I'm, I get excited anyway about anything relating to musculoskeletal care and full orthoses, but what we're going to talk about today, I'm, I'm really like genuinely excited because some of these questions, you know, we, we probably won't find all the answers, but at least having some discussion.

I can't wait to hear kind of some of some of your answers.

But before we get into to the podcast, could you, you know, explain a bit of your journey and your background and kind of how you got to where you are now and then also what you're doing now?

You want a short of the long story.

Well, I, I want the long story because a lot of this comes in like what we're going to talk about kind of philosophy and ethos and I, I don't know.

I mean, I, I really like, I like, I love movies.

So if you could make it, you know, a bit like an action movie where you come from this, this and then change and then go to the better.

But yeah.

And I I like the long story.

Long story.

So yeah, Podiatry here in, in Quebec, Canada.

Quebec is the, I don't know if you're aware of our situation in Canada, but we have a French province which is Quebec, QC is a French speaking province surrounded by English speaking people.

So we have the English, English speaking Canadian and we have also the US at our S border.

And here we have starting in 2004, we started a DPM program doctorate in podiatric medicine.

So it's a fairly new profession here, Podiatry.

So I discovered Podiatry late until like 18 years old.

I just, I was shuffling the, the books of the university to try to find a program and I was thinking about physio, maybe a physician.

I was not sure.

And then I, I saw Podiatry and Oh yeah, maybe it's a good fit.

And so I started my Podiatry program in 2010.

And at the end of my Podiatry program in 2014, I decided that I wanted to do more.

I, so I thought of maybe going back to school for another 10 years to be a physician, to be a surgeon.

That was one of my thinking.

But I, I don't like, I don't like to step to step back.

So I wanted to go forward and I at the time, I believe the best way to go forward was to do research.

So during my 4th year, so it was a little, a little bit crazy at the time, but during my 4th year, I decided to start a masters during my DPM.

So I was doing my DPM and a master for punishment.

Yeah, it was crazy.

I would not recommend to do that, but I started master's Why?

Because I always thought that during my my my training technicians will always tell me that fluorthosis are magic.

Magic is not the maybe not the the correct word, but they were great that you can prevent stuff.

You can treat other other diseases.

So I but, but when I looked at the literature, there was something wrong.

What the clinician were telling me, I couldn't find in the literature.

So with my naive student of mine at the time, I just told myself I will prove that fluorthosis work, which is the worst way to start a master's.

And so I started studying fluorthosis and one thing led to another.

I started a PhD and then I I did a postdoc, another postdoc, and then finally I found a job as a professor here at the University of Quebec, Atroya in Canada.

And I've been a professor since 2020.

December, in the middle of the pandemic, I started my career and it was a challenge.

So recruiting students during the pandemic was a pain.

It was very hard.

Well, I struggle for a bit, but then now I think I'm good.

I have like 11 students, I think 6 PHD's, 3 masters and two postdocs.

So I'm keeping myself busy.

I think that my team is strong.

We're publishing nice stuff and I'm proud of my team.

We're doing good stuff for that.

Related.

So that that's my long, long short story.

So yeah.

And now I'm here with you.

Yeah.

So, yeah.

So I'm assuming you've got all the answers that you were asking in 2014.

You've solved everything.

You've solved the magic.

Why?

They're magic.

Yeah, of course that's, I will.

I will tell you my secret.

Well, honestly.

And I, I saw that you started a PhD recently.

I saw that on Lincoln.

And yeah, the sad thing about research is you start researching a topic and you find one answer and 20 questions.

So I have so many.

Questions.

I've heard that, Yeah, yeah.

Did when, when, when you went through like school in in like 2010 or 2014.

Can you tell me, I guess, and it probably is a little bit more influence from your background prior to that, but how were foot authorities taught then?

And did you find you were just really interested in them and, and how they worked?

And, and you just kind of what you get told, you know, like, hey, Yep, the foot rolls in, you pronate, this goes there, you don't pronate.

That's what we're trying to do.

And that's kind of the end of it.

And it kind of makes sense.

So you just kind of agree.

And then as you get out of school and start looking to literature, talking to people and thinking a bit more critically, like, oh, hang on a second.

So what was kind of your journey there?

Yeah, I will start the root method.

So pronation is evil.

You should put the the feet in a neutral position and in the cast.

Then on the orthosis, the foot will be in this position.

It will be optimized.

You will limit compensation.

So I will start the root method and I will start that photos.

It can prevent flat feet in children.

You can prevent Alex Valgus and all this stuff.

So I was kind of disappointed when I started reviewing the literature because I had to relearn everything.

I, I wouldn't say that my, my training was not good, but definitely it could be improved.

And I think that now I'm teaching in the same school.

So, so maybe I'm biased, but I think the the course now is, is a lot better.

But yeah, I was kind of disappointed during the first let's say 3-4 years, I had to relearn everything.

And it's it's harder to relearn something that learning correctly the first time, so.

Yeah, yeah.

Did you, did you find that when, when you were going through it and now looking back on it and, you know, kind of critically thinking around, you know, root theory and, and let's just say for, for just kind of simple terms, you know, the, the sub tailor joint being in neutral, among some other things.

But if we look to a bit broader and in other research, you know, it makes a lot of sense.

Like, you know, this posture cause your pain, you know, your, your hips are out of alignment.

It it just makes sense on that kind of kinesiopathic model.

And it's similar with the foot.

We like things as human beings to be straight.

You know, your foot rolls in, it's not straight.

Of course, that must be the cause of your, your pain.

Like do you think that's why it held true?

And then second to that, what we're doing with foot orthoses, it's not a, it's a, it's a pretty safe treatment.

Like it's not like a knee replacement.

So you can kind of go through these things and think critically.

And then what we end up finding is, you know, even if you do correct a foot to neutral, you're probably going to unload the tissue anyway and how it's helping.

It's probably just not in the way that you're still thinking.

I mean, why do you think it still holds true so many years later?

Or do you think we just don't have any other better theories or understandings yet?

Yeah, that's a good question.

I think it's not a Podiatry problem.

They they have the the same problem with physio.

For example, a couple years ago then there was a phenomenon called the the Nevalgus in running, for example.

It was the cause of all the all the running injuries.

It was thought that that that was the case.

But we know now that maybe it's not the case.

It looks great to be straight.

So I think that's the main problem because we want everything to be in order, straight and efficient.

But the problem is the human body adapts to to everything.

So if you pronate, you will have, for example, thicker medial ligament tendon to the ankle, you will have stronger tendon, you will adapt, you will change your mother pattern to adapt to this.

And maybe we, we overestimated the, the, the, how can I say that the, the importance of being straight and we did not take into account all the mother control theories that maybe we're more modern.

It's kind of new.

It's like 1970 eighties going forward and all the the alignment theory goes back 100 years ago.

So maybe that's why we are stick to this pattern.

But I think that it's kind of fading right now.

I don't know about Australia, but here we talk less and less about alignment and more about function.

What about in Australia?

I'm curious what's the current way of thinking?

It's still, it's still root theory because we still like and just basically putting the, the subtailer joint and neutral and having the foot kind of revolve around that.

I mean, my which would be, you know, great for for you to kind of pick that apart.

The way I I teach and think about it is, you know, understand, irrespective of obviously, you know what's happening, communicating to the person, having them understand what's happening, understand the tissue.

So diagnostically is the tendon, the bone, the joint, understand what loads are most likely to provoke that and then choose the appropriate materials and then optimize and adjust and change just like we do with exercise.

But rather than saying with every condition, it doesn't matter it's tip post big toe or shin pain or anterior knee pain, you know, we have the the neutral subtiler joint.

And obviously that can can help because when, when you're, I guess you're thinking of your selection.

And I kind of wanted to, to ask this because this is the question that come up the most when I put it out to the spear of, of LinkedIn, but also to Instagram, where I post a lot more and I put this question out to thousands of people.

The most common question that that kind of came in is the, the, the critique from clinicians is that the research doesn't the scripting in the research doesn't represent what they would do.

So someone comes in, let's say, and I'm sure you've heard this 1000 times, someone comes in for heel pain.

The control group gets maybe a simple off the shelf.

