months and months. But now, I try and we really try to settle it down.”
Paratenonitis/Peritendonitis: “We always recommend speaking with your pharmacy or doctor. So it’s using Hirudoid cream mixed with Voltaren, you wrap it over the peritendon and you wrap it in Gladwrap and you do it for seven days… If you talk to anyone that has used this, they will tell you that they’ve had some response. And I see responses consistently in the clinic all the time. So you wrap it up, you do it for seven days. And because the peritendon is so superficial, it’s really meant to help settle it down. So we use that in combination with heel raises and just basically treat it like a stress factor without the boot where it’s no loading. It’s no running, it’s no gym loading. You chock your heels when you’re doing squats because it just needs to settle down. My partner had it and it took two weeks of no activity at all to settle down. And then we did a great reloading process where, you know, with a tendon, we talk about a three or four, you know, the joke is tendon talks to us the next day, it should be a three or four out of bed, you know, during the activity. With a peritendon, we say, well, I say that, you know, it should be a one at most, it really should be minimal because if it’s getting sore, it’s just gonna get worse, whereas a tendon is gonna warm up and it’s okay to have some of that pain with loading. But yeah, they’re a nuisance, they’re a nuisance.”
“I don’t do it [cream’ often for the tib post or the peroneal compared to the Achilles [paratenonitis/peritendonitis] because it’s just so superficial. The cream only goes down so far. It doesn’t go very deep. So for the tib post, it’s a matter of doing the same thing for the Achilles, but the idea of using inserts, they are significantly effective when we’re trying to unload them.”
“Getting them out of the pain phase, we kind of have two options when it comes to trying to reduce your loading. We can reduce the number of loading cycles that you take… So instead of doing 10,000 steps, you might do 8,000 or 6,000 or 5,000… or we can reduce the amount of stress per cycle.”
“You see people, they’re walking around barefoot or they’re walking around in flat shoes. And I’m like, this is an easy thing to do that we can implement right now. Why wouldn’t we do it? And that’s where we come into inserts and orthotics. It’s the same thing. We can utilize these devices to reduce the stress per cycle to allow it to recover.”
“If you broke your arm and I put a cast on your arm, you know you’re coming out of that thing in six weeks. Once the bone heals, you’re back to normal. But we don’t really feel that with foot orthotics and we’re trying to get to the point where we can explain that to patients. We use it, we unload your tendon, the tendon feels better, we start the rehab, we take the device out and you’re back to normal.”
“I don’t ever use foot orthoses for anyone with hip or back pain, other than if they really want to and they’ve tried everything else. ⁓ You can’t really influence the hip with a device. I’m not gonna influence someone’s glute tendon with a foot orthotic, but I can really influence the tib post, because an orthotic has its greatest influence over the subtalar joint. And that’s the joint that the tibialis posterior controls. So I can really help them out with such an easy lower risk thing.”
Softer inserts: “I see a lot of people that have those devices and they say that foot orthotics don’t work because it wasn’t enough of a force application. And it’s the same with your tendon. If I go to do some calf stretches to make my Achilles tendon stiffer and I go to you and say, ⁓ exercise didn’t work. My Achilles didn’t get stiffer. You’re like, no, no, it’s just the doses. The doses wasn’t high enough. And it’s the same thing with foot orthosis.”
“I use form orthotics and foot bionics and they are great.”
“It’s not about supporting the arch, it’s about having force application to a tissue to unload that tissue.”
“You can’t really tape for the Achilles, but for the tib post and peroneal, we can… If I know the tib post is under the most amount of load in dorsiflexion and pronation, I wanna take the foot to roll out. So I wanna come from the outside of the foot and I wanna tape it into eversion. Cause that’s gonna apply a force that’s gonna oppose that pronation moment. And here’s the, this is the rocket science. You need a PhD to be able to say this. What do we do for the other side? Of course we just do the opposite. We just type it into the other way and we unload those tendons.”
“If I want to make my tissue stronger when it’s not painful, I should go barefoot or wear a really minimalistic shoe because it’s going to make my Achilles tendon stronger… But if I want to try and unload a tissue for the Achilles tendon, it all just comes down to pitch.”
