Get ready for a mind-expanding journey into the innovative world of podiatry with our esteemed guest Matt Dilnot, a leading podiatrist and clinical supervisor at La Trobe University. We're challenging the conventional orthotic-focused approach and delving into the intriguing role of stress adaptation over time in pain management. With Matt's field insights, prepare to discover how the human body's amazing ability to adapt, combined with an enhanced understanding of tissue stress models, can revolutionize the way we treat foot pain.
Venturing beyond the confines of traditional treatment protocols, we explore the profound impact adopting broader, more holistic approaches can have on patient care. As we analyze tissue loading, training loads, and technique, the conversation illuminates the need for continuous professional development and the value of learning from the practices and language of other medical professionals. This episode promises to shift your perspective and provide a comprehensive understanding of the intricate dynamics within modern healthcare systems and their influence on podiatry.
Our conversation doesn't stop there. Prepare to be enlightened on the significance of strength training, particularly posterior chain exercises, in improving mobility and joint strength. We examine the vital role of the soleus in foot and posture control, and the contribution of the Achilles tendon to elastic recoil. As we journey through the processes of muscle and neurological adaptation, and their impacts on training programs, we can guarantee that your understanding of podiatry will be forever changed. To wrap up, we pay tribute to Matt's enormous contributions to the field, including his pioneering work in textbook writing. So tune in, get inspired, and witness the adaptable world of podiatry like never before.
@mattdilnot
@simplythebestpodiatry
@jasonagosta
@p3podiatry
Foot Orthoses: Thomas Michaud
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Get ready for a mind-expanding journey into the innovative world of podiatry with our esteemed guest Matt Dilnot, a leading podiatrist and clinical supervisor at La Trobe University. We're challenging the conventional orthotic-focused approach and delving into the intriguing role of stress adaptation over time in pain management. With Matt's field insights, prepare to discover how the human body's amazing ability to adapt, combined with an enhanced understanding of tissue stress models, can revolutionize the way we treat foot pain.
Venturing beyond the confines of traditional treatment protocols, we explore the profound impact adopting broader, more holistic approaches can have on patient care. As we analyze tissue loading, training loads, and technique, the conversation illuminates the need for continuous professional development and the value of learning from the practices and language of other medical professionals. This episode promises to shift your perspective and provide a comprehensive understanding of the intricate dynamics within modern healthcare systems and their influence on podiatry.
Our conversation doesn't stop there. Prepare to be enlightened on the significance of strength training, particularly posterior chain exercises, in improving mobility and joint strength. We examine the vital role of the soleus in foot and posture control, and the contribution of the Achilles tendon to elastic recoil. As we journey through the processes of muscle and neurological adaptation, and their impacts on training programs, we can guarantee that your understanding of podiatry will be forever changed. To wrap up, we pay tribute to Matt's enormous contributions to the field, including his pioneering work in textbook writing. So tune in, get inspired, and witness the adaptable world of podiatry like never before.
@mattdilnot
@simplythebestpodiatry
@jasonagosta
@p3podiatry
Foot Orthoses: Thomas Michaud
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Music, you, you, you, no-transcript. And joining me now is Matt Dillnott from Melbourne Foot Clinic in Mon Albert and also a clinical supervisor and educator at La Trobe University. Hi, matt, and I'm stoked you've come on to simply the best podiatry with me.
Speaker 2:It's a fantastic Jason, so good to be invited. It's a real honour, of course, to be invited onto your show.
Speaker 1:Our quick discussion a couple of weeks ago was really thought provoking and a really underlined a couple of things that I've become very aware of after all these years that people like you and I can sort of lean on a depth of knowledge and a depth of understanding. Having worked through you, know some of the difficulties of starting off in a profession and learning, or bumbling your way along.
Speaker 2:Yeah, I think, when reflecting on our discussion, I think it's probably good and bad in a way, in the fact that you get to see what the foundations things are built on, whereas perhaps, if you come along at the end, when it's all finished, you don't realise how you arrived at the point that you're at. Whereas I think there was that, you know, you and I, of course, were reflecting on when we graduated. We were immersed in the root by mechanics at the time, you know, and it certainly has its place, but I think there was this mystery or this idea that once you understood it perfectly, then you would know everything.