The other group gets a custom contour device 3 mil thick, let's just say with a, with a covering on top.

And then the clinician says, well, I wouldn't do that.

I would do a medial flare and this various posting and I would do a 2.5 here and I would use poron and heel aperture and all these different materials.

So the research hasn't asked what I would do and I, I see it work in my clinic.

So of course it must be beneficial.

So I just wanted to ask you, I mean, there's no better person to ask like, why, why is that the case?

Like, why does it need to be like that in research?

And you know, a bit of your work is obviously changing that with your scripts becoming more individualized, but what's the problem with that?

Yeah, it's a, it's a really good question and I've been asked this question a lot.

We published a paper in early 2025 with three colleagues.

Try to just put that on paper about this problem.

Yeah, I'll link that below.

I've read that.

I'll link that below.

Perfect.

It wasn't editorial for In the Foot.

I think it was 1000 words, not a very long paper.

I wrote this with three colleagues, perhaps you know Ian Griffiths.

He was one of the co-authors and two Canadian collaborators, Dominique Shikwan and Kelly Rum.

And I, I think that I'm very, very well put to answer this question because I, I have the both ads.

So I'm a clinician, I'm a part time clinician, but I'm also a full time researchers.

And the three co-authors on this paper, the, they are full time clinicians and part time researchers.

So we tried to answer this question.

And if if we go back a bit in clinic, the problem with only evaluating our treatment based on patient outcomes is that there are many, many biases.

The first one is let's let's use an example.

If you have a plantar heel pain patient, you prescribe fluoridosis, the pain is 10 out of 10.

You see the patient two months later and the pain is now 50%.

So you have a 50% reduction in pain.

The logical way of viewing this is saying, oh wow, my orthotics were like very good.

The pain reduced by by 50%.

But when we look at we take a closer look, we may notice many other covariates that are not possible to see in clinics.

The first one is time.

Most musculoskeletal disorders will heal on its own without any treatment.

So that's the first one.

The second is the placebo effect.

When you use a treatment, put orthosis or any other treatments, there is a placebo effect that can help alleviate the pain.

In research, what we do, we use a control group to just to make sure that the effects we are looking for for the photartosus are not biased by the placebo effect by the time by other treatments and all this.

So usually the outcomes in clinics are reported to be higher than in research.

And one causes this is in clinic you don't control for these covariates.

And also I don't know about you in, in Australia, but here patient that are not satisfied won't come back.

So when you at the end of the the month, you, you assess your, your outcomes and you oh, yeah, I have a 90% success rate.

Yeah.

But the 20 patients or the 10 patients were unsatisfied or just did not come back.

So you it over inflates your your success rate.

But I understand what you mean.

But when you say that most clinician just want it will criticize the orthotics we use in research.

And I know the struggle.

I think the same thing.

I think the especially for custom devices, I think that in most studies, the the devices that are used are generic.

Often they are a glorified prefab.

So basically it's a, it's a, a molded device, but without any features or personalized features.

So that's why I try in my research to evaluate most of the time two or three devices just to compare to see how how photo artosis will react within two or three foot orthosis will react for the same population.

Because I don't think that the literature on custom foot orthosis is perfect, or at least I'm not sure it's I can call it good.

There are a lot of good studies, but there are a lot of bad ones out there.

But why we do this, we try to homogenize the the foot orthosis is to control for covariates.

And as of 2025, we don't have any prescription guides to follow.

So when we will have a guide, it will be very, very easy just to follow the guidelines and say for chronic, for foot pain, we need this kind of fluorthosis, we need a top cover, we need something softer.

But we don't have that in 2025 S basically every researcher is taking the decision.

And sometimes researchers don't have a clinical experience, so they rely on what they see in the literature.

And sometimes you just take a, an article from 2010, you do the same thing.

You don't correct what they did wrong, so you just push that in the future.

So I need that we, we need guidelines to better help researchers and clinician.

And I think that we should include more clinicians in research, in clinical research on phalartosis.

I think that it's missing because they have the the the enzyme experience and most researchers don't have that.

Yeah, I saw that.

I'm sure it was your study.

I I, I referenced you and I included in a recent a conference presentation that I did in a recent course where you had a group of comparing it was just shoes.

I think it was a custom device and then you had a custom device with a big medial flare and maybe a four or six mil heels dive.

Was that and you were looking at the kinematics in I'm sure it was a dotted quine flat foot.

Is that right?

Were you involved in that study?

Yeah, yeah, yeah.

I mean that, I mean, that's a representation.

I mean, like, yeah, but that, that that's what I would do in the clinic.

Like I would do a medial flare, a sky, a deep heel cut relatively 3 to 4 mil.

Like, and that's, and I referenced this in, in the course and for people online as well to say, you know, it is, it is getting better because that's getting closer to what, you know, what we would all do.

And correct me if I'm wrong, you would know better than I that was shown to to I mean change the most amount of ankle frontal plane kinematics, isn't it?

Yeah, and.

The flare, yeah.

And when I look in the literature, the, the, the most studies variable is rare foot a version.

Historically it's been the, the variable that is evaluated.

And in our study, it's not that one, but we published a similar study I think in 2024 and we observed a, if my, if I remember correctly, it was a six degree reduction in, in rare foot aversion with the custom, the, the custom custom for dortosis.

But if we look at the literature, the average is 2, maybe 3.

So I think that with a good device, we can achieve more kinematic effects than with only molded devices.

So maybe if we publish more good quality studies on kinematics, effects of thrartosis, maybe we'll see more effects.

I'm I'm convinced that they will never realign the lower limb like we we used to believe.

But I think that the kinematic effects of furarthosis may be underestimated.

I'm convinced that if we publish more high quality studies, kinematic studies on furthosis with better orthosis, that are more personalized to the participants we recruit, we will see more kinematics effect.

I'm convinced that they will never realign the lower limb like we used to believe, but I think that the kinematic effect may be underestimated in the literature.

Yeah, Now the big question and you know, we are and myself and Ian Griff, I did a 2 hour podcast on this and it took us about this long to get to to this question.

But tell me, how do you think they work?

I want to, I want to ask, sorry, two questions to that.

How do you think they work speaking to clinicians?

And then if you were speaking with a patient and they said, you know, what are you doing?

What is this treatment?

How would you explain it?

That's a big question.

Actually, that's my life, my last question.

Just answered it.

Just 20 seconds if you just keep it simple and show it.

If you want a simple answer, deep push onto the foot.

That's pretty much like the simplest answer I can give you.

But honestly the the most honest answer to this is I'm not quite sure if you were.

You asked me this question in 20/20/14.

I would have tell you that it's 95% mechanical effects.

I don't agree with this anymore.

I would say that it's one third, one third, one third.

So 1/3 mechanical effects.

They push onto the foot, the medial arch, they they redistribute plantar pressure.

If they push enough, they will have a an effects, an effect on joint moments, and if they push more than that, they will induce a change in movement or position.

So that's the mechanical part of the mechanism of action.

The other part is the sensory somatosensory effect, proprioceptive effects.

We as podiatrists underestimated these effects for a long time.

And I must disclose that I'm not an expert on these effects.

I have a colleague in Wilford, Laurie in Ontario, Canada.

She did her PhD on this Kelly rub and it's a hold on the other world.

So it's very complicated.

But I think that they stimulate the mechanoreceptors under the planter aspect of the foot and they induce some neuro changes to proprioception and all that stuff.

And I'm not an expert in this part.

I will try to become an expert on this part, but I'm more biomechanically oriented, but it's very, very interesting.

And the other third is the psychosocial or psychological effects.

I think that they induce A placebo effect, for example.

And I don't mean a placebo effect in the in a pejorative way.

I think that at the end of the day, what you want is your patient to be satisfied.

And if it it has to come from a placebo effect, so, so so be it.

I'm not saying that you should prescribe photosis with the aim of inducing A placebo effect, but I think that's part of the game.

So that's part of the old whole program of prescribing photosis.

And I think that all this should be merged together to have a good effect with photosis.

And for patient I, I go a lot simpler than this.

I just saying you, I will place a fluorthosis under your foot.

It will change the way plantar pressure affect your foot and I will redistribute the load.

