Mark: Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC Canada, a physiotherapist of immense renown, and we're going to talk about running foot pain. Something you have a little bit of recent experience with, Iyad. 

Iyad: Yes, unfortunately. How are you, Mark? 

Mark: Good. So what's the deal with this pain in the foot thing? Can you just ignore it? 

Iyad: As I learned, absolutely not. So it could be anything. The unfortunate thing that we see with foot pain and running is that wherever the pain is in the foot, people will self diagnose it as plantar fascia pain or plantar fasciitis or plantar fasciopathy or anything that, you know, they could find online that kind of points to that.

Now, sure, that is one of the diagnoses that could happen, one of the conditions that could affect the foot, and usually it will start at the heel and into the arch, but that's only one of many other things that could happen. Recently we've been seeing a lot of like, especially with the nice weather that we've had late into the fall, people are still exercising and running, and it's been good. It's kind of gotten cooler, so the running distances maybe get a bit bigger.

You start to develop these aches, most of the time in the foot will get them in either the, let's call it on the way outer side of the foot. Like at the, if you think your pinky toe here, it would be at the metatarsal, which is kind of there. And that could be due just to running pattern, for example.

Where you're hitting on the outside of your foot first. Most people come in and tell me, Oh, I pronate. But pronating is the opposite where you go into the inside of your foot. I pronate too much when I run. And it could be that you're doing the opposite of that. So you're hitting on the outside and then your foot's kind of flopping down like that repeatedly.

And now doing this once or twice isn't going to do much for you. But if you're thinking about, you know, take about a 1000 steps per kilometre of running that adds up. Those repetitive small impacts could get up to quite a bit that your foot has to adapt from.

So that's a simple case where we could have the bones get sore and as part of that recovery then, we need to figure out where along this healing timeline that this thing is. If we catch it early, we could start different kind of training programs for example, that help maybe it's some issues with control of the hip or the thigh that's allowing them maybe they have to hit really hard to kind of compensate for that deficit in the chain. So we would kind of do some training there and then some day training. 

Unfortunately, we see people too late sometimes where they don't even know that they have an actual stress fracture going on in the foot. So then when we send them for the proper diagnostic testing, which most commonly will be the x ray 1st. And if you see it on an x ray, and that's probably like a later development, not an early development of that bone injury. But even if it's negative on the x ray, we will do more tests. Sometimes an MRI or CT scan are actually better to find this stuff. And usually we'll work with our family doctor colleagues for that diagnosis.

If it's still in the early phases that we can manage it by managing the volume of things. And modifying the activity and also training up on other areas where necessary. If it's in, unfortunately, in the fracture phase, then we have to work, like in a complete fracture. We'd have to work with our orthopedic surgery colleagues, try to figure out the best plan. 

And the unfortunate thing is it's a bit controversial, so there's no 1 size fits all to this. Some people are proponents of no weight bearing and some people are proponents of early weight bearing. So, I think this depends and I think we'd have to follow the medical advice and what the team decides based on that individual themselves.

Mark: So it's not something to ignore. You have to pay attention to it sooner than later. 

Iyad: Yes, and the most important thing is sometimes I find the most common reason we get this is when people will try to change their running style to fit something that they saw on a magazine, like a forefoot strike. If they're a heel striker or a midfoot striker, if they're a forefoot striker, that's a common reason.

The other reason is recent footwear change where they go from something that's very high in foam and then to a more stiff shoe without a proper transition. Or just simply running way too much, which was my case, for example. And I think yes, intervene early 'cause you could do a lot. And then you could also in many cases, if we know what it is early on, we can continue your training in a safe way instead of just getting you to stop completely to allow things to recover.

Mark: If you're having running foot pain, get in to see the physiotherapist at Insync Physio. You can book online at insyncphysio.com. Or you can call the Burnaby office at (604) 298-4878. Vancouver is (604) 566-9716 to book. You have to book ahead. They're always busy. Insync Physio. Thanks Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync physio in Vancouver, and today we're talking about, you know, what's the latest body and fender work that we want to work on? Heel pain. We're going to talk about inner heel pain you said, what is this all about? 

Wil: Well it's interesting because like quite often when people have heel pain and I don't know if it's more common now, and people are more aware of it, but they think of this term called plantar fasciitis. And some people are more aware of it than others. But then there's more to it. Like, if you actually diagnose it, or if you actually assess it properly, you can determine, well, is it really that, or is it something else that's going on.

So the more common, like the plantar fasciitis, basically what that is, it's an overuse issue, there's connective tissue on the bottom of your foot. And it usually happens more in the heel, and it can happen kind of around the inside of the heel too but there's other things that can actually be that's not plantar fasciitis, but can also be pain in that area.

