328: Expert Edition. Thomas Do Canto-Podiatrist & AUS Distance Running Rep. Tricky Conditions: Sesamoiditis

- Hi, my name's Tom DeCanto. I'm a sports bidiatrist and a lead distance runner. And today, we're gonna be talking about tricky conditions, sesmoid artists, and you're listening on the physical performance show. (upbeat music) - Failure is not an option. - I've had my ups and my downs. (upbeat music) - I think it's an absolutely breakthrough experience. (upbeat music) - Welcome to the physical performance show, the show designed to inspire the pursuit of your physical best performance. I'm your host, Brad Beer. Listening as we delve into how the world's top physical performers achieve their success, as well as the highs, the lows, and the journey of getting there. - Let's get ready, set, let's go. Welcome to the physical performance show, brought to you by Polar's stunning new generation, running watches, the Polar Pacer and the Polar Pacer Pro. I'm Brad Beer, sports and exercise, physiotherapist by trade and training and founder of Pogo Physio. Each week, we'll bring you the latest and greatest information and inspiration designed to help you perform at your physical best. Of course, we do this across a range of our different episodes. Interest editions, coaches, corners, learnings catch episodes, featured performers, and expert editions. Now, in this calendar year, we have started to explore some conditions that affect the running and endurance community, which we are terming tricky conditions. And as the name suggests, they can be tricky to get on top of and typically quite persistent. Real forms in the athletes side. Now, back on episode 319, we took a look at one of these tricky conditions, popliteal artery entrapment syndrome, with Dr. Matthew Hislop. And then on episode 321, we had a look at proximal hamstring tendonopathy with PhD candidate and APA titled Sports and Exercise Physio Anthony Nasser. And on today's episode, 328, we take a look at a foot condition known as Cessamoiditis, with a strain-long distance running representative and senior podiatrist, Thomas DeCanto. Now, on the running front, Thomas is no slouch. He has been an Australian half marathon representative. He boasts PBs across the half marathon of 62 minutes, 13 seconds, the full marathon of 214-1, and 10,000 meters, 2835. In 2021, December, Tom finished second in the Nike Melbourne Marathon Festival, a race 31 in 2016. Now, during today's expert edition, you'll hear Tom share around the diagnosis, management, treatment, and prevention of Cessamoiditis. So get your pen and paper ready. Here is my conversation with pinnacle sports podiatrists, senior podiatrist, Australian long distance running, representative Thomas DeCanto, exploring Cessamoiditis. Tom DeCanto, welcome to the physical performance show. This one's been a long time coming. Thanks for having me, Brad. Yeah, we finally got to see it up, so that's good. Organizing between two relatively busy practitioners is not always easy, but Tom, we do appreciate not only your clinical expertise as a very accomplished sports podiatrist, but obviously the marriage of your professional work with also your elite running status is a rare blend and one that definitely the running community respects and benefits from and appreciates. AKA the running shoe geek out over with our friends that are inside running, who many people may know you from. But Tom, we've brought you on today with the sole intention of diving into what we call a tricky condition. And that is this condition known as Cessamoiditis. So many people will have heard of that, some will have experienced it. But Tom, can you start by just outlining what Cessamoiditis even is in terms of a diagnosis? The first thing I think is funny is that even the way it's pronounced is probably different. Like I quote Cessamoiditis, I don't know you're saying it differently. So who knows what's, how you actually say it. But yeah, so it's relatively common, I guess, for a podiatrist. And often when not the first protocol, I actually see it a fair bit from referrals, maybe from physios, it's just a bit of a tricky case that hasn't sort of resolved with time and with standard care. But yeah, essentially, Cessamoids are just small round bones. I think Cessamoid is from, maybe, Latin or Arabic for Cessimicid. And they're literally just these small round bones. And when we talk about Cessamoiditis or Cessamoid pain, it's generally the ones that are underneath the big toe joint. But even the battella, the kneecap is, I guess, also a Cessamoid. And actually, I like to use the knee joint as a bit analogy for a lot of people coming in with Cessamoid pain when I'm discussing management, because there's actually a lot of crossover with how you might manage anterior knee pain and Cessamoid pain. But yeah, essentially, those two bones are underneath their weight bearing. They distribute the weight over the first metatarsal head. The big toe joints