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Thank you. So, as, uh, verity said, my name is Jen, I'm a physio that works with Verity in the Foot and ankle clinic. Um, and I'm gonna talk about what I do in the management of my patients, um, that I see with foot and ankle conditions in. So I've picked a few examples of some specific conditions. Um, I see most frequently within my clinic. Oh, the first thing I do do with a patient is take a really good, um, I wanna know the full problem is it repeated problem if they heated, uh, injuries, what was the mechanism mechanism of the injury or if they've had surgery, the date of their surgery, date of injury, any investigations they've had? Um, and if there's any product advice or restrictions from Vera that they need us to follow, um, because that might change. And then I want today, the patient's current symptoms, um, are aggravating easing factors and function and activities were. And what's that compared to now, what's their current level? Um, we'll take a, a self screen, ask them past midday, um, screen for any red flags and we'll specific question them to see if there's any rheumato symptoms as well. And then I want to know about their work and their hobbies. Can they still these, um, are they impaired? Do they had to completely or change it? And then we'll have a chat about their goals. What do they want to get back to? Are they realistic because we might need to have a conversation around there? Um, and then I'll talk to the patient about their expectations of physio. Um because as a patient, but to me, um it's a partnership between the two of us and we need to work together to try and get a realistic outcome for them. Um And also if any barriers to treatment, tendinopathy, the two most common that I tend to see are achilles to post issues. So there are risk factors for tendinopathy that we're gonna be aware of. So, obesity, um the link between cytokines in the system and uh tendon uh disruption um their age um because they can get an ad uh accumulation of advanced glycogen end products um and reduced cell turnover, which can lead to fibrosis over time, particular if they're elderly or diabetic. Um And anyone who is postmenopausal has had a drop off of their estrogen as that reduces uh collagen turnover. Um those who've got zero negative arthritis or positive HLA markers. Um And if they've got more modifiable risk factors, um we need to include these in uh the patient edition. Um and we may need to refer them back to their GP or sign post relevant services to try and manage their comorbidities a little bit better. Um And then there are some mechanical or extrinsic factors that can contribute. So uh toast, excessive subtle of valgus, um puts a mechanical, increased mechanical demand on the tip post, which can lead to uh pathology. But ultimately, tendinopathy is linked to a tendon overload. So either their sport or their training or an activity that they're doing uh an underload. So, reduced stand on the tendon um trauma or microtrauma, which is leading to a failed healing of the tendon. So a normal um if you pillow through the tendon or increase demand on the tendon, um we'll get an initial breakdown of collagen matrix and synthesis of the collagen and matrix. The tissue will adapt, it will become stronger. But if we've got uh a pathological tendon or a tendon that uh at its optimum um putting load, normal or excessive load through that tendon can lead to decreased collagen and matrix production. And tenocyte death will get a decrease in the collagen and matrix and it's more vulnerable to injury. Um uh forms of an inadequate repair. So the tendon uh is in disrepair, degenerative or it can lead to a reactive adenopathy. And the other thing that we need to take into account for side is that collagen sens peaks around 24 hours a 24 hours after a tenants be loaded Um So it's still in this breakdown phase at 12 hours after loading and it returns to its base over around a 72 hour period. So with physiotherapy tendinopathy, um we do a lot of education with our patients explaining why they might have got a tendinopathy. What rehab is likely to look like how we might approach that for them um as an individual and what they want to get back to and what we know is that rest doesn't improve the tendon in the long term. So any rest to be relative, um name of calming down symptoms so that we can get in there and try and help rehab. So we may need to modify their activities. Taping can be useful. Um for an achilles, we might consider some sort of heel raise to offload it. And for really severe ones in clinic, we've actually had to put people in a boot to uh slow them down and try and get them to relatively rest. So we can rehab and rehab generally consists of a progressive loading of the tissues. So if we have an underloaded tendon, we won't get that tissue adaptation that we talked about. But if we overload it, we're gonna cause that uh breakdown cycle and just perpetuate the pain, we use the intensity and volume and frequency of the exercise to progress or adapt the rehab. So in the evidence, uh slow, heavy resistant reading has been shown to uh cause changes in the tendon and muscle tissue. So that might look like for a patella tendon, it might look like a weighted squat and with the achilles, um weighted heel raising um isometrics, which is where you're contracting the muscle, um but not causing movement of the joint um has been shown to reduce pain. So we may use that if somebody is in the early stages and is too sore uh to do uh other exercise