So if you have a tissue or something that is overloaded, I will take that load and I will put it somewhere else.

And, and that's pretty much what I do, because I'm not talking about realignment anymore, because I used to do it and back in 2014 when I thought that furthosis realigned the lower limb.

But I, I think that it just keeping the myth alive that furthosis realigned the lower limb.

It's easier for a patient to grasp this information, but it's not inadequate and it's inaccurate.

So we should not do that.

Yeah.

So you, you mentioned you, you have, so you have material that applies a force.

You know it has application with the foot that applies changes planter pressure if it's enough, it can induce some changes to the joint and then to the tissue.

So based off that, does that then mean this kind of there is this threshold for planter pressure application?

And if we assume that, then a custom device would always be theoretically superior because it should be able to have more of a force application than say an off the shelf device.

It's a little bit softer.

That's a good question that would be nice for podiatrists because I won't like you.

It's very lucrative for podiatrists, but I think it depends if you, I like to, to use a tissue stress approach and if you're near the, the, the, the threshold of, of pain or tissue injury and you just need to reduce the low, let's say for 5%.

But if you want to reduce 5% of the load under the metaparsal heads, for example, you can very easily do this with a prefab device.

You don't need a custom device.

So in that case, if you prescribe whether whether you prescribe prefab or custom, you will have the same outcome.

Yes, you will be able to reduce more effectively panter pressure with a custom device, but it's not necessary to achieve a positive clinical outcome.

So in that case, no, I I wouldn't say that custom device is superior in terms of clinical effectiveness.

However, it will be more durable.

So if you plan on having your patient aware of the fordartosis for a long time, maybe you should go straight to custom devices.

But if you want to have them more aware diarthosis for a short term period, you shouldn't go prefab all the way.

But if you have a very injured patient, let's say we talked about adult acquired flat foot earlier, you have this, it's a very debilitating disorder.

It can go South very easily.

You should go all the way custom from the beginning because if you go prefab and it's not enough, the patient can deteriorate very easily.

Yeah, yeah.

And I think, you know, we were saying, oh, fair, like my custom to prefabricated ratio and it was probably 5 to 5:00 to 1:00.

But even just it's almost like in scripted in the way that we say, because we say prefabricated, but I think I was so in showing your picture and you might have seen on my LinkedIn, I'm customizing it to that person in front of me.

Like if they have a saw tip post, I'm putting heel wedges, I'm putting thicker material in through the MLA.

I'm basically playing arts and crafts.

So we kind of call it a customizable medical grade orthotis and then like a custom made to the to the foot because that's always their critique from people as well as a custom device is always going to be superior because it contours the foot and it's going to be more durable and basically stiffer to that cyclical compression.

But you're kind of saying, you know, there's a threshold that's probably a little bit lower, which we can probably reach with a medical grade device.

But then also saying that it's not this those dependent relationship where the more you offload automatically, the more the tissue feels better.

Like you can't just say because you've got 20 with an extra, that means 20 with an extra reduction in pain.

It doesn't kind of work like that.

Yeah, it's a good, it's a good question.

I'm interested about your thought about this.

What do you think?

Well, it doesn't, I mean, it doesn't seem to hold true.

Like I just I looked at other other treatments and it doesn't seem to hold true for exercise.

Like if you have a sore Achilles, without a doubt, there's a therapeutic threshold and there's kind of a maximum safe dose.

But if you feel better with 10 doesn't mean you're going to feel better with 20 or 30 or 40.

And we're kind of dealing with with tissues.

But then in saying that if you put someone in a wheelchair, it does take their foot pain away because they don't have any load through there.

So the loading it is important, but I don't know how we can how we can.

Do that, I think the problem is we are not able clinically are in research to really evaluate the tissue strain because to do this, we need to put sensors into the, on the, on the tendons, for example, or the ligaments.

And to do this, you need to cut open your patient or your participant.

So it's not feasible.

So what what we do is we estimate the tissue strain with surrogate measures such as ankle reversion, ankle moments and and all this.

So we estimate what what is happening, but we are, it is an estimation.

It's not the, the reality, or at least it's not 100% precise.

So in clinic you have a patient with Achilles standinopathy, for example, and you don't know the actual strain on the tendon and you don't know the, the, the limit of this tendon.

Is it, I don't know like X Newtons or or Y Newton, you don't know.

So that's why you will always, always have trials and errors in clinic or in research because it's it's not feasible in 2025 to estimate the actual load on a tendon or ligament or plantar fascia or or namethan.

Yeah.

And do do you think there's a big window of effectiveness for different devices for the same pathology?

If you took 10 people and every variable was the same and you had 10 different clinicians or prescribed different devices, you know, they probably all have relatively similar outcomes because you know that there's just a big window.

It doesn't have to be as precise, you know, to the point of of a degree.

Yeah, I think the window is quite large.

It's larger than we like to believe because I'm teaching the course on photoretosis to Podiatry students here and I'm amazed.

Every year I want to go to that.

That would be awesome.

How's your French not?

Very good.

I just have the translation now.

I saw Apple just released the thing on your earbuds.

You can have it translate for you in real time.

Yeah.

So maybe I could do it?

Yeah, it's actually quite extensive.

Of course it's 40.

I don't know.

It's 60 hours of theory and 30 hours of lab.

So it's a pretty extensive course.

Yeah.

What I was saying about this course.

Yeah.

And at the end of the theory part of the of the course I'm in the exam, I always put like two or three cases and just prescribed for thoratosis.

And every year I'm so amazed about the, the, the variability across prescription.

And most of them get it right.

So they don't take the same Rd.

But at the end, I believe that the devices will help the patient so they get the points.

And in in real life, it's the same thing.

So maybe, for example, you like EVAI don't like it, I put plastic and we'll get the get the same result.

Maybe you like to wedge your for tortosis.

I don't like it.

I want to put a calcaneal hill sky.

Maybe I like to put a medial arch over the medial arch pad over the arthosis.

You don't like it, You like to wedge your arthosis.

Maybe you like poron.

Maybe I like plastizac.

So there are so many roads to take.

But at the end of the day, most of the time the arthosis works and the clinical outcomes is very similar.

But that being said, if you prescribe a very, very thin foot arthosis for a adult acquired flat foot, it won't work.

But there are there is a big window of possibility to achieve the same clinical outcome.

Yeah.

And what do you like, what do you use as a, a gauge for like when you're, I love this question.

I, my, my heart rate's rising.

I'm so excited to ask you this question.

How, how do you determine the, and what we call it correction, Albeit I never use the word correction ever.

I just use it because that's what podiatrists have used.

I just call it the dosage or the amount of material.

How do you determine how much to do?

Like let's say you have a give you a case adult acquired flat foot maybe.

And let's say we do our neutral and neutral and resting calcaneal sanitation.

Again, truth be told, I don't do that in the clinic because I just use the material and and kind of increase and decrease the dosage.

How do you choose your prescription?

How do you choose your rear foot?

Why do you go five degrees 8° and how do we, how do we get better at that?

How much time do you have?

Yeah, it's yeah.

It's a good question and I don't, I don't have a really like specific answer.

And because my, my answer would be it depends on the case and if I take a step back usually or historically we we like to prescribe fluoridosis that are comfortable.

We like the fluoridosis to be like walking on clouds and all this.

I don't believe this and I'll explain why.

I think that historically food orthosis were prescribed for long term periods.

You would prescribe food orthosis patient will wear them for five years in order to prevent musculoskeletal disorders.

So in that case, I understand the need for the orthosis to be comfortable because as a patient you will never wear fluorthosis that are that uncomfortable for a long period of time.

That's just not feasible.

But as of 2025, we are moving towards a, a new paradigm of wearing fluorthosis, maybe for shorter term or at least that that's how I practice.

Let's say I have a patient with adult acquired flat foot.

If I, if I'm, I think the example of my, myself in 2014, I would have prescribed A fluorthosis for life.

Now my my take would be to prescribe an exercise program for let's say three months, prescribe Fluorthosis for let's say three to six months.

And after that I will try to taper off the foot orthosis for a couple of weeks for the patients to remove them.

After that.

