Why Everything Starts at the Foot with Expert Podiatrist, Justin Coulter

Foot health is often overlooked, yet it underpins how we move, perform, and stay pain-free.

In this episode, we sit down with Justin Coulter, specialist podiatrist and founder of First Podiatry, to explore how the feet influence the entire body, from the ankles and knees through to the hips and spine.

Drawing on his experience across private practice and complex orthopaedic cases, Justin shares a clear and practical perspective on how many common musculoskeletal issues can stem from poor foot mechanics and inefficient movement patterns.

We break down the fundamentals of foot function, the role of gait and biomechanics in long-term health, and the early signs that something isn’t working as it should.

A key focus of the conversation is the ongoing debate around orthotics versus natural foot function. Justin explains when orthotics are genuinely needed, what they are doing biomechanically, and whether there is a risk of over-reliance over time.

We also explore foot development in children, when intervention is appropriate versus when natural development should be allowed, and how modern lifestyles and footwear may be contributing to weaker, less resilient feet.

Finally, Justin shares practical, actionable strategies to improve foot strength, movement quality, and long-term lower limb health.

🎙️ In This Episode, We Cover

• Why foot health is critical for movement and performance
• How foot mechanics influence the knees, hips, and spine
• Early signs of poor foot function
• The role of gait analysis and movement assessment
• Orthotics vs barefoot: when support is needed
• What orthotics actually do (and don’t do)
• Custom vs off-the-shelf orthotics
• Foot development in children: when to intervene
• How modern footwear and lifestyle affect foot strength
• Simple ways to improve foot strength and resilience
• Common misconceptions around foot health

🎯 Who This Episode Is For

• Anyone dealing with foot, knee, hip, or back pain
• Runners and athletes looking to improve movement and performance
• Parents concerned about their child’s foot development
• People unsure whether they need orthotics
• Clinicians and coaches interested in biomechanics and gait

🎙️ Powered by Mayfair Health

At Mayfair Health, we specialise in recovery, performance, and proactive wellness. Whether you’re managing ongoing symptoms, rehabilitating from injury, or looking to optimise your long-term health, our multidisciplinary team is here to help.

🔗 Website: https://www.mayfairhealth.co.uk
📩 Contact: info@mayfairhealth.co.uk
📞 Phone: 020 3985 1500
📱 Instagram: @mayfairhealth

Transcript

SPEAKER_02 0:00

Welcome. I am super excited to have another episode of Move Well, Live Well, Perform Well. Today we are going to chat to an amazing podiatrist who I've known for probably 20 plus years. You might correct me on this. But we're going to talk about orthotics. We're going to talk about children and being hypermobile. We're going to talk about how the foot is super important to the whole kinetic chain and what it means if your foot is unstable or not moving particularly well. So I'd love to welcome Mr. Justin Coulter today. Thank you for having me. It's a pleasure to be here. Thank you. So, Justin, I'm going to give you a little bit of background on Justin. Justin is a specialist podiatrist focused on biomechanics, gait analysis, and lower limb function. He's the founder of First Podiatry in North London, where he worked with adults, athletes, and children to improve movement quality, reduce pain, and build long-term physical resilience. Alongside his private practice, Justin works with the London Orthopedic Group and he manages more complex and chronic musculoskeletal cases. Certainly we have shared new probably hundreds almost over the years. His dual role gives him a unique perspective across both performance optimization and clinical rehab. He has a particular interest in pediatric foot development, helping to identify when intervention is needed versus when natural development should be allowed to progress, and we'll dive into that. And Justin's approach centers on understanding how foot mechanics influence the entire kinetic chain from the foot and ankle through to the knees, hips, and spine. Through gait analysis, orthotic prescription, and movement retraining, he focuses on addressing root causes rather than simply managing symptoms. That's a bit of a mouthful all that. That's a mouthful. It is a mouthful, yeah. So, Justin, tell me a little bit of your background. How did you get into this?

SPEAKER_01 1:55

Yes, I was in the medical corps for two years of national service and I loved it. So I wanted to do something medical. Yep. Didn't really know what I wanted to do, traveled, came back, and then um I found this podiatry school in South Africa. Now there's only one school on the whole continent. One. One school of podiatry. Still? Still? Still? That's remarkable. Yeah, yeah, yeah. It's very small out there. Um and I think from my year there might have been 13 or 14 of us that qualified. So you've got a very small cohort that eventually qualifies per year. Yep. So um, but the big drive for me was sports medicine. Okay. I love sport. Yep. And I saw what they were doing just the day I went there, they were doing a biomechanics clinic. Okay, cool. I find it fascinating. Yeah. I thought, well, you know, I didn't even know what a flat foot was. In fact, I remember getting drawn into the army, wishing I had a flat foot, not knowing what it was, so then I could get exempt. But um, yeah. You probably don't want a flat foot. No, you don't. I'm I'm glad I did my two years, to be fair. Um, but yeah, so that's how it started.

SPEAKER_02 2:59

Okay, cool. And so you've been a sort of a clinical podiatrist for how many years now? I've been yeah, 30 years now. Okay, well. Uh so tell me what role do the feet play in overall movement, health, and performance? Like they're so important to that overall kinetic chain, aren't they?

SPEAKER_01 3:18

They're hugely important. I suppose one of the ways of looking at it is take, for example, a person who is injured. We've all been injured, we've all hurt her foot, right? Yep. Um it just completely takes you out of the equation. You you're in pain, you limp, you you lose speed in walking, everyone's walking past you. Yes. Your back starts to ache, your other the other limb can start to ache. You can't wear shoes that you might want to wear. You can't do your sport. Yep. You can't do your exercise.

SPEAKER_02 3:52

You get grumpy as well.

SPEAKER_01 3:54

Or you get very grumpy with that pain. And um, it goes on and on and on and really affects your life. Yeah. So that is a prime example as to how important they are. No one really appreciates their feet until there's a problem. Until they can't walk. Yeah. And then there's another classic saying that when your feet hurt, you hurt all over, which is also true. Yes. But you know, as a as a as a um, you know, as an organ, if you like, they have um they've got to deal with your balance, they've got to deal with altering terrain. Yep. Uh, they've got to keep you upright, they've got to, they've got to deal with load. So if you're standing, you're at 50% your body weight. Yes. But if you're walking, you're at 100 to 125% body weight. Yep. If you're jogging, you're at 300% body weight. If you're sprinting, you may be 400%. And if you're jumping, it can go up to as high as 800% body weight. Yep. That your foot's got to then absorb along with the rest of the kind of change. And and transferred load. Absolutely. You know, but if you if you if you're thinking about it, we've got we've got gravity always pushing us down. And your foot's the interface between the ground and your body. Yep. And so it you've got to have absorption of that load and dealing with that load all the time.

SPEAKER_02 5:11

Yeah.

SPEAKER_01 5:12

And so without that, we've got a problem. Yeah. Because the foot anatomically is super complex. Super complex. 26 bones, 33 joints, 100 ligaments, tendons, and you know, you name it. It is a very complex species of kit.

SPEAKER_02 5:25

Yeah. And pretty remarkable how it needs to be able to transfer that load because propulsion happens essentially, you know, the big toe is involved big time, excuse the pun, in in in in in that propulsion phase, isn't it?

SPEAKER_01 5:41

Hugely. Yeah. It's a it's a massive factor. But um the other factor that that if you're looking at propulsion, it's also how efficient the system is. Yeah. And it's an engineering marvel, really. So it's a it's a ridiculously efficient system when it works. Yes. When it works.

SPEAKER_02 5:58

So how do sort of complex uh pain issues uh often originate from the feet? You know, we have shared a lot of different patients over the years. We both see quite a lot of hypermobile individuals. Um and we often talk about this malalignment syndrome, whereby uh you know, someone might have fairly pronated, which is akin to a flat foot. Yeah. Um and then that loads up through the chain. It loads different factors up through the chain. And it's really easy to see someone when they walk into our clinic that that's probably a uh part of the problem. So, how does the foot sort of set this process up?

SPEAKER_01 6:44

Well, um so the the way I look at it is it's like a circle.

SPEAKER_00 6:52

Yep.

SPEAKER_01 6:53

Like I was saying earlier, you've got gravity coming through a system. Yep. And if you're looking at the foot in isolation, if we're assuming the entire system is working effectively, uh-huh, and then you have a foot that isn't, yeah, you've got perfectly good load coming through, and then it's not dissipated appropriately, which then on the return then sets things off. Okay. And then that in the longer term can then have more of a negative effect on those proximal or those structures that are further up. Yep. The knee, the hip, the back.

SPEAKER_02 7:24

Either with too much load in certain parts or not enough load in uh i in in parts up the chain.

