Welcome.

Welcome back to the Sports Medicine Project episode 120.

With me, you're stuck with me, like with us, and I'm solo.

Today I'm on my own because nobody wants to talk with me around football posters.

Now, I'm only kidding.

Plenty of people want it and we're going to have some really fun and hopefully good discussions in the next couple of months around this.

But I wanted to do a, a, just a short episode on trying to help other people understand, put off OCS.

And I'm going to give you an example.

If you're a podiatrist, you've got a pretty good understanding because utilizing them you wouldn't want a university level and you've probably done some courses or some further education on that.

But for other health professionals listening to this, I want to be able to help you understand how we as a profession think of them because we have so many similarities between, you know, whether it be exercise or medications or injections or surgery.

So custom put off OTS, that's non custom.

What are the differences?

When are they more indicated?

How do we make that clinical decision?

All those those types of things I want to be able to answer because for a framework to think around, if a patient comes to see me, you know, as an initial appointment and walk in the door, they sit down and they say, listen, I've seen this person, I've had Achilles tendinopathy being diagnosed and exercise didn't work.

It didn't work for me.

It isn't right, of course, for me to say, OK, then.

Well, let's you know, let's rule out exercise.

Obviously not going to work for you.

You know, my next question asked that is always going to be OK, well, let's go through and just see if it was tailored for you.

Do we get the intensity right?

Do we get the dosage right?

Did we avoid compression early on?

Do we go into compression too early?

And we didn't have that.

Maybe with some heel Wiz and some shoes.

So it felt a little bit better.

Do it more frequent enough.

Did they test you in the gym?

Did they watch you do it?

All these types of things that we need to to go through.

And I know that I'm able to evaluate that and, and kind of make the decision and then show them and say, hey, yeah, you know, you said you've done exercise with, you know, you've done stretching or you've done some heavy deficit calf raised into a lot of anchor dorsiflection and that just stirs up your tendon.

And that's means it's really hard for you to keep doing the exercise and you haven't got the consistency.

You've really struggled to then build the capacity and the strength and and maybe you've done a little bit too much of the passive and a lot of reactive or vice versa and able to evaluate and communicate that.

And I think without the health professionals, my experience online has been that potentially other health professionals don't have the tools or no one's really explained.

Like, yeah, this is how we think of what authorities and this is how I explain it with my my patients.

That's what we're going to try and encounter today.

So when we think around what are the principles and what are the, the kind of guiding bio mechanics we think of what are those?

Just like any other load modifier.

Just like when you tell someone to do a little bit less.

So there's not enough stress, you know, on that that tissue, let's say it's the tendon or you do a little bit less faster running, there's not much tensile stress.

And I want you to avoid dorsiflexion.

There's not enough compressive on the Achilles.

And I want you trying to avoid how many steps you take.

So when your heel hits the ground, start getting you a strong tissue can recover and your knees are on the GMI want you to to reduce your squat.

So your line is on how many times your knees, like the telephammel joint is going to be able to settle down a little bit quicker.

So we're just utilizing them to unload a tissue that is sore because we are thinking that that should be able to help the tissue recover better, which is an awesome bonus and get this person back to what they want to be able to do.

And secondly, it can help with with their their pain.

We're not trying to correct or change, you know, the foot because it's wrong and the foot's caused all these issues.

You know, the idea of trying to have the foot function in this person fix subtallergy neutral, always perfect position, although people can still get relief.

If I was to say to someone, I'm going to give you this off body and stop your pronated foot and it's going to be a neutral foot and you have associated tibialis posterior pain.

Guess what that's that's going to help that person, but it's probably not helping you in the way in which I think, and we see this anywhere else in posture.

You know, you sit forward for 50 minutes at a time, your neck and a weird angle and someone says, hey, fix your posture.

It needs to be perfect and you move and change it and it feels better a topic because the posture was wrong.

You just change the position.

You're probably putting some stress somewhere else.

You know, as the saying goes, your best posture is your your next posture.

So I'm not thinking around my orthotic design to to do this.

I'm thinking I want to take some stress off a painful tissue.

And then when we think of that, we can start to then move a little bit away from some of that.

The older theories, although we're still using a lot of the, the material science and understanding how the foot functioned.