or you might do it before you do a rehab session to try and get control of the pain so that we can use that as a way into rehab. But the type of exercise that has the most evidence behind it, particularly for achilles, tendinopathy is centris, which is where you're loading the tendon as it lengthens. Um So for an achilles, this may look like uh what we call a two leg heel raise where they're coming up onto both toes and we're concentrating on that lowering down. Um And typically you, you might see that performed with the heels over that so that we're getting uh increased tendon length. Um I can use the repetitions of exercise, the steps of exercise, we can add weight to that um to uh influence the rehab and how much owing it. And you can advance that by getting them doing that on just the affected legs that they'd be going up on two legs, lifting up the unaffected leg and then slowly lowering themselves down on their affected side. If I tend to avoid uh stretching and compression of a tendon because that can be aggravation aggravating. But there is some evidence that stretching can cause uh some realignment of tendon fibers. Um So I may or may not include stretching depending on the individual patient in front of me. So we look at the, we consider the principles of rehab. Um And there's a weak spot with loading. Um If we underload it, we don't get any adaptation. If we overload, it won't it to uh cause more symptoms. So we want the bit in the middle where the patient feels like they're working. Um But we're not causing pain that's long lasting. Um Some of the evidence says that the pain that you cause with rehab should settle down within 24 hours. But a lot of my patients don't particularly um like that approach. So, um we tend to go with what they're most comfortable with, tend to begin with eccentrics. But if it's not working, then we can consider the high, low concentric, which is more of, of just your high weight heel raises and achilles and we'll look at the frequency. So because the tendons are still in their breakdown phase after 12 hours, and those collagen changes continue for up to 72 I'll often say to my patients, well, we need to leave a 24 hour window between your rehab sessions and it may be that they do their exercises every other day to allow that, um, healing phase to take place depending on the patient and how, uh irritable their symptoms are. Um, I might start them in non weight bearing and move them to weight bearing and to functional, um, exercises trying to work towards uh, the range where they've got the most pain or problems. Um, we need to increase tendon loads slowly and gradually and they do say it can take 16 weeks attendance to change physiologically. So I'll often say to my patients that we're looking at a 4 to 5 month rehab period um for tendinopathies. And I may well consider um whether I need to offload or protect the tendon during rehab. Um They might need some orthotics, we might need to have a chat about their footwear. Um If it's an achilles, they might benefit from either a heel race or a shoe that's got a slightly raised heel. So some running shoes have got a slightly raised heel compared to forefoot. We might take um to try and help relieve their symptoms and we'll certainly be discussing their and modifying those if needs be to try and uh manage pain whilst we rehab. But in addition to exercise, there are some other adjuncts that might be appropriate for some patients. Um So manual therapy, particularly if they've got a stiff ankle joint or a subtalar joint, um I might do some mobilizations. So you often come across Maitland or mulligan's mobilizations with movement are some of the most common um soft tissue mobilisations or massage can give some short term benefit as well. That can give us a window into rehab uh to try and get them exercising more comfortably. As I said, we might introduce a little bit of stretching as long as I'm not provoking pain or symptoms, but that subtalar joint must be in neutral. Ok. Might refer to orthotics, particularly if you got post tenon, then we'll certainly be looking at referring to orthotics to try and improve uh the foot position and offload those tissues. Um A shock wave therapy might be something we consider for those that are not responding um to treatment. So another common um pathology that, that often gets referred to me as plantar fasciitis. So with this particularly, we're gonna look at the lengths of gastroc, there is a link between the types of gastroc and the severity of the heel pain. Um It's not been proven, but there is a strong correlation in the literature. So we will assess gastro length. So we might use silver scos. Uh we might look at the dorsiflexion range of motion with the knee extended. Um and we'll look at the CIA length. So we use a knee to wall test. So you put the foot against the wall with the toes, touching Subtalar neutral heel to the floor and try and touch the, the wall with your knee and if they can, we just move them back a bit until they reach the limit of their movement. And then you can measure that distance between the toe and the wall. And it's a nice active marker to retest. We'll look at the windless test. Um So passive dorsiflexion of the hallux and weight bearing. Um And there are, there is some evidence out there that the pathogenesis might be similar to tendinopathy and related to overload and the failed healing cycle. And we know that uh although it's self limiting, it can take quite a long time for plantar fasciitis to resolve. So, from a physio management view, Morrissey, um