SPEAKER_01 7:32

Absolutely. And it's uh yeah, so that the loading is not in a way it it's not occurring in a way that the human body was designed for. Yeah. So it's not efficient. It's not efficient at all. And then that that over time becomes more of a chronic problem. Yep. Um, and then then you're trying to deal with the whole the whole system.

SPEAKER_02 7:48

Yeah. Okay. So how early in life does the foot function sort of begin to influence our longer-term movement patterns? I mean, we both treat, and we'll probably talk a lot more in detail, we we treat a lot of ch kids. Um and uh it's pretty essential that their foot by mechanics work very effectively from very early on. Is that is that a fair statement?

SPEAKER_01 8:15

Uh it's a fair statement. I mean, it's it's a learning process. Yeah. So if we take away away, you know, in utero, in other words, developing in the wound, problems like that, you know, those kind of things. We if we forget about them, assume that, you know, the child is going to be walking at a at a typical age around one seems to be the the the typical age. Um what you generally find is um I would look at a a child, for example, that's coming into the clinic with no real symptoms. How how young uh children do you actually treat? Treat um or C. C. So I've had you know three-year-olds come in. Okay. And it's really uh it's it's really more a parent's really worried about them. And it's or they've been walking, they started walking like a two, and they're falling over all the time. And those are those are those are kids that you've got to help. Yeah. Um, but uh habitual patterns in gait I usually find are compensatory.

SPEAKER_02 9:15

Yep.

SPEAKER_01 9:16

So for example, if we go back to talking about a kid who might be hypermobile, and we know kids are generally quite flexible, but to some much more than others. Yes. Yeah, the kids with quite doughy skin, and you know, they're very lax in their joints and whatnot. For them to function is really difficult. So the analogy I would use for children in that group is it's much like us trying to walk on a beach.

SPEAKER_00 9:41

Yep.

SPEAKER_01 9:43

You you you know what it's like to play beach volleyball. It's really hard. It's bloody hard work. It's hard work. Your muscles are really working hard. You're pushing against the sand, the sand is giving way. Yep. So pretend the foot is pretty much functioning on sand. Yep. There's no stiffness within that structure. So that poor kid is trying desperately hard to generate stiffness, force, and force production. So it's overusing their muscles the whole time. And so your common complaint that you'd find is my child doesn't like long walks. Yeah. Or is a buggy baby. Yep. You know, they basically put their hands up and say, right, I want to go in the buggy. And they've got no endurance. Yeah, exactly. So they fatigue. They fatigue hugely. That's a real problem. Or can't keep up with their peers. Absolutely. That's the classic one. They they they're falling behind their peers. Yeah. They're still tripping a lot. Yeah. And they're just not, and and that that pushes them away from activities in sport. They shy away, which then leads to more weakness. Yeah. So that cycle continues. Yeah.

SPEAKER_02 10:43

And when you test these kids, you know, as we strength test them, they're inherently so weak around their core, through their glutes, through the posterior chain, because they haven't built that resilience or built that strength in through normal activities and normal patterns.

SPEAKER_01 11:02

Absolutely. It's it's it's a compensatory pattern all the time. Yep. So when you've got that fatigue muscle, how is it going to strengthen adequately and it's just working incorrectly? Yeah. So one of the compensations, or there's several compensations that kids have to deal with this. What they're trying to do is create stiffness in their own foot. Yep. So as they get a little bit older, and I have let's say, for example, that I'm seeing them at six, seven, eight, they haven't been seen before. Um, a fairly classic compensation strategy would be a very early heel lift. So they bounce walk. Yep. Now, what happens when you bounce walk is you uh the probably the best way of of describing is if we look at walking as three little phases. Okay. The first phase is from when the heel touches to when the front of the foot touches. So we call that our initial loading response.

SPEAKER_02 11:57

The second normal phase, sorry, um, is a normal normal walking pattern is is a heel strike. It's heel first. A little bit of a lateral, mid and lateral heel strike.

SPEAKER_01 12:10

Yeah, yeah. With kids it can vary. Yeah. But yes, a lateral heel strike is what you're really looking for. Yep. Then you're loading onto the forefoot. Yep. The second phase would be when you are, your, your body is moving over your ankle. So you're starting to load the foot a little bit more. So it's what we call your center of mass. Yep. So if your center of mass is behind the ankle and moving forward, you're going to start to load the forefoot up a little bit more. And that's when, in a very flexible foot, it starts to deform. It's then the third phase would be when your heel lifts up and you go into what we call the propulsor phase. Yep. And when the heel lifts up, your foot will stiffen in order to create propulsion to push off. So basically going from that sand onto maybe grass. It's a, it's a it's easier to try and get a propulsion.

SPEAKER_02 13:01

Because there's a mechanism called the windlass mechanism. There is, yeah. Which stiffens the foot up and almost locks that bit of the rear and the midfoot up to drive propulsion, is that right?

SPEAKER_01 13:13

Indeed. There is the windless mechanism. There's also something called auto-supportive mechanisms or mechanics. Okay. So if you imagine that the foot is a whole bunch of loose bones together and you want to create stiffness in that system. In this individual, their ligaments which bind bind joints bone to bone is all very loose. Well, then that's really quite difficult to do. Yeah. And I suppose analogy is if you imagine you've got library books and you pick library books up and you've got to move them from one place to another and you squeeze and you create compression. Yep. That's a lot of effort. Yeah, yeah, yeah, yeah. What's an easier way of moving them? It's just turning them that way. So that you've got gravity pushing onto you and your hand is pushing back.

SPEAKER_00 14:01

Yep.

SPEAKER_01 14:01

So you get compression that way. So if you think about the bones of the foot like those library books, when you tilt them up, they compress against each other, which is a very efficient system. Yep. Which is why, just deviating a little bit, a lot of hypermobile women much prefer wearing a heel to a dead flat shoe. Which is another misconception you might find is that high heels are terrible for you. For also some people they feel much more comfortable. Absolutely, they can be useful. Yeah. So what your reason for that is based on that mechanism that you just described. Exactly. The foot is more stable.

SPEAKER_02 14:36

Yeah, exactly. Yeah, you've got that compression. You're loading it into compression.

SPEAKER_01 14:39

Into compression. So uh going back to what children might do is in that second phase where you get deformation, everything gives way. Yep, they very smartly go, okay, well, I'm going to reduce that. I'm going to take that time and minimize it, what we call a mid-stance time. They minimize that and prolong their push-off time so that they're less effort. Yeah. But so that's where they get the early heel lift. That's where they get the early heel lift. Now, normal heel contact time, so the amount of time from when your foot touches the ground to when you lift off is around about 60%. Yep. That's on average. What you find with children who who have this gait pattern, they can be 35, 40%, right? So it's very early.

SPEAKER_02 15:26

And they're going to be putting a lot more load through their forefoot because they're spending more time.

SPEAKER_01 15:32

There is there is the load going through the forefoot, but there's also a lot of load going through the posterior chain. Yeah. And the reason being is that the push-off phase of walking is actually quite efficient. So if you imagine that I'm walking and my swing limb is coming through, that's a heavy piece of kit.

SPEAKER_02 15:50

Yep, yep.

SPEAKER_01 15:50

It is swinging through, creating a momentum, a force dragging me forward that I can then pivot over my foot. So it can almost be a passive affair, if you like. But if you've got it, and that would be at 60% heel contact. At 60% heel contact, your swing limb is already past your standing limb, and it creates that momentum and lifts your heel up. At a 45%, you're lifting before that swing limb has even come into play. Yep. So you're having to drag that center of mass forwards. Exactly. You are pushing it at effort. At effort. So calves, size, knobs, calves, size, knobs, hams, exactly. All those classic things you places you find people with hypermobility are generally quite tight. The other issue is that whatever goes up has got to come down. So when you have an early heel lift, you are lifting your center of mass up and having a rapid deceleration. Deceleration. And that they have to absorb.

SPEAKER_02 16:52

Yeah.

SPEAKER_01 16:52

And generally they do okay with it. But as a going back to your question is about what sort of influence will have on you long term, tight calves is definitely one of them. So if you look at idiopathic toe walking, which is where children tiptoe and idiopathic because they don't know what causes it, but I think hypermobility is a big player in that. Um they are three times more likely to have posterior problems. Yeah.

SPEAKER_02 17:18

And this is where you know surgeons like to have come along and and do a you know a gastroc release or an Achilles lengthening procedure. Indeed, yeah. When in fact maybe some functional retraining could change might change things.

SPEAKER_01 17:34

And and I think that's where it comes in with your with your intervention being earlier? Yeah. Or do you wait for that neuromuscular inputting to be so entrenched that forget about it? It's much hotter. Yeah, it's much hotter.

