0:00

There's

0:06

a contingent of those with plantar heel pain that have

0:08

got kinesiophobia. Exercise

0:10

may actually address the fear of movement.

0:13

as opposed to necessarily making them

0:15

bigger and stronger. So again,

0:18

the clinician probably needs to think about in

0:20

what context am I doing this? If

0:22

I've got somebody who wakes up in the morning and

0:24

they've got heel pain and they've just got fear

0:27

of walking to the bathroom as

0:29

opposed to it only just

0:31

being about them being not strong

0:34

enough to walk to the bathroom, is

0:36

it plausible to utilise

0:38

some exercise intervention to try and reduce

0:41

that fear around movement What

0:48

foot and ankle strengthening regime is

0:50

helpful for our patients with plantar heel pain?

0:53

And what does the evidence say? What

0:55

footwear is recommended for those with plantar heel

0:58

pain when exercising? John Osborne

1:00

is an experienced sports podiatrist

1:02

and the first podiatrist in Australia to successfully

1:05

earn the Certified Sports Podiatrist

1:07

credential awarded by the Australian

1:09

Podiatry Association. He's currently

1:11

completing his PhD at La Trobe University

1:14

about the role of muscle strength in plantar heel

1:16

pain, all of which has made him a fantastic

1:19

guest for today's conversation. So

1:21

lace up your shoes. There's going to be some great

1:23

advice to inform your practice. I'm

1:26

Sarah Yule, and this is Physio Explained.

1:32

Well, thank you for joining us today, John,

1:34

and welcome. No doubt we'll see

1:36

how many puns I can fit into the discussion

1:39

today. Well, let's kick

1:41

off with the first question. What

1:43

kind of a foot and ankle strengthening regime

1:46

might be helpful for our patients with plantar

1:48

heel pain?

1:50

I might actually rewind you

1:52

a step and talk about maybe whether

1:54

a foot and ankle strengthening regime is helpful.

1:57

And that's probably the question that we can't answer.

1:59

If we look at systematic

2:02

review that we published way

2:04

just before COVID, It certainly

2:06

showed that there was no difference in calf

2:09

capacity between those who have heel pain

2:11

versus those that don't. So that's actually

2:14

a sister of doing orthopedic

2:16

sports physiotherapy, if you look

2:18

it up. But you'll find that there's

2:21

conflicting evidence

2:23

for a range of reasons as to whether there's

2:25

even a muscle or a size

2:27

or a muscle strength deficit in those with

2:29

heel pain compared to those without. So

2:32

then to blanketly

2:34

turn around and say well you know what

2:37

is going to be or you know is there

2:39

a particular regime that's going to

2:41

be beneficial it's sort of it's it's difficult

2:43

to really come out and say

2:46

yes there is or no there isn't more

2:48

recently there was the Delphi study

2:50

that again we published it's

2:53

sort of on the back of a number of other regimes

2:55

that have been put out by Enric Riel

2:58

and Mel Fratovich-Smith

3:00

and a few others. It was more to

3:02

try and get some consensus on what

3:05

the experts would suggest for

3:08

violating the foot and ankle strengthening regime. And

3:11

you'll notice that everything that came

3:13

up in the Delphi study is really

3:16

looking around calf rises, some

3:18

digital flexion, and then

3:20

sort of the 2K and maybe the short

3:22

foot exercise. There's sort

3:24

of the 2 or 3K exercises

3:27

that kept popping up. The other interesting

3:30

sort of thing that for me that came out

3:32

of the results of that study was

3:34

that there was not much difference in across

3:36

the three programs between an

3:38

athlete, a middle-aged person and

3:41

an elderly person. There was effectively,

3:44

if I was doing three sets of 10

3:46

or 15, if again, we're looking at sort of

3:48

best practice of what would be a strengthening

3:50

regime to be helpful for those with heel pain,

3:53

realistically for an athlete,

3:55

three sets of 10 is probably not enough load. And

3:58

I would probably even turn around and say the

4:00

short foot's also not enough light as an exercise.

4:02

So to answer

4:04

your question more directly, I think the jury's

4:06

still out. And I think we still have to probably,

4:10

you know, go back to drawing board and do some more

4:12

research. But I think that the building

4:14

blocks are there and are beginning

4:16

to be there to perhaps help us

4:19

come up with some better protocols that

4:21

we can apply now. to each individual

4:23

patient as we see them, whether it's for plantar heel

4:25

pain or whether it's for other foot and ankle pathology.

4:29

It's always challenging, isn't it? It's combining

4:31

that sort of evidence-based practice

4:33

with what the patient needs, with what we

4:36

have seen starting to trend

4:38

with working versus not working. So

4:41

do you mind dissecting a little bit more that

4:43

consensus study that you were

4:45

involved with?