Because although I'm saying I'm not trying to correct the foot from flat to neutral or, you know, from really lateral in caves to to neutral, I still need to have a pretty basic understanding of foot bio mechanics and how that functions.

Well, let's use the subtailor joint as an example.

If I just think, yeah, the subtailor joint just works in one plane, It's the sagittal plane.

We know it works in the, you know, it's triplanar.

It works in the transverse in the frontal and in the sagittal plane, but mainly in the frontal plane, which is going to be inversion and a version.

And if I'm thinking around how I'm going to apply force to that foot, if, you know, we've used the subtailor joint axis.

And I don't want to get too much into into that.

But if you imagine a line, imagine an imaginary line going in through the foot, It's on a bit of an angle.

And let's say it's going from the lateral to the medial.

I said, let's just say it's, it's going straight through the foot.

Don't be a little bit easier to to think about.

It doesn't go just straight through the middle.

But I want you to imagine that.

And this gives you an idea of of how we think we've kind of bio mechanics.

So the axis is going straight through the middle of the foot.

If I apply some force with my fingers on the inside and I'm just using the sub Taylor joint, I'm going to apply some force.

That force is going to be I'm going to apply a pronatory force that is going to supinate the foot or it's going to Ebert the foot and because of that road, that line going through there, imaging the foot's going to rotate around that.

And same will be said if I apply force on the on the outside.

So I still need to have an understanding of that.

And it's it's really beneficial when it comes to them thinking around, well, do we use full authority for everyone with with lower limb pain?

And of course we don't.

Can we think of the Achilles tendon?

Well, if I'm going to use my foot authority to have a lot of influence over the sub tailor joint and that inversion and aversion, how much influence not going to have on reducing the tensile force for a mid portion of Achilles tendonopathy?

It's going to have some, but it's going to have a lot and that's because of where the Achilles tendon insert onto the base of the calcaneus.

Now if I talk about the TBL posterior, that's a whole lot different.

If I think of where that inserts in the main insertion vehicle, tuberosity is The Cave forms if it's on the inside.

If I'm able to apply some force around the sub Taylor joint and reduce how much the pronator each guards on, basically how flat the foot gets, I can reduce that tensile strain and some of that compressive strain into the tip post.

And because the tip post goes past the ankle and and past the subtailor joint, and it has a big role to play when it comes to the subtailor joint, I'm going to be able to influence it more now I think, Well, I'm thinking again with the subtailor joint, the planar plate, or let's say the second or third metatarsal palladial joint.

If I'm able to influence the subtail joint a lot with the foot orthotic, well, how much is that going to influence the the planar plant as we get to push off?

Probably not a not a whole lot.

It will a little bit, but but not a whole lot.

So that's where this clinical reasoning and understanding I will come into to our, our foot authorities prescription and, and thinking, you thought if someone come to see me and they say, you know, I, I tried foot orthotics for my Achilles tendon, you know, great, we'll have a bit of a look.

And the main thing I'm worried about is like, do they have the heel less?

And I'm probably just going to give them a, an 8 pill heel raise and a hybrid shoe, whereas they come in and say, you know, I had the foot orthotic for my TBR posterior pain.

I want to be able to pull out that device and evaluate it properly because it can have a greater influence.

So I'm thinking or is the shell shape adequate?

Did it have a medial flare?

Did the heel cup at the back come up and up?

Was the material thermal?

So all these questions that they come into it.

So for other health professionals, you know, I'm gonna try and give you a couple of bits of information to at least about be able to evaluate if it's if it's adequate, because then very clearly a good quality evidence based treatment.

And they can can really help people be able to manage their symptoms.

That.

I mean, if you're looking at someone that's managing the low knee pain and they're spending eight hours on their feet or they're running fifty 6070 kilometers a week and let's just call it loading cycles.

Someone with compressive heel pain, if they're taking let's say 200,000 steps a week, every time the heel hits the ground, we count that as a loading cycle and that stress through the tissue.

And at the moment we can at least assume that they're coming in for us, the stress is too high for the tissue to recover.

So all we're trying to do is bring down that stress so it can recover and we do it in lots of ways.

We use cushioned shoes, we use taping and we might use a cushion unisole or a photophonic as as well.

So hopefully that that makes a little bit more a bit more sense.

We're using them to modify load, modify stress, let that tissue recover and then we can speak around, well, does that tissue still need the stress away from it?