You have padding in that heel, kind of like, you know, your butt, so we call it the fat pad. So that's sometimes getting irritated, and it's not necessarily the actual connective tissue. So it's just an irritation of that. And there's a lot of nerve endings there. And so that can be caused from the improper, like motion or mechanics of, like, if you're a runner and you may have really stiff hips and then it's causing you to not really transfer your load into your whole foot properly. And so then you end up heel striking harder. And running, you shouldn't be heel striking. Walking yes, you do. But not in running. So there could be like changes in that that are happening. 

The other interesting one. Actually, someone came into the clinic with this issue and they came in and saw one of our physios and they had this inside ankle heel pain. And it only happened after like longer walks and no pain in the morning or evening or sleeping or anything like that.

And it was interesting because usually with plantar fasciitis, you get worse symptoms in the morning and your first few steps kind of thing. And so with this person, it was more like after they've been walking for a while. And so when we assessed their gait, well, actually, when we first assessed even the person standing, the foot was fully collapsed.

And I was like, Oh, that's interesting. And so we measured the length of the legs. And that didn't seem hugely off, like it was like maybe a very minimal, you know, in terms of leg length differences on the left and the right. But when we actually started to look at the stability and what was going on in the ligaments, because when she was lying down, it looked fairly normal, it was only collapsed looking and looked really off when she was standing.

And then she started walking, it was like, Oh, well, if I had an issue like that, I would be getting foot pain too. Turns out that her ligaments on the inside of her ankle were torn. Now, it was funny because when we asked her about it, when the physio asked her about it, she didn't say anything about having an injury.

And then she just suddenly remembered, that she twisted her ankle about 15 years ago. And the thing about those kind of, so this is an eversion, which is basically not the most common type of ankle ligament injury sprain, which is on the inside. And so she had this eversion sprain, and typically like when it's a really bad one, and she said it swelled up, but it wasn't too bad, but usually when you tear all the ligaments, then there's other stuff that potentially can happen, like a fracture or something like that.

Because the ligaments are so strong, they attach more to the bone. But it was a little bit loose, definitely. And then she had like all this collapse and all the muscles that have compensated. In terms of like for this injury and nothing was working properly. So all those muscles that were supporting the arch before and she was getting the inside heel pain, was the whole sort of inside of that arch area because it was collapsing. So there was nothing supporting it.

And her arch was was collapsed because everything around there was insufficient. And so she came in to see us with this sort of chronic issue that just started like a couple weeks ago. But it probably would have been ongoing and she had been taking up a lot more hiking just recently this summer.

So the antidote or I guess the treatment for this is really looking at trying to stabilize. So we look at the mobility. She's got good mobility there. In fact, it moved too much and where she's really lacking is strength and really looking at what to activate. And how to activate it and then really ultimately get it giving her more of that stability that she needs. So whether it's like as we get her stronger and maybe she also needs a little bit more of a revision in her orthotics, that she's not getting that support anymore.

Mark: What sort of exercises would that involve? 

Wil: Yeah, so depending on what we find, like usually in that area, there's certain muscles that kind of stabilize that whole inside of the ankles and prevent it from collapsing. And so, I mean, I can name off a few, it's like big names, like the tibialis posterior muscle is a big one. You know, that can be really helpful. Because for her, especially, it was not activating at all. Like when we started and here's the interesting thing. She would just stand, her normal stance would just be like in a collapsed position. That's her comfortable stance to try and get her to activate that muscle, it was really hard. 

But when we did like, Oh, that feels different. And then you can see like when we did it was supported. So the challenge is keeping her supported while she walked. And so ultimately, the thing that we would do is taping it and supporting it physically in that way. Her orthotic may be helpful later on in the revision in that, but doing things is supported or braced or something that just really helps to keep that medial arch more supported. And lo and behold, you know, that taping did help a lot.

And that's how we know that there's not other things that are bigger going on either. Because when we can really look at, Oh, yeah, hey, that really helps. Oh, my gosh. 

Mark: Is there an aspect of the taping that brings someone's attention to that part so that they maybe it triggers that muscle reactivation after it sort of you know, been dormant for 15 years?

Wil: Yeah, that's a good question. So the taping that we do specifically is a little bit more rigid because we want to help support that. But also there's an aspect of taping that we can do that's a little bit more facilitating sort of the nerve muscle connection. So that can help with that. And then combined with doing specific retraining and rehab for that system is extremely helpful.

Mark: Yeah. And does that make her walks a little bit more pleasant so she doesn't run into so much pain? 

Wil: Well when we taped her up, it was definitely night and day. It was funny because she said, yeah, I only get pain with when I do longer walks. But then when we got her in a clinic, just literally doing like walking for like 10 feet.

