Smart Athlete Podcast Ep. 125 - Mark Gallagher - THE FOOT DOCTOR IS IN

Yeah. My main interest as a youngster at school growing up was football. I think like most boys and I guess girls now here in the UK, we all wanted to try and get into professional sport, and football was my thing. I played at a reasonable level, but I think I played at a reasonable level because of my fitness. 

MARK: [00:00:00] Yeah. My main interest as a youngster at school growing up was football. I think like most boys and I guess girls now here in the UK, we all wanted to try and get into professional sport, and football was my thing. I played at a reasonable level, but I think I played at a reasonable level because of my fitness. I think there’s technically better footballers than me out there, but I was always physically fit. So, indirectly when I look back, I used to cycle everywhere, partly because of the geography of where I lived, and how public transport was limited. So, that was part of it. And again, the running side of things, it wasn’t a conscious decision to be a runner. It was just — I enjoyed it and it never really registered on my radar that I was physically running a decent distance or riding my bike.

[Intro Music]

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JESSE: [00:01:44] Welcome to the Smart Athlete Podcast. I’m your host, Jesse Funk. My guest today is going to give us some pretty concrete helpful hints on how we take care of ourselves, but more specifically in his specialty. He is a podiatrist and the clinical director at PodiatristRx. Previously, spent 10 years at the Royal Orthopaedic Hospital in Birmingham. His specialty is kind of musculoskeletal trauma, predominantly civilians, although he did tell me before we got going that he had some military experience in some of the injuries in that area as well. He’s a runner, cyclist, interested in football, which, for the North American listeners, that means soccer, I assume. Welcome to the show, Mark Gallagher.

MARK: [00:02:29] Thank you, Jesse. Thank you for the invitation.

JESSE: [00:02:32] And I wanted to clarify that because I think it would be hopefully immediately clear by your accent that when we say football, we’re not talking about American football. But since you hadn’t said anything yet I figured it’d be easier just to clarify on my own so there was no confusion about what we’re talking about.

MARK: [00:02:53] Indeed. Yeah, this is, yeah, soccer as we know here in the UK. The American football is too complex and it goes on too long.

JESSE: [00:03:04] Yeah. So, I live in the middle of the country where we have an American football team that’s done pretty well the last couple years, though they’re struggling this year. And our soccer team is usually one of the better teams in Major League Soccer. And I kind of got my wife into watching our soccer team. And then I myself have gotten into watching the American football team, even though I didn’t grow up playing it. And she’s just like, how long are these games going to go on for? Like, they just keep going.

And I think part of the problem, especially if you didn’t grow up in a culture that watches American football, is there’s so much starting and stopping versus if you’re watching soccer or traditional football, the game play is like there’s no — I guess if injury time or penalties and fouls. That aside, is essentially the half is played, we get half time and the other half is played, there’s no stopping, there’s no timeouts, none of that stuff. So, I think it’s a little easier to watch because there’s always something happening. So, I want to ask a little bit about your kind of athletic background, running and cycling. Did that come prior to getting into podiatry? Or was it the other way around? Did they happen at the same time? How did that develop?

MARK: [00:04:34] Yeah. My main interest as a youngster at school growing up was football. I think like most boys and I guess girls now here in the UK, we all wanted to try and get into professional sport, and football was my thing. I played at a reasonable level, but I think I played at a reasonable level because of my fitness. I think there’s technically better footballers than me out there, but I was always physically fit. So, indirectly when I look back, I used to cycle everywhere, partly because of the geography of where I lived, and how public transport was limited. So, that was part of it.

And again, the running side of things, it wasn’t a conscious decision to be a runner. It was just I enjoyed it and it never really registered on my radar that I was physically running a decent distance or riding my bike a decent length of time. But as you get older, you start to look back at how much time you did commit to those events, and therefore, it just became part of, I guess, my psyche, really, and I played football up until I was 41.

I’m 48 now and I stopped mainly because of a back injury, which is then when I spent more time running and riding. And then the age element and we might touch on sort of the different problems your audience might encounter. But you know, and I think when we spoke before we started about your life in triathlon, the fatigue element, sometimes the quality in your running or your riding becomes effective because you’re doing two disciplines, for triathletes doing three.

I always say to my triathlon patients with injury, the beauty is you share the load across three disciplines. The problem is that you’re always running on empty or you’re there or thereabouts on empty. So, I had to choose at some point, and I’m saying I had to choose for a performance element. So, my preference is my bike. I ride my bike a lot on the road race or I ride my bike and I race bikes. And bizarrely this year I’ve got into cyclocross, which is a completely different discipline. And I’m actually really enjoying it because it’s a different way of training. But yeah, for me, riding a bike or running, I don’t see it as anything other than it was always part of my lifestyle.