And that's the question we're always asking and talking around with our patients, do you need this for the long term or the short to the medium term?

And we have that open communication with the patient.

I probably, I, I, I do get annoyed a bit online when I, when I hear other practitioners saying that they've been heard from their patients that yeah, that panache said I'm in the IT needs for life.

And I'm not aware for the people that I speak to that anyone is actually saying that and to provide some support for the maybe the people who are and to have some critique of of others when we are speaking around them, it's always a nuanced conversation.

We know very clearly the prognosis of some of these conditions.

The prognosis of planning heel pain is a whole lot better than the prognosis of midfoot osteoarthritis or adult acquired flat foot or CMT or someone with low tone hypermobility and a connective tissue disorder.

But they're very, very different.

And we have some clear research on this.

If someone comes to see me and they have heel pain that's been going on for a couple of weeks versus a disabling adult acquired flat foot structure actually change foot it.

It's a whole lot different around, you know, listen, this is probably going to recover within the heel pain and we can manage the symptoms, you know, and get you back to it before recovering on the other side.

We're doing the same thing, but we need to acknowledge the reality.

There's some changes in the Physiology of the tissue.

Your plantar fascia has a different adaption cycle to the joints that are osteoarthritic in the mid foot.

And you look at knee osteoarthritis.

If anyone sees anyone with an EOA, I'm sure you're not saying to them, yeah, we'll get this better really quickly.

It'll go OK, of course, we'll try, try to do that.

But there's some changes in the Physiology.

The cartilage is different.

We don't have replaces for cartilage at the moment.

And that's why people are getting near replaced.

And we have some other junks, which I'm not going to speak about, nor am I qualified to speak about our injectables and things like that.

But we can talk around, you know, managing comorbidities and weight and that kind of thing.

And we're still doing all that in the, in the foot, in the ankle.

But I want you to to kind of ask the question and certainly ask the patient, do you feel better using these foot authorities?

Like do you feel as though your quality of life is better?

Is your pain less?

You feel like you can get around more on your feet and we can certainly try and utilize them less.

We're acknowledging what's happening with the foot.

You have an understanding of what I'm saying and let's try and utilize and lessen and see how we go.

We can try and work on some foot capacity and strength, you know, building up a car, the footing trendy, getting some more time on feet.

But if we're trying to do this and you're really struggling and having a flare ups and you're getting quite down about it, we might have to utilize this a little bit more and it might be for the foreseeable future.

And here is why I'm saying that.

And that's different to what I'll say with other conditions.

So I would like people to, you know, of course, be aware that these cases are happening and we are working with these cases.

And this is what I'm saying with, with my, my patients.

Again, we're trying and hoping for the best, but acknowledging the, the, the realities.

We can't just say great, you're, you're not going to be in this for line or foot authorities are a short term, but to, to kind of counteract that as well.

There are cases where people probably are in football politics and they don't need to be.

And we have that conversation around trying to test your resilience and spending a little bit more time out of them and getting the foot moving a little bit more and the tissue a little bit stronger and more capable.

That takes a, a really, really long time people to do and of course we can do that, but people have a lot of things on their their plate and they can put this foot orthotic in their shoe and they feel a little bit more comfortable.

You know, I can explain the risks and associated potential consequences, which are quite minimal.

The the evidence is very mixed, you know, thinking what you tell me.

I'm aware of the research on footing foot intrinsic changes, some get stronger, some get weaker in there and everyone in the in the middle.

So we don't have any contensions on that.

But again, it's about the person.

If my mom had some heel pain and she felt better and a cushion her in her soul and she can do more walking and her quality of life is better and she's more active.

Like that's meaningful for that person.

I would challenge clinicians that are saying like come out of these two quickly to ask your patients and have that that open dialogue.

So there's there's merit to both sides.

I believe that more people can spend less time with them, and I also believe that some people, you know, are going to have a better quality of life.

But again, it's with the person in front of them.

I can never give, you know, general override and advice because every person I work with and I sit down without explaining their situation, We're talking through their situation.

And that's a part of being a good clinician.

So when you're thinking as another health, health professional and like evaluating floor posts, it's difficult because you don't learn around the the features and the shells a little bit too far.

This one's a little bit more flexible.

When does it matter?