Yeah, I feel that. So it's like sometimes we just ignore the, you know, until it gets. So if it's like a two out of 10 pain, we ignore it. Until it becomes like oh, yeah, now I feel pain. So even like she was like two out of ten from two out of ten to zero out of ten and feeling supported. I think that that's definitely gonna help 

Mark: if you're encountering some sort of heel pain instability with your heels, fat pad pain, where the bottom of your foot kind of feels funny, and you're in Vancouver or North Burnaby, you want to see Insync Physio. They can help you diagnose exactly what's going on and get you on the path to recovery. Insyncphysio.com to book your appointment. Or in Vancouver, you can call (604) 566-9716 in North Burnaby (604) 298-4878 to book your appointment. Thanks Wil. 

Wil: Hey, you're welcome.

Mark: Hi, it's Mark Bossert. I'm here with Wil Seto of Insync Physio in Vancouver. And we're going to talk about something we haven't talked about this before. Heel pain in children. How are you doing, Wil? 

Wil: Yeah, I'm doing good, thanks. 

Mark: So what causes children to have heel pain and what are the symptoms?

Wil: Yeah, so essentially heel pain in children and this is a condition called Severs Disease. And so the reason, it's called Severs is because it was actually a term coined by a doctor back in 1912. His name was James Warren Sever. So Sever's disease is, when you have this issue in kids where their bones are not fully mature, what happens is that in that attachment point where the tendon is the Achilles tendon you know, basically because of the repetition and the overuse and the overload or the microtrauma where it attaches, it starts to traction so much so that it basically starts to kind of pull off and cause this inflammatory process that's right at the detachment point.

And so in some ways, if you really think about the actual, like, sort of mechanism and what's actually going on in there, it's like tiny little micro fractures that is pulling it off the bone kind of thing. 

Mark: So is this associated typically with a lot of running?

Wil: Yeah, just basically a lot of overuse. Running is definitely a huge one. Anything that has repeated impact pressure you know, like on the heel. And the reason why too, is because like I was saying, it's not like the bone is not fully formed and developed. And so bone is kind of more, like when it's mature in an adult, fully grown person, it's definitely a lot harder and it's a different makeup versus when in a child, it's more cartilage like, so they call that a fibro cartilage, which is a lot softer.

And so this is quite typical around when in a child who's seven to nine years old because the bone isn't fused yet. So the Achilles tendon, which inserts onto that lower portion into the heel, there's the pull off of it. And so the pulling, like the growth plate, and because of that high stress from whether it's running, it's that impact loading essentially.

Mark: No worries. So dancing jumping of any kind, like skipping rope or anything that's going to load that heel part of the foot could be a cause of this? Like doing a lot of something at a younger age? 

Wil: Yeah, exactly. And how it's usually presented as a, again this is what's actually really good for, like, in terms of having it assessed because they usually don't have any pain in the morning.

So when you look at people that have heel pain, like as a grown up, you know, when bones are fully mature, it's like looking at, Oh, I got this heel pain. You do your internet search or whatever, and you look for that kind of symptomology and they find that it's like a plantar fasciitis. Well, plantar fasciitis is when you usually have pain in the morning. And so there's all these things like where some things are similar and some things are not, and then we need to assess it too as well.

You know, and obviously you're gonna have more pain as you do more activity and weight bearing on it. There's usually no swelling in there as well, but the pain is increased with those activities. And it can also be associated with a foot malalignment and whatnot. And then typical too is, like, you know, your child will have more limping at the end of whatever they're doing. And there'll be limited range of motion as well. 

The biggest thing with this is that rest is really important, and then initiating, like, physiotherapy. If it's assessed properly, will be able to influence that healing process even more. 

Mark: What is the typical course of treatment?

Wil: Well, the first thing is that if they're going to be engaging, like, I'll give you an example. We have a child whose father brought him in to see one of our physios, and he's trying out for a competitive soccer team. And I think he's only 12. And that's usually the typical age is 10 to 12, and it's usually more boys.

First thing is, you gotta let him rest. So you gotta, like, discontinue the running. And it's hard, you know, the kid wants to play and the dad wants to get him going in the program. It's difficult. But one of the biggest things you got to limit that activity. Discontinue the thing that's going to make it worse. And typically, like for kids, that's very important. Very important. But then it's also after we initiate that rest period for if it's like a week, to at least when they don't have any more pain. Then how do we progress them back on a program that is actually safe and is gradually getting them stronger without re aggravating this.

Mark: So what's the downstream effect? If they don't rest, what can happen? 

Wil: Yeah, that's a good question. So, there's quite a few things actually. So if you don't rest, you can actually end up getting things that can cause like a potential fracture. You know, and basically as you're looking at what's happening with this syndrome, if you're not allowing it to heal, that's huge. And that can affect, like, as the little person grows and they're going to have a sequela event. Because then if they have a fracture there, they're going to be having pain all the time. And then they're going to compensate, and their body's going to maladapt to that.