on the forefoot. And they lie within these tendons, flex attendons so that the big toe joint has two flex attendons. And the medial and lateral Cessamoids is to these two Cessamoids lie within those tendons. And the job is to, I guess, to improve the mechanical efficiency of that joint. So the Cessamoids kind of improve the leverage and leave a arm for the muscle to exert force. Again, a bit like the quadriceps and the knee can sort of help with the knee joint as well. So they can confer a mechanical advantage to the all-important big toe. And how would you describe the importance of the big toe to the endurance sports community, the running population? Yeah, I mean, I think it's really important. There's two main ways people can propel off their foot. We call it high gear and low gear. And so high gear is when people push off through a big toe second toe. And so they're pushing off through that medial forefoot. And then you have some people that sort of propel a little bit more low gear and low gear would be sort of like that axis of second to fifth a little bit more laterally. So being the human body is pretty good to actually adapt. So there are some people that have probably always loaded a little bit more laterally than others and probably those lateral metatarsals were a little bit bigger. So it's more of an issue where people, if they have an injured issue, where they were wearing a shoe or something that puts off their usual mechanics and shifts them to what their body's not used to. But ideally, I guess when you're thinking about ideal mechanics, you kind of would want people to be propelling more of that high gear, that big toe joint for a mechanical efficiency. And this whole theme called the Windlast Mechanism, which is where the flakes attendants and the plants are fascia wrap around where the big toe joint extends. It kind of creates an arch raising position of the foot. So if you're propelling off through the big toe and if that big toe extends nicely, then you kind of get this passive stability mechanism happening through the arch of the foot as those the fascia and tendons wrap around the big toe joint. It kind of creates this arch raising. So the foot kind of resupinates passively by that mechanism, you push off, which you kind of want. You want the foot to pronate, and then you want to resupinate. And yeah, pushing off the big toe joint can help this out. So it's critical just out of curiosity, Tom. You mentioned the two types of runner, if you like, the low gear and the high gear there, depending on which part of their foot they propel from, either laterally or more immediately across that first and second toe. You're determining that through like gate analysis. Is that right, video gate analysis? - Yeah, so combination things will start with just looking at callus patterns. So the first thing I get them up on the bench, I'll look at the plantar service, the foot. And often I can tell where they're propelling just from the callus pattern. And then I'll look at their footwear wear pattern. So then I'll have their running shoes in here. I look at the wear pattern. So I like them to bring in some shoes with a bit of wear. And then I'll do the visual gate assessment. So the combination of those three things, just sort of all confirms kind of what I'm saying. Yeah, it'll just make sense once you sort of go through that process. - So we know the big toe is important. And that as you outline the anatomy there, there's those two tendons that come down and essentially the season where it's living those two tendons, the flexahelicus brevis. But in between those, I think it's worth pointing out, isn't it, there's that big flexahelicus longus tendon that goes between them almost like a river, which I know you might clinically experience often see quite a degree of weakness in that flexahelicus longus tendon that lives between those two ceasamoids. Anything you just add on the flexahelicus longus muscle and it's contribution to running and importance of foot conditions. - Yeah, it's probably, it might be under considered. Like it's, I think it's pretty important. It's a relatively large muscle belly up behind the calf there. And obviously with that long tendon, you can assess it by trying to isolate certain positions with the big toe joint flexion. For example, if someone does have sesmoid-related pain and they've got poor flexor strength, whether that's longus or brevis, that would be a really good strategy to try and strengthen them. I don't know whether it's because I'm not seeing it or whether it's just in the realities and it doesn't happen often, but I don't often see the longest being symptomatic around the actual in between the sesmoids. I often see that more either just distal to it like up as it inserts into the distal phalanx to the tip of the toe or more around the ankle. It seems to be relatively well protected in that position there. I think maybe what a couple of times I've seen