This person's going to assess, avoid injury And am I focusing on the reinforce it's the arch manner or do they have something particularly different?

So I would encourage you to to look through some of the research.

I mean online socials at like sports because I'm trying to put this up so people can can evaluate.

But the way they can kind of think of it as with your device, you know, you'll have the midfoot, sorry, you'll have the rear foot, the midfoot and the forefoot.

And you want to have some features within those areas that are that are specific to the tissue.

Because what I'm thinking around my design, again, I'm not thinking making the foot neutral.

I'm thinking what are the affected tissue or what is the affected tissue?

What are the bigger loads that tissue is subject to and how can I reduce those?

So when I make that clinical kind of decision and move through those stamps, I can then start to use the next step, which is material selection.

And this is where the difference between custom and non custom come out.

So if I'm imagining I have someone come in and they have a pretty neutral foot type, and I'm going to explain why I'm saying why their foot type matter.

They come in with a pretty neutral foot type.

They weigh about 70 kilos and it's been going on for three months.

And let's assume it's those things happening.

Now I know how much they're going to be able to influence and load through that parental tendon.

We know the perineal what we want to do to unload that is I actually want the foot to pronate so I can unload and reduce that stress, that tensile and compressive stress in through that that tendon.

So it's really important that I have the right diagnosis.

That's very different.

Someone got a fibula stress fracture.

I'm probably not going to be using for all those in in those cases.

So I just want to be clear that we want to get the right diagnosis.

So I know that they can load because it's a tendon that's going to be different to a joint, which is a little bit more compression.

So I'm thinking, all right, how can I reduce those loads?

Well, if I just very simply use my biomechanical brain, if I just put lots of material on the outside or on the outside of the axis of the subtitle joint and smaller joints as well, I'm going to pronate the foot and I'm probably going to take some stress off that that tendon.

Now, I know it sounds really simple, but I'm saying it's simple.

So we can then start to add layers to that.

Now, of course, comfort, the big factor, I can't just stick some rocks in there.

Although biomechanically the rock should probably work, probably would put any pressure on there.

But I need to make it comfortable.

I need to make it fit into the shoe.

Let's say the same case comes in and I have a really cavis foot to have shocker Mary tooth disease.

They've got low tone, they've got no real stability around their ankle.

You know, it's a connective tissue disorder amongst amongst some other things as well.

And every time they walk, they really supinate their foot.

They have really caved and they're just overloading and I'm stressing gone through all the rehab.

They just can't get it under control to even begin and start the rehab because it's so sore.

Now in that case, I know to pronate the foot, I'm gonna need material that is firm enough and stiff enough to be able to make the foot move in the direction.

So I know I need that as one factor.

And then also I'm going to be the actual design of the authority to do something different.

So the standard non custom soles will come as standard nature.

They're not.

They're made to the average.

Whereas with the custom, I can make the outside border really ramp up and call that a lateral flare that comes all the way up the outside.

And that's going to provide some force to the outside of the foot.

And that's going to move some of the stress away from that tendon into the inside.

We're going to load, of course, the tip post the middle structures a bit more, but that's good because I can unload the tissue that is saw and we can also do some small things as well.

If we know the peroneal tendon is a plantar flexor, well then great.

How do I unload the plantar flexor?

I'll probably put a little heel rating through there and you can start to see how we build the design now.

I think well, where does the peroneus brevis run?

Well, peroneus brevis on the base of the 5th peroneus long, which comes on based on the first.

I think well, if the whole foot supinating real foot, the mid foot, they're probably going to be pushing off the outside of their foot.

So what I might do is I might put some material under the outside of their forefoot and that's going to encourage because when they push their like, Oh crap, the materials there, I have to move my way over to the big toe.

But then on that one as well, what material should I use?

If I use a soft cushion, it's probably not going to work too well.

If I use the hard, hard plastic, that's probably not going to be tolerated as well.

So I might use a a medium density evo, which is a good bridge between firm and soft.

Maybe it's the bigger person.

I might use a firmer or the worn something before that's had some material there.

I might go firm as well.

So I want you to just to hopefully understand a little bit how we think around, you know, design and, and what we might do and consider durations because I always explain it very simply so we can start to build from that.

But there's some complexity that goes into it.

That person comes to see the physio down the road and says, listen, I got this orthotic from Blake, custom orthotic.

Explain why I need it.