I don't want to the patient to wear foot orthosis as a as crutches and I don't like the word crutches, but that's why I put the quote on quote.

Yeah, yeah.

So I want the patient to fully recover and to fully recover you don't need any assistive device.

Assistive device.

So that being said, if footarthosus are not meant to be worn long term, I don't care if they're not 100% comfortable.

I don't want the patient to feel like they're walking on rocks, but if they are, they have a little in comfort under the medial arch.

To me, that's not a problem because I'm always say telling my patient, what do you want?

Do you want to be comfortable or do you want your pain, your, your, your disorder to go away?

And most of the time they want the disorder to go away and they don't mind being uncomfortable for a couple weeks if they allow them to be cured or the disease to go away.

So I, I tend to go full blast for this kind of pathology.

So I tried, I go to the maximum level, I think it will be wearable.

And then if it's unwearable, I just trim down the photos.

But I know, I know it's not the case for many podiatrists.

It's not a popular view of our prescribed photosis.

But I'm not a very patient man.

I like the disease to or the disorder to go away quickly.

So maybe I have a more drastical view of photosis, but that's how I I tend to practice, but I always adapt to the to the patient.

If I have a old lady, no fat pad, very frail, I will use my common sense and prescribe maybe a more comfortable for duartosis, less, less correct corrective device.

No, I don't know if it makes sense to you.

Yeah.

No, no, it does and it's going to make sense.

The people that listen, because that's exactly how I prescribe it.

And I've I play arts and crafts a lot.

Like I adjusted an increase and decrease the dosage where I would rather, you know, let's say for adult acquired flat foot, I would, you know, I would rather start a lot higher knowing that I can reduce it in a couple of minutes.

I can just reduce the heel post.

I can reduce the lift, I can reduce the thickness or if it feels comfortable, I can add that on.

And I'm just really forthcoming with my patients of I don't know if you, if you use any analogies, but I like the analogy of like we're using this like Panadol for a headache where you wouldn't take Panadol for every once the headache goes away, we can use that less.

But I wanted to ask you and I wanted to, to pick your brain on that.

With a daldequined flat foot.

There seems to be a bit similar to osteoarthritis.

There really are these physiological changes in the tissues to the tip post tendon, to the deltoid, to the spring.

You know, usually there's some associated osteoarthritis as well.

And you, you can certainly go through the rehab program and build that strength that, you know, doesn't seem to have the same adaption kind of curve and cycle as me doing some biceps when I muscle adapt really quickly.

And it's OK.

And I tend to find that people, I always, I never say they're in them for life, but I say we're more likely, you know, based off what I've read for to be more comfortable in these and if your quality of life is better when you're in them.

We try to come out of them maybe, but some people are just happy to be in them.

And the reason for that is the tissue Physiology is, is different.

So do you find that with your adult flight, adult acquired flat foot cases where some do just like, you know what, I, I feel better in it and I, I've tried all the other stuff and you know, my, my tendon just won't adapt because insufficient.

And I have, you know, Midfoot Lai.

I think the adult acquired flat foot is a is an old on the other world.

You won't approach approach this pathology the same way you will approach a plantar heel pain.

And I I don't know if you're aware of the newer terminology.

I think, I think we exchange on on this online.

Yeah, we did and you were.

So just to be to be clear, like I appreciate that.

But you you because I was being critical of the old terminology and then funny full circle, I think you were being critical of how I was saying because I don't call it adult or quiet.

I'm sorry, posterior tumult head and dysfunction.

Because, you know, I want patients to understand it's kind of a continuum that involves more than just the tip post ligaments that come above the ankle.

And I only say that because I do a lot of Ritchie braces and I kind of use that as justification as to why.

But yes, tell me, tell me new terminology and tell me why I'm wrong.

No, actually I like to.

Learn.

I love to learn.

Yeah, actually I think that PTTD is a is not a good terminology for many, many reasons.

I think, I think that adult acquired flat foot is not a good terminology for many, many reasons.

And I think that progressive collapsing for deformity is not the perfect terminology for many reasons.

So basically what I'm telling you is that it is a pathology that we don't know a lot about right now.

And yeah, all terminologies have their their shortcomings.

I it's quite funny because I exchanged emails with the group.

I don't remember how they call themselves the progressive collapsing for deformity consensus group.

I think I just received an e-mail during the night.

Yeah, the, it's a group that they published the 2020 paper on the terminology and now they have published 15 papers on this.

It is led by Caesar de Caesar Neto and Mark Myerson.

So actually we wrote with the the time difference, they wrote me at 4:00 in this morning, this morning.

So I haven't read their their emails.

But what I like about the new terminology, it's it's more precise.

What I don't like about the new terminology it is that it's too precise.

I think that there are there are 242 possibilities of classification within new terminology.

For example, if you're 1A1, you can be one A1B1AB1ABC1C1.

Wow.

So it's very, very, very extensive.

It's so it's hard to use in clinical context.

It's hard to use in research context.

It is more precise, but it is hard to use.

So that's why I wanted more specification on the the classification and I read it diagonally.

I think the other they have an interesting point of view, but I think it it should be improved and I think it's more surgically oriented than clinically oriented.

Yeah, it is logical if you because a new terminology.

For example, if you're 1A, that means the pathology is flexible and the deformity is located at the rear foot.

In surgical context, it's easier to choose the adequate surgery.

You have a, if you have a erythal valgus, you want to correct this, you, you will use this pathology.

If you have a mid foot abduction, you will use this surgery.

So it's easier.

But in clinical context, if you want to prescribe exercises or you want to prescribe food orthosis, it's hard to use.

So that's my critique about about this this classification.

And what I don't like about the adult acquired flat foot is I think it preserved the myth that having a flat foot is a problem.

So that's why I don't like it.

And the PTTD terminology, I mainly don't like it because we now know that the posterior tip tendon is not the main driver of deformity.

They published the the the consensus group.

They published a very interesting paper with MRI and CD scans and they showed that for many cases the foot flattens without involvement of the PT tendon.

So the PT tendon is intact but the foot flattens and the all the deformities happen.

So that's why I don't like the PTTD terminology.

So I use the PTTD terminology.

In most of my recent research.

I didn't like it.

I use the terminology because I I just like less the adult acquired flat foot terminology.

But I will most likely change my terminology to the new PCFD terminology.

I think that as researchers and clinicians, we should try to follow the parade and homogenize the way we think and the way we discuss pathologies.

And I just don't remember the question because we took it so.

Yeah.

Well, I wanted to know like say you said in that case, you know, let's say that tip post isn't involved and let's say it's more ligamentous and there's some maybe there's some cartilage changes and maybe they have some early, you know, osteoarthritis change.

Or let's just say they've got some moderate to to later stage away.

You know, the theoretically it would make sense, you know, that the adaptability of of cartilage, you know, is different to a nice healthy, say muscle to a nice healthy tendon.

Where these people might just benefit from wearing these foot of those used despite going through a good quality resistance training protocol, maybe looking at their weight management, getting back and being exerciser healthier, eating better, sleeping more.

And I do find on average that these cases, you know, they they might just feel better despite doing all these things compared to say planning heel pain or maybe just a cranky tendon that settles down.

You know what a 35 year old runner say You know, usually the case is we see for myself is 5060 year old female, higher BMI waist girth, other comorbidities present not that active anyway.

The foot become painful.

So their activities even less for some other hormonal stuff going on.

And it's a lot to try and and tell them to come out of this earlier when there's all this other stuff going on and it allows them to do more, but not saying we shouldn't do that.

But I do see that a, a bit of my critique of, of other professions is sometimes and probably the barefoot community, like you need to get out of these things as soon as you can.

Yet when people try, they're just in pain.

And we don't have to know any, any way based off the research to bring them out of it.

But it is challenging because of what's happening on a tissue cellular level.

Yeah, actually in that case, I, I'm not against patient wearing foot orthosis for life for example, because at the end of the day, what we want is the the patient to be happy to be able to go on with his life without pain, with an appropriate function and all this.

So in that case, if when they wear fluorthosis, they are comfortable, they can do what they want, without them they are not able, why remove the fluorthosis if that's what keep them active.