JESSE: [00:07:08] What I always think is interesting is people in the United States seem to come at sports from this really highly structured viewpoint. Not everybody, I mean, you can make an entire blanket statement. But I think it’s not uncommon to see parents like, want to have their kids be in this program and do this very regimented exercise to try to become whatever sport it is, become great at it. And I always think it’s interesting that you’re talking about what is essentially completely unstructured, unscheduled, like cycling and running time as a young person. Not like, coach said I had to go run five miles to get ready for practice. It’s not that, it’s just how it was and you spent time moving and that created the fitness level for you to excel.

MARK: [00:08:13] Yeah. I realized fairly early on in my fledgling, you know, when I’m talking about a teenager and I’m playing football at a reasonable level, that if I was to give myself a fighting chance, I needed to be the fittest on the pitch, it was that simple. And that’s the one area that I could improve on. I mean, technically, I could have improved as well, but there was a glass ceiling on that one. But from a physicality perspective, that’s about the person. And I say a lot to, again, my runners on a return to run program, you actually find maybe their second or third injury in a short period of time. If you don’t have a running history, your physiology is different, your bone strength, and your soft tissue strength is also affected.

So, if I look back, with the exception of the back injury, I really hadn’t had any other injuries in my entire life leading up to that. I played football, I rarely missed games through any sort of injuries, maybe some contact injuries at times, but nothing in terms of soft tissue. And so I think the indirect effect of just enjoying being active. I was always competitive in anything that I ever wanted to do. So, if I run and run, let’s say at school, and again, so there’s people and obviously, clear like most people would want to win and I think performed reasonably well.

And I think when you come to be a competitive cyclist at an older age, which is really what I did, the big concern is, is where are you on that pecking order in terms of performance? You know, my starting point is I didn’t want to come last in any event or race that I did. And the fortunate thing is in the races that I’ve been involved in, I’ve very much been able to hold my own. I’ve never been in the top five or 10. But I certainly haven’t been in the back five or 10, either. So, I’ve actually, I’ve enjoyed them, but I don’t look back and think, what if I did that earlier, and what if I did that with more structure.

But also being active, and continuing to be active, I think is, for me, personally, as a clinician, I think it creates the empathy that you can have with other injured runners, cyclists, golfer, whoever, because we would both understand the psychological effects of being injured. And I deal with cold orthopedics, I deal with the mechanical stresses and strains. But you can’t forget there’s a patient on the other end of that problem that is probably going through different elements of anxiety, depression — the challenge because they’re not active and because they’re not active, that leaves the confidence. And I think that’s probably the one area that I’m pleased that I’ve been able to remain active and relatively fit.

JESSE: [00:11:24] You know, I kind of have this down on my things I wanted to ask you about, and partially because I’ve had a number of injuries throughout my years, predominantly during college were just, it’s a crucible of trying to get as fast as you can and tons of racing and you’re racing all year. But I’ve seen a number of health care providers throughout the years. But I always tend to want to find somebody who’s also active, because it just doesn’t seem like there’s quite the right connection.

Say, I went to like a general practice doctor or something and I said, oh, I’ve got this. And it just seems like, I don’t know of the diagnosing or what exactly, but there’s just some disconnect between how to treat that situation, if they don’t seem to have some kind of background themselves. So, would you say being active and also having your practice, like that combination is what makes what you do unique versus say, somebody who doesn’t have that kind of athletic side?

MARK: [00:12:37] I think, for me, it creates an advantage but you know, that sort of then looks at my other clinical colleagues that I would work with who excel in sports medicine, but have no active interest in being active themselves. But I think for that group of clinicians, they’ve probably been around the industry for a long time. And they’re very aware of the key components to, you know, what makes an athlete whether that’s a professional or an amateur athlete.

I think that what I find reassuring, if that’s the right word, a number of my patients breathe an air of relief when — because for most people, it’s this context, which is when they know that you’ve worked in trauma and military trauma, and you’re working with a blast injury or a gunshot wound, sometimes they feel like the problem that they’re coming with if it’s an Achilles tendinopathy, or they have knee pain, is that for somehow that doesn’t register on my radar.

Well, everything is — everybody that — I say this and I bore people to death with it. Everybody is case study one. You’re coming to me with a problem. I’m not judging what that problem is. I’m just thinking how can we find a solution, how do we plan this out? And what you will come with is some pre-existing beliefs. I have to respect that as well. I need to know where that — I don’t need to know. I don’t actually need to know where it comes from necessarily, but I need to understand what your thought process is about the particular injury that you have.