And that's huge. I mean, I can't stress how big that is. In terms of making sure that this is really diagnosed properly because there's also a lot of other things that you know, when you look at the syndrome or this disease, that you also want to rule out other things going on in there.

So when you have this and you look at the presentation of it, and you know what you can do, and like long term effects of the actual tendon integrity and also the muscle imbalances. Those are huge. But you also have to differentiate is this really a Severs or is this just like a heel spur. Or is this like just like an issue of a fat pad thing going on, or maybe it's just a bit of Achilles overuse, it could be.

We have to diagnose it properly. Usually more in boys than girls, like I was saying, so you have your kid that wants to get back into competitive sports you know, or doing something more active, rather, and be less competitive. So it's so important to be able to get that accurate diagnosis and treatment plan, because then it's just, there's the go down that rabbit hole of just really having these complications. 

And another one is Osteomyelitis, which is basically you can get an infection. I mean, that's kind of a worst case scenario, an infection of that area. And then, like I was just saying, then that would lead to just more altered gait patterns and then maybe a prolonged limp, ultimately. Prolonged pain and discomfort, which can lead to a whole series of things.

Mark: If you need to get accurate diagnosis for any injury or if your child is having some heel pain, the guys to see are Insync Physio. You can reach them on their website, insyncphysio.com to book, or you can call the Vancouver office at (604) 566-9716. Or you can call the North Burnaby office at (604) 298-4878. Thanks, Wil. 

Wil: Thanks, Mark. 

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. Well, let's say they're one of the best physiotherapy clinics in Vancouver. Today we're gonna talk about a probably a pretty common thing, I would guess is heel pain from running that's due to tendinopathy. Is that what's causing this kind of pain typically? 

Wil: Yeah, yeah. Well, thanks Mark. That's exactly it. So quite often heel pain that starts to happen with running, you know, you can get what's called Achilles tendinopathy. So what it is, is basically an overuse syndrome or dysfunction. And it doesn't happen overnight.

So you can start to see the bigger picture like, when someone comes into our clinic, and I can think of someone that came in and saw one of our physios, you know he was telling me about this particular individual, and the picture was pretty clear how it all started.

And so essentially, you're looking at all the factors of like did you start running? And like where is the current fitness level at? And are they doing other types of activities that involve a lot of loading in the heel as well.

And then what are the previous injuries or past history of this person? Like, do they have a colourful history? It doesn't even have to be in the heel or the foot or leg. It could be even in the back, because that can add compensations into your mechanics with running. And then even just you know talking about this with you earlier, maybe the person is a little bit more overweight and if they're a beginner runner and you add that to the mix and then the mechanics are off, then with that actual little weight, that's also gonna, you know, basically cause more excessive, abnormal loading in the heel.

And giving you a lot more tightness into the calf, obviously. And then you're gonna overuse your calf to generate power as opposed to your glute muscles, which you really need that power with the extension of your hip. So then as a result, that tightness and that overuse of the achilles of the calf muscle specifically then causes the Achilles to be tight. And then usually the Achilles tendon is the weaker link, not the actual calf muscle itself.

Mark: So, when you're diagnosing this, what's most important? Is it history, to really dig into what's going on with somebody? Or is it testing? 

Wil: Well, history is a big thing in terms of like giving us a bigger picture of how this was caused and started. Cause that way we don't want it to come back. And we also want to address the ongoing mitigating factors that keep aggravating it. So that's huge. And then also as we assess, that's also gonna help with like, okay, yeah, this is what's contributing to it, these are the impairments and these are the actual things they can work on.

And then the other thing is looking at the, like assessing and looking at like, okay, so if it is a tendinopathy, you're gonna get soreness when you palpate around the area. So that's actually a really easy do it yourself home test. If you're feeling sore, when you're palpating yourself on that tendon, then it's most likely that. 

Because one of the other things that you could be getting, it could be like maybe a, what's called a bursitis in your Achilles. And so that's basically the fluid filled sac that protects the achilles tendon from rubbing on the bone. And so you might have a flare up of that. But if it's all along the tendon, like right on the superficial, like inside or outside or right on top, then usually it's most likely the tendon. But it could still be like some kind of bursitis or it could be something else, but most likely it's that. 

And then you look at, you know, other factors, even if you are an experienced runner, which we do treat a few experienced runners and you know, they take a break and then they start training again and they maybe do some hill training. And so that's gonna cause more stress and strain on that Achilles, just the overloading of that Achilles. Because you're always in that motion where it's more outstretched and lengthened and you're loading it more because you're going uphill. 

So that combined with intensity and frequency workouts and runs. And then just like, how long have you been running for? And then, well, what else are they doing? So maybe this person is doing other things like, you know, maybe they're doing a lot of other activities and sports that require 'em to be on their feet all day and then they go for a run. They don't do any recovery things. Those things are all important factors. 