maybe like a symptomatic right around the sesmoids where it was a differential for sesmoid pain. - With the sesmoiditis, it's a tricky condition. You use the word yourself at the start in that there's so many subcategories if you like of sesmoid pain or sesmoid pain. Can you just outline the different categories if you like or different presentations around pain generated from these two little bones under the big toe? - I kind of try and do it as a diagnosis of elimination. So I firstly want to eliminate any of the serious pathologies that can occur around the sesmoids. And so that would be like a stress fracture would be the main one that would be like either an acute fracture or normally you have more suspicion because the history is like a high impact sort of seeing with acute pain and swelling. But you can get these more insidious onset chronic type stress fractures that you need to differentiate from just the other causes of pain there. So I'd be going through the history like with any injury like you get all the clues from the history and then the physical exam to try and determine how sensitive it is on direct palpation on the actual sesmoid and just some other clinical tests that you might do to differentiate. Pretty much if I have any suspicion of bone involvement or likely refer for X-rays and MR just to rule it out basically. Then once it's ruled out, I'd be more happy to treat more conservatively and like one of the other conditions which I think most commonly when I think of sesmoiditis I think of joint pain. So I just think about a little sesmoid running through the grooves in the plants aspect of the first metatarsal head. And often I think there's pain associated with that joint. So again, it's just similar to the telephomoral pain in the knee joint. So there's just sort of like the contact pressure. A difference being though with the sesmoid it's unique in the fact that it's also hugely weight bearing the compressive loads are high as well as the tensile loads. That's why it is a tricky condition because it is, yeah, it's on the foot and there's a lot of load that can go through them. So once they are irritated, we may need to be quite aggressive with offloading them to let or changing the position of the joint to sort of alter the contact forces around the sesmoid and the first metatarsal head. But there's obviously other conditions like one I've seen a couple of times recently is the bipartite sesmoid. So it's just the sesmoid as it ossifies in kids for growth sensors occasionally instead of just becoming one bone, it becomes two and occasionally three pieces of bone. And to differentiate that between just an anatomical variant versus a stress fracture, which you can normally do from the history in the X-ray. But that can be really tricky because the bipartite sesmoid will have this fibrous connection and sometimes that fibrous connection can get symptomatic and disrupted. And so it is a little bit like a stress fracture in that these two halves that were once connected by this fibrous cartilage, kind of the yet inflamed and irritated and need to be settled. And I think of it again, a bit like another analogy for another injury. I see a lot of this as an eviculous syndrome. So that's where there's like a-- the type to an eviculous syndrome is like where there's the accessory bone so that the medial side of an evicule has an accessory. And it's not attached to the main body by bone. So it's the fibrous cartilage again. And so people with an eviculous syndrome are more likely to develop that if they have that fibrous cartilage connection with their accessory in a vicular. And so I think people with a set with bipartite sesmoid that might be more possibly more inclined to having that pain there due to the anatomy. As you say, rather than it being one bone, it can be two bones or three parts. It is quite prevalent in preparing for today. It's been reported at around 30% of individuals and of those 20% will have it on both sides. So it's not uncommon. - No, that's right, yes. - Merels will be common. - Yeah. - So there's quite a few things that can occur in terms of subdiagnosis if you like of sesmoid or sesmoid pain. I like the analogy, though, Tom, that you think of it in terms of it. It's a joint-related pain. This is a joint. And anyone that's battled with kneecap pain or patellar femoral pain knows that that can be I'm a lifelong sufferer on and off of patellar femoral pain. And so this multitude of factors to be considered in trying to calm that down and also restore people to their desired activity levels. In many ways, more tricky with this condition because of the high forces, including body weight every time we toe off. You mentioned two terms there. Compress even tensile loads on the structure, Tom, just to help those that may not have heard those terms. What do you mean by those? - So your compression is just that direct force from the ground, pushing up onto the foot. So it's just