How much variation is there in the care we provide for our patients? This question was one of the reasons that I decided to interview Ian Griffiths and Mark Gallagher separately for this article. The other reason was that these two podiatrists are in such hot demand that it was nigh on impossible to shoehorn them into the same room.
While Mark and Ian’s philosophies (and fashion senses) differ, their answers on fundamental aspects of podiatry were reassuringly similar. In fact, at some points I wondered whether the pair had consulted before talking to me.
Autonomy offers us the freedom to optimise patient care, but perhaps team consistency is another factor in the high standard of care delivered by PSM clinicians.
Warning: If you have met Mark or Ian, you will already know that these guys can talk: I have had to trim this interview to squeeze it onto the internet.
So to kick things off, let’s fish for some footwear tips from the pros – What do you guys wear on your feet, for work and leisure?
Mark: Work-wise, I wear formal brogues. I picked up that vibe from Tom Bradley in the City. I thought he looked decent in his stylish brogues so I may have taken a page from his style – I’m not sure if that’s good or bad. I used to joke with my patients about wearing a slightly higher heel height because I am 5 foot 7, but it actually has more to do with the fact that I lack ankle flexibility and I also prefer a boot style, for mechanical reasons - it keeps me more secure.
Since I stopped playing football, I have built up my biking. My personal goals are to maintain 100 runs and 200 rides every year. For various reasons this year, my running has taken a back seat and I have spent more time on the bike. I use Speedplay cleats and I’m actually on my third cycling shoe for this year. I’ve got a new set of Giros which are nice – quite old school – but I do need to be reminded by my more snobbish cycling friends to buy something new every once in a while.
Ian: Call me an old man, but I’m reaching that stage of my life where I favour comfort over… almost anything else. The days of Loakes, Oxfords and Brogues are long gone. Actually, the shirt and chinos look has been something of a game changer for me, because they open up the door to... how do I describe them?... it’s a kind of rubber-soled shoe with a suede upper. As comfy as they are, I still slip into an old pair of Asics Nimbus for the commute.
My main form of exercise is Crossfit, and I’m either in a Reebok Nano or a Nike Metcon. In fact, they are so comfy that I usually chuck on my Metcons for the school pickup too. I am kind of nerdy about shoes – I can probably identify nine out of ten of my patients’ footwear from just a quick glance.
I’m sure that goes down well in you line of work. I know you have various strings to your bow. Where do you work when you are not at PSM?
Ian: I consult for Bupa Health and also have links with a few professional clubs across a number of sports. I am the podiatrist for the PGA European tour. I also consult for AFC Bournemouth, Surrey Country Cricket, England Rugby Sevens, although the players almost always come in to see me in clinic in London. As podiatrists, I don’t think we really need to be pitch-side. It’s more getting called in for an opinion or for a pre-season screening. When I’m not in clinic, I’m usually working on research.
Mark, I know you work up at Birmingham City?
I’ve been at Birmingham for eight seasons now. My practice is mostly musculoskeletal, biomechanics and gait analysis. The difference with professional footballers is they actually have time for strength and conditioning; the things that make them less dependent on the orthotics that we tend to use with civilian patients. It’s a real culture shift. I think it defines what we do at PSM as well. We know from professional athletes that, if you are willing to put the time in, you can really minimise your structural risk factors by being strong or being long in certain muscle groups. At PSM, our patients have work and family commitments – reasons why they can’t always invest the time that a professional sports person would. I really enjoy working in football. I screen for Wolverhampton Wanderers, see their injured players and also teach on the FA Masters module as St. George’s Park.
So Mark. How does your work at Birmingham look on the ground. Do you screen the players routinely, or do they just come to you with injuries?
At the start of the season we try to screen the new players. In addition to the Functional Movement Screen that all players will go through, I do a foot and ankle one. This includes ankle joint flexibility and, bizzarely, players’ foot shape and size just to ensure that they are wearing an appropriate boot. You might be surprised at how many players are wearing boots that just aren’t the right fit. As well as the boot’s shape, it can be the stud distribution that just isn’t right for the player. For example they may have previously had a fracture at the base of the fifth metatarsal. There are certain boot styles and trainers that suit certain conditions and foot types better than others. I work with the team to get them stronger, minimise their risk factors and work out what role their footwear might play. That’s where the MDT approach really helps.
Ian, you mentioned pre-injury screening. What does that consist of, in your practice?