Mark: So we've diagnosed it, we know what the symptoms are, the possible causes, the diagnosis. What's the treatment look like and how long does it typically take? 

Wil: Yeah, it varies. Depends on how long it's going on for, because when you're starting to have symptoms it's probably been going on well before you started to have symptoms. So you sort of reach a threshold until it becomes symptomatic. And you may sort of sub like you're below the threshold of having symptoms, but it's a problem. But you probably have noticed that, yeah, my calf muscles are a bit tight, you know, or I feel a little bit tight, but you don't really do anything about it until it's too late usually. So that's an important thing to look out for.

And so how we actually treat it, you can't actually address the strengthening of that Achilles. You wanna produce what's called collagen synthesis. And so basically what you're doing is you're promoting an increase of strength around the tendons where it's been effected. So you're reinforcing that tendon. So you're getting stronger all around it. And that's the key. So doing specific exercises that are based on research, also not just on clinical aspect of where we found successful, is like things that actually address and target specific and then strengthening. So starting off with what's called isometric strengthening.

You know, where you're putting constant tension force of the muscle where it's not moving. To then eccentric, which is basically constant tension force of the muscle while it's lengthening. And that's key because now you're working on getting more of that, what I described earlier as collagen synthesis are the building, the basic blocks of strengthening that tendon around that injured area, which will help with the full recovery. And we've seen some good success with this. 

Mark: If you're having some ankle heel pain from your running. Get in, get it diagnosed, get your gait checked. Is that a fair thing to say almost for any runner, get your gait checked regularly to see if there's any imbalances, cuz you can't see when you're running, you don't see what you're doing, you're just running. Is that fair assessment? 

Wil: Absolutely. 

Mark: Probably a good idea. 

Wil: Yeah, because there's many other factors to consider when you're getting your gait checked. Like how many steps you're taking per minute. And so that's your cadence and then how your form looks and whether or not your centre gravity forward enough and if you're getting enough power through your extensors. So it's a really good thing to do. 

Mark: People to call, the experts are at Insync Physio in Vancouver or in North Burnaby. They have two offices. You can book online either office at insyncphysio.com. Or you can call them. The Vancouver office is (604) 566-9716. North Burnaby is (604) 298-4878. Thank you, Wil. 

Wil: Thanks, Mark.

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver. One of Vancouver's best physiotherapist clinics, multiple time winners of best physios in Vancouver. And we're going to talk about growth spurt injuries part two, we're talking about Sever's Syndrome. How are you doing Wil? 

Wil: I'm doing great. Thanks, Mark. 

Mark: What the heck is Sever's Syndrome? 

Wil: Well, Sever's Syndrome is basically a condition that causing heel pain and primarily in the athletic population of people who are immature muscle bone development. So basically, you know, people who are age as young as 8 up to like 15 to 16 years old. And it's specifically in the heel, like I was mentioning. 

Mark: So what kind of symptoms would show or lead one to start to investigate this? 

Wil: Yeah, so there would be sometimes painful inflammation that you would see and in more severe cases, a lot of inflammation in the heel. And in the insertion point to where your Achilles tendon is basically the tendon that attaches your calf muscle.

So your calf has made up of like three muscles, like your big ball muscles called the Gastroc. And then the one inside called the Soleus and they basically are attached by your Achilles, that attaches onto your heel bone, called your Calcaneus. And your Calcaneus basically for an immature, in terms of a physiological development, you know, ages 8 to 15, that's actually where it tends to happen with higher stress, higher loads tend to be more focused in that area. And also the other thing that you also have to consider is the fact that is there a big growth spurt because if there's a big growth spurt then that'll also be a contributing factor.

 And the other things too, is that you want to look at like how are they pounding? Because with Sever's, you know, if they're actually doing a lot of running and they also have bad footwear, you know, and they're poorly cushioned or worn down.

And depending on the surface that they're running and they're absorbing more of the forces. So there's a huge sort of biomechanical factor involved here.. 

Mark: So we kind of merged symptoms and diagnosis. So basically pain in the heel is the symptom that's going to show up. Is that right? 

Wil: That's correct, yeah. 

Mark: So what's a typical course of treatment? 

Wil: Yeah. So the biggest one is really, you know, you gotta rest. You really gotta let this settle down. Because like I was saying with these immature adults, you really gotta make sure that you give the growth plates and give the growth spurt that they experience to start to mature a little bit more. Because if you don't, then it can become a chronic problem and it can actually have all these other chronic compensations happen later in life. And it can come back and haunt you. 

Myself and our team we've been doing this for a very long time. We have so much experience, like decades of experience in treating athletes and working with young athletes and seeing them through from being young kids to adults and how a lot of them have had problems. Like with volleyball players, with runners, when they've developed conditions of this sort where, you know, whether it's Sever's or another growth spurt issue that they ended up having continued issues in their adult life, as they try to do avid sports.