SPEAKER_02 17:47

So we're gonna touch n we're gonna dive back into treating kids in a second. Um how does that I mean we just sort of alluded to it, how does the dysfunction in the foot sort of wind up further up the chain? Is it that you know, all rather than being an efficient system, all of these muscles higher up are having to compensate and to take more load or your glutes might be switching off because they can't activate efficiently within the whole system?

SPEAKER_01 18:19

Yeah. Yeah, absolutely. So I suppose if you looked at the classic, and you'll find this in you know the back of a prefabricated orthotic box, yeah, is that the idea is that as the foot pronates or rolls in, that creates an internal rotation, so winding in of the tibia or the shin bone.

SPEAKER_02 18:37

Yep.

SPEAKER_01 18:38

And that will wind the knee in.

SPEAKER_02 18:39

Yep.

SPEAKER_01 18:40

And as the knees wound in, the femur's wound in, which then causes the hip to be affected. Yeah. And then you get this what they call anterior pelvic tilt, which then has an effect on the curvature of the spine and the functionality of the spine. So there's that whole knock-on effect. One of the other ones that does happen is um one of the gluteal muscles on the side over time will become quite weak. Yep. Exacerbated by switching glute media really, really starts to switch off, which, as you know, is a huge uh influencer on further function, which goes back to that circular, you know, as they become more dysfunctional, the foot's going to become more dysfunctional. You've got to break that cycle somewhere.

SPEAKER_02 19:21

Yeah. And does it does it start with the foot or does it start up up here sometimes?

SPEAKER_01 19:28

Who knows? Yeah. So I mean, yes, you could have foot dysfunction and um and whatnot, that over time will have an effect. But you are seeing that whole play. That whole chain. That whole chain just just the whole thing plays out.

SPEAKER_02 19:42

And so that's why, you know, we work very closely a lot of the time because you address the mechanics, often will give, you know, exercises and then be like, okay, Simon, can you assess the chain? Can you assess the core? It f it seems like the glutes are switched off, the core's switched off because of the the altered mechanics. Absolutely. Um, from what's happening down around the foot.

SPEAKER_01 20:05

I mean, it's very rare that I I think that physio and rehab is not required in most of these, yeah, of these injuries. It's just you know, you could have a so so for example, I had someone in earlier who um, you know, f had a bike accident, crushed the ankle three years out, limp, now having, you know, surgery to the foot. What's the long-term effect on the chain is huge. Yeah, yeah. So that would be a classic example of yes, a foot has generated a problem further up the chain. But that also goes back to what we talked about initially is you know, life has changed completely. And permanently.

SPEAKER_02 20:48

Yeah.

SPEAKER_01 20:48

Yeah. Permanently. So, you know, never take your foot. Yeah, yeah, for granted. Exactly.

SPEAKER_02 20:55

So what are some of the early signs if someone's foot function isn't working optimally? Like clearly pain is is absolutely one. Yeah.

SPEAKER_01 21:05

Um, stiffness. Yep. Morning stiffness.

SPEAKER_02 21:08

Okay. That's a classic. So and morning stiffness either through the sole of the foot with like a planti fascia.

SPEAKER_01 21:16

Or joints.

SPEAKER_02 21:16

Yep. Okay, or your Achilles possibly. Any other signs that you that people should think about sort of flagging and and and and maybe addressing or getting it looked at?

SPEAKER_01 21:29

Um, you know, people accept what they have. The brain's got an amazing ability to normalize what you do, especially if it's an insidious or slow process. Yep. So if I get someone with a um a degenerated, really um injured tendon, say your tibialis posterior tendon. Yep, yep. Let's say, for example, they eventually come in and they go, Oh, you know, this happened two months ago. I mean, I I can't walk properly. I'll generally say to them, Okay, when did you notice people passing you in the street? And they'll go, Oh. Two years ago? Yeah.

SPEAKER_02 22:03

Is this the British mentality? I don't or is it because in Oz, you know, generally you injure yourself. You're in the physio the next day.

SPEAKER_01 22:10

Yeah, yeah, yeah. Yeah.

SPEAKER_02 22:12

I don't know about South Africa, but I almost think that there's that stiff upper lip in in in in the UK, and it's almost like, well, ah, it'll just find it'll get better.

SPEAKER_01 22:25

For six weeks or eight weeks or two months. Yeah, yeah, it doesn't matter. It doesn't get better a lot of the time. Oh, it's just my age. Yeah. Yeah. So that's one of the ones. Yeah. Um balance. So as your balance starts to go, and it's really not uncommon for people to say, I'm really I've got very poor balance on my right leg or both legs or whatever. So that's one of the things. That's clearly if you don't have balance, there's going to be dysfunction somewhere. Um pain, obviously, as you said.

SPEAKER_02 22:53

Um would you suggest that if people notice that their foot mechanics just look different?

SPEAKER_01 23:00

Absolutely. Or their shoes have suddenly started to conk in. Um or they're wearing shoes a lot. And and to be fair, I do get that quite a bit that people will come in and say, look, my shoes are completely worn on the outer corner. Uh is there something wrong with my gait? And no, that's perfectly normal. Yeah. So another misconception we could put down is that wear on the outer corner of your heel is perfectly normal and preferred to one that's right in the center. If there's something in the center, come in. Then yes, then you should come in. Yeah.

SPEAKER_02 23:33

Okay, cool. So you use orthodox to help control. Well, maybe a better question is can you explain what orthotics do? Sure.

SPEAKER_01 23:46

So it's really a force modulator. Yep. So it's altering say the magnitudes or the locations, the amount of force that might be overloading a tissue structure.

SPEAKER_02 24:03

Does it have a proprioceptive input as well?

SPEAKER_01 24:09

I think there is definitely a proprioceptive element to it. Yeah. Um I think proprioception is negatively affected when the foot is unstable. Yes. The proprioception is thrown out. An analogy would be putting a marble in a glass jar and shaking it around. Yeah. Your proprioception is going to be thrown. Yep. And we know in hypermobility, proprioception is poor anyway. And in a deconditioned hypermobile proprioception is even worse. So what the orthosis would then do would just be to calm that system down and stop excessive And control the amount of force. Modulate. Yeah. Control's difficult. Um, but you are modulating. You're trying to to uh limit the negative forces in order to have a positive outcome. Yeah, okay.

SPEAKER_02 25:00

So orthotics can help to control I won't use control, to dampen or to modulate. That's what you the word you use. Modulate force via you know reducing the speed of which someone might overpronate. Yep. Because typically you're dealing more with an overpronated foot, which is where the foot is collapsed in, as opposed to a a turned-out foot, a supernatated foot. Yeah, right.

SPEAKER_01 25:31

Much more common. Um not to say that a supernated foot doesn't cause its own problems, but uh yeah, the pronated foot is the most commonly affected one. Not to say that pronation is necessarily a bad thing. Yeah. So pronation is a normal movement. It's just when it's in combination for a normal walking pattern. For loading, we have to do it to absorb load. It's when that that system is broken somewhere along that that system. Excessive pronation. Excessive or or an or under pronation as well. So more of that supinated. Indeed, yeah. Can have a negative effect on on tissue structures in and around it. And we're looking at always looking at the the foot's capacity to tolerate the load that it has to accept. And we talked earlier about how much load it has to accept, which is a huge amount. Yep.

SPEAKER_02 26:28

So walking is you you said up to about 125% of what you eat. Yeah. Yep. And then if you go running, you know, three to four times. Yep. And then sprinting. Sprinting more. Five to six times. If you're jumping, playing football, playing cricket, then you're looking at six, seven, eight times.

SPEAKER_01 26:47

Yeah, it's variable, but yeah, you're looking at a huge amount of force that you're having to dissipate through that system. Which is a hell of a lot. Hell of a lot. On one leg. Yeah. If you look at running, you're one leg. Yeah. You know, so that's uh that's a lot of.

SPEAKER_02 27:00

So the tissues need to be strong. Yeah. And so this is where you know strength in the whole system is actually incredibly important to supporting that foot. Hugely important. Uh I was gonna dive in. Maybe um we'll we'll keep following this. So is there one set of muscles that you think are key to the foot? Right. I mean, there's there's so many muscles in the foot. There's so many. But you know, is it the glutes? Is it the calf? What like I'm sure it's the whole the whole system. Yeah. But is there one area that is consistently underdone in people?

SPEAKER_01 27:49

Uh yeah. So so let's go in, let's do let's do it in segments because it would be unfair to say less important. The glute is less important. Um so if we look at glutes, so it's a glute mead, I find so many people with weak gluteus medius muscles.

SPEAKER_02 28:07

So glute medius is the muscle that sits on the outside of your hip, and it's really, really important for the s stability, producing a stable pelvis and also stabilizing your hip to a degree. Um, and so that often is weak and underloaded in people with foot problems.

SPEAKER_01 28:26

Yep. It's it's underloaded, and by it not doing its fair share, that load has got to go somewhere.

SPEAKER_00 28:33

Yep.