Speaker 1:Yes.
Speaker 2:And I think when things didn't work out, you probably blamed yourself and thought well, it didn't work out because I don't really know what I'm doing. I just need to research or go to a few more conferences and eventually I'll know all the answers to root theory and it will all come all fit together. Yeah, and it just didn't. And I think we started to see those exceptions to the rule and I think a good example of this is that person who comes in, and I'm sure you and I would have had the same reflection is that you had that person who comes in and they've got what appears to be one of the worst looking feet and you think, oh my God, that must be so painful. And they go, what? No, I just came in because I've got a corn, yeah, and you couldn't see this correlation, this direct correlation between having a bad foot and terrible pain. There is some correlation, yeah, but it wasn't a one-to-one correlation.
Speaker 2:And so we were sort of developing this idea that there was this sort of neutral, perfect alignment type foot and we should all be aspiring for that neutral, perfect alignment foot development. And then you started to realize that there were just an extraordinary number of people are going out are running around doing quite amazing things, who didn't have perfect feet. And you think, well, how can this be? And I think not too long after I graduated, but probably within 10 years, that we started to get that coming through the tissue stress model. Essentially, a foot, even if it's not a well-aligned foot, could actually adapt to stress there's as long as you gave it time to adapt to that stress. And so we could end up with a joint that wasn't a great joint, but if it sort of degenerated over years and years and years, well, it gradually got used to being that way and the joints around it got used to it being that way and they sort of put up with the one joint that doesn't work and adapted around it.
Speaker 1:That's it. The pathway of movement may have changed, but the person has adapted to that. Yeah, so changing alignment or changing position, yeah, that's right.
Speaker 2:Exactly One of the things I've done with the students at times is you sort of pull up those wonderful examples of people who don't have ideal biomechanics but clearly have done well. Yeah, and I think those outliers are the ones that I look at. They're really interesting outliers. The ones you probably remember I think it was Jep too, I think it was the issues the famous Ethiopian female runner 2012 Olympics.
Speaker 1:She had this amazing knee valgus that they talked about. Yeah, that's right, yeah.
Speaker 2:And if she came into your practice, you would say, no, don't take out running, you're not going to do so.
Speaker 1:Well, Exactly, but there's countless number of people who you can think of with their feet and alignment being asymmetrical and not perfect, and they have been so efficient and adapted super well to themselves over time. And that's the key, I think, is realizing that you and I and everyone else, we are fantastic at adaption.
Speaker 2:Exactly. That's right, and so I think, when I was pondering about our discussion and saying what is the main thing that's happened for me, when I talk to my patients is when they present their particular pain, one of the first questions I have is what's changed? Watch, change for you. The patient will come in. I think we had this wonderful discussion about a patient of mine and I can fool them from week to week. We all have them. I had that wonderful patient who came in, who I'd seen for years, and he had a pair of orthotics. In fact, I think he'd had a couple of pairs of orthotics through me, disappeared off into the sunset, came back 10 years later, let's say, came in to see me a couple of weeks ago and said to me I thought I might need an orthotic review because I'm getting knee and ankle pain, and so he holds up his orthotics and hands them to me and at the same time says they're looking a little bit worn and I thought this might be the cause of my problem. Yeah, now and I think this makes you really reflect about how much people like you and I have developed this skill we know that when you were first year out, you would have taken on face value. Here's the patient. They're convinced of the orthotic they handed over. You just had that new green graduate stage. Think, yeah, it must be the orthotics. He said it's his knee pain and his ankle pain. He's had these pains before they got better with the orthotics. It must be the orthotics. And so you spent the next half an hour fosicking around with his biomechanics and looking at maybe the orthotics are just, you know, maybe it's a slightly off by one degree or something.
Speaker 2:My initial thing was well, what's changed? When did your pain start and what's changed in the last little while? And if you remember that conversation we had, he then said to me actually I stopped playing badminton about a year or so ago and I started playing again and he goes straight back into it playing badminton X number of times per week. It doesn't have that nice break in period or he's lost his fitness, he's on bank, straight back into it. And he started to develop some pain. He said actually, you're right. Actually, when I started back at badminton, he started to give it a saunas. And I said well, have you done anything different? And he said oh yeah, actually I started doing 100 squats a day and he's never done squats in his life.