This is a grey area and I try to be as transparent about this as I can and try to lean on the evidence base as much as possible. Firstly, there will always be some quantification of ankle dorsiflexion, usually via a weightbearing lunge test. I certainly wouldn’t want to see tibial inclination of much less than 35°. Major asymmetry between sides would also be something that I’d want to look into. I also use the supination resistance test; this is something I did my Masters thesis on. While I wouldn’t want to oversell this as a magical test, I do wonder the implications of high resistance on structures such as tibialis posterior. I don’t measure foot posture index, but I will make a visual observation on navicular drop during sit to stand as there is level one evidence linking navicular drop to medial tibial stress syndrome.
In runners I always look for tibial varum. Current literature suggests that the tibial bending moment is one possible causative factor in medial tibial stress syndrome. I also check proximal control on a single leg; this is something that I can feed back to the physio team if I find a problem. Finally I have a look a their footwear, but without context (of injury), this can be incredibly vague. The reality is that we still don’t fully understand the human foot as much as we would like.
Mark, you must see a lot of football players with ankle sprains? If they have structural instability, what is your advice to them? Do any of them use ankle braces or do you prefer taping? At what stage would you consider surgery?
We tend to use taping a lot. Ankle bracing is rarely tolerated in a professional sporting environment, although we do use it with England netball. Of course, both of these groups are also highly amenable to good ankle control programmes. You beast them in terms of ankle proprioception as much as you can. We have players that have a completely absent ATFL. The question is often whether the other two (ligaments) are doing their job properly. I’ve got some great videos of positive anterior drawer tests. Sometimes I just think ‘how can that ankle perform?’. But if you secure them with tape and give them as much control as possible, life becomes manageable.
When would I refer them for surgery? If they get reactive oedema after every training session with pain (of 4-5/10) that limits their next training session then you have to consider the value of allowing them to continue. We can probably keep them stable within reason, but really at this point you should refer them on. Often you can time their surgery in the off-season, in the interest of keeping them playing. So I would say that, as much as you want three ligaments on the outside of your ankle, you can often manage with two.
Now to your work at PSM. What is your approach to assessing a patient?
Mark: The framework that I use is the foot posture index - but assessing a patient standing with two feet on the ground is just the starting point. I think that basing assumptions on how a patient moves from watching them standing is of limited value. I move from double limb support to single limb support to see what their ankle control is like. I look at how hard they are working their intrinsic and extrinsic muscles in order to stabilise the ankle. Then I look at single-leg squat, probably in the same way that you do, but my focus is more on what happens to the foot position. The two main parts of the foot that I assess are the rearfoot and the navicular height. If you see a real loss of rearfoot position and a drop in the navicular, you can be fairly sure that there is a rotational component to their symptoms. At that point I get the patient walking, then running on the treadmill, to see how it all fits together.
When I read referral letters, I often see, “the patient stands with a moderate degree of pronation”. Now I know that Griff is a real obsessive when it comes to terminology, but if you screen for mechanical risk factors with two feet on the ground then you are missing a big part of the problem because most patients don’t get symptoms in a standing position; symptoms come on when they move. It’s fundamentally important to allow them to move at their own pace and to mimic their sport as best you can.
At conferences I often see reps marketing those technical and expensive looking pressure systems. What are your views on these and do they form part of your assessment?
Mark: Rarely. When I was at Sellyoak Hospital in Birmingham I held a monthly clinic where we saw our non-responsive mechanical patients. When patients walk through your door with multiple things inside their footwear, you have to try and make sense of it. I think pressure systems have a role to play, but when I teach on the FA MSc module, I do a session called ‘Technology: Essential or Excess?’. Regardless of the systems that we use, as clinicians we still need to interpret that information. Pressure systems are objective measures, but won’t necessary tell you what the problem is. I see a lot of clinicians hiding behind technology. Sometimes patients bring me reams of information. I’ve been doing this for 25 years and there are still times when I have to say, “I have no idea what this is telling me.”
Ian: There are many different types available: pressure mats, in-shoe pressure systems etc. We have a pressure plate at Bupa. It makes magnificent theatre for the patient. But I don’t believe these systems tell you anything that you can’t get from looking at shoe wear patterns, the sock-liner or callosities on the foot itself. So, clinically their usefulness is negligible. In the research arena, that is a different debate. Pressure systems are not to be disregarded but for things like tibialis posterior tendinopathy, patellofemoral pain – basically conditions that we see on a daily basis at PSM - they are not a game changer. There are plenty of clinics out there with lots of kit, but as we know, it is the interpretation of such information that is most important. I’d be particularly wary of clinics who use two-dimensional information (pressure plates) to construct foot orthoses. I mean, if I go to a Saville Row tailor and ask them for a custom-made suit, I don’t just hand over a photograph of myself.