and his colleagues uh have done a systematic review with meta analysis and expert opinion and developed some best practice guidelines back in 2021 and the mainstay of management is individualized education for patients. Um What that consists of would really depend on the individual patient and their presentation. Um But we will typically consider measurement, what are they doing on their feet? How much are they doing? Can we modify that to try and reduce a load? Um Pain education, um talk to them about the problem, why they've got pain clarify? Uh what's probably happening, what the prognosis is likely to be? Um If they've got any long term conditions or comorbidities, we need to consider the impact of those on the management of the plantar fasciitis. Um So we can refer back to the GP or we can refer to community services, um, locally and then we need to look at their footwear. So they often find that soft supported shoes are the most comfortable, but they also need to be, uh, acceptable for them to be wearing the majority of the time. Um, and then shoes often with a, a ra rare foot forefoot drops. So running shoes or similar where the heels higher than the forefoot, um, they often find those are more comfortable and then plantar fascia stretching and gastro stretching in cellular neutral is one of the first things that I will want to do with my patients. Um I get them doing it as, as a prolonged stretch after several minutes, uh several times a day, as long as they're comfortable with that. Um In the evidence, low dye taping can also be beneficial at giving some short term relief of pain. So you'll often see that done as two strips of tape around the heel from the base of the, um, first to the base of the fifth. Um And then three strips overlapping under the heel. And that can, um give some patients some short term relief, which means we can try and get a window in for rehab. And as I said, there's some similarities between plantar fasciitis and tendinopathy. So there is some research that has looked at high load strength training in addition to plantar fascia stretching. Um But this is using the windlass mechanism. So they had a rolled up towel underneath, um the big toe putting it into as much extension and comfortably managed. And then they had them going up onto their tiptoes and then back down again. And that was a 12 week program. Um I think with progressive loading and in the short term, the loading uh gains uh faster pain relief. Um and they improve more uh more quickly in the short term. In the long term, the outcome uh was very similar and in the evidence, they've postulated why that might have have uh improved symptoms. Um But I think that's something that's still ongoing. But if conservative treatment over a period of time is not effective, then we will often look to uh refer them for shockwave therapy, um orthotics and in the last resort, um potentially uh injection. Uh One of the most common things that come through to, to my clinic is lateral an sprain. So it's the most common uh musculoskeletal injury in the lower limb. And it has a high economic cost both in work days lost and in the cost of health care. So you're more at risk of an ankle sprain if you're of a younger age group, but if you have a previous sprain, your risk of another doubles in the year following, and there are some modifiable risk factors for sprain. Um So if you've got control with reduced hip and ankle strength or joint position, strength reduced reaction time around the ankle, um and increased BMI and it's most common in high friction surfaces. So, indoor court sports wearing studs and they're most at risk in the jumping or flight phase of a sport. Um partly because they're saying that it's due to reduced uh preactivation of perineals prior to landing. So they often land um with their foot in a plantar flex position, which isn't ideal if you've uh had an ankle sprain. So in the evidence, there's that 20 to 50% of ankle sprains have long term symptoms. Um and developed chron chronic ankle instability. Um and 80% of chronic ankle instabilities have had symptoms for um 10 years will show degenerative changes in the talus. Um and these patients often present with uh pain giving way or recurrent injury. It can start at any age, it can start after an innocuous injury and they think it's, it's partly a combination of mechanical instability. Um So ligament laxity, um those with hyper mobility. So that's something that I'll check for. I'll look at the baton score. Um and just that I'm not missing some hyper mobility, uh but also functional ability, which is due to proprioceptive and neuromuscular deficits. Um So in physio, we'll look at the anterior door tt ligament testing. Um we can measuring around the ankle using a figure of eight. Um we need to manage the swelling because that's gonna cause arthrogenic muscle, which isn't what we want during our rehab. Um, we'll look at their range of motion because there's often a deficit of dorsiflexion um in these patients. Um, and I'll use the need to wall test as we drive before as a nice subjective measure. Um It can also nice exercise to try and help restore that range of motion. Um We'll look at the muscle, muscle strength, um around the ankle and the perineals. Um, often look at the perineals in heel raising as well to see if they tip into um version. So they've got more functional control around the ankle. Um Also look at T post FHL Plantar flexes, but I'll also come up and look at their glutes, their hips, their quads um and have a look at their general