And that's huge to really understand that you got to let it rest. And you don't want to be like, oh, it's like a tendonitis, but it's not. Because it's immature muscle, immature tendon development that you gotta just give time to really recover. And with younger folks and younger people, you just got to give them that chance. 

Mark: So if your kid's having a bit of knee pain, a bit of, in this case heel pain, the guys to see are Insync Physio. You can book online insyncphysio.com. Or you can call the Vancouver office at (604) 566-9716 to book or in North Burnaby, (604)298-4878.

Get your kids in there. Get them healed properly. Get expert advice to relieve their pain so they can get back to their favourite sport. Thanks Wil. 

Wil: You're welcome, Mark.

Heather: So we had a warm stretch here in Vancouver, and it pretty much felt like summer. And the client came in the week after just saying, Oh, the bottom of their foot, like along the arch was really sore. And after talking to them about like what had changed, a very common question that I asked with foot pain is, have you changed your footwear recently or any changes there?

And it turns out that with the warm weather they had transitioned from wearing like more of like a running shoe or more supportive shoe to just a basic flip-flop, like the ones with the foam. Very very standard kind of flip flops that you see. And that can contribute to their pain that they're having. So that's what we're here to talk about today. 

Mark: So is that a function of just kind of transitioning too quickly into changing the footwear? 

Heather: Yeah, exactly. It can be a shock to the foot. If you think about what your foot is doing when it's in a running shoe, there is actually a little bit of a heel lift. So your heel is elevated within the shoe. So your foot gets used to that position. And also just the forces and the pressures that are going through your foot get used to that. And then when you transitioned to something like a flip-flop or just being in your bare feet more outside, your feet aren't strong enough.

They're used to being in this very compressive shoe, this very supportive shoe, and then you walk around and your foot can splay more with the flip-flop or even just in your bare feet and your feet aren't ready for it. As well as then the heel is no longer elevated, it's quite flat. So that puts a lot more strain on your calf and in through the bottom of your foot. 

Mark: So I have some other questions about that, but let's talk about how do you diagnose what's going on? And then what's the treatment protocol.

Heather: Yeah, so it always starts with a detailed history. So like I said, with this person, we found out kind of that something had recently changed in their life. And then you go into more of the, we call it an ergonomic assessment. So we watch how they walk and we watch how they stand, and then we do like a manual assessment. So we get our hands on the foot and we test out muscle length, some muscle strength, and then also just the joint mobility. So in the foot there's so many little bones and how are they all moving and how do they move within one another?

And sometimes there's something stiff, but often it's something that's a little bit tight. And one of the common things we see is calf tightness. And that's what this person presented with, this calf tightness. 

Mark: So is that just then prescribing some stretching exercises or is there more, do you pull out the needles?

Heather: Yes, we can pull up the needles and we can do something called IMS. And so that can be very useful in releasing that tension, especially something in this case where it was something very acute. We can often mitigate that pain in one or two sessions quite quickly for the person, with something like IMS. But also then we can just do some manual release like massage in through the foot and stretching, and then following up with some home exercises for this person. 

Mark: So foot pain, I'm sure it's something not just switching from winter footwear to summer footwear, but what about shoes breaking down?

Heather: Absolutely. So shoes can become, they do, they break down. The rubber, especially in running shoes, they break down, you can see that maybe you flip your shoe over and you look at the bottom and you look at the wear pattern on it that you've worn down more, maybe more, a part of a heel or more part of, one part of the shoe than the other, or just the rigidity within the shoe.

You take the shoe and you kind of like bend it and you should have, not all shoes, but some shoes, most shoes have some rigidity to them a little bit. And some of you can just kind of like fold up. And if we're used to going from a more rigid shoe or your shoes and slowly breaking down, sometimes you can detect that.

I myself know when it's a new time I run a lot. I know it's time for a new pair of running shoes. My knees start to hurt. When I run, I get new running shoes and the pain goes away. It's one of those like telltale signs for myself. That I know it's time that my shoes and the cushioning and my shoes are broken down.

Mark: Yeah. I've learned for myself now with how much I walk, that it's three months. I got to change them every three months. They're toast. 

Heather: Yep. Yeah. Yeah. It depends on everybody. They kind of people, they kind of figure it out. They know yep, it's that time. They walk that certain distance in that time. Or they run that certain distance or something and it's time for the new pair. And it's unfortunate sometimes the shoe looks really good still. Like it still looks, it still looks brand new, but it's just, it's lost that cushion. 

Mark: Yeah, my wife was complaining about how her feet were sore. We went for a walk the other day and her shoes are a year old, only oh they're only a year old, they still, there was nothing there. Tissue paper. What about barefoot running? Barefoot shoes, all that kind of stuff. What's your experience with that? 