“The Achilles works mostly in the sagittal plane the tib post and the peroneals are pronation and supination, that’s what we call the frontal plane. So if you’ve got your wrist out, bending up and down, that’s the sagittal plane, and rolling in and out, that’s the frontal plane, and then side to side is the transverse plane. So the tip post and the perineal work in the frontal plane. So we think about shoes, well, what features of shoes are gonna be most important? How wide the sole is of your shoe determines a lot of the load that goes through those tendons. So if I have a really wide shoe, it means that I’ve got more surface area, more contact with the ground. So I’m going to have more ground reaction force underneath the foot. So I’m going to be more stable in the frontal plane. If I have a lot of material on the inside of my foot, I can’t really pronate over that. Whereas I have a really, really slim shoe, you’re just going to fall off the shoe and I’m going to really roll hard and that’s going to load the tib post. So you want to look for a shoe where the sole of the shoe is wide through the mid foot.”
“If you’ve got a thick shoe, so the thicker the material, it increases the longitudinal bending stiffness. So what that does is when you roll forward, it reduces the plantar flexor torque around the ankle joints, reduces the plantar flexor force. So that’s why I deal with a lot of bone stress in runners. And we know that plantar flexor is the biggest contributing load to bone. And same with the tib post, it is a plantar flexor… if I have a shoe here, it’s got a thick sole, so it rocks them forward, and that’s the rocker sole shoe, significantly reduces the load.”
“The bony bumps on the inside of the outside of your ankle, one’s a part of tibia, one’s a fibula. They [tib post/peroneals] wrap around the insides of the main one, the tarsal tunnel as it wraps through there. That’s the location where people most report pain and it is the most avascular or reduced blood flow area of the tib post… But then on the insertion of the tib post, which is the bony bump on the middle of your foot, which everyone you’ll be able to feel that, that’s the insertion of the tib post. So if you’ve got pain there, you still need to be careful though, because you can have pain there and it being the navicular bone. So you just need to be careful there.”
“The majority of running injuries come from not usually not running style or footwear or how you move or anything like that. It’s usually just a matter of just doing too much to what the body can handle.”
“I look at the person sitting in front of me and ask, what is your meaningful activity?… So someone comes to see me and their Achilles is sore, my tib post is sore, my foot is sore, and they’re doing 10,000 steps. I know if they’re telling me that on the days they do less and it feels better, can we just do that for a week or two just to settle it down?… At the moment, it seems like you’re just doing too much. What’s meaningful for you and what can we change and what can we substitute?”
Plantar Fascia: “It’s not a tendon. It’s a completely different tissue. We know load is exercise is really important for a tendon. It’s not the same for the plantar fascia. There’s been plenty of papers come out to show, there is no difference between giving someone a quality exercise program and just giving them a custom foot orthotic and education. They’re the same. Of course, there’s good benefits for exercise.”
“There’s two types of plantar fasciaitis usually. Compressive type (compression on the heel) and tensile type (more on the arch when you pull back your big toe)… I treat the heel pain one more like a bruise…. you can do all the exercise in the world, it’s not gonna make that heel more tolerable because it’s the heel strike that’s painful. We just want to cushion the heck out of it… with tensile type, I heavily focus more on the rehab, a little bit more on the arch, more about arch support or arch contouring.”
“If OOFOS become more prominent for heel pain, I’m gonna be out of a job. They are the most unbelievable shoe for people with compressive heel pain. And it’s the same thing with the tib post, peroneals, Achilles, every time you take a step, it’s a chance for us to influence the load. If we influence the load on the tissue, it should be able to recover and feel better.”
Out of the pain phase: “So I like to get people doing banded inversion and eversion. And I really want them to be, it’s critical that the setup is appropriate. Cause if you, if you’re just seated now, knees at 90 degrees and your hips at 90 degrees and you get someone to do inversion. So you get them to lift their foot to dorsiflex and lift it up and come in and out. People would naturally just internally rotate their knee and they just basically use their hip rather than their actual foot… we want them to able to go fluidly from eversion, maximally everted to complete inversion. And I usually like to start with either three sets of 10, three sets of 15. And ideally we’re doing it sometimes twice a day, but usually every day because they’re smaller tendon and I find that this helps with the pain, getting it moving… I’ll dodo some big toe flexion with the band as well, so the band underneath. So then I progress them onto doing some calf raises.”