Speaker 2:That's it and so and I look at his orthotics, and the orthotics are virtually in brand new condition. The covers are slightly flaky, but nothing exciting. I spent the rest of the 20 minutes talking about loads.
Speaker 1:Loading.
Speaker 2:How we can exactly? How do we gradually get you back to this stuff?
Speaker 1:And that's what you're getting at, though, is that there is that protocol which we came out with, like you know, a foot injury, pronation, orthosis and there wasn't that broad thinking about how good we are at adaption or tissue loading or training loads or technique and all the things you mentioned about the root concepts, and we were just indoctrinated in this, and if it didn't work or didn't go down those lines, well, we weren't really thought, we weren't really told or given the incentive, I think, to think broadly.
Speaker 1:It's only recently though I must have been after all these years, and I said this to Johnny Osborne on air when he interviewed Anna Verena-Belling in our earlier episodes, and it's worth a good listen to. I said to John that it's only recently, and she's the first person who has actually underlined my thoughts about keeping people mobile and not restricting motion of the foot and lower limb and not assuming an ideal position, and we don't have to lock everything, we don't have to have a rigid foot, and I think those concepts are really starting to be more understood now and, hopefully, through guys like you, passed on to the new, younger graduates To think broadly about this, because we did bumble our way along.
Speaker 2:There's no doubt about it.
Speaker 1:And we did struggle with it. We're going back 30 years or so, but hopefully it's a lot different now and we can have platforms like this to impart those scenarios and areas of knowledge. Yeah, you sound like you've been really stimulated from that though, over the years, that change of thinking. And yeah, absolutely yeah, you sound like you've been quite fascinated with the change of protocols.
Speaker 2:Yeah, I think it's that problem solving that we're most health. I think if you're going to be a good healthcare practitioner, you want to be someone who likes to solve problems. For a start, you want to be looking at ways that refine the way you do things. You develop a gut feel for Just doesn't feel like the way we're going about this feels right. I just feel like there's going to be a better way of doing this. Yeah, and sometimes it takes a while to get those runs on the board. Try this particular approach, this style of thing. Well, you probably need to practice for 10 years before you actually realize whether it's working or not, because you need about 50, 60, 70 cases under your belt before.
Speaker 1:Yeah, that's it.
Speaker 2:I think it is those real outliers when you do a treatment and someone who's profoundly successful has profoundly effects on them, better or for worse, that you go, ah right, that's that moment where you think, ah right, I need to be doing this more often. I tell you what's interesting now also.
Speaker 1:we also have social media as well, With this discussion right now talking about professional development coming through as a young practitioner, I have to say this to you because you'll love it but I saw something online where somebody had posted something that had so many likes and the comment was this was so well received and I sensed that it gave this person this status and it was about running. Without being too judgmental, it's not what I would have posted. We are now in an age where things like that creep in to for some people, the responses to their media will give them a certain status and that really, that depth and that to me is a big concern.
Speaker 2:It is, it is, but I think that's probably always been a concern, and I think it's one of those areas that I consider myself a failure at, because I'm probably more obsessed with fixing people than selling myself, and there are some people who go.
Speaker 2:I don't need to know, anything I just want to sell myself. And as long as I sell an orthotic, as long as I get patients in the door, that's all I care about, and they get really good at branding and selling their business and so forth. That's it. I think there is a balance. I think there is a balance and the reason I say this and I say this to the students is that, and so there is that interesting balance that we have, that if you want to be known, you have to tell people about it, but I like to think that it's underpinned by good experience and good knowledge, a good knowledge base and understanding. Exactly yeah, that's right, Exactly rather than just a flashy, flashy sign. I put myself into the university and into the professional association very early on and instead of putting my energy into building a practice and you realise that the money that I lost by putting more time into those things rather than building- a practice.