lower limb strength and then static balance. Um that's often a deficit. Um In the literature, there's the best test. Um And there's a foot lift test which is essentially single leg standing and counting how many d uh they make with the um and comparing that to the other side and then the dynamic balance, it is either called a star excursion test or a Y balance where we've got a ay shaped uh being marked on the floor, they stand those lines intersect, um stand on the unaffected leg and see how far it can reach along each line with ved leg. And we can measure that and then compare to the opposite side and see what this is like again, that can be a nice rehab tool and a nice objective um marker for future assessment to see how they're progressing. So rehab, uh we often say for six months, at least, um they should be improving within that time. We should be able to be retesting them and see if things are improving and they should be able to tell us that their function's improving as well. So we're aiming to restore that range of motion. So exercise um may be enough need to all um as a nice stretch, but also manual therapy to the ankle joint um can be quite effective and that's often a a tailor glide. So gliding the talus in an ap direction relative to the tibia and again, NW MS and Maitland mobilizations, there's lots of examples of those um out there soft tissue techniques to try and reduce pain and swelling in the short term. So again, we can get a window for them to start exercising. Um And there's a little link on there. Um That's got a nice video showing uh somebody doing that taping can also be a nice adjunct for these patients. It can help reduce pain, but also it can help to discourage movement into painful provocative positions or ranges. So again, enable them to get going in their rehab. Um If there's any muscle strength deficits identified in the assessment, we'll work on those. Um So you might have seen people doing perineal exercises quite often they're given a band and asked to event um the ankle against resistance, um but not forgetting the rest of the chain in the lower limb as well. And we will aim to progress the load and speed to get them working their strength into their full range of motion. And then we need to add in static and dynamic balance. So you can use the tests um as a nice rehab tool. And obviously, we want to push these patients and progress by adding the activities that replicate what they want to be able to do with their foot and ankle in the long term. So we'll be guided by their function and activities. Um, so for example, um, we might put them in a step, standing position, do 1 ft in front of the other and get them practicing the push off phase on their affected leg to try and preactivate the perineals control the subtalar joint motion. Um, I've added thera band to that to try and either help or, or make it more challenging. Um, I've had rugby players where once we've got control up in plant flexion, they've needed to practice things like being in a scrum. Um, so lots of bear crawls. Um, so on your hands and toes on the floor or, um, they've got equipment. So pushing the sled, um, working on pronation and see pronation, control of the foot. So I'll make do that in single leg stand and get them to kind of rotate their trunk or reach um or even a nice bit of thera band around the ankles and get them coming up on their tiptoes, rolling out into supination to control that back in again. Um standing on one leg on a slope. Um because these patients don't need to just have good control on a flat surface. They're gonna be on different terrain. Um We can add in trunk rotations, head rotations um to challenge the vestibular component of balance um to try and retrain that sensory motor component. And for those that need to be able to jump and land, we'll practice that. So because they often are more at risk in that flight phase and landing in plant flexion or quee them to land with a flat foot to try and retrain that preactivation perineals. We might go on to lateral jumps. Um jogging. Um You can use canvas, you can get them to jog and touch the wedge if they need to push that far. Um And pli metrics. So low height, jumping, horizontal distance, jumping um on two legs, moving towards one leg um getting them to work in multidirection um and speed and changing direction depending on what they're aiming um to get back to. So it can be AAA 4 to 6 month rehab um for these patients, but those that aren't progressing. Um So if we retest and they're not getting anywhere um or if their pain and symptoms persist or if they're preventing rehab. These are often the ones that we will be, um, coming back to clinic. Um, it's a further review. So if you're referring to physio, what's really helpful for us is, um, giving us an idea of how long they've had this problem for. When was the injury or the surgery or the onset of their symptoms? Let us know if there's any restrictions or protocols that you want us to follow. Um If the patient can't work due to their problem, um that's really helpful for us to know that beforehand. Um If they've got caring responsibilities that they're struggling to fulfill because of their problem, that's really useful to let us know as well. Um And then I've got a whole load of references that can be useful. Um I want to see a bit more and then there's a couple of websites um that can be um they're quite nice as well. A bit further information that perfect. Thanks Jen. I mean, all of this as you know, has been recorded will be up on the medal website anyway. So.