SPEAKER_01 28:34

And it's going to go through that chain. Yep. Um, I mean, from my own experience recently, had some back pain from carrying a very heavy object that then lit six months later gluteus media started to become a little bit painful. Yep. And three to four months later, I'm getting plantar fascia on that side. Nice. This is a nice lovely. It's a nice, you know, it's a nice. But thankfully, hop on the exercise, get rid of it very quickly, sort it out, and and deal with it, and it's done. Um, but it just shows the impact that just one muscle would have through a chain. Yep. Okay. Because it's just it it breaks through that tolerances and the capacity. Okay, so glute meat around the pelvis. Glute meat around the pelvis, yeah. If we then look at the calf, right. So calf weakness, definitely. Calf tension, hugely. Yep.

SPEAKER_02 29:26

So can a calf be weak and tight at the same time? Yes. Yes. Absolutely. Great. So we'll throw that out as a misnomer because you know, a lot of people think that, okay, well, if something's too tight, it's too strong. Yeah, yeah. But actually, a lot of the time, tissue is way too tight because it's under-muscled and under-strength.

SPEAKER_01 29:54

Absolutely.

SPEAKER_02 29:55

Um, and under-resourced. So it actually reacts by tightening up to try to protect itself. Absolutely, it's like a defensive strategy.

SPEAKER_01 30:02

Yeah. Yeah. Yeah. And you'll find that if we look at the ileotibial band, kind of moving on from that, I find that tightens up a lot with people who have, say, the hip dysfunction, then that would tighten up significantly. And then you start to develop a little bit of anterior knee pain. Yep. And and so it goes on. But that tension, that reactive tone, we call it in the in the calf and how tissues and for for children, hypermobile children, a lot of times they complain about quadricept growing pains in inverted commas for them. Um because they they're not they're six. Yeah. You know, it's just weakness. Yeah, yeah. It's just that sort of thing.

SPEAKER_02 30:43

And it's weakness around the glutes, around the hips, a lot of the Okay. And so, calf, are you talking the gastrocnemius and cilius?

SPEAKER_01 30:51

Yep. Um, gastrocnemius very much so. Yep. Um, so we do we do a little test called the Sylphoscale test where we look at that calf tension. And have you tried to say that really fast several times? Try and spell it. Yeah. So um, yeah, so the uh the tension in the calf is a big player. Yep. Um, and a lot of people have calves which are too tight. Yes.

SPEAKER_02 31:19

And so we need to look at okay, calf as well.

SPEAKER_01 31:26

What about the foot muscles? Okay, so so I think let's have a conversation about their role. Yep. The intrinsic muscles of the foot. Uh I think one of the one of the the belief system is that if you crunch your toes on a towel and you know wiggle your toes about, you can recreate the arch. So there's a a very good um colleague of mine in um Australia called Luke Kelly, who's done a lot of work on the intrinsic muscles of the foot. Yep. And um he's he's done some studies since 2014, I believe. Um, but basically found that what your intrinsic muscles are primarily doing is preparing your forefoot for push-off.

SPEAKER_00 32:17

Yep.

SPEAKER_01 32:18

Not necessarily stabilizing your arch. So they did a study where they loaded the foot at 150% body weight and anaesthetized several of the main um intrinsic muscles. So deadened them. Yep. And the the shape of the midfoot didn't change. Right. So clonofascia does, that resists load and that's like a spring, but the intrinsic muscles are primarily there to stabilize the toes in push-off. Yep. And what they did find is when they need the ties that the toes became a little bit more floppy. So they're really more of a of a toe. Force transducer almost. And and aiding in that really important push-off phase that we we we do to improve the energetics of the system.

SPEAKER_00 33:05

Yep.

SPEAKER_02 33:06

So it's it's more of the bigger muscles, like your tip post, that perhaps has a bit more of an impact on your your medial longitudinal arch.

SPEAKER_01 33:16

Absolutely. And the tip post will work with your peronius longus, which is the muscle on the outside. And if you think of it like a sling underneath the foot to stabilize that that unit, and then that creates some nice um because your perinos longus loops in and under absolutely. So it goes underneath to the back of the first dress. Stabilize that midfoot. So it's a big player with that, as with your tzolia that helps out as well.

SPEAKER_00 33:40

Yep.

SPEAKER_01 33:40

Um, but yeah, so your in extrinsic muscles are key players in stabilizing your your foot. Yep. Along with your plant fascia, which is I always call that the last line of defense.

SPEAKER_02 33:53

So orthotics can be used to help to control this force or uh manage. Manage the force. And predominantly people over pronate most cases. Vast majority. Yeah. So when do you need sort of off-the-shelf simple orthodox that Amazon sells and versus some custom-made orthodox?

SPEAKER_01 34:22

Sure. So I think break that into three off-the-shelf that you buy yourself from Amazon and you good luck choosing. Um, then modified, customized, prefabricated orthosis.

SPEAKER_02 34:34

So basically what we both use for our clients.

SPEAKER_01 34:37

Use a a lot. I use a lot. And and then you've got your full-blown custom. So when would you use what? Um I think if you are dealing with an acute injury and you want to stabilize that circle that we talked about. Yep. Um, I think a prefabricated orthotic is a is a great idea. Yeah. Especially if you're you're you're noticing the foot is going to have an increase in load because their muscles on top are not doing their job properly. Um by giving that foot additional support, you improve its ability to resist the increased loads that will occur because they are not functioning adequate until they fully rehabilitate it. And then you can just take it. Until things get stronger. Exactly. Yeah. So that's a great way of using a prefabrication.

SPEAKER_02 35:25

And the prefab, you're talking about the the say we use a brand called Vasily. Is there that's the ones that you're talking about? Or you're talking about any simple one that you could buy off Amazon or your boots chemist.

SPEAKER_01 35:39

Well, I think the Vasily have got a better track record than a lot of what you'll find anywhere else. Yep. So I think probably sticking with them is probably a better idea. Yep. Because there's so many out there. Yeah, yeah. There are so many out there, and it's very difficult to choose. And I mean, I I wouldn't know half of them. I've got to see them, feel them. Yeah. But I know with the Vacilies, you've got a you've got a relatively um well constructed. Well constructed. Well constructed, and it's done by a podiatrist, and etc.

SPEAKER_02 36:08

So that's one area that orthotics can be useful. Some prefabricated ones off the shelf for acute pain. Yeah. When would you look at continuing to use those, or when are, you know, some more substantial, custom-made orthotics um advisable?

SPEAKER_01 36:30

For example, one of the with customized devices, I find controlling velocity, so speed of movement very difficult. Okay. Because they're generally going to be a little bit more rigid, and yes, you can construct them a little softer and whatnot, but I think that's probably a waste. I think if you're dealing with velocity, I've got a better platform to um to manage that speed by using a prefabricated one because I could build it up with a lot of cushioned wedging to try and decelerate any negative rolling. But because people might ask, well, why is velocity a problem? Yep. And human tissue is viscoelastic. Yep. So it will stiffen with the higher the rate of loading. Yes. So you want to make it a slower, a softer, gentler. Gentler. It gives more ability for the muscles and everything to function adequately. Yep. So I use prefabers a lot for that. Yep. And then eventually there might go. So you pad them out. Pad them out. Exactly what I want to try and achieve based on my analysis. Um, so that's a that's a classic one. As far as replacing them all the time. So if we look at a longevity curve for a prefab, they're not that great. Yeah. And and especially with You mean the longevity of the orthotics? Yeah. Yeah, yeah. Yeah. So I mean, I used to use an old Vasily. A year? If you're lucky. So I used to use an older Vasily. I I would get three years out of them. Okay. Like no problem. Yep. Now, with one of their one of the products that we might use, six, eight months, done. Yep. And I have to reinforce it all the time. And from a cost, a cost basis alone, it doesn't make any sense. And in three years, you've almost you've almost cut covered the cost of what you'd have on a customized device if you were needing one for longer term. Yes. Um also with that the consistency of of of of efficacy, yeah, how good this thing is over time will degrade. Yes. And then they'd slip back into an injured state. I've seen some come in with a completely flattened out prefab. They're going to look I'm in a lot of pain. My products aren't working anymore, you think? Yeah. So um, yeah. So so from that perspective, if you're looking at a much longer term case, or the forces that you're trying to deal with exceed the capacity of a prefab. Yes. Go custom. Yep.

SPEAKER_02 39:05

So would that be guys who are a bit heavier that you might look at steering towards a custom aid quicker?

SPEAKER_01 39:16

Yep. That that that would be one of the one of the ways. Um people with significant pronatory problems that I can't control with the prefab. Yeah, it's just not going to cut it.

SPEAKER_02 39:27

Or a very I mean most patients I'll often send across to you when I can't even begin to control them in a simple prefab because they've got a very complex foot. Yeah. And the morphology of their foot means that the prefab just will not do what it's required.