Speaker 2:On the other hand, I think people know me because I've been in the university for a while. I've ended up doing lots of other things because of those professional experiences down the track and I wouldn't trade those experiences now. When you build a practice, there isn't definitely some positives there, but you are buying yourself into a business that requires 100% commitment to get it going and building it up, and by not doing that and instead spending my time in the but I actually association or whatever else I did, I think in the long term I probably benefited from that.
Speaker 1:Sure.
Speaker 2:Just probably yeah, but I think most of the things I did my early days I was funny enough. I probably wouldn't change that too much.
Speaker 1:I think what you mentioned there is important, though it's having a broad base of experience. That's what you're talking about.
Speaker 2:Absolutely. It's fundamental, and that is missing, and still missing to some degree less so now than it was was the fact that we were not integrated with the healthcare system as well as in the medical system as well as we should be. And I think so much can be learned by just sitting in the room with a neurologist, sitting in the room with a vascular surgeon. Just look at the way they go about their business. Their modelling of behaviour that you can pick up so much from the language that they use, the way they interact, is something that I think is really powerful, unfortunately for myself, and I can speak on behalf of all the other people who work in multi-disciplinary practices and particular sports medicine practices.
Speaker 1:I mean, I myself was very consistently exposed every day to the sports physicians, the physiotherapists, the massage therapists, the psychologists, nutritionists, you name it and that was amazing broad experience, as you said, in learning how people behave.
Speaker 2:At the start of this little business, a book came out which you would know, which is Foot, orthoses and other four forms of Thomas Micheals. Yes, thomas, micheals Tom released his book in 1992. I think it was right at the end of my time at uni. I was starting this little business and the book suddenly was no longer available. This is a good book. I'm going to just send a letter to Tom.
Speaker 1:It was a great book.
Speaker 2:So I got a letter or an email back from Tom saying actually the publishers don't want to produce another version or do another print run. And he said I'm thinking about self publishing. And he said would you like to sell the book in Australia for me? And I said, sure, that's great. And so it started off this bit of conversation with Tom. As a consequence of that, not long afterwards I got to know Tom quite well and Tom basically has been my mentor for the last 30 years, so I've been over there.
Speaker 2:We've been in contact ever since and I helped him put together his last textbook called Human Locomotion, so gathering all the articles for him, editing it as much as I can, and Tom has probably been. It's been the most thoughtful, stimulating person I've met within the healthcare industry.
Speaker 1:So, in speaking about professional development and Thomas Micheals, is that book, foot Orthosis, still relevant today? Do you think?
Speaker 2:Yeah, look the new edition of it which is called Human Locomotion. It's still the foundations probably. It's a hard read for a lot of people and I recommend it to students not to sell them books, but probably just more of the case of. There aren't too many other books out there that cover that world of biomechanics as well as book charts. He's approached to it the ability to take high level research and see the essence of it and see how it can be incorporated into clinical practice.
Speaker 1:So, before we move on, I'm just going to just summarise what we've spoken about in this part of speaking about professional development. We've spoken about the imperfect feet sometimes perfect and it's all about adaption. You mentioned, and really emphasise, about thinking broadly as a young practitioner and learning behaviours from others. It's essential and I think having a mentor is crucial. I think someone to lean on, someone to ring or email about anything. Really I think it's crucial. And finally, what you just mentioned then underlines everything again applying research to clinical practice. So, moving on, you did mention to me that one of your key things that you focus on is strengthening, and I'm interested. When you were talking about this, you were talking about improving ankle range and posterior leg strength.
Speaker 1:So what do you sort of focus on clinically? What can you impart?
Speaker 2:Yeah, so it's. Probably we need to look at the ability of the body to transverse. The ankle is obviously, as I said to the students, we need roughly 10 degrees of dorsiflexion at the ankle joint and obviously we need to get easy passage of the body across the ankle.
Speaker 1:The posterior muscle group of the leg are just so important that controlling the forward motion and, of course, the propulsion phase what are the important things with that ankle joint range that you can do clinically to help and also that posterior leg musculature?
Speaker 2:So many of my patients when they're coming in, they need to build up their strength, to protect their joints, to carry their joints better and to also improve their mobility, which is what we talked about before.
Speaker 2:So the mobility of joints and so the most significant exercise that I can do for that particular patient is basically doing posterior chain exercises for their legs, which doesn't sound very sophisticated.