How important is footwear for the lower limb patients that you see at PSM?
Mark: Show me the person who wouldn’t benefit from shock absorbance being improved at the foot level. Of course, the body can absorb impact but footwear can help to moderate that impact force. I also think that, at times, footwear can be over-engineered. Footwear is maybe 10% of the equation. The question for the patient is, “do I want to do anything beyond the benefit I can get from optimal footwear? Do I want to commit to a strength and conditioning programme to maximise my potential?” Every patient who walks through my door will gain insight into the role of footwear, but rarely is it a complete solution. I think that footwear can be the reason that things can just drag on. It’s not going to be a game changer 9 times out of 10.
One of the most common questions that I get asked by runners is, “what is the best trainer for me?” Unless you have a criteria that allows you to answer this, you’re clutching at straws. If your assessment reveals a significant rotational component, you might favour motion control features in footwear. I also look at ankle flexibility – I usually measure tibial inclination using an app. If a patient lacks ankle flexibility, this gives you insight into what the heel-height profile needs to be on their trainer. Someone with a stiff ankle who wears a minimalist shoe – that’s not going to be a good combination. I think that this approach allows you to make well-informed recommendations on what each patient’s optimal footwear choice may be. This usually allows for around 5 or 6 varieties of trainer that a patient can try. I think that at this point, comfort is important. Forcing someone to wear a trainer that doesn’t feel comfortable is going to cause problems.
Ian: My answer is not going to make any headlines: It really depends… Firstly let’s consider football. One of the most common problems that I see is sesamoid overload. (As Mark said,) You have to examine the stud configuration of a player’s boot. In this setting, footwear can be a key factor - a big stud located right under the 1st MTPJ presents a real barrier to recovery.
Now consider the world of running; where footwear is discussed most prevalently. Go back to the 1980s and it was ALL about the footwear – it was suggested your shoe had the absolute ability to control your injury profile. Move forward to 2002-2012, then the pendulum swung completely the other way and the barefoot discussion rose from the ashes. Footwear became (allegedly) irrelevant and had absolutely no bearing on injury risk. Barefoot running has gone quiet again now, but it will come round again for the next generation of clinicians I’m sure. The reality, in my opinion, is that these two stances are a false dichotomy. The truth is rarely found at extremes and nothing is going to work for all of the people, all of the time. It depends on the individual sitting in front of you.
It has now reached a point that, whatever your bias may be, you can now find five or six articles online that support your contention. So while there is currently no verdict in the literature, I cannot believe that footwear is not an important factor for a lot of the people that we see. But we lack the predictive models to be clear on what actually causes injury. I am also clear with my patients that their footwear requirements are likely to change over time.
When there is pathology present, the situation becomes much clearer. Some conditions require a shoe with a higher drop while others, such as a neuroma, may demand a shoe with a much wider forefoot/toebox.
Mark, what are your views on minimalist footwear?
Mark: For me, footwear choice is important to a point, but how and where you land on your foot is more important. I place my runners in 2 camps. If you are heel dominant, you are going to generate a higher impact force – a higher ‘bone burden’ on the shin, the knee and the lower back. If you land on the front part of your foot, there’s a bigger eccentric demand on the calf muscle group and therefore a bigger soft tissue component to their injury risk. But if you look at the structure of the foot, where is the biggest bone? Well, it’s the heel; the metatarsals are not designed to take impact force.
So the best of both worlds theoretically becomes midfoot landing. When I have this discussion with my (forefoot) runners, I have to respect that this is something that they have taken on board in making this transition. I think that the patients that I see often don’t make the transition over a long enough period of time – it can be a real shock to the system. I think that if you are going to evolve from a rearfoot to a forefoot strike, you’ve got to do the strength and conditioning work required.
My question to the patient would be, “what are you trying to achieve from this?” I think you make the change for one of two reasons; either to reduce your injury risk or to improve your performance. Rarely does it do either. Personally, I just see a different pattern of injury – more Achilles tendon stuff and metatarsal stress fractures; this makes them unable to train as hard over the short to medium term. Don’t get me wrong, there are people out there who have made the transition – but if you are changing to forefoot strike as a first-line treatment, we have probably missed an opportunity to change something else.