And I think having injuries or being around people that are injured or working in a team environment, or even working in a discipline where it’s a single athlete in isolation, if you’ve been around those environments, I think you probably have a better skill set or a more appropriate skill set to deal with that injured athlete.

And in a similar respect, do you need to know every sport that’s coming to you? I guess the one that will throw a curveball to me at times is dance injury because most of the dancers are the ballet, whatever dance you choose. Footwear strategy for me in terms of how I manage somebody with a knee problem as a runner or somebody or on a bike, I’m invariably modifying or manipulating what’s happening at a foot level. But if you’re not wearing footwear, then the tools in the bag for me are going to be quite limited. We can get you stronger, we can get you maybe with better flexibility or better landing [inaudible 00:15:08]. But I guess if you put me in front of a dancer or a dance population, I should have value somehow somewhere.

But because I’m not a dancer, and you know, if you ever saw me on the dance floor, you’d recognize that quite quickly. I can’t empathize with that group as well as maybe the other sports and disciplines I’ve been heavily involved in. So, I think there’s an element of even within sports medicine, as a clinician, you need to recognize that they’re probably better qualified people than you because you find regular exposure to that particular discipline. And you understand the forces, stresses, and strains and just how that dancer might deal with their injury, and I think that puts you ahead of the curve. So, if you’re saying to me I’ve got a colleague, she’s a ballet dancer, are you the right person? Well, I’m probably going to add value.

But if there’s another one of me who’s got more dance experience, or has been a dancer, then probably that’s the right person for that individual. So, I think there’s an element of you have to understand the mechanisms somehow, somewhere. I think, we touched on it earlier, that the sport, what connects every sports person is that willingness that wants to be better, to compete, all the other bits that come with being active in sport, I think there’s a connecting theme. But there are some specific elements in each sport, discipline, whatever, which might create a different path for somebody to follow.

JESSE: [00:16:44] I have to back up a little bit, because you said a lot. So, there’s a lot of things that can go on. But you were talking about people coming to you. And if they know you can come from that, like, have that military trauma background, and they kind of minimize themselves like, well, I’ll just like, my Achilles hurts. And like, that’s not that big a deal. It’s like the same thing you even said, remembering that there’s an injury, but there’s a person attached to that injury. It’s like this weird minimization of themselves. Like, oh, I’m not important because that’s clearly worse than anything I’m dealing with. So, don’t worry about me. I don’t know —

I’m not sure where that comes from, you know what I mean? Like, I do it too, I think there are definitely episodes of the podcast where I talk to say runners that are faster than me. And I’ll minimize my own accomplishments because I’m like, ah, I’m not like that person. But I’m not sure where that mentality comes from to minimize your own situation, especially coming to you where it’s like, clearly, this is a problem, they come to you. They’d love to have it resolved, I’m sure. But then at the same time right at the last minute, they’re in front of you, and then they kind of like, back away, you know?

MARK: [00:18:08] Yeah. I mean, I’m not intelligent enough to turn back the psychology of the person to that detail. But I agree, you see a lot in clinical practice. And at times, it might be because they’re sat in the same waiting room as somebody who’s got some form of a bit of kit on the leg, and it’s like, wow, that’s a problem. And it’s like, well that’s — If you’re not able to do the things that you want to do, then that’s a problem. And if somebody wants to judge that from outside of our circle, that’s fine. That’s up to them.

But I know what I’d be like if I couldn’t ride my bike because of an injury. I’m going to be a grumpy person somehow, somewhere and that’s got a negative effects on all key elements. And I think what I try and say to injured runners, if that’s who it is, then this is context, this is creating a problem for you. You can’t do the things that you do and enjoy and that’s just — let’s focus on this bit. Whether you see somebody outside that you think looks in a worse position, or is more deserving, that’s a judgment call on that person’s behalf. But for me, when I’m seeing somebody for the first time, and I’ll always go, well, what’s the story? Or how can I help? Or what’s the problem? You know, it’s that opening question.

As you’re listening to their story, you’re starting to think already about how you might provide that solution. What you’re not thinking of as a clinician is, wow, that’s a bit miner. Or, really, have you seen what’s outside in the waiting room? You know, there’s no — And I don’t think I’ve worked in any unit or team where we’ve had those types of discussions because if it’s a problem enough for you to pick up the phone, make an appointment turn up to location, then it’s a problem in any way, shape or form. So, yeah, I guess it’s a human nature thing that I’m sure there’s books out there. And I probably need to read them. But yeah, I think it is, and you know, you mentioned about running times earlier and what I always find interesting [inaudible 00:20:15].