Speaker 2:One of the things that I do a lot of is basically doing gastro-cellular strengthening stuff and I'm typically aiming for how do I get the best bang for buck for my patients, because I know that if I give a patient 20 exercises to do, they're not going to do all of them, they're only going to want to do maybe one or two of them. The most powerful thing that I can do for a patient a lot of the time is basically do reeducation of their gastro-cellular to improve their strength, which also incorporates what I'm doing at intrinsic strength FDL, perineal strengthening. So a lot of the exercises I'm doing with patients is basically showing them how to do a range of exercises simply on a step which they've got at home hold on to some rails or stuff and showing them that graduated program of building up a basic exercise program they do two or three times a week so that they can actually get better control of their foot posture, I suppose.
Speaker 1:So from doing what exactly off the step, Like I'm just yeah cool. So the least is because it's easy to do what you're doing clinically Absolutely Exactly.
Speaker 2:Okay. So basically my standard program is to show them standing just up against a bench just doing some standard calf raises, very boring calf raises. I then show them a variation of that is obviously going onto a single leg calf raise, no big deal. I then show them doing the same calf raise within the slightly bent so that we're isolating, or more isolating, the soleus, soleus. Yep Soleus makes up well, I think it's about 50% of the muscle bulk in the posterior group. It's the most powerful of that group, just really important in forward control of the foot and the posture of the foot in general.
Speaker 2:As far as improving the function of that, we want to do a lot more of the bent knee stuff which we've seen continuously in research now that the soleus is basically involved from everything from slow walking all the way up to sprinting. The soleus stays involved all the way through all those activities consistently, whereas the gastrocs aren't necessarily through all those different movements. Particularly. We're seeing new research now that the lateral gastroc is highly significant. Going back, I don't know how much detail we want to go into here.
Speaker 1:Is this significant in limiting the extension as we extend over the foot, or is it during? Last phases of the day.
Speaker 2:Yeah, so I want to talk to you basically briefly about the achilles tendon is highly important in its elastic recoil, as I'm sure you're aware.
Speaker 2:Yeah, and if we look at the research been around for a long time now the effect of the muscles whilst walking and particularly with running, is applying good tension on that tendon so it gives good elastic recoil to maximize, as we call it, the free energy from the achilles tendon, as we commonly say to patients, as you get older so you know the figures, I'm sure once you get past the age of 40, you lose 0.5% of your muscle fibers per year.
Speaker 2:Once you get to 50, you're losing 1% of your muscle fibers per year. And once you get to 80, you've lost 50% of your muscle fibers, the muscle fibers you have left behind. You can still triple your muscle mass at 80, but you can never get back to that original muscle strength you had when you were 20, of course, because you do have less muscle fibers. In order for you to maintain adequate elastic recoil on your achilles tendon, those muscles have to shrink and tighten themselves to make the achilles tendon adequately tight so it can provide that elastic recoil. And so it's very common as people get older that their calf muscles will actually shorten as a consequence of that to maintain that elastic recoil from that tendon. But in addition to that, the tendon itself becomes less elastic as well. The achilles tendon is the most elastic. It's like it has a 11% extension in general.
Speaker 2:It's an elastic tendon yeah.
Speaker 1:So let me sort of try and understand this or paraphrase this a little bit. So as we extend over our foot, we need our gastroxialis to be strong, strong and flexible, Strong and flexible but that also influences the tension on the achilles tendon. So then when we go to plantaflex we have that stretch reflex or that elastic recoil as you mentioned. The less muscle, the less recoil energy for plantaflexion through the gait cycle. Is that correct?
Speaker 2:Correct. That's a nice little summary over there, exactly. So one of the things a lot of patients develop as they're getting older is that loss of strength and the flexibility, that combination, and so the key thing that we need to do with those patients is improve the ability to apply force over a larger range. And this is when I go back over my history. One of the things that I worked on very early on was cerebral palsy. We all see people with.