At PSM I would occasionally get parents asking me to assess their kids who walk on their toes? Is there a particular point by which children really should be walking with a heel-toe gait? What should we say to parents?
Mark: Yes, it’s presentation I see a decent amount of. I think that if there isn’t a physical restriction to that child getting their heel to the ground then they should be using it. The dilemma is that for most of the patients we pick up, it’s a real habitual pattern. So a lot of it is gait re-education – this is something that I think I have undervalued historically for a number of reasons. When faced with that patient group, telling both patient and parent that there’s no structural reason why that heel can’t reach the ground, it may be that we start looking at footwear with a higher heel height, just to get that initial engagement. Before you start getting them into barefoot heel contact, there has to be some feedback. This tells them “my heel’s on the ground; I’m safe, I’m happy”. Then we can start transferring this outside of footwear.
Ian: I’m strongly of the belief that, within podiatry, we should sub-specialise. The foot is complex: increasingly so when you try to incorporate the sporting foot; the paediatric foot; the geriatric foot; the diabetic foot. I certainly don’t feel smart enough to be the master of all these areas. I know Mark sees young patients at his Kensington clinic but at Canary Wharf I never do (due to the demographics of the area). If a child is older and it sounds like Sever’s disease or Osgood-Schlatter’s then fine, I’ll happily talk about it. But in the same way that if a diabetic patient walked in with a neuro-ischaemic ulcer, when we talk about the younger, developing foot, I would refer that patient on as I’m aware it is not my speciality. As a parent myself, I would like to say that if anyone is ever concerned about their child then definitely take them to see someone, because you are never wasting that clinician’s time.
Now for some questions on foot and ankle surgery. What are your views on hallux valgus correction?
Mark: These are the criteria that I use: What is the size of the deformity? What is the degree of structural shift? What level of pain is the patient experiencing and what impact is it having on their day-to-day life? There is a staging system for hallux valgus. Generally we pick people up at stage two or three; stage four is the point at which most surgeons will say, “ok, that’s a decent deviation.” That ticks the first box, but if their pain is only 1 or 2/10 and it doesn’t bother them in day-to-day life then I’d advise against surgery. There’s life in that joint. It’s only when you start getting above 5/10 consistently and it’s starting to affect sport or walking that I’d think about asking my surgical colleagues to give an opinion.
And what about hallux rigidus/osteoarthritis in the first metatarsophalangeal joint?
Mark: I’ve been working with footwear companies for six or seven years now, looking at shoe stiffness - how much the shoe bends during walking – trying to reduce the dorsiflexion moment through the hallux. I think that if you get patients in stiffer shoes, life becomes a lot easier. We can’t give them any motion back, but we can reduce the need for the joint to bend in the first place. The dilemma with using a stiffer outsole is that the shoes needs to have the classic rocker-shaped bottom. You show me the person who wants to live in stiff, rounded trainers. So really, there are conservative tools that we can use, but our ability to use them is limited. If they are stiff – painfully stiff – then they might need an orthopaedic opinion.
Is there anything that you would want orthopaedic colleagues to know, from your experiences in podiatry – anything that you think could perhaps be done differently?
Ian: I have definitely found myself gravitating toward certain surgeons. Firstly, I like surgeons who only operate on the foot and ankle. I think that surgeons are gradually narrowing their field in this way to be honest. Secondly, I like a surgeon that sends back about 50% of the patients that I send him without operating. I don’t want them to be sitting there with their scalpel ready at the first consultation. I want them to be brilliant when they do operate, but to consider surgery as a last resort. Again most nowadays are very much like this anyway. Now, I recognise that certain scenarios do demand surgery, but I also believe that, in most scenarios, the conservative options should be exhausted first. I mean, would you want to be on an operating table wondering whether orthoses or physio might have worked?
The final thing I look for in a surgeon is the recognition that this foot is attached to a human being, who has a certain amount of time left on the planet. It’s not enough to look at an X-ray and say, “yes, this has been a radiological success” when a patient is still in pain every step of the way. So, a working knowledge of biomechanics is a prerequisite.
