Ian Griffiths Sports Podiatry
Foot, Ankle and Lower Limb Injury Specialist

Do we Know How the Foot Really Moves During Gait?

It’s no secret that this is one of my favourite papers of all time and if students ever ask me what “biomechanics papers” they should read this is top of the list. To further spread/translate this message here’s a very short whiteboard summary of it.

 

 

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Is Categorising or Labelling Feet of Clinical Use?

Many clinicians will habitually group feet they see in clinic; some based on cursory observation (“they are a pronator/overpronator” etc) and some may do so more formally after performing something such as the Foot Posture Index (FPI-6). Whilst it may be descriptively accurate to call a foot a +3 or a +12 (and then attach the associated pre-designated labels) if the FPI-6 is your weapon of choice, what context this is then put in (given the inter-rater reliability of the FPI-6 in your own hands/department, how/if this correlates with dynamic function and ultimately how this information will be used to actually manage the patients) is key here. The expectation of a large number of feet with an identical ‘label’ should certainly not be that they will behave identically in terms of their kinematics and kinetics, and this for me is the crux of why I personally do not categorise or label feet in the clinical setting.

Whereas most would certainly be able to differentiate between say a +12 and a -12 as defined by the FPI-6 (the feet at each extreme of the spectrum), could the same differentiation be said of the majority of feet in the middle? Furthermore, the use of arbitrary lines in the sand to suggest normality and abnormality is hugely flawed. A wonderful analogy of this was given by American Orthopaedic Surgeon Mr Henry Feiss back in 1909:

“Given a series of objects animate or inanimate, which differ from one another only to a slight extent, it is impossible to state just where we should draw the line dividing one group from another. If we take one hundred shades of color, say yellow, and arrange these shades in a graded series from a light yellow to a brown, the differences between the individual shades which are placed next to each other are so slight as not to be detectable. Yet if we compare the beginning with the end of the series, the difference is very striking. The same holds good in a given structure in the human body in which the individuals are arranged in a series according to the variations in that particular structure…. This, then, is our problem; the difficulty in dividing the series is apparent; there is no natural dividing line in this arrangement which can be used to define the limits of normality.”

Yes, that was published in 1909. That isn’t a typo. This paper is one of my favourite papers of all time. It was sent to me by my friend and mentor Simon Spooner several years ago and I re-read it regularly. Its got some other brilliant paragraphs in it that everyone should see. This is a link to my dropbox where the full PDF can be accessed. I’d encourage everyone who reads it to constantly remind themselves as they are doing so that is was written 108 years ago. Simply brilliant. Enjoy.

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Gemma’s Story: Lessons for all…

I don’t normally post this sort of thing but this story is too good not to share. This is by no means a testimonial for me, nor do I take any significant credit for the outcome.

Back in 2012 I saw a then 26-year-old female who had started running the previous year.  Her lifestyle mirrored that of many; she worked a 50-hour week in a stressful environment and sat at a desk for 100% of that time. She was in excellent general health and was highly motivated. Her long term goal, again like many, was to run a marathon.

I first saw Gemma shortly after her first half marathon in early March 2012. She had some left sided iliotibial band issues. She still had a lot to learn about sensible training methods and load management at that time (this has dramatically changed since), and had a real love for running shoes and owned more pairs than anyone I knew (this has only got worse since). We analysed her gait and my impression at the time was that her issues were driven from more proximal issues rather than distal (unsurprising for someone with a sedentary career) and as such I referred her to my Physiotherapy colleague for their involvement.

We reviewed things in 2013 and there had been dramatic improvements made in her pelvic control. Her iliotibial band issues had resolved and her running volume was increasing.  She achieved her goal of completing her first marathon (London) in just under 4 hours with a 9:07/mile pace. She was suffering with some plantar fascia irritation at that time, again more of a load management issue rather than an indication of any ‘sinister movement patterns’ at foot level in my opinion. Management of Gemma at this stage continued to consist of strength and conditioning and education on load management, and she had also seen a running coach I had guided her towards to discuss her running technique in more detail.

Just before the end of 2013 Gemma sent me (and the Physio) an email.  She had been at a Running show and whilst there had taken someone up on the offer of a free ‘consultation’.  She shared the report with me and asked for my take on it.  The key sentences from it were:

“You suffer with chronic ITBFS, and plantar fasciitis.  These have been unsuccessfully managed to date with routine MSK treatment modalities, for good reason”

Gemma told me in the email that she was informed she would never fully align her pelvis without the help of an orthotic as her right leg was longer. The person she had seen was certain of this.