So, when we’re doing treadmill analysis, for example, where you get an analysis, my first question to them is what’s your 5K time? Because your 5K time will then look at their tempo speed, and therefore you can set the treadmill to [inaudible 00:20:29] kilometer out, whatever it’s going to be. And I would say, nine times out of 10, your runner will say, yeah, well, I’m not that quick. And I go well, before we commit to a number, be careful what you say next, because I know what my tempo pace is. And therefore you’re waiting for them to say they’re quicker than you [inaudible 00:20:48] like, yeah, we’ve all got — We all have this feeling of where we are on this pecking order of I guess that’s human nature. I don’t know.

JESSE: [00:20:59] Yeah. Well, I find that, and I am absolutely positive that there’s probably some egomaniacs out there. However, I have met and interacted with athletes from people like on — So, if you’re on the YouTube channel, if you’re just listening, there’s a YouTube channel version where you can see Mark’s very wonderful background and skylight and all that kind of stuff. But I also do a running show and people comment and ask me questions and they’re like people that are just starting out. So, like running 50 minute 5K’s or just trying to complete. So, I’ve talked to people from that spectrum all the way through Olympians. And I don’t know that I’ve yet met anybody that’s not like, I will say self-deprecating, but just humbles about it. Like, I don’t know that anybody’s like, I’m the greatest.

I think everybody understands they’ve been beat before, they’re probably going to get beat again. And even though, if they’re faster than us, we look up to them and go, oh, I wish I was that fast or whatever. They don’t necessarily see it that way. Because they’re like, there’s somebody faster than me and I wish I was that fast. Like there’s — And even if you’re at the top. I don’t even think that those men and women, I don’t — I go back to, I bring her up a lot because she’s my easiest touch point. My friend and former coach Barb Lindquist, who is a pro triathlete for a number of years. I think she raced for 10 years. She raced in the 2004 Olympics, she was ranked number one in the world.

She’s the most humble, helpful, triathlon coach you’ll ever meet. It doesn’t matter. If you’ve never done a triathlon before and you’re 300 pounds overweight and you’re just trying to finish, she’ll spend as much energy on you, as somebody’s trying to win the Olympics. So, it’s just weird that we minimize ourselves, yet, we all have this very same experience despite what our speeds are. So, how do you suss that out of people you do? Do you get people that underplay and you be like, I need to go a little bit faster? Or do people usually give you a realistic range for themselves?

MARK: [00:23:36] Well, interestingly, some people actually don’t know what their pacing schedule is, which from an injury risk perspective, is of concern because you know, from a runner perspective, being a robust one is the ability to tolerate multiple impacts. You know, that’s, that’s all it is. And if you spent a day with me or a week with me, and you looked at the running population injuries that we see, there’s some very distinct little subsets. So, there’s people that have gone from zero to hero quite quickly, and they obviously break down. There’s cumulative load over time, there’s back to back running days, all of these things which have a physiological reason why they break down, are all relevant to the discussion in terms of well, one, how do we minimize the risk or how do we solve the problem? How do we minimize the risk of it happening again?

If you don’t know your running time, I’m not saying you need to be geeky in terms of Strava status every single time but you need to know what your tempo pace is, first and foremost, because there’s a neuromuscular speed to which you will naturally move. And as you get stronger and more robust, you will modify that tempo baseline. So, when the question is asked, what’s your 5K time and they don’t know that, it tells you that there’s a risk factor there, which is they’re not sure what their body’s capable of. And that starts a discussion, which is, I’m not saying that you’ve got to map everything out. But let’s say we’re going to return to one program, and we’re eight weeks down the line, because we’ve got you stronger, your tissues are more compliant, you’re not getting pain walking around day to day, which is our starting point for returning to run.

The question is, where do we start with the return to one program? Because the questions you will ask me is, how often, how far how quick? Well, if we don’t know your tempo pace, then we’re just clutching at straws. And we can make an assumption. But you know, my return to run protocol is to run every third day. You’ve got two days as a physiological window to recover. And we’re going to go in and around 80 to maybe 90% of your tempo pace. Because the natural reaction to most injured runners returning to run is I’m going to run slower. Well, if you want slower, your mechanical makeup will be different. So, your contact time on the floor will increase. Your knee flexion moments will increase. You’re just going to change things because you think you’re dampening down impact force, possibly [inaudible 00:26:09] you’re thinking.