I need a more force application.

I do have somewhat of a deforming within my foot.

I've got low tone.

I need the material to be stable.

That's why I got the custom because.

Oh, great.

Yeah, that makes plenty of sense to to me.

I listen to that podcast that Blake did the sports medicine project.

He's a lovely guy.

How how do they say that?

So they pick up, oh, but it's so comfortable.

I don't like, I don't think authorities are working for me.

So what I would hope is that practitioner then say then that's okay, that that happens all the time.

I give people, I give my patients exercise programs and sometimes they flare up and they don't like it.

But I know it's not the exercise itself, it's probably the dosage.

Then I would would hope that practitioner pulls out that device and go, OK, you've got a firm material which you need to generate more force.

You've got a lateral flare, it comes up on the outside.

That's good.

That's going to provide some stability just like a brace would be getting the where does it feel uncomfortable?

And they kind of point to the forefoot.

And let's say the material Patrick goes off, the material doesn't feel very comfortable.

It feels too thick, doesn't fit into my shoe.

And hopefully that the practitioner on the PC goes, Oh yeah, that's fine.

They can adjust that.

That will take them like a couple of minutes.

We can they can adjust the dosage just like I adjust my car phrase prescription.

I might have given someone 20 and made them sore.

So I'm going to give them 10 or I told them to run 5K and they got sore, but I don't have painted 3K.

So I might say, let's run 2 kilometers.

So as a recommendation, say, yeah, great, go back and see them call out the clinic and just say, hey, I've had a problem with my O 40 and come back in and help me out and they'll be able to come back in and I can adjust that.

True.

So I can adjust it in 5 minutes.

All I have to do is grind down the material.

I have the tools within my clinic and it might be me taking one meal of that out, put it back in.

How does it feel?

Yeah, it feels good.

By truth, it's good, but I still have some of that stability or they put it back in and go it's way too full.

I take it all off me, put it back in.

That's OK.

I'm just adjusting and finding that that dosage.

And then you can start to see how we utilize them just like any other other treatment.

But the the idea of the customers non custom, I can still have some force application or that material do something to the foot with a simple off the shelf device that I've built in to support and I've customized it to their presentation.

We kind of call them a, a medical grade customizable foot authorities.

I can, I can still do that.

But if I'm thinking durability and long term and then being able to provide more support, I can theorize in my mind, it is probably going to be superior.

And as an example, if you are, if you just pick up a bit of material in front of you, pick up something that's soft and something that's that's firm, the firmest stuff holds it's it's.

When you try to apply pressure and it's just a classic deformation like for for bones, I mean, if you've got a stick and then you've got a a bit of, we'll call it so like cushion from a shoe and you try and bend the stick, it takes more force to bend the stick compared to the cushion.

So the same thing when someone's applying your force to that with their foot, it's going to take more force.

So we're going to be able to oppose some of that force and hopefully unload the tissue and it's all coming back to unloading that the tissue.

If someone with that supinated foot is really now pronating, but they're feeling really good, their quality of life is better and they're feeling comfortable and everything else is going OK, we'll, we'll awesome.

That's that's the the goal.

And again, we can adjust that and change that.

And sometimes I'm not saying overcorrect because that's not a good term because we're not correcting anything.

If they say, I feel like I'm putting two more, sorry, too much weight onto the inside.

That's fine.

That's that's OK.

I'm just I just took my best educated guess.

Let me just adjust the outside of it so we can have you feel a bit more even.

I don't care about yourself tailored.

Don't neutral British, I just I care about what you're saying to me and then I can I can hopefully start to have that person understand what I'm what I'm doing.

So as a, as a general framework for people to think about, you know, when we might consider a custom over a prefabricated medical grade customized full authorities.

What I'm kind of thinking is what I mentioned before, we might be talking around, you know, deformity.

So if someone go out and don't decline flight forward and their foot has structurally changed the ligaments, the soft tissue, their tendons got some insufficiency and it's just not doing their the work that it needs to.

I might think I'm going to need something that's got more stiffness within that material.

Durability is a big on working.

You know, people in the Army, their devices are going to be subject to a whole lot of different rain and mud and everything kind of else.

So we need to be to make sure that we're getting that right.