this compressive or squashing sort of load that you'll get. And then tensile being, I guess you could think about the tendon stretching. So those sesmoids lie within the flexor, the bravest tendon, the big toe flexor tendon. And so when that, I would say that sesmoid will be under more load as well. When that tendon is under more stretch, or yeah, that more tensile load, just stretching, which you typically get, just at that moment of heel off in the push off phase, you get that tensile stretch. And often you'll ask people about, even when they're in a clinic walking around, you can ask them, what point are you feeling most that pain and often it is in that push off phase? And they just sit back to, when the heel just comes off, and they're getting into that push off phase, and you'll have most tensile load there then. The compressive load comes just slightly after that, but it does go hand in hand. Before we shift to the presentation of this condition and then the management, Tom, putting you on the spot here, but are there any metrics that you tend to educate your runners and patients around with regards to forces that the big toe deals with in terms of metrics of body weight or anything like that? - In terms of how they can measure how much force is going through that. - Just for many studies in the field that may have been done around the mechanics of the big toe for propulsion, contribution, or multiples of body weight that it deals with at various running speeds? - No, I'm not sure of any studies to be honest of the actual loads going through first, but yeah, you could be pretty certain that there's multiples, five, 10 possibly times body weight load going through that, if they are propelling us through high gear. - Yeah, for sure, it's, yeah, it's high loading. - Yeah, which I mean, inherently makes sense, doesn't it? - You're listening to Pinnacle Sports Pediatries, Thomas DeCanto, sharing around Sesame Ditus on this tricky conditions, expert edition of the show. 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What things, so for the listener tuning in, possibly, I should say, quite rare, though, that if they're listening, they're like diagnosing this, says some weed pain during this podcast would be quite a first. But what things do people present with this condition, Tom? - It's normally very localized pain, so the pain is directly under the ball of the foot, the big toe joint on the planter aspect. So there's no, well, yeah, there's never pain on top of the joint unless they are also having another condition as well. So the sesmoid pain is always on the underside of the foot, normally quite localized. They can get co-presentations often, especially if it's been acutely overloaded through training or other changes. They could be swelling like visible swelling and it can be quite painful just to put any weight at all through there. And it's like fat-pads-flelling or both-siders that can happen just underneath the sesmoids. So you could feel or see some swelling there, but that doesn't have to be any swelling to have sesmoid pain or sesmoiditis. They're the main things. Obviously pain in push-off, as mentioned before, so it's this pain on if you're just trying to do a single leg calf raise their foot on a hard floor. You know, if you've got a sesmoiditis condition, you're quite irritated right locally in that area around the underneath of the toe joint. So localized pain in the any area of concern, swelling at times. I've certainly had one bout of this last year after a bucket list, cycling race, the Grafen Varel 228K, is with 3,000 meters of climbing. And I finished the race, I could feel pain in that area. And my toe was huge underneath my mesismoid, a sesmoid sorry. I actually was very worried. I thought maybe I'd somehow fractured it, which would be unlikely, but I was stressed because it was the size of almost half a golf ball. So I think it's probably worth pointing out this can be super swollen at times. And then pain with push-off, like you said, you've already mentioned MRI and plane films, but the use of those, when would you decide to do one or not the other or a combination? I'm often to both together. If I'm going to do one, I might do both. There's occasionally there'll be something on the MRI where it's not the actual bone and out of these, not as clear as I'd like. And so you get a little bit of information from the X-ray, but the X-ray can't give you the information that you want from the MRI, which would be like any staging and bone stress. So you won't know if, you could see a plane fracture, but you won't know the level of the ball that fracture is or how active that fracture is, which would be indicated by the level of swelling in the actual bone, which would see on MRI. Occasionally I've had, there's been some that I refer to the GP that goes to the sports doc, who may want to get a CT. So just a little bit more detail around the bone anatomy, just checking for any