Mark: I think that my orthopaedic colleagues know that, by the time my referral gets to their door, I’ve explored all the conservative stuff. Generally I’m looking for the solution that gives the best outcome for the patient in the shortest amount of time, and I try to be really honest with the patient about that – so I refer my patients to orthopaedic teams that follow the same kind of approach. We talk a lot about what happens to our patients’ biomechanics following surgery. It’s really reassuring to know that there are surgeons out there that really try and think about a patient’s life beyond their surgery. It’s not just a six-month follow up, it’s what might happen 12 months or two years later. Those are the type of surgeons that I like to work with. Someone who recognises that, at some point, their patient has to walk out of the door.
Plantar fasciitis/plantar fasciopathy, or whatever it’s current name is? What is your approach to treatment?
Mark: It’s the commonest condition that I see. My Masters thesis was on it: ‘injection techniques in chronic heel pain’, back in 2000. At the time, I was working with the rheumatology team, chasing patients around the room with a 23-gauge needle and syringe while thinking, “there’s got to be a better way of doing this”. During my research I came across an ankle block injection technique – it’s like when you go to the dentist really, a local anaesthetic. An ankle block allows you to block the tibial nerve at the ankle level, making the heel go numb in less than 20 minutes. Then you can really put the needle into patient’s heel without having to chase them up the bed. So then I would inject things like saline and local anaesthetic into the plantar fascia origin, getting decent outcomes at times.
I think my biggest criticism of this method of managing plantar fasciitis is the stop-start approach that it follows. I don’t think that there is a single thing that is going to solve it. If we are going to treat this, we need to ensure that we are reducing the mechanical load, because every single step causes stress-strain in the tissues. That’s why most foot and ankle conditions drag on, but especially plantar fasciitis. So, unless you are de-loading that structure and giving it a chance to recover, then all the other modalities will have limited impact. It is a frustrating condition to have and can be frustrating to treat, but I think that it helps to do the right things at the right times.
Be very aggressive in offloading the plantar fascia during the first six weeks. Whether you choose to use taping, or something else; be consistent. Emphasise to the patient that just using a tick-box approach is not enough. Especially as by the time patients walk through our door, they have often already had the condition for six months. Use the sports doctors at PSM. Try to use shockwave. Smash it – try to get some tissue repair going on, alongside the mechanical offload. So in summary: mechanical offload, tissue repair and try to keep the momentum.
Finally, when you fit a patient with orthoses – are you fitting them as a temporising measure, with a view to removing them later, or is it, in some patients, something that you envisage them using lifelong. How do you approach that discussion?
Ian: This will vary, depending on which podiatrist you talk to. With my current understanding and interpretation of the evidence base, I am increasingly confident that orthoses are not a life sentence for the majority of patients that we see.
If we climb into our DeLorean and take a trip back in time, we used to believe that orthoses were ‘arch supports’. There were able to ‘correct faulty mechanics’, ‘improve alignment’ and ‘restore normality’. Now if that’s the theory that you subscribe to, it makes absolute sense that you would consider orthoses to be a long-term feature in your patients’ lives. Many people refer to the spectacle analogy: “glasses don’t change your eyes, but they do improve their function. When you are prescribed glasses, you expect to be wearing them for the rest of your life”. I personally do not believe that orthoses are analogous to glasses.
They do not ‘realign the skeleton’ in any predictable fashion. They work more via a kinetic than a kinematic mechanism; ie. Modifying loads and tissue stresses. Thus orthoses are simply one arrow in the quiver of load management. So if we prescribe orthoses with a view to modifying the load on an injured tissue and then improve that tissue’s capacity to handle load over time via training, we also have to entertain the idea that at some point, those orthoses should be made redundant.
Mark, do you have any tips for your colleagues when making referrals?
I would say that the further you go away from the foot and ankle, the less likely I am to make an impact. An exception to this rule would be when someone has an obvious leg-length difference and lower back pain. Do think seriously about referring your patient if things aren’t going the way you expect.
An example would be a patient with patellofemoral pain, who is six-eight weeks into a programme. You would expect them to be 30-50% improved by this point; if they aren’t following this timeline, think about getting us involved. Equally, try not to make it a surprise for the patient. It helps to set the scene early on – tell the patient that their foot position could be linked to their knee-loading pattern. If the patient’s proximal control isn’t great then of course we need to address this through physio, but if things aren’t going the way you expected then consider getting me, Griff or Alex involved. Foot position might turn out to be that fly in the ointment.
Mark and Ian, thank you very much for talking to us.
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