If I'm managing someone with a stress factor or MTSS in the tibia, I'm trying to use a plantar flexor load, my heel lift and whatever I'm doing to the device, which would usually be something on the medial side because the plantar flexors are on the inside and they'll do a little bit more than the ones on the outside.

You know, I want that to be able to be able to last the force applications a big one.

If I'm trying to have more force to an area for say, a bigger person, maybe a foot that's a bit more out of the average or, you know, quite a flatter foot or or a foot that's quite cavous.

If I'm using these words, I'm hoping you're understanding.

I say a flatter foot posture with an associated pathology.

Someone comes in asymptomatic with a flat front.

I'm like, cool, your foot deducted.

This was awesome.

I love this foot, You love this foot, We love this foot, but there's an association where the tip to be honest, posterior, maybe they're big toe, they're flexible is longer their Sessimoy, they're deltoid that their plantar fascia.

Well then I can use my biomechanical mind to say, well, we should be able to know that these tissues are under stress.

I'm going to use this device to unload them and when it's better, you know, we probably won't need them at all.

And we'll kind of we'll see how we will cross that bridge run when we get to a majority of people.

I don't need it just like pentanol for a headache.

So the prognosis conditions as well.

I was taking a course on the weekend and I use an example of some of the chronic fry birds.

It's got a degenerative second MP and they're really MBJ joint and they're really active.

So we did a stiff extension and make there out of a relatively flexible but firm plastic.

And what that would that would do is that would then reduce how much it bends and take away some of that pressure and also patient preference.

Some patients just want to have a customer device that can be from numerous actors from they think customers always better and they do that or something around their health fund maybe covers well, whatever it may be that there's some utilization there.

So we're starting to think around that then we can make these better informed decisions and then also speak with our patients where they say they come in and they have some heel pain and they are, they ask you was a physio and say or a car or a doctor or surgeon say do you reckon I need custom orthotics?

My heel is really sore and I touched down a car.

Well, yeah, it's a good, good question.

I mean, how much we're going to have a look at the foot.

Well, it's a pretty average looking foot and it's really sore when you come down.

It's more compressing.

Probably just need something that's more cushioned and we'll try some tape and some shoes and rust and cushion.

And from an inner sole, they can probably use a medical Graine for opportunities and make it quite cushioned.

Or they may use a customer can use a particular material that is quite caution.

And that's a discussion for the the podiatrist and the and the other health, sorry, podiatrist and the and, and the patient where if someone comes in with maybe some medial, let's say some typical arch pain, insertional TBR posterior pain, pretty average for it hasn't been going on for a while and then managing pretty well.

You could certainly make it have a good faith debate that they may just seem something simple and we just beef up the arch a little bit or just someone adult acquired flat foot comes in will bend.

They they will need something that's more accommodating to the foot.

That's wine in the shell and comes up around and hugs your foot and offers that support so you can see how these things are to change.

I would encourage, you know, you as a practice to reach out to your local pod because you know, full of offices can have a really, really good outcome and it can really help people manage and certainly help the things that you're doing in regards to exercise.

If someone's tendon or structure is sore at the end of the day when you're trying to give them some rehab, I mean this can can really reduce maybe how sore is getting in and soccer to do that rehab process.

So you can see around the bio mechanics and the material selection.

There's some complexity to it that we're trying to figure out where me, I'm trying to figure out the best way to help other professions understand, you know, what we're doing and how we're thinking about it, because my experience has been it bio mechanics in this way.

It's been a little bit played by like this is a secret.

Don't you dare even think.

Talk about custom football.

You know what you're talking about.

And for me, that's just never going well.

I want to show other professions what I'm doing and why so we can work more collaboratively and they can better understand what I'm doing.

And then when referrals are better indicated so we can work for our patients and and get those outcomes.

And then you feel more confident evaluating when someone says our time for all police, they didn't work great.

Well, let's have a look at them and evaluate them and see did they give you some relief?

Do they have the features, you know, on the inside or the outside to have?

Maybe the arch is ramped up, the heels a little bit deeper.

And you can at any practitioner you can use, you know, general common sense, like if I've got 4 foot pain and there's no pad below, sorry, behind where the source spot is.

Oh, well, that's OK.

Me, there's some modifications that we could make and I can see the, the podiatrist and we, they can work.

And maybe I'll send them a letter and say, hey, patient, you know, so they were a bit concerned.