“You cannot progress from this state using normal MSK clinical treatment modalities (although a joint complex may respond to treatment, the force vectors will simply move to the next joint until the symmetry is restored and the CoM resume its normal sinusoidal motion pattern), however, you have not been treated by anybody at my level before.  I would advise you to take my advice and try the orthotics and not be guided by non medical opinions”

We’ll leave the overmedicalisation, nocebic language and complete lack of application of the biopsychosocial model for another time. Needless to say Gemma is very sharp, and as such rather than be scare mongered into signing on the dotted line there and then fortunately she ran it past us.  We reassured her she was on the right track and to carry on with the plan.

Over the next two years Gemma continued to increase her running mileage (and get faster), began running full marathons and predictably had occasional ‘niggles’ (because that’s the nature of the beast). Some Peroneus Longus tenosynovitis and some insertional issues with Tibialis Posterior featured.  Each time things were managed with appropriate rehabilitation and discussions on load management.  I have seen Gemma a total of seven times in the last 5 years; each time we review her pelvic control and running technique on video, and often she brings her new shoes with her and we take a look at them and discuss their design features and what that may or may not mean for her tissue loads at foot and ankle level. I have not once (rightly or wrongly) felt she was a suitable candidate for foot orthoses nor suggested she gets them.

Gemma has been the model patient. She always listens, she always does what she is told rehab wise, she eats well, she sleeps well, and she is outrageously motivated. This is evidenced by the fact that over the last 5 years, whilst maintaining her stressful job in the City, she has now completed well over 30 half marathons, 6 full marathons and very recently in Manchester ran a 2:59:37 marathon (6:51/mile pace) and was 14th female over the line.  She documents her journey on her blog and this has been shortlisted in The 2017 Running Awards (go vote for her!). Her Instagram account now has over 11,000 followers and she gets given loads of free stuff (that’s the bit I’m most jealous about in all of this!) I spoke to her on the phone recently to ask if she was cool with me writing this post and congratulate her on her recent PB – I won’t give away her future goals but lets just say she’s far from done yet.

What are the take homes from this story?

The human body is incredibly robust and adaptive; if you put in the work and do so smartly (and over the time period required) then goals are usually achievable.

If (when) you get injured running, don’t scan the internet forums looking for a quick fix – see a professional/s and adhere to the plan they give you (even if it isn’t what you wanted to hear).

Podiatrists don’t/shouldn’t just dish out foot orthoses like smarties; be wary of any professional who appears to be treating you like a wobbly table in a restaurant or a broken car.

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Book Giveaway…

To celebrate when my Facebook page hits 5000 likes I’m going to pull some books off my shelf and post them to someone (anywhere in the world). We did this when the page hit 4000 likes and are keen to keep it up. The books up for grabs for one lucky winner this time are:

– Physics Essentials for Dummies
– Mechanics of Materials for Dummies
– Structures (or why things don’t fall down)
– The New Science of Strong Materials (or why you don’t fall through the floor)

I mentioned back in a post on national book day how I thought we could all do with spending a bit more time learning physics and mechanics principles rather than just reaching for anatomy or podiatric biomechanics texts, so hopefully these choices reflect that.

Perfect for the Podiatry student or new grad – but don’t be tricked by the “for dummies” titles – something for everyone here and these principles govern every single thing we see and do in clinic from gait analysis through to foot orthoses provision.

So to enter the draw simply like my Facebook page (if you don’t already) and then tag THREE friends in the comments section of this post who you think may want to repeat the process in order to enter the draw themselves. Only one entry per person. Good Luck!

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Pain Science Resources for Podiatrists

If you’ve followed my Facebook page for long enough you’ll know I have a real fascination with (but a mediocre understanding of) pain, and in particular how we communicate with patients regarding this. We (Podiatrists) are definitely guilty of thinking too mechanistically most of the time, and sometimes probably at the cost of not adopting a biopsychosocial approach (that should be subscribed to with all patients given the current understanding of pain science).

My interest began back in early 2015 when I attended one of Mike Stewart’s excellent https://www.viagrasansordonnancefr.com/viagra-prix/ ‘Know Pain’ courses. I posted a copy of the notes I took during the course at the time here.

If you’ve missed other previous Facebook posts, there was this one from over a year ago which links to must reads from Derek Griffin and Gregory Lehman. There was also this incredible TED talk from Lorimer Moseley which I posted at the end of last year (if you only do one thing in your coffee break today make it to watch this).