small cracks that might not be seen on both MRI or X-ray. So it would be the third layer of imaging, I'd say it would be a CT, if things aren't just tracking well with normal treatment. And with the bone stress side of things, obviously, there's the acute, sorry, the stress fracture presentation, but then like any other bone in the kinetic chain or the skeleton that's a common site for running related bone stress injuries, there's also that possibility that there's like stress response in the C-semoid, correct? - Yeah, definitely. - Yep. - Which would require an MRI, like you mentioned, to determine. - Yeah. - And then you could sort of then guide on back to run how long that might be. I saw how long, how aggressive you'd want to try and offload it if there's bones falling. So the management of this condition, Tom, you use the word offloading several times, that I think is fairly inherent that people need to change their load in. Any guidelines or suggestions there, or is it all based on clinical presentation in the clinic with you, their degree of symptom irritability and of course their diagnosis. But how do you navigate that with running athlete, for example? - Yeah, so it's all that, it's all that you mentioned. So just to figure out the diagnosis and a severity and then see, so thinking about the loads that often, if they're symptomatic, I want to reduce some load and we can obviously do that by manipulating their training and figuring out what their training looks like. And if it's something that they can transfer, then modify and mostly intensity and heal. So taking out some of the faster running where they'd be more up onto the forefoot and a heals where they might also be loading the forefoot more. Often they need to stop running completely for a period of time, but if I can offload locally by mechanical means, that means they might be able to get that quicker or train through to some extent and keep jogging a little bit. So then reduce the load mechanically, seeing things like footwear and padding strapping and orthosis. So that's kind of the approach I would take. - There were some great tips there about returning to run, obviously reducing the workload, but being mindful of running hills and decrease in intensity work to get off the forefoot a little with footwear. Tom, obviously this is something a deeply passionate and knowledgeable about. What strategies can the sufferer of this condition consider in terms of footwear choices? - We're pretty lucky now, because essentially what you're looking for is a maximum type shoe. And so you're looking for a shoe that's high stack so has a lot of cushioning and potentially has a stiffening element into it. So something like a carbon plate, which will increase the bend in stiffness, which would then require less extension of the big toe and push off, which would then reduce tensile stress and the cushion in a maximal type shoe will reduce the compressive stress. And so there's also options now and I would base my recommendation of their biomechanics. And so if they've got the other issue would be, so that that also loads well kind of thinking about the sagittal plane, so thinking about the bending stiffness of the shoe, that the forefoot rocker design, allowing that forward transition and push off face to be quite efficient and reduce load to the sesame. But you've got to consider, I guess, with a maximal type shoe, they're higher off the ground and there can be a little bit more inherently unstable in the frontal planes. That's the side to side plane, so supination or pronation. And so someone also has quite a pronated foot function and there might be sort of really rolling across onto that big toe joint. I'd want to make sure that maximal type shoe is also not too unstable. So there are some models that are more stable than others. Then I'd be recommending first people that have that foot that really kind of rolls in a lot aggressively across the big toe joint. Yeah, just a more stable model. So it might be the difference between, some of the newer ones using the really soft foams, like more of the foams that are using the racing product. Instead of using that, it might be just more of the train, like the models that EVAs that aren't as soft. So you want cushioning, but you don't necessarily want something that's so much more soft, that it decreases the stability in the frontal plane, the side to side. So yeah, there's a bit there to consider, but mainly you're basically just trying to get more shoe on the foot and make sure it's not too unstable. Brilliant summary, get more shoe on the foot, but be mindful of the stability of the shoe, as you mentioned, Tom. Sometimes the higher stack shoes typically have more motion in that side to side plane for keeping it simple in terms of people's understanding. The rocket, just to dive, pull it apart a little bit if we can, Tom, the rocker bottom design in shoes, obviously this is more prevalent now in the shoe