4:47

What we rolled out is we rolled out the

4:50

three different Exercise

4:52

regimes. Yeah, three different sort of exercise

4:55

regimes. So we had an athlete

4:57

and we had a middle-aged person and we had an older

4:59

person. The premise behind that was to

5:02

sort of cover the breadth of

5:04

the different people that could otherwise have

5:07

unhealed pain. And I suppose

5:11

as the clinician doing the research,

5:14

I want to make sure that if I've got an athlete

5:16

and I'm providing them with an exercise program

5:18

that's more structured

5:20

around where their needs are, you can't

5:23

necessarily achieve that again in Adelphi

5:25

because you're

5:28

making a lot of assumptions about what the patient presenting

5:30

looks like. So as

5:32

a clinician, if you're trying to translate this out,

5:35

if you've got somebody that's got great

5:37

absolute strength, in their

5:39

digits or grand absolute strength in the inversion

5:42

or aversion in the ankle or dorsal

5:44

plantar flexion in the ankle, wherever it is,

5:47

then you probably use that as your guide to

5:49

begin with. So that's probably

5:52

the best place to start

5:54

thinking about it. But the

5:57

application of, say, some of these

5:59

three different programs, so there's a stage one,

6:02

stage two, and stage three, and

6:04

then each of them has exercises

6:07

in each of those stages. The objective

6:10

was to sort of say, okay, well, let's

6:12

start everybody at stage one.

6:14

So in this way, it

6:16

provides some progression. So one of

6:18

the criticisms of our programs

6:20

that are outlined in the

6:23

research is that their capacity

6:25

for progression is limited. And that was

6:27

a criticism that came from the experts. So

6:29

we wanted to try and make sure. So when

6:32

getting this out for the experts, we wanted to give them

6:34

the option to be able to progress these

6:36

things. So there's

6:38

the capacity to then start with a

6:41

sort of in the younger athletic

6:43

adult, hallux plantar flexion

6:46

against a band, digital plantar flexion

6:48

against a band, the heel rise

6:50

and the short foot exercise. And

6:52

then once they sort of get through their four

6:55

sets of between six to 12

6:57

using an eight repetition maximum as the

6:59

weight, then they can sort of start to do that more

7:01

frequently. Then it steps into that

7:03

stage two where they're applying the toe

7:05

spread out and the heel rise, but in

7:08

the standing position and the

7:10

short exercise in the

7:12

standing position and then to a heel

7:14

rise. This is what the experts agreed

7:17

to. So they got 70% agreement

7:20

to do these particular exercises.

7:23

And then if they didn't agree on one of the exercises,

7:26

it was sort of put back to them to say, okay, well,

7:28

if you don't agree on the exercise, what are

7:30

you going to replace it with? So

7:32

then we can take it back to the experts and

7:34

say, okay, so you didn't

7:36

get 70% consensus on this

7:39

exercise. You provided

7:41

these as your options. Which do you

7:43

think it should be replaced with? Or do you think

7:45

it should stay the same? Interestingly,

7:48

from the researcher's perspective,

7:50

more times an exercise

7:53

wasn't counted. It was often replaced

7:55

with either a short foot or a heel rise. So

7:58

it seems to be that the researchers

8:00

coming up with these ideas seem to be really

8:03

stuck on those two exercises as

8:05

the options going forward. A narrative

8:08

review I've just finished writing. Interestingly,

8:11

I've put out all 300

8:14

of the exercises from foot and ankle

8:16

that have been provided in the research and

8:19

tried to sort of categorize them. And again, those

8:21

two exercises just constantly

8:23

come up in the literature. Just for

8:25

interest's sake, when I went back and

8:27

sort of trying to find where these exercises

8:30

actually come from, the short foot was just random

8:34

suggestion by an orthopaedic surgeon

8:36

way back when, and everybody's just

8:38

piled on and taken it with them. Another

8:41

paper that's yet to come out looks at the

8:43

talk production of all these different

8:46

exercises and how much talk

8:48

production occurs. about

8:50

the MTPJs to sort of see, well,

8:53

are they, how much are they achieving

8:55

as an exercise individually? But

8:58

that sort of just seems to be the common thing. So

9:00

if you were to apply it as a clinician,

9:03

you can apply this just directly and pull

9:06

the, it's all there in

9:08

the paper and the paper is free to access

9:10

on Journal of Foot Make and Research. So

9:12

there's no need to go looking through third

9:15

parties to go find it. It's pretty easy

9:17

to access. And you

9:19

can sort of jump on and you can see

9:21

the exercises and the programs because

9:23

they're all out there and they're out there for you.

9:26

But their effectiveness, we don't know.

