Foot Strength, Peroneal Weakness and Chronic Heel Pain

I had to print your article out right here. I couldn't do it. I'm so cheap, I don't print anything out. I hate paying for the ink in those things. What the heck? Someone, a patient, was in the office the other day, and I have a little thing that says, Liz, present complaints, and he writes, the ink in my printer costs too much. And now I walked in the room, I was like, I don't know what's wrong with you, but I like you. I'm going to spend some extra time with you. That was funny. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales.

Hey everyone, that was about a 15-second roll of the interview I just did with Dr. Tom Machad, which you're going to hear in the interview that he calls it maybe a couple different things. He's actually the author of Human Locomotion, which is a really awesome book. It's very clinically based, so a little bit heavy read for consumers out there, and also injury-free running. You're going to hear about a couple products as well that he uses for foot-ankle injuries, but he's basically the foot-ankle dude. I've actually been trying to set this up, this podcast up with him, for probably about three months now, so I'm really glad we got to do it.

By the way, we are listening right now to the Restoring Human Movement podcast, which is totally rebranded. It's an extension of the Performance Play Sports Care podcast, so I hope you guys are still on track with that. I'm Dr. Sebastian Gonzales, so I'm glad to have you guys here today, and it's going to be, I think, about 45 minutes to an hour, I think, for this one. We actually planned to do about a 20-minute segment with him, but we got into so much good stuff that it got a lot longer, actually, because he's a very busy dude, but as you can see, he's a great conversationalist, so I think everyone's going to get a lot out of this, especially young clinicians and doctors who've probably been, actually, I've been out for 10 years, so I actually got a lot from talking to him as well, so this is a very comprehensive one for the clinicians out there.

For runners, you should probably hear it. Dancers might want to hear it. I hope it's not too technical for you guys, but one thing I did admire about Tom when I was listening to his other podcast was that he was excellent about citing some research, getting a little bit deep, and right before you hit the point, you're like, it's a little bit heavy, then he comes back into a story, so it was great. I would love for him to do more podcasts with people and do some more YouTube videos, so Tom, when you're listening to this, I want you to know that you got something good there. Stay tuned if you have any foot, ankle, plantar fasciitis, Morton's Aroma, stress fractures of the foot, of the shin, or if you overall just wanted to be able to run and be able to perform for a long time, you're going to get a lot out of this right here.

Before we actually start, then, I want to make sure that everyone realizes that the show notes are going to be transcribed, and those are going to be on p2sportscare.com. We have a pretty comprehensive search function now, so I will include the link, direct link, in the media player that you have right now, but I strongly suggest just go on to the website, go to the search function, look up Tom Machad, and, yeah, you'll find all the stuff in there. And lastly, before we go in, we have the personal corner. I guess I'll tell you the story. One story that we kind of have an ongoing joke with one of my friends, and I remember calling this right as I drove in today to do this podcast, is boating season is coming here.

So last year, actually, I went boating four different times in the summer, and I made a commitment to myself that I was going to go at least once a month. So this year, I'm going to do the same, but we have this one friend who's going this time. His name is Larry, and we don't really let him drive the boat much anymore. He actually doesn't want to drive that much anyways, so we go to a lake. It's called Lake Nacimento. It's in the center of California, and it's kind of known for just—I mean, it's a big lake. It's a long lake, but it's also known for being very low in its water level for random years.

And I think last year was one of the ones where it was like around two-thirds, 66%, roughly, of its max capacity, which is amazing. We've never driven so far on this lake, but it's a long lake. Like I said, it takes about 30 minutes to get to the other side. But all along the way, there's kind of these narrow channels and stuff. So it's wide at that point, but it's also deceivingly deep only on one side versus another. So I jumped out, and Larry's like, hey, I'll drive. And I said, okay, well, I'll go in this tube. Go ahead and go. So he's going, and from the tube, I can see the hull of the boat pop up in the air.

And the engine—actually, we have an outboard engine—it kicks up, and you see all these rocks just flying up. And none of them hit me, but actually, they weren't just rocks. They were like, I mean, stones the size of your hand. And so what happened was he ran it into a—not just a sandbar, but a rock bar. And he pinged the engine. He actually—we basically couldn't drive that engine anymore. So we got it back to the marina. We pulled it out that night. And we said, Larry, what were you thinking? You know, and he's like, well, I was in the center of the lake. I said, yeah, but you didn't see those—the arrows with the white little blocks that say it's low?