Heather: There's definitely a time and a place for them. They're not for everybody. But the thing with barefoot shoes and barefoot running is that we have to transition to it slowly. So we can't just go from wearing our traditional running shoe to something that's very minimalist with like a zero drop or something like that. You have to ease yourself into it. So it's kind of like any training program. I encourage people, say, okay, you have to train yourself up. So you start with maybe 10 minutes of running in your minimalist shoe. And then you could even increase that distance or the time, and you have to train your foot and your body. It's not just your foot, but it's actually training the whole way up the chain that your body needs to adjust to that. There's nothing wrong with them. People just often transition to them way too fast. And that's where we see breakdown or injuries happen. 

Mark: So you mentioned how, you know, when it's time to change your shoes, cause you get knee pain running. How much do your feet being properly supported, affect the rest of your body and how can that show up? How have you seen that show up for people? 

Heather: It's very common. You think about our feet support us. We're often kind of abuse our feet. We don't really pay much attention to them, but they're what hold us up all day. Our feet are working so hard and they're brilliant in how they're designed to support us.

But there's lots of things that can go wrong in the foot. Often we get weaker in the foot. And a lot of people see these flat feet, that means their arch has collapsed. And then you see that transition up the chain in that you see then there's more pressure on the inside of their foot, which then puts more pressure on the inside of their knees. And then up into the hips and into the low back, you see these shifts that people do within their bodies to compensate for those changes within their foot. 

Mark: Any quick exercises that you would recommend that people use to maybe strengthen their feet a little bit.

Heather: Yeah, so strengthening and stretching. Common stretches I give for any foot person, any foot injury is a calf stretch. So most people know it's like the good lunge stretch, stretching with your knees straight, and then also bending your knee a little bit in that position. And the other stretching or soft tissue release that I often recommend is just ball rolling on the bottom of your foot.

And the way you recommend people do that is thinking about rolling from your heel and then roll the ball along, kind of pretend this is your foot, you roll from your heel along the line to your big toe. And then you go back and then roll along the line to your second toe and go back and then to your third toe and go back. And it gets all the different muscles and lines along your foot. Rather than just kind of, most people just kind of roll in the middle and we want to get all these different lines. 

In terms of strengthening, there's many different ways you can strengthen the foot. One is just doing a really gentle calf raise and focusing on coming up square on your foot. A lot of times we curl our foot or our ankles turn out and learning how to come up. Where on the foot. So you're across the whole, all the toes are equal. All the way to cross your toes as equal is really important. And that's actually quite hard when you get people to control it slowly on the way up. And then that get them to control it slowly on the way down. Is really nice functional strengthening for the ankle and the whole foot. 

Mark: If you've got some foot pain and you want relief. Go see Heather at Insync Physio, you can book online at insyncphysio.com. She's in the Cambie Street office. Or you can call them (604) 566-9716. Get in there. Get ready for summer. It's gonna happen. It will. Thanks Heather.

Heather: Bye.

Start with one foot halfway off a step. Maintain your foot in a neutral position and hold this position for 10 seconds.

Relax your foot. Perform this exercise for 3 sets of 10 repetitions.

This is a great exercise in the acute or early stages of Achilles tendinopathy, a condition involving the overuse of the Achilles tendon. 

Start standing with both feet halfway off a step. Push through both of your big toes to lift your heels up as high as possible.

Remove the unaffected leg, and then slowly lower down the affected foot into full range below the level of the step. Bring back the unaffected leg and push through both feet once again, repeating the exercise.

Perform this exercise for 3 sets of 10 repetitions.

This is a great exercise in the later stages of Achilles tendinopathy which is a condition involving the overuse of the Achilles tendon. 

So anchor strips. So you want to make sure that you're not at the metatarsal. Okay, so stay off of the MTP area on that part. 

Below the head you mean? 

Yeah below the head of the metatarsal. And you're going to apply with no tension, and you can leave a gap there. So you didn't do a couple strips, but because Lisa's got a bit of a smaller foot, like with yours, maybe I'll do like two strips right. And so for you, remember, you want to make sure you over lap by half, right? 

Yep. 

Okay. So I normally like to go a little bit thinner than this. I usually do like thirds. So I'm going to get you to turn over on your tummy, with your leg hanging off. Okay. So...

I know it's hard, but just be careful with that.

Okay. So...

Do you wanna switch spots.

Alright. So if they're getting pain in through here, you want to support that. So there's a few different ways of doing it. You can vary it up depending on how they feel. Make sure you start off with anchor strip here in the inside. So you want to eventually overlap by half as well. So if you're using the small strips, then you've got to be careful with that.

So you want to start off sort of more right on the medial aspect. And make sure that you don't put too much pressure in through here. You're not cranking. So that's important, because otherwise it's going to get really uncomfortable for her right. And don't go too high. If you go too high, then it all starts to rub under this area, which will be uncomfortable.