Speaker 2:Well, when we see people with cerebral palsy, and the classic things that we'll see is toe walking. The basics of that is that they are unable to voluntarily contract their triceps urea. They have a lack of strength. So, as a response to that, the muscle will waste itself to ensure that it gets adequate tension on the achilles tendon and therefore they can bounce off the achilles tendon. So the toe walking enables them to propel themselves as efficiently and effectively as possible, as we do, as surgeons will do. Come along and say oh, toe walking, that's a bad thing. I want to make you walk normally. I will cut your achilles tendon so you can get your heel on the ground. Sure, their foot looks more normal, but they've lost their elastic row coil.
Speaker 1:Right has lost the power or strength to get as they extend. Okay, exactly.
Speaker 2:So as we take that to a regular human being who doesn't have cerebral palsy, we have the same process going on. You lose muscle fibres as you get older. You get wasting of that calf muscle to some degree, naturally, to maintain that tension on the achilles tendon, to maintain their elastic re-coil and ultimately you start to lose range. You don't have that same range in the ankle joint. You start to lose, you start to virtually develop a slight equinus.
Speaker 1:Right.
Speaker 2:So this is the shuffling that we see the shuffling, the shuffling, the shuffling exactly. So if we want to reverse that process, we need to do things. We need to maximize the strength in the muscle that's left behind and we need to enable that muscle to work over a wide enough range, a wider range. So there is something called and I've referred to this in various places something called sarcomereogenesis. So, as you may have heard of this before, the muscles are made up of sarcomeres. If you exercise a muscle in a lengthened position, then the muscle has the ability to redesign itself to add on extra sarcomeres, but it has to be exercised in a lengthened position. So if you just do calf raises against the wall, you won't get an increased number of sarcomeres in the length of the muscle, Right, If you okay?
Speaker 1:Thank you so much for that, because this is one of my big bugbears with people talking about heel raises as strengthening consistently for not decades but even just in recent times, because my understanding, the greatest load on my gastroxilius when I walk around is when I extend over the foot, not when, I lift my heel off the ground. So what's the point of the calf raise? I don't understand that.
Speaker 2:Yeah, I think you're right. I think the calf raise has it's a good starting point, but it just hasn't been developed to that level that we need to go to. There are so many ways we can re-engineer that calf raise putting it on a step, for example, exercising that muscle through a full range, and then on top of that we can also add in such things as an isometric contraction. So, getting back to your original question, what do I do? The patient might start off, if they're particularly weak or so forth, just doing basic calf raises just for a little while, just to get themself going. But eventually we're gonna get them onto a single leg, get once a single leg stuff going. Great. Now we're gonna get you one, two a step.
Speaker 2:So the one that everyone will do will, of course, be the straight leg calf raise. You go up and down on the edge of a step. Great, yeah, that's fine and that's a useful thing. But it is only hitting the gas rocks, not so much the soleus. As soon as we bend the knee, we then start introducing the soleus.
Speaker 2:So should we do it on a step or not? We should do it on a step. We should do it on a step. That's the ultimate goal. So we want to aim to build that person up into doing single leg calf raises. We want to do it in both a straight leg and a bent knee position and we want to include an isometric contraction. So an isometric contraction at the end. You fatigue the muscle. You do this. So my standard process is stand on the step, raise it up and down until you can't do any more. Then drop your heel down as far as it can go, raise it up two centimetres and hold it there for 30 seconds, and that particular part of it is going to help to stimulate tenor site activity, which will improve tendon quality and strength.
Speaker 1:Okay, fantastic.
Speaker 2:So you may have heard of something called fluid flow dynamics.
Speaker 2:It's relatively recent where it's been one of the real pieces in the puzzle that we've only just uncovered in the last few years where they found that when you do an isometric contraction, a length and position, particularly on the Achilles tendon, it forces water out of the tendon and that, with heavy loads, stimulates tenor site activity a lot more.
Speaker 2:That combination of fatiguing the muscle, isometric contraction in a length and position, for me gives a nice all-round exercise program. So they do one with the knee straight, they do the other side with the knee straight, they come back to the first leg again and they now do another set with the knee bent and they're doing exactly the same thing up and down with the knee bent and then at the end do an isometric contraction at the very end to hold it there for 30 seconds. And I just get the patient to that, preferably every second or third day, depending on their age and building up their levels, and I find that to be a really effective way. Now, if you want to take it up, another level and this is probably even better again is we have that patient intowing at the same time and only slightly, maybe five, ten degrees of intowing.