But if I go back, if you allow me, I think that as a, as a profession, we tend to do recipe.

For example, if the literature tells us that for this pathology, you need to prescribe this kind of exercises, you need to try taping.

And then for our Tosis, we tend to just take that and and use it that.

At least that's what I'm seeing here.

But if you have a adult acquired flat foot patient in front of you and it's fairly recent, you don't see any weakness in muscle force or anything like that.

Proprioception.

Proprioception is good.

It's not altered.

If you don't have any like equinus or things like that, why do you prescribe exercises?

I don't think that they will be very, very useful.

So in that case, I will mostly focus on low management education, shoes wearing for dirtosis, choosing activities to avoid exacerbating pain, for example.

But if I have the same patient, hip weakness, plantar flexor, ankle Panther flexor weakness, you have an equinus, you are unable to stand on one foot because you don't have an adequate proprioception, then I will focus a lot more on this.

And if I take your example, if you have this patient, the PT tendon is injured.

It's you have a partial rupture of your tendon, you have a seal arthritis and if you prescribe foot orthosis for this, most likely you will not restore the 100% function.

So in that case if they wear foot orthosis, it replaced this lost function and the patient is able to do what he wants with foot orthosis.

A a patient wearing foot orthosis that allows allow him or her to be active is a lot better than not wearing foot orthosis and try try them to be active.

The consequences will be a lot less damaging to wear foot orthosis for a long term.

Because I know at least here we have a debate, an active debate that foot orthosis should not be worn long time, long term because it'd be weakened defeat.

It'd be weakened the muscles, the tendon ligament.

I don't agree with that.

I think that perhaps for active patient, let's say you, you, you look at fairly healthy and active.

If you wear foot orthosis, maybe there's a chance that it will weaken your foot structure maybe and I'm saying maybe, but if you're injured, you've been injured for two years or three years, you decrease your, you decrease your activity level from let's say 50% because you are you are in pain.

If I prescribe for lortosis to you and it allows you to to be more active, I'm pretty confident in saying that your muscle structure and your foot structure will will be strengthened with the wearing for lortosis for the long term.

So I, I think that we should be careful be before just throwing statement like this like foot orthosis, weakened feet, it's more of a case by case basis.

I think that we should approach this.

Yeah.

And how do you, how do you create your foot authorities, let's say a custom device, how are you scanning?

Are you casting, are you casting the four foot to reinforce, you know, creating the MLA?

What?

What does it look like?

Yeah, actually we changed our system for a 3D printer pretty recently, so in March.

Do you have a 3D printer?

Yeah, We have a, we have a, we have a full lab here because I'm not working in private practice anymore.

I'm, I've, I've done clinic, private clinic for five years during my PhD, but now I'm working 100% here at the university and we are very lucky.

We are one of the few universities around the world with a full lab for otosis, lab dedicated to research and dedicated to the Podiatry clinic.

Wow.

So you don't need a research tech.

I'll just get on the broom.

I just want to say it.

I'll just sweep.

I'll sweep up at the end of the day.

That would be awesome to see that.

Place that's so cool you shouldn't come visit.

It should be fun but it's very far.

I think it's a 30 hour flight from from Australia so but yeah, you should come.

Yeah, so you're scary, but you were gonna say you have, you have an Australian over there.

You know what you said.

No, no, no, no.

Actually, Kylie Williams, I don't know if you you know her.

She's yeah, yeah, yeah.

She's coming over next month.

She's giving a speech in Toronto.

It's nearest like 5 hour drive from from here.

And I invited her here to give a conference to students.

And then the day after I'm organizing a, a conference day with the Quebec College of Podiatry.

And she, she's giving a speech and a, and a workshop.

Cool.

But yeah, going back to the lab, we, we changed everything for a,

we have the form labs fuse 1:30.

I don't remember what printer we have the fuse sift and the the polisher it cost, it cost us like 20 two $100,000.

So it's quite expensive purchase, but we are very happy with this.

And so yeah, starting now or like in May, we started scanning the feed and 3D printing for thoratosis.

And how do you scan them?

How do you?

Scan.

Yeah.

How do I scan them?

I, I, I'm very conservative.

I use the, the root approach.

So I scan the feet in neutral position.

I correct the forefoot to neutral and I, I go from there.

And the reason I do this is very, very simple is when you look at the literature, like 95% of what was what has been published in the past 30 years, they use this technique to take the mold of the feet.

So if you change the way you scan or mold the feet, maybe the literature is not representative of what you're doing.

So maybe you cannot use the literature the same way.

That's why I use the same technique.

I know it works in the sense that I know that patient are satisfied, the arctosus are comfortable.

I know that I can achieve what I want in term in terms of outcome.

I know that foot won't be on neutral position when they are on the device, but it doesn't matter to me because that's not what I, that's not what I'm looking for.

I'm looking for clinical outcomes.

I'm not looking for biomechanical outcomes.

Yeah, yeah.

And tell me, tell me what goes through your head and how you teach someone, give you a perineal tendinopathy comes in and you need to create a custom device.

What goes through your head and understanding what you're going to do And also just how thick you're going to make the material?

Is it based on what you've done before?

Do you think about the tissue and the load placed upon the tissue and then using material to do that, you know, based off BMI and foot type?

Because you know, we're saying that like, yes, the foot type, you know, it's it's important in the sense that we need to see how it moves and functions, but we're not trying to correct it to neutral, but certainly electrally, electrally loathing more immediately, sorry, laterally deviated subtitled joint and putting more pressure on the outside.

It's probably going to need quote on quote, a higher dosage of material or more material to have influence over that foot.

You know, if it if it's flexible.

So how does Someone Like You who's read it all and teaching it?

How do you How do you do it?

It's a good question because if you look at the literature, you won't find anything on this pathology.

It just doesn't exist in the literature.

So it's always a challenge to teach this to students or colleagues because I have nothing to to show them.

I can't show them.

And look at these three articles.

It will tell you what to do.

So my approach is to go back to the theory of foot function and foot artosis.

So in that case I will use the.

I would use the tissue stress approach.

So my goal is to reduce the load on the parallel tendons.

How do I do this?

By pushing onto the lateral part of the foot, inducing an inversion moment or a pronation moment.

Usually as I said, I would use the root technique to mold the feet and I will put everything all the the correction or the the features in extrinsic.

So I would pronate the device, I would add a cuboid notch, for example, or I would increase the yield cup height.

So I will do everything extrinsic because I'm a big fan of using the same molding technique.

And I will use, I would use my knowledge on what the foot orthosis do during gauge, during locomotion.

And I know that for example, having a lateral wedge will increase the pronation moment.

So if that's what I want to do, I would add a let's say a 5° lateral wedge on the foot orthosis.

So that's how I approach the this kind of cases because I just can't look at the RCT what they did and copied their model.

It just doesn't exist in 2025.

Yeah, it's amazing.

And I guess credit to the to the people that are critical of the research like that they are right in some respects.

If we don't have the, you know, the perfectly genuine, if you look to like, you know, the ACL, there are their books and curriculums written on every single stage post operative.

Or if you do the cross bracing, Yep, six weeks to the 6 1/2 to this.

If they can't do this, go back to here, they can't do that, go to here.

Like it's so prescriptive and which makes a lot of sense, but you know, in the foot authority's world, not so much.

So do you, how do you think around footwear as well and how that has influence over the device?

You know, you can only use it, you know, in in shoes and shoe technology, as you would know, as has come a long way, especially with the new technology in mid soles and you know, the the amount of return and and depth in the shoes.

So do you do you typically recommend an athletic job guard?

Do you recommend, you know, a kind of dress shoe?

What do you find yourself even teaching as well?

Like you're saying, don't put too much in the device if they're going to go into a more stable, you know, thicker shoe that's potentially more quote UN quote supportive.

Yeah, actually I think that as podiatrist we don't fuck focus enough on the shoes, or at least maybe, maybe not here, because I find that most patients with chronic musculoskeletal disorders, they don't wear proper shoes, or at least it's not optimized in my experience.

So if the the shoes they are wearing is not good or very, very not good, I will first start by asking them to buy a new pair of shoes.

I'm not a big fan of recommending a specific brand.