So, I’m saying to my runners, there’s a window that I want you to work and I want to slow it all the way down here. I want you to work within a window that is close-ish to where you need to be for your natural running rhythm if you like. I remember I never run a half marathon, I wasn’t mentally strong enough. And I think physiologically as well, myself and my ex running mate. We did a number of half marathons. On one of those half marathons, we continued our training to do a full marathon probably four months later. And the longest I got to was an 18-mile run. And I just said to my mate afterwards, I can’t do this. I’m not enjoying it. I’m broken. I was playing football and riding my bike at the same time.

So, there’s an element of stupidity in that as well, from my perspective in terms of fatigue. But the biggest challenge that we had as a running partnership, we were a similar size, our training pace, would it be? Probably six minute 40 fives per mile. So, what’s that 425 kilometers, is we found it really difficult to run slower to get more distance in. So, I don’t know if your Garmin is the same as mine. But if you go over a certain pacing strategy it’ll start bleeping at you.

So, we would run together and we will get reminders to run slower. Well, that was also part of the frustration for me as I couldn’t run slower to get more distance. I just found it harder to run slower. So, there’s this ingrained neuromuscular pacing within us, which is your tempo pace. You can improve that over time. But fundamentally, how you start and how you work out your timing strategies will partly dictate how we look at return to run program for you. You’ve got to have those metrics, at least available to refer to so we can start building blocks again.

JESSE: [00:28:03] You said a lot of things I think are interesting. One of the things I wanted to nail down was what you mean by tempo pace, because people use that term for different meanings. When I say tempo, I usually mean some three, if that means anything to you. So, zone four would be like 5K pace. Zone three would be like a slow 10K. That kind of thing. So, are we on the same page, we’re still — [crosstalk]

MARK: [00:28:29] Same page. Yeah, so threshold will be zone four and pushing zone four. Because it’s like me and you running a 5K together, and we’re just not going to be able to talk because we’re sort of towards the top [inaudible 00:28:43] capable of. And as men, we wouldn’t accept that because we’d still be [inaudible 00:28:46]. But yeah, that’s where I’m at.

JESSE: [00:28:48] Okay. So, that’s the intuitive thing, right, exactly what you said is like, you come back from an injury, you want to go slower. But then like, you adjust your gait or the mechanics adjust when you slow down. I’ve actually been dealing with this. Recently, I noticed that I hadn’t been engaging my glutes enough on the right side, just the right side. So, then I was getting excess strain on my soleus because it was taking more push off power instead of using my glutes. So, I’ve got to like, consciously get back into that a little bit. Just little things, but it adds up miles and miles and miles and all of the impacts. And that, as far as injury risk is concerned, it’s something I don’t think people take into account enough. And it’s hard to take into account because you do it somewhat subconsciously to try to baby the injury.

And then if you can’t see yourself or have somebody to see you to go, no, then it’s hard to diagnose that that’s the issue until you’ve re-injured an area. It hurts and then you go, something was wrong. They come back to you. And you go, okay, let’s start over. But the idea of coming out at tempo pace is interesting. I don’t know that — I guess I’ve had a number of injuries over the year. I don’t think I’ve had anybody ever suggest that to me. But it does make some sense of trying to have that more locked in, you know, I’ll call it natural gait instead of trying to go slow and baby it and doing weird things and overcompensating and creating other issues.

MARK: [00:30:36] And remember, you [inaudible 00:30:37]100%. — 5K route, it’s the route — 5K — Garmin, and you’d be roughly within… unless you were feeling super strong and [inaudible 00:30:58] is very much based on… the treadmill, it’s a slightly arbitrary… you see the changes… from 14K an hour to 10K an hour… that you see in terms of landing mechanics. So, it comes back to… metric… aware of where your body is in terms of what its speed is if you like.

JESSE: [00:31:35] If you’re listening, Mark’s cutting out a little. We’re getting most of what he’s saying. I think he can still hear me. But we might try switching back to your onboard mic. So, apologizes while we switch things. We may edit this out, we may not depending on how quick it takes. And we get a little bit of feedback from my mic, but just so we make sure we actually hear you. And then we’ll just need you to say something real quick, Mark.

MARK: [00:32:06] Yeah, [inaudible 00:32:07] now.

JESSE: [00:32:08] Okay. Good. Yep, we’re good. I don’t know if it was — what it was. Anyway, so we’ll get back on. Thanks for being patient with us as we adjust things to try to make sure you can actually hear Mark and the good things he has to share with us. So, I do want to ask you and you probably get this a fair bit, but are there commonalities? Are there very common injuries you see over and over and over again? Or is it like, just a wide variety of things? Like, oh, I’ve never seen this before. I assume there’s some kind of like, common circumstances that happened to people.