More brilliant (and free) resources worth bookmarking are the downloadable pain flash cards from Ben Cormack.

Finally, subscribe to the noigroup blog as the regular posts there are brilliant and thought provoking. The image below is a brilliant table summarising target concepts and the blog it is from can be found here.

Just a few of the resources here that very smart people have been kind enough to provide for free to help less smart people (me!) to improve our understanding of this complex topic. Hope you find them as useful as I continue to.

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Podiatric Biomechanics: Is it going round in circles?

Back in 2000-2003 I was taught to assess a treat a foot according to a model/paradigm that was conceived in 1977. Incredibly cursory summary: it consisted of criteria of normalcy for the human foot and was a tiny bit STJ centric.  Fast forward 40 years to 2017 and students are still being taught it as the primary approach to foot and ankle biomechanics.  Whilst it should still be taught in a historical context (as the quote at the bottom of this post affirms) there are significant enough flaws with it that it is certainly surprising it is still the front runner.  Sadly, this then transfers to practice where a large proportion of the profession subscribe to these rather outdated concepts, which are easily refuted with even the shallowest of dips into the evidence based waters.

The work from Dr Hannah Jarvis’ PhD is something that needs to be taken notice of.  Some of the papers published by the same team from Salford (here and here) should also be essential reading for all students and graduates alike. However what is even more fascinating is that almost these exact same concerns were documented in an excellent edition of the now defunct Australsian Journal of Podiatry Medicine in 1997 – the halfway point in this four decade story.  Professor Menz has kindly uploaded a PDF of this entire edition to his blog and I can’t recommend reading it highly enough.  For me, it is eye opening to read something which was published before I even began studying the human foot and for it to challenge everything I had been subsequently taught.

What does this tell us? Well, it may seem like we are not making any progress. Are we to predict that in 2037 there are papers being published about this 1977 model being out of date and failing to stand up to scientific scrutiny? Despite this will it still be the prevailing model being taught and practiced 60 years on from its conception? Let’s hope not.

They say it can take 17 years for published research to translate to clinical practice. Well its 40 years and counting so far…

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Running Shoe ‘Drop’: The Latest Research

I’m a huge fan of Laurent Malisoux and his team in Luxembourg; they have published more work on running shoes than any other group in recent years. The ‘drop’ of a shoe (the colloquial term for the heel height differential) has become very popular to discuss amongst runners, with some individuals and companies claiming there is an ideal or optimal – something anyone who understands human variation obviously finds difficult to accept. There has not been much data or research on this topic over the years, with claims usually being just anecdote (or marketing).

Just a few months ago Malisoux et al. published this paper in AJSM which concluded that overall injury risk was not modified by running shoe drop, but lower drop shoes could be more hazardous for regular runners.

This team now have 2 abstracts in for the IOC conference in Monaco which is taking place next month (16-18th March):

Part 1 (here) is an RCT looking at running injury prevention and risk, and again concludes that injury risk is not influenced by the drop of running shoes.

Part 2 (here) is an RCT looking at running biomechanics, and suggests that shoe drop did not seem to influence long term adaptation in running biomechanics.

In conclusion, dichotomous and inflexible comments made about the perfect drop of a shoe are not currently scientifically supportable…

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Foot Orthoses: CPD Lecture Summary

I had great fun last week at the excellent free evening lecture series that is put on by London Sports Orthopaedics in the City. Amazing location and food (and a free bar…) Get to these in future if you can.

It was a pleasure to speak alongside Consultant Foot & Ankle surgeon Mr Abassian who gave brilliant talks on metatarsalgia and when to consider imaging following ankle sprain. I promised the organisers I’d send them a list of the main points of my talk for the 60 or so people who attended (or for those who couldn’t make it) so I figured I may as well post it here too.

Final comment: Thanks to big Trevor Prior for coming along and being a friendly face in the crowd, not giving me a hard time during the Q&A panel and for capturing the photo of me in what looks suspiciously like mood lighting.

KEY POINTS:

It is 2017 and we are duty bound to be evidence based practitioners (and rightly so). This means not believing things just because they have always been believed, and not doing things just because they are always what have been done.

The longest standing and most widely subscribed to theory/paradigm/model for how foot orthoses ‘work’ is that they re-align the skeleton to vertical (STJ neutral); a suggested definition of ideal or optimal. There is also the suggestion that these effects will be predictable and consistent regardless of the person using the devices, with orthoses seemingly exempt from the well accepted concepts of subject specific responses to interventions.