I don't like to have this conflict of interest.

I will tell them about the features I want the shoes to have, like for example, let's thick sole, A rigid sole, have laces and everything that you know for sure.

And then maybe I will show them a couple models just to make sure that they know what I'm talking about.

And if they wear proper shoes and don't work, that's where I will prescribe for the orthosis.

And I will make sure that for the orthosis can fit in because I'm not a big fan of down grading the quality of the photo orthosis to fit in their shoes.

If the shoes can take the photo orthosis, the problem is not there, the orthosis it's the shoes, in my opinion.

So I will tell them that for you, you need this can this model of furtosis and it won't fit in your shoes.

You have two choices.

You change your shoes and I prescribe the adequate furtosis and your chance of success will be very high.

Or I try to fit the furtosis into your bad shoes and most likely it won't work, but you'll you'll have to spend a couple $100 on a device that won't work and explain like this.

Usually they take the option of changing their shoes and but, but I I'm still human.

I I understand the context, the financial the financial context.

This sometimes by buying a pair of shoes like let's say $200 in a photo orthosis, a pair of photo orthosis $600.00.

That adds up to a lot of money.

So sometimes I try to accommodate them, but if I see that they can, they can buy a new pair of shoes.

I will emphasize that I want them to change shoes 1st and usually they want to get better so they they they change shoes.

But I find it more difficult and and people where working in offices or women working in like not not fashion but in in work that they need to be dressed more.

I don't know how to say this.

Work.

Work specific, yeah.

Basically just low volume, narrow, Yeah.

Shallow depth shoes.

Exactly, Yeah.

So in, in, in those cases, I don't have a choice but to reduce the size of the foot orthosis.

But I specifically tell them you take a a good device or an excellent device and maybe it will only be good or OK device because you need to remove a lot of correction to fit it into your shoes.

Yeah.

And do you think, do you think we're going in the in the right direction with material science?

Like, I don't know what, what material, but you use, but over here it was, was polypropylene went to PA 10, had some fractures and we went to PA 11 and that's what we use the majority P11.

I don't use a lot of Eva other than off the shelf devices.

But PA 11 like which is this or which is this here?

You know, it's, it's about 10 to 12% stiffer than polypropylene for the same.

Oh, you know, you know what, you know, tell you what, I never thought in my life I would be exchanging for all those here on camera with someone at this time of the day.

So that that's cool because it's thinner, but it's still, you know, 10 to 12% roughly stiffer.

So do you think technology is getting better and moving in the right direction to get, I guess where does it go from here?

Just getting even thinner and still stiffer so we can fit more or maybe increase the dosage more.

Actually, maybe it's a it's an hot take, but I think that there there has been little evolution on photorethosis therapy in the past 50 years.

Like across the board.

Yeah, across the the whole world, because I think that 3D printing photorethosis is an improvement and a significant one, but not on patient outcomes on manufacturing.

I think that it speeds up the process, it reduces waste.

For example, it's easier to replicate a device.

So for the manufacturing part, it is an evolution and a big one.

But a plastic shell is a plastic shell regardless of how you may you make it.

So if you use polypropylene and you mold with a positive cast or you 3D print a device, a plastic device is a plastic device in my opinion.

So in terms of patient outcomes, I think that since the 1970s with the root devices starting I, I, I don't think the devices evolved in very significant way.

I think that we are more than due for a revolution of how we about the devices.

I'm not saying that they don't work.

I'm saying that maybe we should focus on the next revolution on photoretosis.

But the sad part is I don't have the good idea of what's the what the revolution will be.

Perhaps it's not plastic at all.

I'm I'm, I'm I'm not sure, but I don't know if you follow the literature or the what what is happening with the diabetic foot ulcer prevention on with foot orthosis with the, the, the orthosis that gives you feedback on the, the pressure.

There's a company in the USI think it's called Orbix.

They published in RCT with these foot orthosis.

Basically you wear a smart watch and you have sensors on the photartosus and when the pressure reaches a certain threshold, you have a warning on your watch saying, hey, the pressure is too high, you should change the way you walk.

So that that's very good.

That's.

Amazing.

Yeah, it's called or pics.

I have no conflict of interest with them.

I actually, I don't know them, but there, there's an RCT that, that was published a couple of years ago.

And I don't want to say stupid things.

I think there, there there was a 67% reduction in, in rear acceleration, but I, I'm not sure.

So don't, don't take this for granted and verify the, the, the numbers, but the, the numbers were pretty good.

But I think that we could maybe use the, this technology for other musculoskeletal disorders.

Let's say that you have a a chronic 4 foot pain, you don't want the threshold to go higher than let's say 200 kilopascal.

You could use this device and you will have the same warning saying hey, you're over the threshold, I don't want you to go over.

And I think that could perhaps improve patient outcomes.

Same thing with let's say adult acquired flat foot.

If you wear sensors on the foot orthoses or maybe on your, your ankle, your foot, you could maybe evaluate the OR estimate the load on the, the medial ankle and you will have the same warning on you're watching, hey, that's too much.

You need to decrease or you have done too many steps in a row, you need to take a break or I don't know.

I think that maybe we should take out a think outside the box on how we prescribe Fluorthosis and maybe it's not a purely mechanical device and maybe it's adding technology to Fluorthosis, but I'm thinking out loud, I don't have anything that.

'D be awesome because it would basically just be like a progressive program, just like we do with running like run until you get some discomfort, stop, rest, run a little bit further the next time It could, it could be like that, you know, with our device.

And do you think you know, at the moment there's, there's a move towards in, in Australia using plan of pressure, mostly just plan of pressure treadmills and just seeing where pressures are and seeing the impulse and things like that.

And then trying to maybe use potentially footwear and foot authorities to see how that changes because you get the raw number.

But my, my critique of that is for the people I'm seeing in pain, I just use what they're telling me.

Does your second metatarsal feel better when I do a deflection with APMP and a heel lift in a nice shoe?

And that's my outcome, although not validated them just telling me it feels better.

Do you think we need the pressure and do you think that makes our intervention better to think outside the box or just to evaluate how what we might do differently?

Yeah, it's a good question.

And maybe I'm a little biased because I purchased a a Zebras platform for hypothetically.

I was talking about.

So zebras is exactly what I was talking about.

Yeah, yeah, yeah.

So a colleague of mine, they, they distribute it here in, in Australia and, and I think it's awesome.

I'm just, I always want to be critical of both sides because you know, it is, it makes logical sense.

But similar with, with exercise and testing the strength of the calf.

It's not having a strong calf that's, that makes you better.

It's the act of getting a strong calf.

So it's, it's not so much you need to know the output.

I just know you need to do the exercise.

So, yeah.

What do you think for the plan of pressure?

I think it's not mandatory.

You can have a a very successful practice as a podiatrist without having these technologies.

I think it's useful, but we should be conscious that it's not the the truth in a sense that as you said, at the end of the day, the important part is how the the patient feels.

However, what I like about this technology is you can document the progression.

Let's say you you prescribe a met pad, you document a 10% reduction of plantar pressure under the second met head where the pain is.

You see the patient like 3 weeks later, the pain has decreased only 10 or 20%.

So you will try to move the pad to get to 20% and then you try for another couple weeks and then you see, OK, the threshold is this size, the pain went away after a 20% reduction.

And then you can document your clinical treatment and, and at the end you'll, you'll see what works for your patient and what works in your in your clinical context.

And in that sense, I think it's useful for you as a clinician to, to see what works, what don't work and you can understand what you do clinically, what, what it really does to the foot of the patient.

So it's, it's teaching you a lot about, about the link between devices, modalities and the biomechanical effects and the clinical effects.

So, so it is useful.

It's not mandatory, but to teach student I, I, I think it's very useful because they, they understand a lot better.

But you are a, a trained podiatrist.

You've been practicing, practicing for a few years.

So these road to the, the, the, the, the clinical outcomes, they are well made.

So you're good.

You don't have to do it one more time or or at least you should know this by now, but when you start your career I think it it could be important to to understand this better.

Yeah, yeah, I agree.

I think the the the two things that I wish I did when I started was understanding the modelling how full orthoses are made because then you can picture it in your head and how it fits the foot and all that type of thing.