Speaker 1:To reduce the lateral aspect of the cuff, the lateral gastroc exactly.
Speaker 2:You may be familiar with. It was an interesting study, say 20 years ago, that they found that in insertional Achilles problems, and I think even in mid-portion Achilles problem, they found that the degeneration is primarily on the front of the Achilles tendon. They never understood until relatively recently. What they then found is that the muscle fibres in the tricep sewerage not evenly spread. You have a fair number of fibres coming out of the medial gastroc which have a very straight path down to the calcaneus.
Speaker 2:The lateral gastroc has a much more circuitous route. It takes a longer route to get to the calcaneus. Therefore more tension goes on to the medial gastroc and much less onto the lateral gastroc. And when you look at the Achilles tendon, the part that's at the front of the Achilles tendon where the most degeneration occurs is actually at the front where the lateral gastroc inserts.
Speaker 1:So the lateral fibres come down more anteriorly and they're the ones that degenerate because they're not being used or loaded.
Speaker 2:Correct.
Speaker 1:You've got it.
Speaker 2:Yes, so if we're trying to rehab people with Achilles problems, we need to be hitting those anterior fibres by strengthening the lateral gastroc, and we can do that. There was a particular paper published by Noons, I think it was in 2020. It was published in the Journal of Strength and Conditioning Research. It was a really good paper, but they looked at EMG activity and they basically looked at which exercise hit parts of the muscle better and basically, when you intode, you ended up hitting the lateral gastroc Absolutely Exactly.
Speaker 2:So our perfect combination then is if we want to improve in search. In search, as you know, are one of the hardest things to treat and most of the treatment regimes have failed. Even the aphrodite technique I mean the follow up of the aphrodite technique for repairing Achilles tendon problems has shown that 60% of people are still have pain five years later. It's not the golden bullet that people thought it was going to be. So, as far as if we're going to improve the best we can in that posterior muscle group, which I think is incredibly important, then we basically need to be doing slightly intode isometric contractions, 30 second holds, celius. All that gives us a really fantastic foundation for strengthening up that posterior group.
Speaker 1:That's fantastic, matt. The students at La Trobe are going to love this, and they don't know how well off they are. Oh God, I have one question for you. Well, firstly, a comment in that, as practitioners, we have to judge who is appropriate to take on whatever stage they can get started at, because we do see a lot of people get worse, don't we? And they have pain from doing their heel raise or their strengthening. So we have to be really judgemental as to who is appropriate, and age comes into that and, obviously, the pain the patient presents with.
Speaker 2:Oh, exactly, and that's a real art, isn't it? Being able to work out where do I start this person of what is too much? Am I going to lose this page? Another thing I just want to quickly talk about, and I think one of the things that I had a problem with when I first graduated was people were suggesting, oh, you should do strengthening for a patient, it'd be good. And I thought, well, first of all, what do I do and how much do I do it, and how long do they do it for before they get a result?
Speaker 2:Yeah, and that took me years to actually and to find the research and to get together a package of information that works, delivering that message to patients. If you look at the studies only, I think, at three months after a physio hands out exercises, there's only 25% of people who are still doing the exercise after three months, so it's a relatively small number. That's to make it to that three month point. And that's actually a really interesting point, the three month point, because I know I'm sure you probably did PA. Did you PA at school, high school? Yeah, for sure. So, yeah, as in the, did you year 12 PA?
Speaker 1:Yeah did the whole PA course for year 12 jumped up and down a lot during that too.
Speaker 2:There you go, there you go.
Speaker 1:Actually I didn't study too much. I was overseas on teams. I don't know how I did it there you go. It's going my way into podiatry Just go to one.
Speaker 2:One of the things even I remember from when I was going through is do you remember why people get such significant improvements in strength in the first four to six weeks?
Speaker 1:Because they haven't done anything.