There is no suggestion in the literature that orthoses work in this way. No published (or unpublished) work has ever supported the contention that this is the case and there is good data available strongly refuting this theory. Visual, observable, measurable, angular changes (i.e. kinematic changes) with orthoses use are unpredictable and may not occur whatsoever; if they do they are likely to be incredibly individual (and again unpredictable). For this reason consider the limitation of drawing strong conclusions from research which mean pools its data – in future we will hopefully see subject specific data being published.

Despite this we know that patient outcomes are (usually) good and their feedback is (usually) favourable. So how can they work without looking like they work? (Or without working as we were all taught they should?) The current evidence base suggests to us that orthoses are far more likely to elicit their effects via altering kinetic parameters (forces) – something we have historically ignored in favour of focusing on kinematic patterns.

Forces can (and do) change within structures without an accompanying positional change necessarily occurring. Hence they can work (in a clinical outcome context) without looking like they are doing anything (with respect to kinematic change).

It is therefore inappropriate (in my opinion) to refer to orthoses as braces or arch supports; they should instead be considered as simply another arrow in the quiver of ‘load management’. Our clinical reasoning process for recommending them (and our habits when prescribing them) are probably more appropriate to be performed within a tissue stress/load modification model rather than the goal for every patient to try to be ‘re-aligned’.

Be careful not to throw the baby out with the bath water: the message here is not that foot structure and dynamics are irrelevant. It is to ensure we do not look at only those in isolation without considering loads/forces.

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Golf & Podiatry (Walking Vs Swinging)

There are some companies which promote golf specific orthoses and/or footwear; the rationale for which being the undisputed difference in demands of the front and the back foot during the golf swing. I also receive emails from other Podiatrists occasionally saying they are not comfortable seeing golfers as they aren’t familiar enough with swing mechanics, and asking me what ‘special tests’ they may need to do.

Whilst I have always been a very firm believer that you should completely understand the demands of a sport to treat individuals who play that sport, this for me raises an interesting point – do you need to know about the golf swing to effectively treat golfers with foot pain?

When you look at the stats in the image here, you can see that on the European Tour last season tournament golf consisted of significantly more walking than it did swinging (perhaps Mark Twain was right after all). So why would we consider ‘optimising’ a golfers foot level environment for 5 minutes of a 5 hour activity? Now arguably these 5 minutes spent swinging are the most important 5 minutes (particularly if this is how you earn your living), but would setting things up for this jeopardise comfort or increase injury risk for the other 4 hours and 55 minutes? It just might do.

A few further considerations of course, and as always it comes back to the individual and the history taking. Is the golfer a tour professional or do they play 18 holes once a week in between work and family life? There will be obvious differences in volume here, and we should be mindful that professionals will also spend hours hitting balls on the range each day compared to amateurs (so swinging with no walking at all). Would professionals therefore require different orthoses prescriptions for practice than they do for play? They just might.

A useful question to ask golfers (of any standard) is when they experience their foot symptoms the most. In my experience the majority of them will usually prioritise the walk as more problematic than the swing itself. This, combined with my crude maths shown suggests (to me at least) that ‘golf swing optimised’ footwear or foot orthoses have next to no place in the sphere of the amateur/club level golfer and that if you understand walking, you can probably treat this level of golfer with confidence.

Golf Infographic

 

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New Year… New Injury?

overweight-runnerI was back in clinic today after a nice break and it probably won’t be too long before the January injury rush which I tend to see annually. People often turn to running as a quick, simple and cheap way to turn over a new leaf from a health and fitness perspective or maybe just to burn off some festive excess.

We know from the work of Drew & Finch and from all of Tim Gabbett’s research that if we deliver a load to the body that it isn’t prepared for then things often don’t go well. However, the literature also identifies some other risk factors for injury:

– No running experience [here]

– Previous musculoskeletal complaints not related to running [here]

– Previous running injury [here, and here]

– High body mass index [here, and here]

Danish researchers have purported that those with a BMI of over 30 should not run more than 3km in the first week of their training or their risk of injury greatly increases. And data from another group in Denmark suggests strength training (historically avoided by https://www.acheterviagrafr24.com/ runners) can reduce overuse injuries by 50%.

Therefore, if we find ourselves in a fortunate position over the next several weeks where we are screening people before they commence their resolutions these are the things we need to probably be discussing. As the famous joke goes; What is the biggest risk factor for running injury? A: Running. The risk of injury is never zero, but with good load management principles (and if possible getting ‘fit to run’ before just starting running to get fit) we may be able to mitigate some of the risk.

Happy New Year!

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