SPEAKER_01 39:49

Exactly. It's just not enough. It's a nice try. And and unfortunately, sometimes that steers people away from from following the path of podiatry more because they go, Oh, I've tried orthotics, it didn't work. That's just nowhere near. It's like buying a pair of reading glasses in your minus seven. It doesn't really work.

SPEAKER_02 40:05

This is where you just touched on it there. That podiatry almost feels like it's a bit of an art and a science. It is. Because we didn't necessarily dive into sort of what a custom-made orthotic is is made up out of, but I I I often use the analogy to patients. Now, if you go to ten different podiatrists, you'll probably come home with ten different pairs of orthotics. Maybe similar advice or similar diagnosis. And so blending that science, which is objective data, your objective tests, you use force plates as well. Pressure mapping, pressure mapping, yeah.

SPEAKER_00 40:56

Yeah.

SPEAKER_02 40:57

Um, and then 30 years of clinical expertise. You get quite often quite a different outcome when you see different people.

SPEAKER_01 41:07

Yeah.

SPEAKER_02 41:08

Why why is that?

SPEAKER_01 41:11

Uh I mean I th I think a lot hinges on your initial training. Yeah. Your interests, your influencers, the people that you have looked up to and taken, you know. Your mentors. Your mentors, yeah. You know, um paradigms that are shifting. As a physio, you know that very well. Yeah. Um and experience. I think you know, you you would sometimes get stuck in, you know, in a bell-shaped curve. If you took a bell-shaped curve and you say, right, if I give this piece of plastic to someone or a so one of my colleagues calls it a meat pie. Um into into someone into into someone's shoe, yeah, you you you might well get a positive outcome within that bell-shaped curve. Yeah. And outside of that, you've got a problem. So if someone's very happy to work within a bell-shaped curve, they'll just dish this out like candy and go, well, the the likelihood is it's, you know, it's going to do something. Yep. Yeah. So therefore, I'll use that all. I've used it all. Yeah. Exactly. Yeah. If they haven't pushed on and they keep pushing those boundaries, then following the evidence, looking at what's what's going to work, um, there's been massive shifts. I mean, looking at physio. Yeah. Right? You've gone from ultrasound to manual therapy to no manual therapy to talking to someone.

SPEAKER_02 42:41

Which is completely, completely backwards. And if there's one thing that you know, when we get someone to interview, you know, they need to be able to put their hands on someone and do some manual therapy because it makes such a big difference to being able to load the tissue or unload tissue. And so, yeah, there's lots of different paradigms.

SPEAKER_01 43:07

The change. Yeah, absolutely. And then pain, and we'll just talk to someone. You know, we won't, we won't touch them, we won't treat them. That would be terrible. We'll just talk. We'll just talk. Because then you'll get better. Yeah. So, you know, when when it's it's just that that model that's just followed. And so so it depends where people are and what's worked for them in the past, what belief systems they've had. And I think that's right across the board for medicine.

SPEAKER_00 43:28

Yep.

SPEAKER_01 43:28

Um, and I think that's where the art comes in, experience. Um, and failure. You know, one of the things you learn from you learn from failure. You not your mess ups necessarily.

SPEAKER_02 43:39

No, no, just it hasn't worked. It hasn't worked. And when, you know, a patient when fails conservative treatment or for whatever, that's when, you know, reflection should should occur. Could we could we do it have done anything differently? And yeah.

SPEAKER_01 43:52

I mean, I don't think you know, I was speaking to someone today and saying, you know, do you still enjoy your work? And I go, I love my work, because every single case. Is a puzzle. Yeah. And every single case has its nuances. It's not, yeah, come in, here's an orthotic, here, come in, there's an orthotic. Yeah. Everything is different. Every story is different. It's it's fascinating.

SPEAKER_02 44:11

Someone may have a very similar diagnosis, but it's got multiple flavors. Absolutely. And you know, there's a very probably a very different outcome that they're trying to achieve, and there's a lot of different inputs that have led to that particular um diagnosis example.

SPEAKER_01 44:29

Absolutely. Huge, huge. So you've got to get you've got to listen to that story. Yeah. That story can go back a long way. Yes, yeah, yeah, yeah. You know, so that that's what I find fascinating about it.

SPEAKER_02 44:40

So can people grow out of needing orthotics? Sure. Yeah? How often do you see that? Is that is that someone that has to be really bloody diligent with their rehab, get themselves much, much stronger, and can a flat foot retrain?

SPEAKER_01 45:00

Um can a flat foot retrain? Generally, I mean it there's a lot of genetics involved. Yep. Um I mean, just as an anecdotal story, I I treated a gentleman years 25, 30 years ago, and he had massively supernated feet, very high arches, very stiff. Yep. And um eventually had to be supernated feet. Very stiff, absolutely very stiff. Loved his sport. Uh eventually had it um ruptured the tendons on the outside, the peronial tendons, had to have surgery, which was a heel slide, so they sliced the heel bone and move it across to make the foot more effective. Um, and anyway, he he brought his two kids, his sons, to see me as they were quite small. Yeah. And he said, Look, I don't want this to happen. Yeah. You know, can you can you help me out? I'm looking at them, going, look, they they look good, they look fine. And um so we we we gave them some orthoses just to give them some balance, and it was all very pre prefabricated and and whatnot. I then saw them as adolescents, it was like Jekyll and Hyde. Yeah, yeah, yeah. I mean, the whole foot had morphed into dad's foot. So you've got that genetic component of what's what's on the on the in the future is in the future. You can't really manipulate that.

SPEAKER_02 46:20

Um but touching on genetics, yeah. There's only a few genes that are that are more than sort of 50% sort of genetics, 50% lifestyle, yeah mechanics. Yeah. Is the foot one of those?

SPEAKER_01 46:38

Well, I mean, bunions, for example, is definitely a genetic factor um involved with it. The hypermobility is a strong genetic factor, well above 50%. Yeah, yeah. Um, so you know, those are your big big factors. I mean, even toe differences or you know, a an elevated fifth toe, my dad's got it and whatnot. So you have these little nuances that that that are our strong genetic uh marker. Predisposition. Yeah, absolutely. But I think from you know, going back to your question of can you have an orthosis and then not need to grow out of it. If we looked at that flexible child, normal flexibility, you know, they're on that border, um, as they get older, they do tend to stiffen up quite a lot, especially boys. Yep. Stiffen up quite a bit. And the way I look at it is it's a flexibility to weight ratio, uh-huh. Or load ratio, if you like. Yep. So they get heavier, but their flexibility stays the same. Deformation and whatnot is going to increase. Yep. So if you find a balance between those two, or they stiffen a lot to cope with their day-to-day, they don't need it. Yeah. But if their load increases, they might need lead it. So the load to when deformation becomes a problem. Yeah. Okay. Um, that's that's when you want to deal with it.

SPEAKER_02 47:55

So do you see that people can retrain a flat foot?

SPEAKER_01 48:04

No. I mean, it depends on the course. I think I have. It can, it depends on the cause.

SPEAKER_02 48:10

But what you know, if you're retraining, what are you retraining? So I think often retraining Tib posts, your salia's, I think you're retraining your whole your whole chain.

SPEAKER_01 48:19

So so what you're really tra doing is you're strengthening. You're strengthening. And the foot is out of that. The foot's out of that. So was it a flat foot or a foot that just couldn't cope with the load? I I yeah. So basically, so is it inherently a flat foot? If you took a full-on flat foot, you're not gonna I think we're lazy as human.

SPEAKER_02 48:40

Well, uh our our computers are very goal-driven. My view is that we're very goal-driven. We want to get from A to B. And actually the body just takes the path of least resistance. Absolutely. And so a lot of the time that'll be this lazy walking or gate cycle where you just collapse through your midfoot, your transverse arch is gone. And so if you start bringing a bit of awareness back into that, and okay, and a whole lot of retraining, I've seen people change, but it's pretty hard. It's really hard. And there's few and far between that that and generally my line to people uh when they're asking, oh, well, am I always gonna need orthotics? I'm like, probably yes.

SPEAKER_01 49:24

Yeah. Is is that your take? Absolutely. I mean, it's it's the the work rate required is huge. Yeah. So the anal the uh the the the analysis I would use is a ballet dancer. You've got a ballet dancer who is hypermobile because they cannot do the ballet at the level they are unless they're hypermobile. So being hypermobile, their foot would theoretically have a tendency towards collapse. But if you look at a ballet dancer, they do not collapse. Yeah. But pound for pound, they're some of the strongest athletes in the world. Completely. I mean, ridiculously strong.

SPEAKER_00 49:57

Yeah.

SPEAKER_01 49:58

And they maintain that structural integrity through how many hours of training? Yeah. Could you get your 12-hour day banker to do anything of the sort? Not a chance.