market. How can that have a negative or positive effect on this or it depends? I'll say generally it generally positive. So the rocker will allow the shoes to sort of help you with that propulsive phase without the big toe joint having to extend as much. And it's different to toe spring. So traditionally in lower profile shoes, it has a thing called a toe spring where the four foot kind of bends upwards. And that's just more to do with the shape. It's not really a true rocker design. To do a proper rocker to also load the sense of the joint, it needs to be a high stack shoe and the midsole needs to properly taper into the toes where it just gets thinner. But the actual plane of the, where the foot sits is relatively flat. So the big toe is not necessarily preloaded into extension. That's just sitting on a flatbed and the rocker is more to do with the geometry of the midsole tapering from the underside. And that generally works really well. This is that rocker design is then, especially with a stiffening element like a carbon plate. It just helps with that forward repulsion without the big toe joint having to extend. And the more the big toe joint extends, the more load there are compressive loads and tensile through the steps more. - So increasing the bend stiffness of the shoe, however that's achieved is generally a good principle here. - Yeah. Even having a thicker sole shoe, it will increase the bendness stiffness. But then when you add stiffening elements like carbon plates, that will take it to the next level. Whereas if you have like a very thin shoe, like for example, traditional racing flats that runners used to run in, like they were just so flexible through the forefoot. And even when we went through a bit more of a minimal face or footwear and more brands are bringing out more minimal type shoes, you know, they were very flexible. But as soon as you go to a more standard type shoe, there's more inherent stiffness just because there's more foam. - Tom, so there's some off-loading strategies, put choices that can footwear choices that can modify loading. And podiatrist, sports podiatrist, you're so well versed to also make some modifications inside the shoe. What strategies can you deploy there? - Often simply either modify the original stock liner that the shoe comes with, with seltz or often I'll use a good pre-fabrothodic, so anothodic that is off the shelves, that if it matches the footwear relatively well, it can be easily modified. And modifying it would involve both reducing compression and tension, it can do that via, you can reduce the compression by doing a pad that extends into the forefoot that has like a cutaway or a deflection subfirst. So underneath that first, it's almost like it's got a little cavity to sit in and we're trying to shift all more of that weight bearing pressure around the sesmoids to like second third fourth fifth and just behind the sesmoids into the distal arch of the foot. And then you can use a thing called a metatastel dome and metatastel dome is just like this dome that essentially sits just behind the forefoot that can take maybe a little bit of load off the sesmoids. And then the main thing is as well is good contour through the arch can often take some load off contact load. So if the arch is taking a bit more weight, then it's just a pressure redistribution thing. So if the arch is now weight bearing the chip once wasn't, it's taking some of that weight as well as if that arch profile is stabilizing the foot from rolling in a little bit more than it was without it. You may reduce a little bit of that tensile cooling stress because every time the arch flattens and lowers, we get a little bit more tension through those tendons and the sesmoids and that may help as well. So a little bit of mostly pressure redistribution and maybe a little bit of reducing tensile stress through supporting the arch. It with footwear or with these orthotic install modifications, it's all about just reducing load to get symptoms down, maybe help them to, if it's at a level they can train through a little bit then that's great. Or it's just gonna allow them to get back running maybe a little bit sooner, maybe allow them to rehab a little bit easier. And then my goal is always to at some point, once we've addressed other issues, if they're strength deficits or they're the shoes with the same issue with the shoes, then they can eventually just, they won't require that sort of extra offloading. It's not gonna be a lifelong thing they need because of some structural thing. Often they're injured because of a training load error or just all of a sudden wearing a shoe that their foot wasn't ready for to use. And there's obviously some of those cases where really chronic, this is one of those conditions where occasionally you'll get someone with sesmoid pain for three years, for example. And they're more someone where they might need to be managed with an orthotic long term because they