They didn't know what to do.

I was just like, at least a review.

And then, you know, you can better communicate or maybe it's really good.

It's like, yeah, this is OK.

There's something more that we, that we can change or do, but it's still worth a review and just communicating.

I mean, practitioners and clinicians in my experience are really nice and, you know, calling out from the sense of like, hey, I just saw one of your patients.

I just want to learn more about them.

I'm told them to come back for a review.

This is kind of how I communicated it.

And, you know, patients feel like you're working together and you can hopefully get get better outcomes.

So hopefully that gives you a bit of an understanding of why.

And you think, well, is everyone with foot pain who needs less stress or tissue who need foot authorities?

Of course not the answer.

There's a lot to of cases where, you know, we we don't need them and always deal with this analogy to think of majority of people we think of full of those who just like pan and all for a headache.

But for some people, it's a bit like type 2 diabetes where it's probably some things that sorry, that there are some things that you can do to essentially reverse some of that that disease and maybe bring your DGLS and your HBA 1C to a little bit more consistency and maybe the medication dosage comes down and there's some lifestyle factors like, you know, weight control and exercise and calories and all that type of thing.

Now I know and, and you know, listen, that's, that's difficult.

Having someone have a sustainable weight and meeting their physical activity guidelines is hard.

And there's a pandemic of that amount of billions of dollars put towards trying to understand how we can, can do that.

So I don't want people to think or patients even to think, you know, they're they're stuck in these forever because you certainly not.

There's plenty of things you can do.

You might have to commit to rehab for six months and do it every second day and really do it appropriately and consistently.

We might be able to see some training.

I can't guarantee that, but we can certainly try.

And that might be life with this full of like you do function a lot better and all your metrics are better when you're in it and you want to come out of it.

It's going to be difficult.

And if you're a practitioner saying, yeah, everyone should come out of them, I would challenge you to to go ahead and and one, teach me and teach other people like how you're getting those those results every time.

I just don't know if that's happening.

I mean, how you're managing your chronic mid foot away.

We've had multiple surgeries and it's overweight and they feel better in their foot authorities.

You know how you're getting getting around that.

I would would love to know.

And then for some people, it's like type 1, you know, diabetes, where that's something that's, you know, genetically within, within them, of course, and the changes, it's not something that you can either reverse.

And that's why, you know, that's, that's such a disabling condition to people where, you know, you need to have insulin in that stomach that you need on a physiological basis, it's very different.

And that might be some of with a connective tissue disorder, maybe rheumatoid arthritis, maybe CMT, maybe they have cerebral palsy and they have a foot drop and they need to do the brace to hold their foot up.

So, you know, to the other people, and this is the I work with a smaller population that that have that and they function so much better without that and they can't change.

But what's happening there.

So for them telling them how you need to get out of it as soon as you can, it's so detrimental to your health.

That's not the case either.

So there's these kind of categories that we were trying to work with.

I'll just explain that with patients as well.

And it seems to have made a little bit easier to understand.

I hope it's made a bit easier for the health professionals listening this to understand as well.

And you feel a little bit more confident, you know, just understanding how I'm thinking about them.

But then also the nuance as well.

I really do need to evaluate them to be able to make a decision.

If this person say they did not work, what is it about didn't work?

Was it shoe fit that the heel pressure, the arc pressure?

Because all these things are changeable.

And the reason we want to think that is it might be the slightest easiest change.

And that can have a huge impact where the heel does feel a whole lot better when they're in there, but it doesn't fit into the shoes that they wear to work.

Or they bought a new pair of shoes and it feels like it's it doesn't fit properly.

You know, we can help with those people and we want to be able to help so we can work collaboratively collaboratively.

Alright, I 30 minutes.

I just spoke for flat out and I reckon I could have gone on for six hours.

I've kept it for 30 minutes.

Hope that's good.

Please, if you have any questions, I really I I would love to to talk about this stuff.

I've got a, a talk coming out with physio network, which is going to be really exciting where I'm speaking around these principles to again, just have us all understand, can I feel confident in evaluating exercise?

But from the communication and conversations that I've had, other people don't feel confident in evaluating floor poses.

And I think it's something that we can can work on to again, achieve better outcomes, help Podiatry become more recognized as well.

Make something that we do that sound pretty cool.

More more recognized to you guys next week.