SPEAKER_02 50:08

So I I I think that I it comes back to actually what they do. If they're a desk worker, I'm like, you're not gonna change it. Absolutely. If they're a personal trainer and they're on their feet all the time and they're very body aware, I'm like, yeah, okay, maybe you can change this. Yeah.

SPEAKER_01 50:26

You've just got to go and do the work. Yeah, absolutely. Absolutely. So, I mean, again, it boils down to is it a true flat foot or is it a flat foot that's been punched beyond its capacity and it's therefore deforming under load? It it can't cope with that and you change all that load, then that's great. Yeah. And in the short term, you might need orthosis so your foot isn't injured while you're building up. But yeah, a lot of times I can take them away. Yeah. And especially with the flexible going back to the flexible group, they will stiffen.

SPEAKER_02 50:54

Yes.

SPEAKER_01 50:54

And so once you've taken it away, but in at the same time, you've allowed them through their development to function and therefore strengthen.

SPEAKER_00 51:03

Yeah.

SPEAKER_01 51:03

The ones that I see who are 17, 18 years old, never been treated before, hated sport, never done anything, they they're they're difficult. They're on a really difficult path. Yeah, because they're playing a hell of a lot of catch up. A lot of catch up. Whereas if you can get it earlier, so the whole question of should children have orthotics or not, that's a a question I hear all the time. Should you be giving it uh, you know, a child orthotic because you you you're hindering their development? Or sometimes you're not. Actually, you're aiding their development. And that's what you've got to look at from the individual basis.

SPEAKER_02 51:35

Are you ever hindering their development? If if if a child has an inability to attenuate force and they're getting pain and they're they're not functioning well.

SPEAKER_01 51:50

No. Yeah. I mean, purely for the fact that that load attenuation is going to come. You've got your receptor being your foot, and you've got your control being above. Yep. And all you're doing is you're stabilizing that receptor to allow those muscles above to function how they should be.

SPEAKER_02 52:08

Yeah.

SPEAKER_01 52:08

And so that's what you're trying to do. Yeah.

SPEAKER_02 52:11

Yeah. So children. Let's touch on that. We we treat a lot of hypermobile individuals, children and adults. Yeah. Um, and maybe we need to just specify hypermobility is uh essentially a genetic change within the protein of your collagen. Indeed. And we use a scale called the Beta scale, which is uh often a pretty poor scale some of the time. But kids need to score a little bit higher than adults on the on on the Baton scale. And uh generally, I think I can uh uh see someone walk into the clinic into my room and I'll know whether they're hypermobile or not. Yeah. Although in in some adults you get a stiff hypermobile, so it can be a little bit different. So in children, I think we're seeing a whole bunch of kids who are weak, under muscled, and awful movers. Why do we think that? Is that our PlayStation generation? Is that how we're developing? Are we seeing more of that now than we used to?

SPEAKER_01 53:20

Yes, I would say so. I mean, I don't know what the official evidence is, but certainly in my in my professional career, that is what I've noticed. Yeah. Um I used to do a lot of work with a um a pediatric rheumatologist, um uh Dr. Hassan. He was excellent. Yep. And he was a really strong believer on the fact that kids are just way too weak. Yep. Um, what are the factors involved with that? Um I'd say modern lifestyle is one of them. Uh us as parents, maybe a problem there. Yeah, overprotecting parents. Yes, I mean, we've been led down that path in belief, oh my goodness, you know, don't let them be kidnapped. Or don't climb that tree, you're gonna hurt yourself. Yeah. So, you know, those basic things are playground. Yes.

SPEAKER_02 54:09

So climbing, running around the playground is actually essential to kids' development. It's huge.

SPEAKER_01 54:15

You've got to have that impact, you've got to have that stress on the system. Because it helps to build strength. Exactly, and bones and everything else. So, have you been to a playground and watched how few children could do monkey bars? We're not strong enough. Not strong enough. No. I mean, you do get your your outliers, but you go there and it's a really fascinating thing to see because they get one or two and they're off.

SPEAKER_02 54:36

They're not doing it. I used to s I used to have this 30-meter tree in our front garden, and I used to just go and sit up it. Yeah. And I look back and go, oh my God, would I let my kids do that now? Yeah, exactly. And and I used to love climbing it. Yeah. But actually, generally we don't do, we don't facilitate that in kids. And actually, excuse me, it's a really important part of building the support in the whole system.

SPEAKER_01 55:06

Yeah, absolutely. It's essential. And and you look at it like so so some of my some of my patients in will have PE once every two weeks. Yeah. So if you look at the CDC's recommendation for exercise for children, it's 90 minutes a day, yeah, every day. And that's not walking. Yeah. Which people here go that well, walking is exercise. No, it's not. No, no, no. It's what they call well, our old colleague John Althwaite used to call trash exercise. Yes, yeah, completely. Yeah. Um, so it's it's it's essential that they build that. Go back to PE.

SPEAKER_02 55:36

Yeah.

SPEAKER_01 55:37

So PE for me was torture. For all of us was torture, right? Push-ups, sit-ups, war squats, rope climbs. We we used to do proper strength stuff.

SPEAKER_02 55:44

Now what do you do in PE?

SPEAKER_01 55:46

You throw a little ball around.

SPEAKER_02 55:47

Yeah, you just play some games. Yeah. You don't do anything. Which which is great for a lot of kids. Okay, they can run around and play soccer or sorry, football, but or cricket, and they're exposing kids to perhaps more games, but they're not actually teaching good movement patterns. Yeah. They're not actually teaching kids how to be strong in schools anymore, I don't think. No, I agree. And that is part of the reason that I think we're seeing a lot more kids who are under muscled, poor movers, and having a lot of orthopedic problems that really they shouldn't need to.

SPEAKER_01 56:24

Yeah, agreed. Completely agreed. I mean, I think uh, you know, a lot of the schools don't have the facilities. Yeah. That's a big problem, the city schools.

SPEAKER_02 56:33

Or maybe the skill set these days. And you know in our days, you know, you the our slightly woke society probably wouldn't have allowed some of the stuff that went on in our PE classes to actually occur. Like, you know, you you don't you don't do well in gym class. Well, you're running around the pitch in your speedos. Yeah, absolutely. And and that was like, oh shit, okay, we we we we better work hard here.

SPEAKER_01 57:04

Completely. And also not saying that's necessarily the right approach, no. But but one one of the things that always got me is um when I when I started in senior school, I'd never picked up a hockey stick in my life.

SPEAKER_02 57:18

Yeah.

SPEAKER_01 57:18

And I was playing for the G team. I ended up in the G's G's. I I don't that's gonna be a decent sized school. It was a good it was a good school, but you we pushed it within a couple of years. But yeah, G, it was way down. Yeah. But there was a G team. Yeah. I mean, granted, you didn't really have inter-school stuff, and then your skill level went up and then you played, but you were in a team.

SPEAKER_02 57:41

Yeah.

SPEAKER_01 57:41

Here, if you don't play in the team, you go home.

SPEAKER_02 57:44

Yeah.

SPEAKER_01 57:45

Which is okay, they don't have the facilities, but you're also stopping people developing sports skills, stopping them developing their strength, doing all of that. I mean, in all sports, um, sports should be absolutely compulsory, less time in the classroom because their brains are switched off in the afternoon anyway. Just put them outside and let them play and go.

SPEAKER_02 58:03

Yeah, I completely, completely agree. But the thing about this is that actually the you mentioned it earlier. The child who has is hypermobile often will find movement much harder because they're unstable. Yeah. They won't have that efficiency of movement. And you can see it in some kids. Some kids are just they just move well. Yeah. They're graceful. They're quick. And others, you can see they they can't run.

SPEAKER_01 58:34

No. It's it's like they're running in mud or trickle.

SPEAKER_02 58:37

It's just and that reinforces the narrative of, oh, well, I don't like exercise. I don't like sport. Yeah. I don't like doing things. So they actually miss out on all those years of development. Yeah. And actually the parents need to keep pushing. Or or looking at, okay, well, why doesn't that child like exercise or get fatigued more so?

SPEAKER_01 59:00

Yeah. Or they were they I know my child prefers the books a little bit more. Yeah. I mean, there's there's the crucial ages, is around six, you want to get that system fired up. Yeah. Your arch is fully developed and and developing. You want to get that system fired. That's a crucial age. Yeah. The other one is A-levels. You know, South Africa, 17, 18, this is first team rugby, first team cricket, first team hockey. No one cared about the academics. Yeah. I mean, sport was everything.

SPEAKER_02 59:30

And the South Africans are still doing okay.