just find that every time they don't wear it, they just have more symptoms and more issues. So we kind of, there's gonna be a subcategory of people where we've got to be more mindful with ongoing protection, but that's a very small, I think I would say that's very small percentage of people with sesmoid pain often. It's just de-load, let it recover. And then gradually they can get back to using, not using orthotics and not being too worried about the footwear that they're using. - That's brilliant. What you've just shared there, it's about pressure redistribution and potentially supporting the arch to decrease tensile load in. Tom, for those that don't come right with these strategies and they, as you know, as well as I do, that these patients, these runners exist, these athletes, at what point would further surgical consideration be indicated? - I guess it would come on the diagnosis. So if there's a really problematic fracture or bipartite that's taking a long time, then I'd be more likely to get them into the surgeon's sooner for opinion, to assess what artist case that's just six plus months where they've actually tried all the stuff that they should have tried. Then I always say it's there's no harm in going and having the consultation. It doesn't mean they're getting surgery, it just means they're having that conversation with the surgeon. What do they think, if there was a procedure, what's the procedure, what are the pros and cons? So at least they just have that information, it doesn't mean they have to get the surgery, but they've got an idea of, you know, if this still continues to not improve, what other options are there? - Yeah, and sometimes it can be reassuring to be told that they're not a candidate for surgery, right? Because it can be an ongoing process, the rehabilitation efforts, and sometimes it's nice to have already covered that and been told that, right, you've got to focus on this and be patient with it, because I find this is a condition that requires a lot of patience and adherence to the work. - Yeah, definitely. - Any tips lastly, Tom, on the strength and condition inside of things apart from the obvious, it needs to be graduated and progressively increased in its demand. Any tips that you've sort of picked up over your years? - So I'm very sensitive to the fit. So before I assess function of shoes, like in recent years, I am trying to be very strict with just every single runner that comes in or anyone, like assessing a fit of the shoe, I'm making sure that they have a appropriate toe box space. Because for a lot of forefoot pathology, I think a big contributing factor could just be, they don't have enough space in their shoe, it could be length, it could be width, it could be that's too much tapering, even a lot of running shoes are too tapered in the toe box. And if they've got a relatively squared off or broad foot and not allowing for much toesplay, I think that could increase their risk. So firstly, checking the fit before function and making sure that I've had some easy wins in the past where they've had set more pain and we've just, okay, you need your size up and your shoes, you feel like there's slightly more wriggle rooms, maybe a little bit broader through the toe box and had really good results by just getting a better fit. Either once they've got that or if that's not the issue, then still wanting to facilitate, like an exercise that you can do at the very beginning, it's not going to irritate it, is like a seated intrinsic exercise. And one of my favorites is just, which I also get to people with say with bunions, is just using activating the abductor hallucus which is just the muscle and the arachnus foot that when contracted, the big toe moves out away from second. So that movement can, I think for some people help with better weight transfer through the sesmoids and push off. So often people with sesmoid pain, they can't even, they don't even know how to do it. So I ask them to do, I show them on my foot, the big toe steps are moving away and because they've never tried to do that movement before, their brain is not really connected to that muscle and they don't even know they can do it. So once they can actually get the motor control to actually do that exercise to get that big toe to display and move away from second, I think that can be quite helpful and easy when, because it's not going to really put any mechanical stress on the sesmoid, it's not going to increase symptoms, but that can really alter the loading that goes through in function. If they then got the ability to feel what it feels like to have the toe display to get that big toe to move away from second, it could alter the contact forces through the sesmoids as they're pushing off. If they can start to get a little bit more of that, that's play bending function. And often I'll do, you can junction with the exercises is maybe some strapping to help when they're in function to get that splaying