MARK: [00:32:48] You know, let’s try and put it in the top five. You know, the commonest thing I see within my civilian world is plantar heel pain. So, plantar fasciitis. I mean, there are three subsets of plantar heel pain, but let’s say plantar heel pain is a generic term. Achilles tendinopathy will be the kneecap pain, so patellofemoral joint pain, stress response, stress fracture that’s probably more relevant in my professional football world rather than my — So, my running population has a big bone stress combination.

And that can be sort of stress fractures and tibial stress fractures or stress responses. I think probably the further you go from the foot and ankle, the less impact that’ll have unless there’s some obvious asymmetries. You know, if you’ve got a leg length difference of two centimeters, there’s going to be a mechanical cost somewhere.

So, balancing it will be a sensible choice. But I would say that those are the main groups. That probably is 80% of your population. And the reason why it’s not dull, because if you were saying the same thing 80% of the time, you’re thinking, so how can you enjoy clinical practice? It’s that biomechanics element, which is we are applying mechanical principles to human tissue. And the difference is that human tissue is different from person to person. So, your tendon strength and my tendon strength will be different. I’m predominantly a cyclist these days more than a runner. So, you’re going to win in terms of your plyometric strength, you’re going to win in terms of your bone density, but I might have a stronger cardiovascular system. You know, so there’s going to be a trade off in those risks, those inherent risk factors.

So, the reason why clinical practice is interesting, at times challenging, and at times frustrating is that variation in somebody’s Achilles tendinopathy will respond to X, Y and Z. Yet, the next three people might not respond to the same protocol. So, you have to have that experience and that understanding that again, it goes back to it and I do bore people with it. Everybody is case study one. What are your risk factors involved, the risk factors that we can change and modify? And also, not to a lesser extent, but to a meaningful extent, what’s your buy in? You know, I’m expecting you, if you’re my patient, to do the things that I’m asking you to do. And then you’d be amazed at how often that doesn’t happen, you know.

JESSE: [00:35:26] People not following directions, I don’t know that that — it doesn’t actually surprise me, I guess. I mean, both as a person in just — I don’t know, I may see it with consumer products, people just not reading directions, not following directions. And it’s obviously much more important when they’re coming to see somebody like you, and you’re trying to resolve an injury, and then not following directions. That’s another like, one of my undergrad degrees in psychology.

So, I have an interest in people. So, I often come back to that kind of aspect, but just, it’s where I go, people are weird why would you not — You made the appointment, showed up for the appointment, went through the the diagnostics to figure out what’s wrong, Mark gave your regimen, then you didn’t follow it. Like, you did all these other things, and then stopped at the — Like, why? Why would you not follow through?

MARK: [00:36:31] Yes. And the other element to that is, I’m in private practice full time. So, people pay for that experience as well. And I do say to a reasonable number of patients per week, per month per year, I can see you again in three weeks time and we can charge you the same amount of money and we can have exactly the same conversation. Which direction do you want to go in? Because when we first met, you said to me that you’d be willing to do anything to get this right. And we’ve established the fundamentals, which is a footwear strategy, maybe something inside footwear, a strength program, a [inaudible 00:37:01] program, an ice pack regime, vitamin D for your bone health, whatever that strategy might be. Yet, you’ve only done 50% of what we talked about, and we agreed with it week one or week two, whatever that’s going to be.

And I guess it’s the reason why we are busy in practice is people, and I’m part of this as well, is people often do enough to function at a reasonable level. Are people prepared to go in the gym and get themselves stronger to be at a high level? It depends what their drive is. But from experience, I think it’s probably human nature. We do enough to get by at times, and that and that can be fine. But I think when you’re looking at recurrent injury, which we do for a small group of patients, fortunately if you said to me, what are the fundamentals of risk factor management? Being strong. Being strong is fundamentally important to being an athlete of whatever description and in whatever discipline.

JESSE: [00:38:16] Yeah. I think you’re right on the money there with, we do just enough to get back to some kind of functionality and then like, pull back. I don’t know if it’s a matter of like, think of like, maybe the idea of like, you got stabbed. And if you pull the knife out, let’s suppose that obviously, this isn’t how it actually works. If you pull the knife out, so now it doesn’t hurt. Like it’s healed up. But the knife is still right next to your skin. You can get stabbed in any second. Yeah, but it’s not stabbing me right now. It’s that mentality, like, it doesn’t hurt anymore. It got taken out. Like, yeah, but if you move a half an inch to the right, you’re going to get stabbed again.