9:29

Are you struggling to keep up to date with new

9:31

research? Let our research reviews

9:33

do the hard work for you. Our team

9:36

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9:38

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9:40

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9:42

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9:44

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9:47

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9:49

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9:52

It sounds like, obviously, the heel rise and short

9:54

foot are your two that remain

9:57

to be consistent. You mentioned earlier

9:59

that short foot is difficult to

10:01

progress. Where would you see

10:04

its progression going?

10:07

So, me as a clinician, I would probably

10:09

only use it at the very,

10:11

very beginning, just maybe to get

10:13

some... neuromuscular

10:15

activation going on, I probably

10:18

wouldn't even use

10:20

it, if I'm honest. My clinician

10:22

hat on says it barely

10:25

represents anything that we actually do. And

10:29

my researcher hat on

10:31

turns around and says it doesn't, like

10:34

it's contracting over such a small

10:37

space and such a short length

10:39

that it's not going to generate much force either.

10:42

So I would probably

10:45

be shifting my attention towards other

10:47

exercises. Not to say that

10:49

it should be completely discounted and discredited

10:51

because I know a lot of people still

10:54

like to use it and still use it for some

10:56

of their certain circumstances and pathologies,

10:58

but I would have it right down the

11:00

end of it. For the amount of teaching

11:03

time it takes, it

11:06

produces a small amount of return.

11:10

And then on the other end of that spectrum, what

11:12

do you think are the exercises that

11:15

you've seen that do produce a

11:17

great return and a great output?

11:19

Yeah, so I've got a paper

11:21

about to come out which probably answers that

11:24

question for you. So we're just in

11:26

the final stages of writing

11:28

that paper up, which is the one I was talking about

11:30

before about talk production at MTVJ.

11:33

So we've ranked exercises

11:35

from quiet standing and squatting

11:38

and then we've taken all the way through

11:40

to variations on heel rises.

11:43

So I'm going to save my

11:45

answer to that question so

11:47

that when the paper comes out, it has some value.

11:51

But I think you'll find that

11:53

if your aim is to try and get people stronger,

11:55

then utilise that. One

11:58

of the things that is a common theme

12:01

in the research around from

12:03

the exercise is that everyone's doing sort

12:05

of three sets of 10, which is great for

12:07

a beginner, okay? And it's not

12:10

to say that that can't be successful,

12:13

but successful to a point. So I think

12:15

if we're trying to engage

12:18

our patients in getting bigger and

12:20

stronger, then we need to think

12:22

about how can we add and how can we increase

12:25

the loads that they're trying to carry from their feet.

12:27

At the end of the day, if they can walk in your

12:29

door, then they're probably already

12:32

starting to carry their body weight in terms

12:34

of load. So are we

12:36

then also providing

12:38

that as a capacity for rehab?

12:41

Fantastic point. And presumably, and I noticed

12:44

it written in the study, those progressions

12:46

were based around weight-based as

12:48

a preference rather than repetition-based

12:51

increases in terms of increasing

12:53

loads.

12:54

Yeah, so in that paper, it was all around

12:56

increasing the weight or the load

12:59

in that sense, which

13:01

I think is a nice thing.

13:03

The other thing that I quite like about

13:05

the way those programs are laid out in the study,

13:08

although you can argue it's a criticism, is

13:10

that we've got the repetition maximum as

13:12

the weight. So rather than turning

13:15

around and trying to say, well, everyone needs to lift

13:17

three kilos or five kilos or

13:19

a hundred kilos, it's working within

13:21

the participant's current repetition

13:24

maximum. So if clinicians are

13:26

able to say, all right, well, we're getting everybody

13:28

to target six repetition maximum or

13:30

eight repetition maximum, I think that

13:32

they're going to be better targeting the sort

13:35

of weights that they need to be getting

13:37

these patients to try and achieve. And

13:40

I think you'll find that there'll be some insight for the

13:42

clinician about what is so where

13:44

the capacity is for the patient

13:46

that they've got in front of them. Where the criticism

13:48

comes in is that, yeah, the broad range of repetitions

13:51

is provided, say, 6 to 12 or 1.8

13:54

repetition maximum. Well, if they're repetition maximum

13:56

is 8, they can't really do 12. Another

13:58

way to perhaps conceptualize that if you were

14:00

to try and apply it clinically is that

14:02

if, yes, a person is sitting at eight,

14:05

they may not be sitting at eight forever and

14:07

that eight may change day to day. So you

14:09

try to sit between that six to 12

14:11

mark and you're aiming for failure within

14:14

that is probably a nicer

14:16

way to try and conceptualize

14:18

it as a clinician.