And then second to that would be pressure and data and seeing how different devices and choose have influence which which would be important.

So do you, you know, in clinical practice, sorry, in your at the, the university and with the students, do you do a lot of grinding and adjusting and changing and adding pads and covers and all that kind of thing as well?

And do you, do you encourage that?

If we're dealing with human beings who are varied and we can always only take our educated guess on how they're going to respond, we need to be able to make these changes.

If we need to kind of, you know, increase or decrease, Do you, do you encourage that?

Do you do a lot of that?

What do you think?

Actually it's changed, it changed when we started 3D printing for thoratosis because one critique I have about 3D printing is it's very difficult to modify the device compared to polypropylene chill with the neuron pose for example.

It was very easy if the post was not comfortable to just use an E gun and tear it apart.

It's it took like 2 minutes.

Now if you want to grind the pose, it takes forever.

It messes all your grinder because it melts.

So now we try to teach students to be more precise about their prescription to try to avoid modifying them.

But all modification are done by students and here because we have the lab, we have a certified arthatis with us full time.

So student can go with with him, learn about modification and he's always there to just look at what they are they're doing, improve their skills.

So we are very lucky to have him here because students are getting very, very, very good at manual skills, all about modifying photorethosis and they do everything.

Everything we do in the clinic, it's done by students, supervised by podiatrist or by our orthotist.

Yeah, yeah.

And when, when you're giving a sorry, when you've given a prescription, do we have any data on internally how much these joint angles are changing?

Like if I prescribe a 10° device, let's say 10° roof and post PA 11 with a 20 meal heel cup with the goal of influencing the sub tailor joint.

You know, how much do we actually really influence the joint, you know, because if we're saying we're correcting it from 10°, either, you know, to neutral or neutral calcaneus.

What?

Yeah.

What do we have all that, if anything?

Actually, I'm, I'm working on that right now.

That's my, my goal for the next couple of years to try to be able to predict the effects of photosis and to better determine what we should do.

I don't know if you read our, I think it's 2024.

We we wrote a paper on this supination resistance resistance test and the effects.

Of was that with Ian?

What was it on this paper?

I'm not sure.

Maybe.

Yeah, actually I've published so many papers in the past two years and I don't remember everyone.

Perhaps Ian published a couple of papers with me on spination resistance, but we it was with the Sean McBride.

I don't know if you know him, he's a physio based in the US.

Yeah, maybe I can remember the outcome because the outcome was, it was correlated, wasn't?

It yeah, yeah, yeah.

So the outcome where the the main outcome was that with this test we can predict how one will will react to photo orthosis therapy on the lower limb bio mechanics.

So if I summarize, the greater the supination resistance the the lesser the effects on roof with aversion.

So basically if you have a patient with a great or very high supination resistance, your device need to be more aggressive or corrective.

Yeah.

So, and this paper was on adult acquired flat foot, but we published a similar paper on only people with asymptomatic flat foot.

So basically if I go back to the clinic, if I have a patient with adult acquired flat foot, I will, I would do the supination resistance test.

And let's say the value is 20 kilos.

That's a lot.

That's very, very a lot.

The, the average is more like 10 to 15.

That's the the average we see.

So that's a lot 20.

So I would prescribe a really, really corrective device, thick shell rear foot and fore foot post and I, I would incline the the the post in the I would add a medial wedge and I, I would go full blast straight from the from the beginning.

But if I have the same patient, the supination resistance test, it tells me that this spination resistance is like 8 kilos, which I don't think it's feasible for or possible for this patient.

But let's say it is.

I would probably just prescribe a thin shell and perhaps a riff of POST because I know that the device will be very effective biomechanically wise.

Yeah, yeah, it's, it's interesting.

I mean, so for me I would probably get like 3.8 mil.

Like how thick are you talking?

When when you say how thick?

I think in our study we we use a four, 4mm four.

Yeah.

Yeah, but it's harder with the the 3D printer.

It's it's harder to print a a thicker shell.

We had problem with our modelling platform over 3.5.

We we are getting errors in the the models.

We need to work on that.

But yeah, definitely I'm not afraid of using it for 4mm.

Yeah, I don't know if you've read some of the old, old opinion pieces from like Doug Ritchie and and Kevin Kirby and and another set of light they were doing with Polly 3 1/2 four four like they would call.

And I've got this as a poster in the course.

A4 mil for someone 100 kilos is semi flexible or flexible for some cases.

Like they all go on really thick and it makes makes sense of how much weight goes through that.

But you know, you've got to obviously be aware of of comfort and things as well.

Yeah, but yeah, actually I wrote to Kevin Kirby before undertaking this study.

I'm exchanging emails with Kevin Kirby like, you know, let's say 3 or 4 * a year.

The fun part when you e-mail to Kevin Kirby and it gives you a lot of lecture to do when you write with him.

But he's very generous of his time.

So I like to e-mail him when I have the chance.

But he told me that.

For some of his patient, it would prescribe A5 or six millimetre thick shell.

That's a lot.

But I think there's a a geographical difference between or at least between Canada and the USI don't know about the about Australia, but here in Canada we focus a lot on a medial arch conformity with the foot.

We really, really, really make sure, yeah, that the contour is, is 100%.

And I've practiced in the US for four months during my externship in, in Podiatry.

So I, I went for a month, four months in New York and New York City to at the New York College of Podiatric Medicine.

And I at least what I saw back then is that they don't put the same emphasis on on contour.

Most of the time the the arch is flattened a little bit to increase comfort.

So if you decrease arch height, you decrease by by the same time the stiffness of the device.

So if you have a very iheart photosis in let's say 4mm polypropylene, it could be the same stiffness as a device with a flat arch, which is like 5 or 6mm of.

Maybe that explained the difference in thickness between the US and other countries.

That's an hypothesis I'm but I think that could be logical.

Yeah, I like that.

And it's, yeah, it's funny that kid I know like, and I don't know if you're on that study like where they did like the, the thick of the stiffness of the MLA and rear foot pose.

Well, like I will, I'll add a lot between pose and flares and plentifacture groove just to you add more.

It makes the device different for the same thickness.

But that, that's really cool.

We've got to get you over to Australia to deliver a lecture at our conference on on the supervisor.

If you have time.

It sounds like you're pretty busy.

Yeah, bring the family over.

Yeah, but actually next year I will be on sabbatical.

Actually, that might be perfect.

Yeah, but when I say sabbatical, people think that I'm not working, but actually it's a research sabbatical.

So basically my my teaching load and my everything around it.

Actually I'm 100% doing research.

So I thought of going to Australia for for a couple of years now.

I'd like to see your universities.

I'd like to see how you do it and do it.

But actually there.

So maybe I'll come and I, I think that I'm I told you about the I don't remember the what it's called.

You have AB annual conference, the conference.

Is it the a put a?

Put a conference.

Yeah, yeah.

And I saw this on LinkedIn.

I see the, the, the outline of the, the, the conference, the and I'm amazed the year after year.

I think that you have very, very knowledgeable clinicians and researcher in Australia.

So maybe next edition I will come.

I, I I'd really like to come.

Yeah, I got a last couple of questions.

But on that last point, how about this?

Just just think about it.

You fly over, I pick you up from the airport, you come and spend a day in the clinic with me and we just prescribe and we scan and we go out on the research into the treadmill, into the bio mechanics lab, and we create some foot authorities and then we can go out to the conference.

That'd be the goal.

It'd be awesome just to imagine sitting there watching a patient and we just talked through the prescription.

I mean, we'd probably talk for a couple of hours.

That'd be really fun.

Anyway, that's just a dream of mine, but I wanted to ask you resource wise and I'll have some of the papers we discuss, plus a link to yourself and, and some of your PhD students.

But if someone wanted to learn more around foot authorities and prescription, do you have any resources you know, for them to get an understanding?

Could it?

It's hard to, to find.

And this is the reason we, we had our foot authorities course was because if you wanted to go and learn around Achilles rehab or ACL or survived any headaches, it's easy.

You there's heaps of stuff, but not so much for foot authorities.

So what's your your kind of advice?

It's a good question because year after year I, I'd like to add a book to my course, mandatory book, book to for the students to read.