SPEAKER_01 59:32

They're doing okay. Yeah. They're doing okay. Yeah. Um, you know, sport is a massive part of their lives, and and it's it's essential. Yeah. So when you're in your A-level time, no one's doing any sport. Yeah. You know, you look at you look at a uh my son's in his A levels now, doing his A levels now. It's it's like university. He goes to his classes, he comes back. He's not doing any sport. None. Nothing. Nothing. He goes to the gym. So to be fair on him, he goes to the gym and it works out that way.

SPEAKER_02 1:00:00

But there's no there's no there's no So I think different schools like my son's schools probably m maybe they're not quite at A levels yet, but seem better at that.

SPEAKER_01 1:00:11

Going up to GCSE, end of GCSE is pretty good. Getting to A level, it's about the A level. Yeah. The A levels all that counts. The number of people that stay in the sport, especially girls, yeah, decreases dramatically. And that I think is a huge negative because the body needs that for the final set step in your development. I mean, you know, that's when you're really developing all this boys' testosterone's up, they're developing their muscle bulk, they're getting things, and that's the platform they will take forever. Yeah. And if you look at it like that's your baseline, yeah. And it's weak, every time you're not exercising, you go back to your baseline.

SPEAKER_02 1:00:42

But now, and with some other colleagues of ours and pediatric orthopods, I've now started seeing um some disuse osteoporosis in in teenage kids. And because, you know, we talk about and we've got a bone health clinic, and we talk about osteoporosis being a childhood disease, because if you don't load effectively through your teenage years and late teenage years, you're probably not going to achieve peak bone mass. Yeah. And peak bone mass has happens late 20s, early 30s. And so we're seeing in these kids who perhaps weren't great movers or weren't encouraged to exercise that actually they've got bone density issues at a very, very young age. And that's part because they're not running around and exercising.

SPEAKER_01 1:01:34

Yeah, absolutely. And that's what we've got to try and encourage. Yeah. You know, the movement right across the board. Yeah. You know, from the children from a developmental aspect, going in through to your adults, the people who are sitting at their desk. I mean, what's the current thing? Exercise snacks being a good, a good adjunct to people's lives. You know, just one minute every hour. Completely get up, do some squats, come breathless, move. There's a great, I think there's some good research on it. Um definitely great research on it. So, yeah, I mean, we've got to get moving, we've got to get people thinking about this a lot more.

SPEAKER_02 1:02:04

So touching on, just looping back to kids, you use orthodox for kids quite frequently to help to give them a stable platform so walking is easier and they can build up the strength over a period of time. Indeed. And along with that, often they're doing some specific rehab exercises or seeing a physio as well.

SPEAKER_01 1:02:27

Yeah. That in the initial stages, definitely. And once you've created that baseline of strength and functionality, let them hit the sports field and off they go. Yep. And then hopefully then they don't need those associates. I mean, a lot hinges on, you know, if if they're hypermobile and they're long-term hypermobile, you I might keep them going on that for quite a while. But the idea is create the platform, build the strength. Yes. And build the functionality. That's really it.

SPEAKER_02 1:02:53

Okay, cool. So what what about some of these um sort of traction apophysitis injuries that we sometimes see in kids? Yeah. So the kids that play quite a lot of sport, often boys, might come in with Oshkrid Sladders or Severs as a as another one. And we've been talking earlier about these uh new style of orthotics for Severs, that I think is a game changer to sort of change pain in these people. Um and Severs is probably you know, maybe this is controversial, but probably a growth plate disorder of your heel, where uh there's a lot of increased tension uh uh pulling on that growth plate. Um and uh boys and girls who exercise quite a lot just get very sore through their heels and and struggle to be able to weight better when it's particularly nasty. So in that sort of group of population, what do you do? How do you approach um these kids? Do you use orthotics in in in those groups?

SPEAKER_01 1:04:05

Yeah, very much so. So um what I found, and I've looked at this for for quite a while, um, is I found a lot of these kids have that early heel lift compensatory strategy. And if we go back to Do you think that they've had that for a long time? I've had they've had that for a while. Yeah. Because if you look at the age of Severs comes in, right, and you've got anything between 11 and 15. 11 and 14, yeah, exactly. Exactly. Around there, right? So they've already had all that time, they've developed that compensatory strategy and they am bouncing all over the place. And you just go in the streets and have a look at kids, you'll see them bouncing all over the, you know, everywhere. But you won't find that as adults. Nowhere near as much. So um the odd few, uh odd few, but it's it's not it it it peters out quite a lot because they're obviously much heavier and everything else, and it does change. Um, but if you think about the force that's applied to that part of the heel, yeah, when they are fighting full-on gravity without that swing limb coming through as aiding and reducing the load, you've got that full-on load coming in with that very early heel lift. Yep. What I have a tendency to do is look at if if they are, if they are presenting with that, yeah, I'll try and I'll try and manage that. I will try and dampen down their their heel contact time. So they're not pulling on that tendon. And remember, kids have got short little steps, so they're pumping through 10,000 steps per leg. Yeah, you know, so that's a lot of load going through all the and then they've got their little backpack on that they're bouncing around with, right? And so what do you use there? You use So use usually um nine times out of ten, it's a prefab, well, is all always a prefabricated orthosis. A lot of it also depends if I've got if there's um pronatory forces that I think are contributing, yeah. I will I will try and um reduce those forces. Yep. But a lot of times I'm using a lot of cushioning. Yeah, and that dampens that heel down. They've got it's almost like you're sinking into mud before you can pop out of it. So even if it reduces by say three or four hundredths of a second, but that's ten thousand times a day, it has a dramatic effect. Yep. Should they use that in football? Probably not. Yeah. Because A, it doesn't fit in the boot. And B, it's not going to make much of a difference. What you've done is you've reduced that accumulated stress over the day, which has contributed to them playing in the afternoon, but already they're fatigued, so the heel hurts like anything when you're putting significant load through like football. So what you're doing is you're titrating the load through the day so that when they are really pumping it through on football, they can manage. Yes. If they can't, that's when I'll use that insole, um, the soulmate insole. The soulmate insole because it's fantastic at creating an offload. Yep. Which keeps them active. Yes. So a lot of the kids who have got a lot of pain, it might take a long time for the for the orthotic just to work, whereas the soulmate is immediate in pain reduction. Yep. So they can keep them active, keep them running, so they don't decondition, but you're also in the background dealing with a causative mechanism.

SPEAKER_02 1:07:04

Yeah, cool. Because I probably have a subtly different approach where I would often use the soulmates almost solely to begin with.

SPEAKER_01 1:07:14

Yeah.

SPEAKER_02 1:07:15

And then we're addressing their strength mechanics, we're trying to change their and then we're bringing them back in and assessing, and then perhaps shifting them into a more standard orthotic when the pain is settled. But because they are, they do change pain very, very quickly, the soul maids' orthotics with people. It's immediate.

SPEAKER_01 1:07:35

Because you're offloading it. Yeah. I mean, it's basically putting someone into like an aircast boot and yeah, you go, off the road. Oh, fantastic, I feel free. But you take it away, yeah. And say walk on your heel, they're in agony. Yeah. Whereas over time with the with the the the cushion, they're actually you're dealing with that mechanism and and and and it works. So I think the two were. Yeah, the blended approach. Yeah.

SPEAKER_02 1:07:58

Okay. And so um these types of conditions generally kids will grow out of. Yeah, definitely. Over a couple of periods. And so y the way you would approach them is that you're supporting them for that period.

SPEAKER_00 1:08:13

Yeah.

SPEAKER_01 1:08:13

Yeah. Just for for you know, to allow them to be active, to create the baseline that they can then develop into adulthood. Yeah.

SPEAKER_02 1:08:21

Modern lifestyles, all these amazing carbon fiber shoes, all the big chunky souls. Are we inherently setting ourselves up for kinetic chain issues, for epimechanic issues, because we're cocooning ourselves. We're supporting ourselves too much.

SPEAKER_01 1:08:47

Yes. I mean, I I don't I don't think one could one could say then if you wore an orthotic, does your foot get weaker?

SPEAKER_00 1:08:55

Yeah.

SPEAKER_01 1:08:56

There's no evidence to to back that up. Yep. Are we talking about a foot weakness issue with these shoes? I don't think it's necessarily a foot weakness issue that's going to be a problem. Yeah. I think if the shoe allows you to walk and utilize your muscles more effectively, I'm all for it. Yep. Um, I don't see why we have to stick our feet into you know something that's uncomfortable. Yeah. Yeah, yeah, yeah, yeah. I'd rather have comfort and go for a walk. Yep. You know, if if I if if I have a patient, right, who's who wants to wear a very fashionable pair of shoes, and I'm saying to them, look, this is killing you. They're too small for you. You've got your blisters, you've got blisters, you're getting neuromas, which are is is a little nerve issue, and they're getting these shooting pains, but they want to wear this this shoe. Yeah. And they can't even walk in the thing. That that to me is insane. Well, but you're not a female. No, I'm not. I haven't seen you in high heat.