14:20

That makes sense. I know from there's

14:22

studies in years gone back that we sort of have benchmarks

14:25

around what the age-related norms

14:27

are for single leg heel raises and those sorts

14:30

of things. What consistencies

14:32

have you noticed potentially if there are any

14:35

between either strength

14:37

or morphology or whatever it may be between

14:39

those with plantar heel pain and those

14:42

without it?

14:43

There's not a huge difference in morphology

14:46

between And there's almost no difference in calf

14:48

rise capacity in those with heel

14:51

pain compared to those without. One

14:53

of the calf rise capacity, if we

14:55

were to put everyone on those wonderful

14:58

looking box plots, the box

15:00

basically sits squarely right on the

15:02

zero and the little whiskers that

15:04

go outside to find your outliers

15:07

are really tiny. So as far

15:09

as calf rise capacity is, there

15:11

really wasn't much. There's

15:14

not a huge amount of studies done, So

15:16

that may change. But similarly,

15:19

well, not quite similarly,

15:21

when it comes to muscle morphology,

15:23

there's far more variance.

15:26

And depending on the study, depending

15:28

on the way they've done the study, they'll

15:31

either say that there is some difference

15:33

or there is not. It does

15:35

vary. tend in muscle morphology

15:37

to look like. There is smaller muscle

15:40

mass in those with heel pain compared

15:42

to those without, but in some ways it

15:44

can depend on which study you want to pick

15:46

out. And it's hard to pull

15:48

all that data because they've all done them

15:50

all differently. So I think that

15:53

there's more things to watch

15:55

when it comes to that space.

15:58

But I think we also need

16:00

to maybe think about strength that may not

16:02

just address muscle morphology and muscle

16:04

strength. If there's a contingent of those

16:07

with plantar heel pain that have got carnetophobia,

16:09

exercise may actually address the

16:11

fear of movement as opposed to

16:14

necessarily making them bigger and stronger.

16:16

So again, the clinician

16:18

probably needs to think about in what context

16:21

am I doing this? If I've got somebody who

16:23

wakes up in the morning and they've got heel pain

16:25

and they've just got fear of walking to

16:28

the bathroom as opposed to

16:30

it only just being about them being

16:33

not strong enough to walk to the bathroom,

16:35

Is it plausible to

16:38

utilise some exercise intervention to

16:40

try and reduce that fear around

16:42

movement in order to try and get them moving?

16:45

How you measure that, I don't know. But I

16:47

think that movement and exercise has

16:50

its place and that may be another

16:52

reason as to why it can be effective.

16:55

We don't know how effective it is in heel pain

16:58

and I keep on reiterating that point, but

17:00

that's because we really don't know. But

17:02

if you're going to apply for

17:04

a patient more broadly or for those with plantar heel pain,

17:07

that might be a plausible

17:10

reason as to why you'd apply.

17:12

Great point. And I suppose my final

17:14

question, with your clinician

17:17

hat on and possibly seeing

17:19

how physios and podiatrists and

17:21

osteos and how we all might treat

17:24

plantar heel pain, what do you think are the

17:26

low-hanging fruits that we should all be looking

17:29

out for in practice to treat

17:31

plantar heel pain?

17:32

The big one for low-hanging fruit is

17:34

for wear chases. It's a

17:37

really easy one. There's a nice paper

17:39

that came out by Karl Landau and

17:41

some others where they looked at hard surfaces

17:43

and footwear and how they have an impact. The

17:45

other big low-hanging fruit, which is related

17:49

to exercise, is looking at the person

17:51

and their health in front of you. So

17:53

if they have a high

17:55

BMI, which inevitably a lot of

17:57

them will, we probably need

18:00

to find a way to address that as well. Because

18:03

if they're not going to do the exercise and

18:05

those sorts of things to look after their general

18:07

health, are they going to do the rehabilitation

18:10

plan that is in your brain and

18:12

not theirs? So you

18:14

still need to look and view the person

18:17

as a holistic

18:19

thing and sort of try and find

18:21

interventions and ways that work with

18:23

the person. A lot of the interventions in

18:25

plantar heel pain seem to be mildly

18:28

effective depending on where you are, which

18:30

provided a nice general clinical

18:33

overview on how to manage plantar heel

18:35

pain. It's a great paper to go back to

18:37

and use as a reference point for starting, but

18:39

you do need to just consider who the person is

18:41

in front of you. If you can do that, then you

18:44

can apply the intervention that seems to have

18:46

best for the two of you and perhaps

18:48

addresses some of the other questions that they

18:51

might need addressed holistically.

18:54

All fantastic advice, John. So

18:56

a very big thank you for sharing your valuable

18:58

insights on managing plantar heel pain today.

19:01

My

19:01

pleasure. Thanks for having me.