He's like, well, I was in the center of the lake. I said, Larry, you have to look at the topography. Because one side of the lake is deep, deep, deep. You can see the sidewall go almost sheer straight down. The other ones, it's like a plane coming into it. So, yeah, when you boat, look at the topography. So without any further ado, let's go into the interview with Tom Machad. Tom, thanks so much for being on. Thanks for everyone listening. And we're going to get into it right now. All right, everyone. Thanks for listening to the interview with Tom Machad. Is it Machad or Machad? Either or is fine.

Most people say Michaud, but it doesn't matter to me. They may—is that—is Michaud proper? Yeah, Michaud's proper. Oh, I had no idea. I thought I would— Some people say Michaud. You know, someone who was in from Canada a little while ago said Michaud with a hard D. In fact, a friend of mine always tells patients when he sends them to my office that they should pronounce my name Michaud. So whenever anybody calls for Dr. Michaud, I know that my friend Pete sent him in. That's funny. That reminds me—actually, when I was younger, I had a friend that he—I bought him a magazine subscription for his birthday, and just so he would know that all of the junk mail that came after, because that was typically what came.

That's perfect. I called him—his first name was Rusty, but I call him Rastonomy on that. So he gets all this junk mail that says Rastonomy for years, you know, as you can tell. That stuff follows you for decades. I still get stuff when I had an orthotic lab 35 years ago, the Michaud orthotic lab. It's literally been 35 years since it closed down. Oh, yeah? And once a week, I get something. So, yeah, it spreads like a virus. Yeah. So that's pretty funny. He'll think of you every time he gets it. No, yeah. So I thought I'd have you on today. I mean, there's various things that I would—I'd love to talk to you about, but I know your time is going to be precious on this.

So we're going to go over your article, The Best Ways to Prevent Age-Related Decreases of Running Performance. Sure. Sound good? Okay. So as I was reading through this a little bit, I couldn't believe that actually the hips and thighs—or hips and knees really weren't getting weaker as the feet and the calves. Yeah. Well, keep in mind that was a study of runners. So runners have large increases in force production compared to the regular population, especially sedentary people, in hip and knee activity. You know, seven times body weight absorbed by the knee with each foot strike. So, you know, compared to the 100,000 years ago, our hips and knees are pretty much as active as they were then in distance runners.

Mm-hmm. So is this—I know that we're talking a little bit off air of—it seems like we do a lot of the things that we used to do. Is that—do runners realize this by now? Are runners realizing that the foot and calf are— No, a little bit, I would say, but for the most part, I would say no. Most people don't think about, you know, intrinsic arch strength or foot strength in the slightest. In fact, there's like a little bit of a tendency to think, well, don't wear orthotics because they'll weaken your toes, but that's totally untrue. Orthotic doesn't alter the range of motion necessary to produce toe weakness.

So other than just the incorrect belief that an orthotic might weaken you, very few people that I know of go out of their way to strengthen their toes. In fact, I made that toe strength dynamometer about a year ago. It measures force output in the toes. Every runner that comes into the office is shocked at their asymmetry between the sides, especially say they had a navicular stress fracture or a plantar fascial injury for years. You'll see 40% strength decreases in their toes on that injured side, and they're unaware of it. Muscles will atrophy 1% per day with boot immobilization. And, you know, they'll do hamstring curls and they'll do gastroc grazes, but they won't strengthen their toe muscles.

And unless you strengthen flexor digitorum longus, flexor digitorum brevis, that can produce huge decreases in horizontal jump performance, which would slow you down while running. Interestingly enough, you can do, like, say you hurt your Achilles and you were doing eccentric loads on a stairway. That would improve your ability to jump vertically. It wouldn't improve your ability to propel yourself forward horizontally. So that's where toe, and just picture yourself, your center mass is forward, your leg is extended hip behind you. That final phase of push-off is when the tips of the toes project you forward.

Now you're gastroxoleus. You know, in fact, that was the study where Weber showed American Journal of Sports Medicine that when they looked at slow and fast running speeds with the EMG needles and all the muscles, it was weakness of the peronials that correlated with slower running times. And I didn't get into it. I think I can send it to you later. A big paper just came out about a year and a half ago. 105 people with heel pain, they evaluated, they took a control of 70 people. They evaluated strength in tibialis posterior. They checked ankle dorsiflexion, first MTP motion, hypermobility, weight, all these things.

The only thing that correlated with chronic heel pain besides decreased ankle dorsiflexion was toe weakness and peroneal weakness. And peroneal weakness was the single biggest predictor of chronic heel pain. Yet no one ever exercises their peroneals to treat a painful heel. Was that, I was looking at one of the graphs in your Human Locomotion book with the peroneal comes under and it sets the first metatarsal in the correct position to allow for toe drive? Yeah, that's a good point. It comes under the cuboid, wraps around. And in a neutral foot, it has an upward angle of approach to the base of the first met.