“Now, when I’m loading them back into the plyometrics different for the Achilles, I wanna get them to do side to side. And one of my favourite tests to get them to basically see the deficit between either side is I’ll get them to, so I basically have a bit of tape, 18 centimeters apart, and I’ll give them 30 seconds to hop on either side of the tape. And we wanna aim between 45 to 60. So basically 30 second hop test side to side. And that brings in the peroneals and the tib post a lot because they’re going side to side. And when they hit the ground, they’re really pronating, they’re really supinating, they’re really pronating.”
Pain phase to capacity phase to minimum effective dose phase: “It’s a phase of figuring out all the things that we use in the capacity phase and the pain phase. How much do you, this person sitting in front of me, how much do you need to rely on them or utilize them to stay at this phase of where you want to be?”
“My typical protocol for people is two to three times a week, three to four sets of anywhere from six to eight repetitions with two reps in reserve. That’s my isotonic and then my isometric is what we’re aiming for. For the tendon protocols that I’m aware of, it’s four sets of five, three seconds hard, maximal voluntary contraction over 90%, three second rest, repeating that four times, which is one rep, four reps for five sets. And that’s, in that protocol, it’s three to four times a week. So I basically just get people to do an isotonic and an isometric twice a week. That’s my minimum effective dose for a healthy tendon for all of these.”
Wedge work: “At the moment, I’m not convinced. I feel like it’s a bit Instagram-y where it looks awesome and it looks really specific… But I don’t think the tissues are that specific. And if you’re just trying to bias the tendon, well, I could probably just bias it by just dropping down off a step and inverting or everting or coming up and inverting and everting. And I just don’t think that that specific way to load in that position is gonna be superior to doing it as we just said.”
“The idea, and you still see this online, the idea that the foot is a mobile and a rigid lever is gone, it’s dead. That’s not how we think of the foot anymore. people are still telling that and using that, like, we’ve got to train it as a rigid lever. It doesn’t happen like that. The foot is this dynamic structure and it’s dynamic through the whole phase of gait and it’s incredibly variable and we cannot predict it.”
“We have so many bones and joint [in the foot], it’s so hard to predict their function. Of course, you want to encourage more movement, but I don’t know how you’re targeting one joint. Like, are you targeting just the midfoot, the tendon, the navicular, calcaneus, this part of the subtalar joint? Are you targeting the DIPJ or the fifth or the second? Like, it’s really hard to be that specific with the foot. So I think training in general is probably good enough at the moment.”
“I tell people now, this is my terminology, because I like to have it down, say, great, you actually don’t have a flat foot, you have an adaptable, normal, variable foot posture. That’s what I call it now, because I’m like, it’s adapted, it’s normal, it’s just variable within the average, and people are like, I haven’t thought of it that way.”
Seated calf raise for tib post: “The idea with the seated one, which is good, is you can get into a lot of ankle dorsiflexion and you can really load up. That’s a lot more comfortable to then pronate and sit and I feel you can be a lot more controlled because you’re seated because you’re kind of taking out a little bit more of the balance. So I will use that if they have access to it within the gym.’
Shin splints: “I think that the shin itself, it just needs the exposure to the loading cycles. So I don’t know if there’s a good argument in the saying that someone with shin splints doesn’t need any specific exercise. They just need a graded loading program.”
“if it is the patella femoral joint, I think it’s the same thing. What are you trying to accomplish with doing say squats with the patellofemoral joint, it’s still the loading cycles in the joint. And it’s a different adaption to a tendon and muscles.”
“For the tibia, tibial bone load with running is about nine times body weight. Seven of that comes from muscle forces, two from kind of ground reaction force. And then when you’re jumping and cutting and playing basketball, it’s up to 14 times. So it’s a lot more load through the plantar flexors as you do more intensity.”
“What’s more specific to them building capacity than doing the activity? You talk about calf raises and hopping, preparing you for running. I wonder how well running will prepare you for more running if it’s controlled. So I think to myself, there’s nothing more specific than that. And same with the knee as well. If the patella femoral joint is sore and we’re giving you some loading, why not just give you some walking to start with?”
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