So you want to stay right on the calcaneus here. And so you want to also go right to the lateral side as well. So you can do that or you can come in, depending on if she's getting a little bit more sort of pain down through here, to support that a little more. You can do a little teardrop. So really important that this, so what I just did there, you don't want to do, because I'm also talking through this, right, you want to be able to not let it wrinkle. Okay, so that's the first strip. I always go medial lateral, medial lateral, medial lateral. Okay. Sometimes three strips on each side may add too much discomfort onto here. So sometimes I'll go maybe three and two or just two and two.

What if you just do an X?

You can do that too. Yep.

Just go from that side to that side. Just one variation is what you're showing.

Yeah. So you can even just go straight across, so you can just do like a U. Or so with the X, see how it causes the X so you can do that's where I'm supporting in through here a little bit more.

Why would you choose one over the other?

Just depending on what's going on from the ... oh yeah I can get a lot of pain in through there. Then you can support that, that area a little more there, or if it's more immediately then I'll and go that way a little more. Okay. So if that's what I choose and I'm just going to keep repeating that. And so the reason why I started more immediately is because I'm going to go more towards the plantar area. So here I'm going by a half, and then I'm actually overlapping the whole thing and then coming overlapping by half again. Okay. Like that. Sorry that's a  U strip. So this is where it gets a little tricky.. 

When is just the U strip beneficial?

It will support the bottom part more. So if you get a lot of like, tightness in through here, it'll support this area more, right.

More that the X?

Yeah. I mean, they're both really good. Sometimes this can really just give you a lot more support just in the whole heel too, right. And the strain off of here. So laterally. So I'd probably just go two strips with her and then, you know, if she's like, Oh yeah, you know, I do get a little more here, then I can do one strip or next strip, one cross strip, and then one U strip. Just be really careful, you don't hold again. And then, we need you to turn back on your back please.

Okay so because I also want to make sure you remember how I said it supinates a little bit, so I want to go this way. Just so that way, it just helps to bring it back into a little bit less supination, right. So that's the anchor strip. Now here I can also go, I'm just to cover that up, because remember we talked about last week, you want to avoid windows, right? So this has a little bit of a window there, that might be a little bit uncomfortable and sometimes we're like, Oh no, I don't want that up there because it'd be uncomfortable to your individual, right? 

So you can go all the way up, or then you're like, Oh yeah, that's, so you can leave it there and just close it there. That's okay because these windows aren't as bad. Okay. It's the windows that are up in through here because how she moves, that doesn't really move right. So that's not going to be a big issue. But I like to cover it up sometimes, but sometimes they'll be like, Oh, that's uncomfortable. I like to put an extra one on.

I’m going to get you to stand on the table with only like 10%, so stand on the table with most of the weight on that leg or on your knee is actually fine. And then you can just relax… So basically, what we’re going to do when I ask you, you're going to press down as hard as you can. Press down as hard as you can. Okay. And once she's got that a hundred percent weight bearing, then we close it off, right. So that way that gives it that breathability and that sort of flex. Ok a 100% and it closes the anchor strip. And a 100%, there you go.

When you look at a foot, there is typically a gap underneath the inner part of the foot when you stand. This is your arch. This arch provides the spring in your step, and allows body weight to be more efficiently distributed across your feet and legs. The structure of the arch can also determine a person’s gait. People with flat foot will have something known as a fallen arch, where they have either no arch in their feet or an arch that is very low to the ground. A common cause of flat feet includes genetics, as this is a trait that can be passed on from parents through genes. Having weak arches, or a foot/ankle injury can also lead to a flat foot. Flat foot can also come with age, as well as many other factors.

If you’re looking at your feet right now and discover that your arch is low or absent, you don’t need to worry. Flat foot only needs treatment if it causes discomfort, or leads to pain in another part of the body. Many people seem to have a low arch or no arch without ever experiencing any pain. 

Exercises to manage symptoms of flat feet include:
Heel Stretches

• Keep one leg forward and the other behind you
• Press both heels firmly into the floor, while keeping your spine straight
• Bend into the front leg and push yourself against a wall with your arm to feel a stretch in the back leg and Achilles tendon.
• Hold this position for 30 seconds and repeat on each side. 

Golf Ball Roll

• Sit on a chair with a tennis or golf ball under your foot
• Sit straight while you roll the ball under your foot, focusing on the arch
• Repeat for 1-2 minutes.

Towel Curls

• Sit in a chair with a towel under your feet
• Push your heels into the floor and curl your toes to scrunch up the towel
• Hold this for a few seconds and release. 

Other methods to treat flat feet include orthotic devices, motion control shoes, or going to physical therapy to correct flat feet, in the case that it is a result of injury or poor form.

If you have any pain during exercises, or are unsure about what you are doing, please consult your local physiotherapist before continuing.