So when it contracts concentrically, it pulls the first metatarsal down and drives you forward. It makes you more efficient. That's what the authors of the heel pain studies said. They said if you have heel pain, you don't push off. And peroneus longus is one of the most powerful muscles of your propulsive period. So if it's weak, the first metatarsal lifts up and then that pulls on your plantar fascia, transmitting pressure into the heel. So anybody who has chronic heel pain, any plantar fascia patient you have, give them peroneus longus exercises. That was the outcome of that paper. And they all had weak toes, but that had been previously proven about six years ago, wearing shoulder in medicine, science, sports, and exercise.

So I always kept a lookout for weak toes, gave them toe exercise that worked well. But after I read that paper, I had people, and I just came across it, I had people switch to peroneus longus exercises. Again, it was the single biggest predictor of plantar fascial pain. Right. I saw that you, I know you came with that product, the, what is it, the ToePro. Is that? Yeah, the ToePro. That was designed to isolate flexor digitorum longus, brevis, and the peroneals. It's perfect for plantar fascial patients because this platform tilts laterally at a negative 10-degree slope in each direction. And then negatively, it tilts back.

So it isolates gastroxoleus. But the lateral slope down and inverts your rear foot, isolating the peroneal. So it isolates the exact muscle groups that were the weakest in the chronic plantar fascial patients. You know, most people treat plantar fasciitis by just giving them orthotics and stretches. Whitaker et al. just did a review of the literature and found that orthotics had, compared to sham orthotics, had no effect on managing chronic heel pain. You know, the only thing they found that correlated with success was restoration of ankle dorsiflexion. And then the other paper that came out showed that the peroneals were weak, along with flexor digitorum.

Yeah. So, you know, and then think about it. If you're standing up and you lean forward, if you push down with the tips of your toes, you feel your metatarsal heads unload. You know, if you look at that wear pattern, take the insole out of anybody's shoe that's, you know, any patient you have. If you see, like, poor digital activity, but a ton of pressure under the central med heads, or the first med head, that's the reason their heel is probably hurting. You don't need a forced platform. You can just look at the insole of their shoe. Right. Yeah. You got a good picture on that, actually, here.

By the way, actually, before I continue further, did you draw all these? Because this was the book, that book was. Yeah. You're a drawer? Yeah, I drew all of them. In fact, I was looking at when I just, I just drew the picture. If you look at figure one of that, the best ways to prevent age-related decreases running performance article, I just drew that picture a couple of weeks ago. And I was looking for anatomical sources for flexor digitorum brevis and flexor halisus. There were none. Really? And Trevellen Simmons had the image wrong. They had a double slip on it. It shows how few people know anything about intrinsic muscles of the feet.

Half of the books out there, and I'm talking medical books, had wrong origins, wrong attachments, wrong tendinous slips, wrong shapes. It was really surprising. Trevellen Simmons had flexor digitorum longest. The origin of it looked like a hot dog was put on the back of someone's leg. It was the weirdest thing. And I was like, that's a great book for illustrations. But, you know, you could tell Trevellen Simmons knew nothing about lower extremity because all they talked about was Morton's foot causing all sorts of problems. And Morton's foot, the short, first, metatarsal, hypermobile, posterior displaced sesamoids, is really rare.

They act like it's everybody in the world has it. In fact, they talked about interincisal opening being affected by Morton's foot structure. So I was really surprised at the poor quality of images out there for the digital flexors. I had no idea that. How do you feel? How did Netter's deal? Netter was good. You know, Sabata was good. Gray's Anatomy was the best for accuracy of the intrinsics. Netter, Sibagagy, they, whenever they draw off the intrinsic muscles, they draw it off all layers all at once. So if you wanted to see the actual position where flexor halus is brevis attached, you really wouldn't be able to see it.

You'd have to, it wasn't where they would just have one muscle by itself. But there's so many muscles in there that, you know, they just kind of clump them together. But that's why I just wanted to draw just so people could see them. What does flexor digitorum longus look like by itself? What does flexor halus is longus look like by itself? And flexor halus has a strong anchor to the fibula and is a vital muscle in preventing falls in the elderly. That's what I was talking about previously where that paper came out by Mikkel where they showed every 1% increase in force generated beneath the big toe by flexor halus is longus decreased the seniors' risk of falling by 7%.

Yeah, that was pretty interesting stuff. Especially since that TheraBand study had like literally nothing to do, right? Yeah, yeah. I just looked up the actual stats on that because I had to make sure of something because I was using it in a lecture. And there were no appreciable improvements. And it was only mentioned in a graph and no appreciable improvements, especially beneath the tips of the toes. And again, it gets into that if you exercise a muscle in a shortened position, it's not going to get strong. It's got to be exercised in a position of function. That's why I made that Dobro platform.