Speaker 2:No, it's. The reason being is that refining neurological activation, so the ability to actually connect with the muscle, control the muscle use the muscle fibers effectively, means that you actually end up with much greater ability to lift or move things, purely by better coordination of the muscle. So and that process happens really quickly the ability for the little dendrites that coming off the the, the neural tips there, can spread across the muscle and activate really effectively and coordinate the muscle so much that you actually get what you feel is a lot stronger. You think, oh geez, I'm really improving a lot here, but it's almost all neurological. So if you get someone to four to six weeks of an exercise program, you've changed their neurology but you haven't changed their muscle architecture.
Speaker 1:Yeah, and the tendon response takes like double that time to see any correct. You, you've actually got a month?
Speaker 2:Yeah, exactly so the way I frame it and you absolutely hit the nail on the head to patients is that I tell them that you need To get to three months, and this is how it works. In the first four to six weeks you will notice improvements. But, just so you know, this is not because your muscle has changed itself significantly, so the rough process is neurological first. In the second month, the tendons start to adapt itself and In the third month the muscle starts to adapt itself and it's a fantastic Evolutionary mechanism.
Speaker 1:Yeah, so that's a really important point in regards to and I do harp on, this is a hot another whole session about running and training and running adaption. But we always talk about the first three months of starting. A running program has to be so slow because we don't see any Muscle tendon change for approximately three months. The second three months is when you really start to get moving. People don't understand it. The 10% increase per week or whatever is far too advanced. But this is going to be another session on this podcast about how to train properly and it gets back to exactly what you're saying as far as build up slowly and bring on the neuro, neuro changes, the myo changes and, obviously, the tendon change.
Speaker 2:Exactly, and I think, on that particular point, when we see runners, they just like you, you said before people come in and they see you and I say I'm doing the couch to 5k and I've got injured, I think I need orthotics. What are you trying to do? And it's just, it just realized. Just they can't handle the loads, the tissues are just not strong enough, their expectations are too high and after over weeks, exactly exactly I've got to mention to you also.
Speaker 1:We have spoken about this on the show before. Tanisha Reeve from P3 podiatry puts an amazing online program out there for people to subscribe to and she put up a graph recently. This is P3 podiatry, where the loads that you can produce during a calf raise Are not even close to the loads that your calf is under during running. Important to mention because we can do all the strengthening and get better and better up, but Then we have to slowly build up the load of our activity on top of that.
Speaker 2:If you can communicate that in a nicest possible way to your patients and that's the thing, is that, delivery that message to get them on board that I want you to keep running. I don't want you to collapse in three months and find that running is a total waste of time and all you do is get in. Look in the reality was it's? I think it's. 50 to 80 percent of runners get injured in the first year, you know, and so it's. It's a hot it's. And it's not just because they've all got bad biomechanics, it's just the loads that bits of brutal sport as patients.
Speaker 1:I always say if you can't do the easy training, what makes you think you can do the hard things? Yeah, yeah, being inspired to take it. Take your time, be very gradual and next to play the physiology, the understanding of physiology in our profession. You know, physiotherapy, podiatry, whatever it may be, is so crucial and you've just given a perfect example tonight about you know Understanding what we are doing to try and get people better with them with strengthening.
Speaker 1:Matt, thanks for coming on to simply the best podiatry. You have been an incredible influence behind the scenes in contributing to the podiatry profession and you've just like expressed that in In talking to us about Strengthening and your professional development for all the people out there. You know there's a lot that goes on behind the scenes and people like you from when you're a student, when you graduated and your working time. You prioritize Assisting other people, which is what you've done, not just clinically, yep, but professionally outside and for anyone listening. Matt Dillnott has been a mainstay of our profession in Victoria, here or nationally, and has contributed you know, as I said earlier in the intro to the prescribing rights of podiatrist. You know contributing to textbooks even For everyone's knowledge. Thank you so much for coming on the show and presenting also an incredible depth of knowledge. Amazing, matt, and pleasure to have you on.
Speaker 2:That's been wonderful to be on, jason. I really enjoyed it. Thank you so much.
Speaker 1:Thanks for listening to simply the best podiatry, but with you more over the next few weeks and be sure to check the show nights and you can support and follow the show through there, as well as the links that will be put up. Thanks for listening and speak to you soon.