And but I don't think there's a good step by step book that allows you to learn about flourtosis.

So I think the best way is doing continuing formation.

Yeah, exactly.

Yeah.

Like, like, like you do the the training you give and there are many other training that you can follow as a clinician.

I think that's the best way to to be informed to learn about photorethosis because they're, I don't know any books that could be worth purchasing to to improve your your photorethosis skill.

You will see interesting information spreaded across many books, but if you take a look at my books in the background, I don't have a book on food orthosis that I would recommend.

So that's a hard question.

So you can read the literature, but but even then, if you start reading the literature, it will take you a couple couple weeks to get everything from this because you don't have a specific literature review that helps you better prescribe holotosis in the clinic.

You will have a an answer to a question, but you will have 10 more question after reading the article.

So you will go to another article, 10 more questions.

So when once you're in the vortex, you're in for a couple couple weeks and I've been in the.

Vortex for a couple.

A couple of years now.

Since 2014, yeah.

Now tell me if you could any 2 questions.

And I love the second question because it is relevant for you, because you're, you're doing research.

So first question, if you could view anyone you know, dead or alive, who would it be?

And then #2 if you could answer any question in research, fund any study, you have billions of dollars and there's no ethics involved.

Ethics will just be approved.

Everyone's given consent.

What would you do?

And and why would you do it?

That's a good question.

Actually, I think that I would like to speak to Merton Root.

Great.

Yeah, Yeah, that's awesome.

Yeah, yeah.

That's.

Awesome because I think he died in 2000.

I like to say 2002, I'm not sure, but in 2002 I was like 11 years old, so.

I was fine.

I was fine.

I wasn't in private private school then.

So Merton Root, it could be fun to because a lot of things that Merton Root said in the 50s aren't we now know that it's it was wrong, but at the time it was so groundbreaking.

So I'd like to know more about his thought process, how we came up with all these theories and because it was ground breaking.

And if I have like 10% of the impact he had on Podiatry, I would be very, very glad that would be that would be a good career for me because even like 70 years after, we still talked about him.

So he had a great impact, even though a lot of things that he said turned, turned down to be turned turned out to be to be wrong.

So Morden Rd.

will be my my my.

Personal You can tell you're a podiatrist.

There's no one else on earth saying I'm a podiatrist saying him.

Yeah, I, I tried to stick to Podiatry because.

Yeah.

And about research, if I, if I stick to my line of work and Podiatry, Yeah, actually that's a good question.

I think.

Yeah, yeah, maybe what I'd like to to develop is a, an algorithm that allows you as a podiatrist, as a clinician or as a researcher to predict the chances of of success of of adoratosis therapy.

Let's say you you put your age, sex, body mass, you scan the fee, you input the pastor injuries.

AI just computes this and tells you if you wear furorthosis, this kind of fluorthosis, you have a 65% chance of success wearing furorthosis with a margin of error of like let's say 5%.

I just study everyone if you want.

Yeah, that would be my dream, and honestly, I am.

I'm pretty sure it's not science fiction.

I think in a couple years I think it will be feasible with AI, you need a lot, a lot, a lot of data to be able to do this.

But with AII think it's not impossible that in couple years we'll be able to to have this kind of algorithm.

That would be very nice.

How nice would it be in clinic that you just put the info in?

It tells you, hey, you have a 95% chance of of success with the photartosis.

We, I think we should go with this and the patient will be very satisfied.

So that would.

Be do you think it?

Yeah, Would it, would it come up with the prescription for you as well?

What to do?

Yeah, yeah, yeah.

So now.

Question.

The second question to that do we still charge the same amount of money?

It depends if you develop the algorithm or not.

Yeah, Yeah, yeah, yeah.

Because that kind of takes away the, you know, the, the skill.

But I, I do like that that, that would be, that would be incredible.

That would be incredible.

But the problem with that, podiatrists won't have the same impact on the population as before.

Because if you have this algorithm, let's say you can as a patient, you can go online, just enter the information, scan your feet, and it will tell you you need this kind of fluoridosis.

And you don't need a podiatrist to to do this.

So maybe it will be good for patients, maybe it will be less good for podiatrists.

Did I, I don't know if I spoke about that on on LinkedIn or told you that, but they're doing something similar to that in Thailand at the moment where you can walk in off the street, walk on a planet pressure map or or treadmill.

And then it will just print you a device in the corner and print you just basically a contour device that fits into your shoe.

Yeah, which which is interesting.

Yeah, actually we had that in in North America.

I don't think it's a you have, you have this kind of Costco.

Do you know Costco?

Costco is a yeah.

Yeah, we got Costco.

They got big jars of peanut butter we like.

Costco.

Yeah.

So they did that at Costco a couple of years ago.

Really.

Yeah.

You just went there.

You stepped on a platform.

It took the planter pressure and actually the the print the the orthosis were not printed but it would tell you the models so are perfect.

You have flat fee just by 40 B and but they removed it because in Canada it's illegal Because in Canada if you want a custom device it needs to be prescribed by a physician or a podiatrist.

Yeah, we had something, we have something similar, but I'm pretty sure I actually heard this today.

It's funny, we do on the podcast, we have a store called the Good Feet and they were were very similar and they make a lot of claims based off some very, very poor data.

Basically like stop, you know, this is your back pain, your back pains from your feet, you know, your knee pains from your feet.

Just get these files and they're not custom.

They just offer generic of their 16 or so models and they just match you to the closest one.

And then, you know, you get them and they're thousands of dollars.

It's crazy.

We don't even charge that much for our customs.

It's unbelievable.

Yeah, yeah, yeah.

All right, mate.

Thank you.

Thank you so much for being so generous for your, for your time.

I hope you get to catch up in person one day and hope to have you back on the podcast as the new research is coming out.

But to keep up to date with what you're doing, is, is LinkedIn the best way?

Obviously your research, but you you post a fair bit on there about what's coming up, what you're doing and also what your students are doing.

Yeah, I try to to be active on LinkedIn.

I used to be on on Twitter and when it it changed for XI, just never went back.

Yeah.

But I think a lot of researchers just moved to to a LinkedIn.

So I think it's a good platform.

I tried to disseminate my my results, my projects on there.

So yeah, that's the best way to to see what I'm doing.

So, yeah, it was a pleasure.

Thanks for inviting me.

It was very, very fun.

I think you're very knowledgeable and it's always good to have, but that's just vulgarizing information.

I think it's necessary.

I think you're doing well, so Congrats for that.

Yeah, I really appreciate that.

I mean, as I said, it's not I don't know how many times it's been a lot like you're when people are critical of the research on full authority.

I just send them the papers that that you guys are doing because it seems, I mean, I'm sure there's others out there, but maybe, and it's just the right timing for where I am at my career.

But the, the clinically relevant information is always a critique always from clinicians to researchers.

And this just seems like it's bridging that gap and making it narrower.

So you know what, it's just a massive thank you.

And I can't wait to to keep up to date and also share with my audience as well what you know, what these these papers are showing in, in the papers as well.

Actually, I'm moving.

I'm moving towards a more clinically oriented research actually I have a RCT on the way on chronic for foot pain and foot orthoses.

So it should starts, it should start maybe in January and I am been striving to be funded.

But my goal is to do a five year RCT on foot orthoses, custom prefab and placebo foot orthoses on adult acquired flat foot.

So that, yeah, so I'm working on this, but the, the amount of money necessary is just crazy.

It's nearly $1 million.

So it's $1,000,000 to do to do this.

So.

But I'm pretty close to getting the money, yeah.

Yeah, wow.

Just in staff.

Crazy, if you think about it, just in staff.

You recruit PhD students and then let's say a research professional.

It's nearly like 200,000 a year.

So it's very, very expensive to undertake RCT and RCTs and that's why most RCTs on foot arthosis are short term like 6 weeks or three months.

It's it's so expensive, but I'm confident within a couple years you'll see RCT on the Delta Quad flat foot.

Oh, I'm pumped up.

Oh, you got big China.

You just left it for the Cliff hanger.

Well, hopefully I'll have to to have you have you back on after that RCT.

But that's awesome.

Thanks so much.