I’m guilty of this as well, where it’s like rehabbing an injury, get back to running, and gosh, I’ve forgotten who I was speaking to about this. Oh, Scott Johnston. He’s the author of the Uphill Athlete. I can’t remember what episode number. So, if you want to listen to that, you’ll have to go search for it. Sorry. But he was talking about injuries and skiers and whatever their main injury is, the greatest time of recurrence is like, I don’t remember if it was nine weeks or nine months. It’s a considerable amount of time after they’ve already been cleared to practice again. And it can be mitigated by continuing the rehab protocol, which people generally don’t do. So, it’s like they cleared it, they got to go ahead and then just go, I’m fine and forget about it.

MARK: [00:40:14] Yeah. Maintenance programs are the hardest sell, because, and again I probably won’t be the first clinician people see in clinical practice, probably just because [inaudible 00:40:24] working — in Birmingham, or in some well-established centers. And I guess the price point is, is maybe towards the higher end of the spectrum. So, they may well have seen other people before they would venture to see me in my various units. What’s interesting is there’s a lot of stories, which is going back to doing enough to get right. The question is, well, what did you do to maintain? Because the assumption is that when we run or when we’re out running again, and we are creating a strain stimulus from the tissue, no question, physiologically, you get cellular damage, that damage needs time to repair, recover and strengthen. That’s how we get stronger and we build up robustness.

But the support and mechanism with strength programs, as well as a maintenance element we do in professional football, we’ll do to dedicated strength sessions a week with our players, predominantly hamstrings and calf we mentioned about soleus. Soleus is a phenomenally important muscle; it’s your engine room. And as much as we do obsess about the glutes, for all the right reasons, they’re still primary stabilizers. You know, your soleus, six to eight times body weight will go through soleus yet two to four times body weight might go through your glutes. So, go figure, why do we all do squats and lunges? Well, we do it because we want good bum strength. How much soleus work do you do? Most people don’t do a lot.

And actually, when you test soleus strength, even in elite sport and in your military, different subsets, people can fatigue at 25 times their own body weight on single leg calf work. But if you’re doing that, how do you expect to be able to run 10K without mechanical consequence? Because if you’re fatiguing 25 reps you’re on body weight, something else has to do more work to at least duplicate or replicate the role of soleus. Going back to your analogy of soleus is having a problem, something else got to work overtime. Absolutely, that’s the relationship. So, go back to source, let’s optimize calf output. I bore people to death with soleus programs because it’s the fundamental lower leg muscle in my opinion, but I come with a bias because I’m predominately foot and ankle work. I’m more distal than proximal.

And they all are important, but yeah, I will give all my runners, probably all my runners, some form of soleus program to work with not at the cost of gastroc. Because I think gastroc, the second muscle group in the calf will come along for the ride anyway, even in a soleus program. And actually, sometimes when you look at carb strength programs, they’re predominately gastroc biased with no bent knee version of it. Well, if you’re a runner, you have to have bent knee strength.

So, you can see how these patterns build up and all you can do is share your experience with your injured runner, because again, they’ve got one person with experience which is theirs. But I’ve got thousands of people’s experiences because that’s what I’ve seen in clinical practice. And you can give people a message and you can give people the programs. And you can say, well, this is what I would do.

And then actually when we’ve got your back running, and you’re hopefully not going to see me again, for all the right reasons, you still need to think about this program. And if you go on holiday for a week to 10 days and you don’t run, you need to do this program whilst you’re away, ideally. Because otherwise, you’re going to come back deconditioned, return to your two 10K runs once a week and wonder why you got injured with four weeks in. Because you’ve lost that robustness in that even week to 10 days. And this is the only age-related thing I’ll say that deconditioning risk happens quicker as you get older. So, you know, I think it’s even more important that as we get older, we try and commit to strength, lower leg strength somewhere in the system.

JESSE: [00:44:07] Which is good timing because I am ready to head out on holiday here in the next couple of days, although I am planning on running while I’m out. So, we’re doing maintenance miles, not just taking time off. So, hopefully won’t be quite as many issues as taking time off and having to rebuild all that kind of thing. But Mark as we’re kind of winding down on time, there’s a question I asked every single guest each particular season. This season’s question is how do you stay motivated after failing to reach a goal?

MARK: [00:44:45] So, we’re talking athletic goals or — [crosstalk]

JESSE: [00:44:47] It could be anything.