SPEAKER_02 1:09:59

You haven't maybe you haven't. Maybe maybe at night.

SPEAKER_01 1:10:01

That's where there's that. Yeah. Um, but you know, they they they they their whole gait has changed because they're trying to wear this particular shoe. So if you're wearing something comfortable, but you're walking more efficiently and better, and you're using your body more, I'm all for it. If you're walking quicker, I'm all for it. If you're using your energetics, I'm all for it. Because that's what it's about.

SPEAKER_02 1:10:24

What do you think of so there's a bit of a movement around barefoot walking or the vivo? There's one brand, the barefoot shoes, which sort of strip strip the shoe back to real basics. So there's not really any rubber sole. Um much of the support. What are your thoughts on that? And is there a an argument that actually small amounts of those might be useful to strengthen as you say?

SPEAKER_01 1:11:00

So there is evidence to suggest that using them for caveat, small amounts is equally as good as doing an intrinsic exercise program. Yep. So and or walking around the house barefoot. I think if you've got the capacity to do it and it's not a problem, right. If we look at periods like COVID, where people were barefoot for a long time, the number of people I saw as a result of that was huge. So it was good for business, COVID. It was good for business, except I couldn't see them. Yeah, yeah, yeah. Yeah. Um but they started picking up a lot of problems. And um, and so that that really highlighted the fact that sometimes, full on barefoot all the time, is not a good thing. Yeah. And I'm yeah, I'm I'm not a big believer that that should be the way we we function because look at the floor we walk on.

SPEAKER_02 1:11:51

Didn't we walk around?

SPEAKER_01 1:11:52

Yeah, on concrete.

SPEAKER_02 1:11:53

No. But no, in yeah, okay. The African Sahara. African Sahara, yep, we did. What age did we live to? Yeah, there's probably a few other factors in that too. And the wilder beast. Yes, exactly. And the diseases and and everything else.

SPEAKER_01 1:12:14

No, no, no, not at all. But what I'm saying is as you longevity of that, like as kids running around South African Australia, yeah. Barefoot all the time. Yeah, completely. Look at Zola Budd, if you remember her. No? Barefoot, barefoot runner.

SPEAKER_02 1:12:26

Now I try and walk on the beach barefoot and I hit some pebbles, and I'm like, ah, ah.

SPEAKER_01 1:12:31

So it's yeah. And I'm like, I'm pathetic. It's it it's crazy. It's crazy. Um yeah, I I mean, I think you will tune in and your foot will will will strengthen up to up to a point, but you do run a risk. We just don't live in that society. We don't live in the bush.

SPEAKER_02 1:12:48

Small bits of the small bits, barefoot shoes can be okay, but you're not advocating someone goes running in them.

SPEAKER_01 1:12:56

I'm definitely not advocating. Yeah, I'm definitely not doing that. Um, I mean, you know, elite athletes do sand running training. Yeah, you know.

SPEAKER_02 1:13:04

And we are often I've often used with athletes, you know, some outdoor sort of grasswork with their feet. Yeah, it's great. Just to help to get get them stronger as part of that whole sort of kinetic chain. So you're bringing the foot mechanics back into it a little bit more. Absolutely.

SPEAKER_01 1:13:21

But in small amounts. In small amounts, yeah. I think everything in small amounts because our life does not allow it. Yep. You know.

SPEAKER_02 1:13:28

So touching on this, what's a gait assessment? What do you do for a gait assessment for someone? If you're looking at them, you get someone to parade up and down, you put them uh on some force mats.

SPEAKER_01 1:13:40

Yeah, the pressure plates are case. Pressure plates, sorry. So the the pressure plates are used primarily for the temporal patterns, so that's timing. Okay. So I'm looking at timing because timing is really a key part of the and you compare that to sort of normative. And but it's all linked in with the story. The story underpins everything. Yeah. The gate analysis would be all right, I've uh I've assessed that the X tissue structure is under stress. Yep. I want to find out why it's under stress and how is it under stress. Filtering off the fact that their gait might be disrupted because of pain, but looking around that whole story. Yep. So if I'm doing a gate analysis on someone, I'm trying to identify the loading mechanisms to get them better. Okay. And like I say, it could be a compensatory mechanism because they're in pain. Like someone would plant a fascial pain. We'll limp. I'm not going to go and make any long-term plans based on a limping gait. Yeah, yeah. Um, I do a more intensive gait analysis once they have healed. Yeah. And then I can review them again. Yep. So the gait analysis is really identifying where there are elements that need to be worked on. Yep. Okay. Where's the failure occurring? Is it whole body? Is it just the foot? Is it, you know, are the hips okay? How does that correlate with what I found in clinic anyway? And then I can also reverse that and say, oh, hold on a second. I'm seeing you do this. Does this, this, and this hurt? Yep. And then you can reverse engineer it if you like. Yeah. Up to a point.

SPEAKER_02 1:15:05

Okay, cool. So do you walk along the street looking at people's not anymore? No.

SPEAKER_01 1:15:11

No, I don't, I just can't. No. Yeah. No. Do enough of that during the day. I I do that and and I gave that up many, many years ago. Yeah. Okay, cool.

SPEAKER_02 1:15:20

So we've spoken for quite a long time and it's been super insightful. And we haven't even covered all of the the different bits. But to maybe sort of bring it back a little bit and to sort of wrap things up, um what are a couple of simple things that people should think about doing to look after their feet?

SPEAKER_01 1:15:46

Right. I think as we've expressed multiple times tonight, I think global strength and keep your body strong. Yep. Exercise, exercise, exercise. The evidence on it is huge. Yep, yep. Just keep strong. Yep. Um, that will have an effect right throughout, not necessarily on a feet. On a foot perspective, um, make sure your footwear the right size. Okay, yep. Uh so many times. Don't wear things that are too small or too big. Yeah. But they get it wrong so many times. Mostly too small. Mostly too small. Is too big not great as well? Um, if you're slipping out of the shoe, yeah, that's not great. Yeah. But but too small is really destructive. Yeah. Really destructive, causes a lot of pain. And and simple thing like a corn, which is a densely packed callus that pushes on a nerve, creates a significant amount of pain, can affect your entire chain. Yeah. Which is ridiculous. Or a varuca or whatever can have an effect. Yeah. So your foot health in that respect is really essential. Make sure you've got good shoes. Yep. Um, you know, don't be scared to uh have more supportive flip-flops over the the summer. What what people sometimes do is they're they they uh they're usually at an office all all year, they have their summer holiday, they go into a pair of javyanas and they come back with plant flash adders. Yep. They walk the streets of Greece. We haven't seen many of those at all. No, none. None. Loads of those. So you know, just be um mindful of that. Also be mindful about if you're gonna take out a baking activity in January, do it slowly. Because so many people will develop plant fascial pain uh and foot problems because they do think they start too enthusiastically, too quickly off a deconditioned body.

SPEAKER_00 1:17:33

Yep.

SPEAKER_01 1:17:33

Um Are there any foot exercises that people should do? Well, there's this this I mean what we want to try and do because compliance is a real problem and people get bored very easily. Yes. If I had to pick one, I would say calf raises, tiptoe exercises. Um to get your calf stronger. To get your calf stronger. But not only that, if you if you do it on one leg, leaning slightly into a wall. So if you hold onto a wall, but lean slightly forward. So move forward and then progress onto your tiptoes, hold and then down. That will be a getting a little stretch when you're coming back down because you're leaning at an as at a very stretch. But also what you're doing is you're loading your Achilles, you're loading your plot of fascia, you're loading all the intrinsic muscles in the foot, you're loading your tibialis posterior muscle. You're having to engage your quadriceps to do the same thing and your hamstrings to stabilize your knee. So it's kind of a it's it's it's a simple It's a one-stop shop.

SPEAKER_02 1:18:31

Yeah.

SPEAKER_01 1:18:31

Yeah. Not quite, but quite it's a it's a good exercise to do if I had to choose one. The other thing I would also advocate strongly for people with those tight calves, keep them flexible as much as you can. Get a stretchboard, use that, massage guns, all those kind of things. Because walking around your house barefoot won't help that. It will not help that.

SPEAKER_02 1:18:50

Yeah, yeah. And cars we see lead to so many kinetic chain issues. Huge. Um, so rolling them out, trying to stretch them out, getting some tissue work often breaks that cycle.

SPEAKER_01 1:19:02

Yeah, yeah, absolutely.

SPEAKER_02 1:19:04

Justin, that's been amazing. I've loved our chat. Thank you so much for your time. Thank you. Very generous. And um, yeah, we might even have to do a round two at some stage.

SPEAKER_01 1:19:15

There you go. Excellent. Thank you. Good one. Thank you.