Clinical Biomechanics Boot Camps

Taking it to the next level!

Global Podiatry and lower limb related courses and seminars

On a light-hearted note…

With all the travel I used to do for the Clinical Biomechanics Boot Camps I took to having ‘bacon and eggs’ for breakfast once in every city I visited and posting a photo on Facebook. It was always a source of discussion about the breakfast and the travel. After doing it for so many years, I paid one of my girls to scroll through my Facebook feed and collect all the photos and put them together on its own website for a bit if fun: Breakfast of Champions.

Sadly the COVID restrictions have put the breaks on the travel, except for local travel I have not been able to update the site much with any new international cities.

Peroneal Tendinopathy is easy!

In my hands peroneal tendinopathy or tendonitis used to be a challenge. In the past I reckon I was close to a 100% failure rate in managing it. In the last 10 or so years I think I am now close to a 100% success in managing it. What changed? It was based on our research evidence. I talked about that in this blog post: Peroneal Tendonitis in Runners on my running research blog. It was pretty clear that almost everyone with peroneal tendinopathy had a lower than average supination resistance. That means the force needed to supinate the foot was low and as a consequence the peroneal tendons have to work harder, increasing the risk for tendinopathy. This also means that those with it need lateral wedging under the heel to decrease the loads in the tendon. That wedging actually leads to a substantial reduction in the forces that the tendon is subjected to, so hence the lateral wedging is a very and often is dramatically effective to manage peroneal tendonitis.

Yes, lateral wedges do try to pronate the foot more, but never had a problem with doing that. It did take a mindset change to get confident to start doing this 10 or more years ago, but I have not looked back. This is a perfect example of research informing and changing clinical practice.

This also means that a typically arch supporting medially wedged foot orthotic is going to increase the load on the peroneal tendon and is not going to be indicated. This also explains why I had almost a 100% failure on managing this in the past.

Also, of course, we do the usual load management approaches to this tendon once that reduction in load on the tendon with the wedge is done.

“Overpronation” …. oh no!

In social media, everyone is an expert on this. Opinions vary, but facts don’t, but all so often those opinions are being stated in the ignorance of the actual research evidence.

I have written so many times about this in so many places (eg here, here and here), so lets type it slowly and make it clear:

Firstly, there is no clear definition of “overpronation” which is why I generally put it in the “x”, but we all know it when we see it. Yes, pronation is normal, but we generally lack a clear definition of when that normal becomes too much. However, we do have normative data on the foot posture index (FPI), so there is some consensus as to what is normal and abnormal. I am pretty sure most of those posting in social media about “overpronation” have no clue what this normative data is or even what the FPI is that its based on is. This is also probably complicated that the division between normal and abnormal is most likely to be subject specific and mediated by many other factors, such as tissue capacity.

Secondly, yes there is something wrong with “overpronation”. Too many in social media keep saying that it is not a problem. Yes, there are studies that show its not and yes, there are studies showing that it is a problem. This also has to be interpreted in the context of how each study actually measured “overpronation”. When you get conflicting evidence you then need to turn to the systematic reviews and meta-analyses which assess the quality of studies and how much weight to give each of those studies. All those most recent reviews of the preponderance of that evidence have shown the same thing: “overpronation” is a problem; it is a risk factor for running injury. However, it is only a small risk factor, but it is still a statistically significant risk factor.

Thirdly, just becasue someone can show an example of someone who massively “overpronates” and does not have a problem is not evidence that it is not a problem. The video of Haille Gebrselassie (“the truth”) come to mind. This is no different to showing someone who has smoked cigarettes their whole life who did not develop lung cancer. Does that mean smoking does not cause lung cancer? People who use examples like that video of Haille Gebrselassie to support their case really should know better and are just showing their ignorance of causation and the actual scientific evidence and just what a risk factor is and how it works.

Fourthly, there are multiple causes of “overpronation” and if it needs to be dealt with, it is dealt with by dealing with that cause in that individual. Anyone who is advocating one particular treatment for “overpronation” really have no clue what they are talking about. There are multiple options, but the option that will only work is the one that is directed at the specific cause in each individual. You can tell how much someone in social media knows about this based on what they say you need to do to deal with it. One hit wonders are clueless, so ignore them.

Enough said … again.

The Clinical Importance of Navicular Drop and Navicular Drift

I am a big fan of teaching people how to measure the navicular drift and drop. However, the evidence is that for clinical use they are not that reliable, so that does limit the usefulness of these clinical tests in clinical practice.

Having said that, I still think we should be teaching how to do it, but in the context of the unreliability of them. The reason for this is that the concept behind navicular drift and drop does have implications for foot orthotic prescribing. What learning how to do the tests gives clinicians is an appreciation of the relative movements of the midfoot in the sagittal and transverse planes. Navicular drop measures the sagittal plane motion of the midfoot and navicular drift measures the transverse plane motion of the midfoot. Learning how to do the measurement of these two gives an appreciation of the relative motion of that midfoot in the sagittal and transverse plane. Once that appreciation and understanding is grasped, then there is probably no need to do the measurements on a routine basis in clinical practice. You can just observe it and note how much drop there is compared to how much drift there is. Are the about the same or is there more of one compared to the other?

My impression is that the amount of navicular drift should be about the same as navicular drop. If drop is greater, then that means that there is more movement in the sagittal place compared to the transverse plane. This means there is more arch collapse, when means that the foot orthotics need to have more support in the midfoot. If the drift is greater, then that means there is more movement in the transverse plane compared to the sagittal plane. This means that there is more movement of the midfoot medially rather than arch collapse. This means that foot orthotics need more medial and lateral support to control that midfoot transverse plane motion.