MARK: [00:44:51] I think I’m very much glass half full in how I approach things. This probably sounds very sort of T-shirt logo-ish, but I don’t really see problems. I’m just trying to find a solution. I think one of the best books I’ve ever read is Black Box Thinking by Matthew Syed. I don’t know if you know him as he’s an ex GB table tennis player, and he’s now a journalist for, I think, the times or something like that. But really interesting book. What it does, it looks at different industries in different sectors. And it’s about how you learn from your mistakes. And the aviation industry will probably be the best example of they just look at everything to make sure it doesn’t happen again. So, in my life, I try and work towards that. I don’t really browbeat people about problems. In my sector, for example, I make a living personally from putting things inside footwear orthotics.

I work closely with different labs historically. Whenever I’ve flagged things in manufacturing, again, I go at that with a, look, I’m not here to create an issue, I don’t care who or why it’s happened, I just want to make sure it doesn’t happen again. So, I think when you don’t reach your goal, then look at what are the factors that stopped you getting to that. Were they realistic in the first point, did you really want it bad enough? And I would say that is the same in both clinical practice, they don’t want to study enough for this, they don’t want to listen to other people in terms of how they manage this problem.

So, I think you have to use the resources around you to achieve those goals. But if it’s a goal that you are solely in charge of, you can ask yourself the key questions: how badly did I want it, and did I give myself enough chance to do it? And I think, in athletic performance, I know where I sit on that spectrum of good, bad, or indifferent. You know, I’m a half decent cyclist. I was a reasonable runner, I was a reasonable footballer. So, my goals at the moment, for me with cyclocross, for example is, I don’t want to come last. You could say that I set the bar low on that one, but I just didn’t know what to expect from it until 10 races in now. And I’m sort of the top 10 in the region, which I’m pleased about and sort of partly surprised.

My goal for next season is to firmly be in the top five. So, I think in terms of goal setting, they have to be realistic with all the pressures that you’ve got around you. I’ve got clinical, I’ve got my work pressures, I guess, I’ve got my family. You know, you’ve got all these challenges, but yeah, I don’t fall over myself when something’s not achieved. I just look at whether it was achievable in the first place. And again, was I focused enough to get to that end point? Now for me, now it’s my fitness, so I’m using the last six months of this year, just to change body shape a little bit, just to, you know, lose a little bit of weight and try and put on a little bit of strength in my upper body, helping my bone density risk as well, because I’m [inaudible 00:47:55] cyclist.

And I think as I hit my target, at the turn of the year, I think I will have achieved those goals. Now, do I reset in the new year and go right? Do I need to drop even more body weight? I’ll be 68 kilos by the time I get to where I want to be having been 74 kilos in July the first. And I’ve actually really enjoyed the process of going through that. So, I think for me, goal setting is fundamentally important in every element of what I do, both clinical practice, with family and controlling the kids, but you can hopefully give them the advice to do the right thing. So, yeah, I think goal setting, although crucial, it doesn’t define me necessarily. It just gives me targets to work towards. Otherwise, I’ll probably just end up on the couch everyday doing very little.

JESSE: [00:48:53] That’s quite a thorough answer. Mark, I know, it’s going to be a little tough for my North American listeners since you’re in the UK. They probably aren’t going to take a plane to come see you. But are there — you have any social media outlets, any place people can engage with you, check you out, see what you’re up to, that kind of stuff?

MARK: [00:49:13] I’m probably one of those anomalies where I don’t do social media at all. Not really interested in other people’s lives beyond a certain point and I certainly don’t want to publicize what I do outside of my work commitments. I’m accessible through my website. I can certainly guide an advisor where possible. Clearly, it’s difficult without seeing the person to do it beyond a certain point. I think what we learned through COVID, through lockdown, is that things can be done virtually, it doesn’t really matter where you are in the world. I’ve had some interesting experiences in the last 18 months where we’ve managed people that have, you know, I work in London for part of my week.

People live in other parts of the world that would work in London and then go back to their various venues, the Middle East being a good example. We’ve managed people through their stress fractures virtually by just — Hands on is important at times, but having — how do we form a rehab program that can be done as well. So, long story short people are struggling and they’re not finding answers. Reaching out and sometimes getting somebody else’s viewpoint is not impossible. But yeah, my website is really the only port of call. And I think if you Google me, you’ll find various things that I’ve done in the past which, again, predominantly cycling and running related. And I think they’re useful blogs and bits of information. And it probably should have resonance with some of your audience.

JESSE: [00:50:44] Should be great. And I know you and I are kind of similar. I do have social profiles, but I really kind of cut down on the amount of time I spend on them. So, I absolutely understand not really having that outlet. And probably more of us maybe should do that. But despite that, you’re here with me and had a great conversation today. So, I appreciate you doing that. And hopefully you have a good evening.

MARK: [00:51:11] Thank you, Jesse. Appreciate the time. Thank you.

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