happening, to get the big toe away from second. Sometimes a toe space that the strapping works quite well along with that exercise. And then the other main one would be, again, relatively low risk irritation is the seated, just toe flexion exercise. They're just getting them so really, you can go relatively hard, like get quite a heavy resistance there aband and put a lot of tension through it and then get them to really push down pain limiting, but if they can do it relatively pain free, then yeah, I just get them to really work on isolated toe flexor strength before they graduated to any sort of weight bearing exercises. - Yeah, because that return to weight bearing, standing calf raises, an example can be at times quite provocative and quite a dance. - Yeah, definitely. So you often, when getting back to the weight bearing exercises, they're in that protective setup. So they're in the issue with the, you know, the really well-cushion issue and maybe with the, with the methodical deflections or whatever as well. So it takes a lot of that compressive load off and they can do the strength without it really re-retaining it too much. - Yeah, and I brilliant. And Tom, on these tricky condition episodes of the show, we don't typically get a physical challenge for the week, but I think that abductors, abductors how elusive exercise might be a nice physical challenge. So we must get a photo for, we'll pop it up on Instagram of you demonstrating that exercise and we can all try that. - Yes, that's good. - Yeah. - Tom, thank you for your generosity in sharing your expertise around this. One condition of the many that you treat routinely in your professional life. For those that want to engage with you further on this, find out more about you and your services. Where can they go? - So I've just, my business name's just changed. So I've been, I've been Walker Street Sports Pediatry for six years now. Pinnacle Sports Pediatry. So you can find me, I don't think I'm on Facebook or anywhere else, but I'm on Instagram. So it's just Pinnacle Sports Pediatry and also my own account. It's just, it's on the store counter. So yeah, that's if people want to sign me, they can sign me there. - And you'll be taken to the streets again with your running career prior to recording your engine. Hopefully before the years out, we'll see you back and back to your best AKA your second place at the Melbourne Marathon return after COVID there. With what was your finish time there for that one, Tom? - 2-14-40. - 2-14-40. So Matt, you really practice what you preach and do it with such fine style. So we wish you all the best for the competitive side of things for the year ahead as well. Thanks, Brian, cheers. - So V have it another episode of the physical performance show. And I trust that I know you enjoyed Tom's shareings today. If you did, then jump over and you'll find Tom on Instagram at Thomas DeCanto, D-O-C-A-N-T-O, over on Instagram and Tom's Pediatry Clinic, Pinnacle Sports Pediatry over at PinnacleSportsPediatry.com.au. Talking about websites, do jump over to physicalperformanceshow.com and there you'll find all links in the show notes, including endure IQs, training squad, which you can access and enjoy two weeks for free. And also jump over to Polar.com if you're in the market for a wonderful new running watch. While they're also consider supporting the practical production of the physical performance show via Patreon, where you can find the link over at physicalperformanceshow.com and support the show from desk $5 USD per month. And massive thanks to our existing show patrons. And don't forget as a way of saying thank you for your practical contribution. You'll enjoy complimentary access to our entire back catalogue of live stream events, including Dr. Steven Seiler, Dr. Shona Halson, and Rinnie McGregor, and all upcoming live stream events. And at the time of recording, we are only weeks away from announcing our next live stream event guest, which will be focused on the psychological aspect of performance. If you have any feedback for the show, you can find me over @brad_beer on the socials, Instagram, and Twitter. We are always looking for upcoming guest recommendations and also feedback on how to improve the show. If you've been enjoying the show, consider leaving a review over on iTunes. They are, like the pods, it's always a whole lot of fun to see coming through. Thank you for those who have left ratings and reviews over on iTunes. Now we have a smorgasbord of highs, lows, and learnings coming your way across upcoming episodes, including a look into the founding of one of the hottest sports companies at the moment. We delve into the world of artificial intelligence when it comes to endurance coaching. We have some wonderful feature performer episodes lined up and coming your way. So until next week, keep pursuing your physical best performance, I'm Brad Beer, and this has been The Physical Performance Show. [BLANK_AUDIO]