The Lunge Test Should be Done in Footwear

I think we all know that the range of motion of the ankle joint is important for normal function. I have made no secret of how useful I think the lunge test is in evaluating that ankle joint range of motion. While there is some discussion as to what is the normal value for the lunge test (I think its around 35-38 degrees) or even if the ankle joint range of motion must be done in subtalar joint neutral (I don’t think it doesn’t need to be), the lunge test is still proving useful and being widely used in clinical practice.

In the early days of running the Clinical Biomechanics Boot Camps we used to do a lot of practicals on the lunge test. Participants would practice on each other and I would go around the room to check how they were going. It was surprising just how many would be considered tight on the lunge test. I would then use my hand as a “heel raise” and get then to stand on that. Almost always they then had a normal range of motion using the lunge test. I soon come to realise that the “heel raise” of my hand was doing what the shoe did, in that all shoes typically have a higher stack height in the heel than the forefoot (the drop). People function and walk in shoes, so the lunge test (and probably as many clinical tests as possible) should be done in the shoes. When we started doing the lunge test barefoot and then in the shoes at the Clinical Biomechanics Boot Camps, almost everyone who was under what was considered normal, was within normal limits when the test was repeated in their footwear. This has implications of the nature of the intervention and if the calf muscles were really limited or not.

There is a whole lesson in the online version of the Clinical Biomechanics Boot Camp devoted to this.

Please consider doing the lunge test in the patients shoes.

Fluoroquinolone induced tendinopathy

Fluoroquinolones are antibiotics that are commonly used to treat a variety of illnesses such as respiratory and urinary tract infections, with ciprofloxacin and delafloxacin being the most common. However, there is the issue that fluoroquinolones increase the risk for tendinopathy. This means it is important that the drug history of anyone with a tendon issue is evaluated.

Fortunately this risk only appears to be associated with the first and second generation fluoroquinolones with the third and fourth generation drugs not being associated with an increased risk of tendinopathy.

The Entity that is “Functional Hallux Limitus”

Functional hallux limitus is a theoretical construct. There is no doubt that the phenomenon that is functional hallux limitus exists, but that can often be as far any any agreement or consensus gets with this. There is no doubt that there are some feet when the foot is up in the air that there is a full range of motion available at the the first metatarsophalangeal joint yet when that foot is weightbearing during gait, that joint just does not want to move. That is the definition of what functional hallux limitus is.

I have written about this a lot, speculating that functional hallux limitus has many possible causes and that it may be better to conceptualize it as a nothing more that each person having a variable stiffness range of motion at the first metatarsophalangeal joint and that this may be related to the windlass mechanism. If this is the case then what we typically considered to be a functional hallux limitus is really the extreme of this variable stiffness and that functional hallux limitus probably exists as a continuum and not as an either/or entity.

My Interest in Concussion

Concussion is in the news a lot lately and protocols for their acute management have become stricter in most sports as more is known about the long term consequences of repeat concussions. For example, a third of kids who have a concussion develop long term mental health and emotional issues. New laws and rules are being implemented by sporting codes and others are under pressure to do more. I have previously blogged about why I think podiatrists should be concerned about concussion and there is a long thread at Podiatry Arena on concussion.

I see concussion as a major public health issue and podiatrists (and all health professionals) should be concerned and active in advocating on all public health issues (eg smoking, obesity, etc). We should be helping getting all the messages across.

The other reason is that post-concussion is that there is an increased risk for lower extremity injury. More than 30 or so studies now show that.

Finally, we are parents and members of the community and our kids play sport. We may need to step up and use the first aid skills if there is a knock to the head at sport.

I urge all Podiatrists to get involved and interested and become advocates for this public health issue.

Severs Disease / Calcaneal Apophysitis

This is a common topic I write about often. I wrote here about just how much I learnt about the condition when my own daughter got it and just how much that subsequently influenced my management. We did a PodChatLive on it with Alicia James and I published my unscientific study on it here.

Firstly, it should be called Calcaneal apophysitis and not Sever’s disease, but I still use Sever’s disease as that is way more common in the search engines when you want your writing to show up.

Secondly, as I said in my unscientific study, I not sure we can do much to help it. The big problem with Sever’s disease is that if you take 100 kids with and do nothing, x% will be a lot better next week. If you took another 100 and did something, then x% would be better next week, so did ‘something’ work or was it the natural history that was the reason for the improvement.

I know when you visit Podiatry Facebook groups and other social media and see discussions on Sever’s disease, so many have there views on what should be done. I have to fight myself really hard not to get involved in arguments, but I often want to ask them how do they know the treatment that they are advocating actually works and that the improvement that they are seeing is not just the natural history that you would expect to see. They actually have no way of knowing unless what they are advocating has been tested in a proper well controlled prospective randomized study.

So what do I do for Sever’s disease. Not a lot. Educate them on the nature of the condition and the natural history; discuss how to manage the loads and use a cushioned heel pad.

I am a big fan of the Archies Flip Flops

We call them “thongs” in Australia. The Archies footwear come with an arch support built into them. We sell Archies in our clinic in Melbourne and they sell well. Pretty much everyone who tries on a pair buys them They are that comfortable. What is useful about the Archies is that they can be used by those who need or have foot orthotics but want to occasionally wear this style of footwear.

The other great thing about these is that can be modifiable. I sometime get on the tools and make what I call a MOSI Archie modification for those with a more medially located subtalar joint axis. I made this video on the technique.


I also occasionally answer a question online about them!