Everything's cocked back. Your feet are in the position they are in during push-off on force's peak. And that research by Goldman that showed that when you isometrically tense a muscle or contract a muscle in a lengthened position, you get four times the strength gains. That's huge. You know, in six weeks, they got, you know, 40% increases. You're going to single-handedly get all of these retirement homes to get all the seniors out of them. They're just going to be... Yeah, good luck with that. That would require that I not work all the time and that I could actually go market stuff. I didn't even want to talk to you because I have a hard time getting an hour in the day.

I know. I do appreciate that. So if everyone knows that we've been back and forth on this for like three months or so, and we narrow it down to 20 minutes we can get. Yeah, exactly. So we got 10 minutes left for sure. Beautiful. Yeah, I got 10 minutes worth of stuff to say. Oh, I know. I've actually, I listened to a lot of your podcasts and I read up a bunch of your stuff. So there's so many things I can ask you. So I'm really withholding on these. Oh, yeah. Go whatever you want to do if you want to change subjects too. Well, I'm actually kind of curious with before you, since you realize that the toe muscles were a problem, then you realize the peroneals were a problem.

And in your process of solving this problem before you got to that platform that you're using, what else did you try and was there any shortcomings? Yeah, that's a really great question because over the past, like I'll make a new exercise device once every two years for something. I made an ankle rock board that inverts 20 degrees, everts 10 because that's the foot your range goes through. I originally got the idea just as a way when that Reber paper came out, you know, 20 years ago. I treat a lot of runners and Reber showed that the biggest force deficit in a runner muscle deficit was in their peroneals.

That's the reason that they slow down. That's the reason they're not as fast as they go into sprinting speeds. And a friend of mine was running on the beach and he was going south on Cape Cod and he asked me which muscle was sore. And he ran for a long distance and I said, because you were going south, your left foot would be inverted so your peroneals would have been tight. And he said, yeah, the outside of my left calf is killing me. And then I thought if you could make like a jump platform that was inverted bilaterally, because you couldn't have someone run on a can because one side would be inverted, one side would be inverted.

So I made this wooden platform that was three feet by two feet that was pitched 20 degrees and I just had people do jumps with weights on it and landed. But there was a risk of ankle sprains on that. So I kept playing around with the angles and then I just kept tilting the shape around to have it become smaller and a little more pitched. And then with all the, you know, I've always done eccentric and concentric loads for Achilles disorders. And then I found that paper on toe strength and then Goldman's paper showing that when the toes were exercised in a length and position. So I just kept adding pieces of clay to this platform until I came up with a shape that was right.

Then I made it as small as I possibly could. Then getting the durometer or the foam right was impossible because it has to give more under the toes. So I ended up after having it manufactured, I'd had to have it remanufactured with a gouge out beneath the central grind where the toes are. So your toes would compress more, but the peroneals would stay under tension. And then for older people, I made the gouge at the base so that when they lean into it, it would give under the tips of the toes so that they could increase their anterior fall envelope. And that's that thing when you stand up. Most falls, people who aren't familiar with falls in the elderly, 40% of people over 70 fall annually.

And most falls happen at the initiation of the gait cycle when you start to walk. So if you just stand up, balance, and then keep your arms at your side and just lean forward with a straight spine and torso, you feel the tips of your toes pushed down. Some people, now that I've been doing this thing for a while, I can go to like a 40-degree angle forward. The distance you go is called your anterior fall envelope, and it's determined by toe strength, particularly hallux strength, big toe strength. And that's what I really set out as a goal with that thing to strengthen. But then you saw all the stuff with improved running performance when that article by Peke came out showing that older masters runners, and these were, you know, guys in their mid-30s, and they were slowing down.

11% decreased force output in the foot and ankle. I had just previously read the article by Booth where they talked about how our genes were developed to respond only to activity. Satellite cells sit on the side of muscle fibers, and if you don't stress it to a certain threshold, they don't rebuild. So that's what made that article so fascinating. I just had finished reading Booth saying we need to exercise because hunter-gatherers don't get age-related muscle wasting like we do. I mean, you lose almost half of your muscle fibers between 50 and 82, and it's avoidable. And you can use light weight.

That whole thing, American College of Sports Medicine says you have to do four sets of 10% and 90% full effort. When those fibers start disappearing, when you're in your 50s and 60s, they're replaced with scar tissue and fat. And so if you attempt to lift 90% full effort, you're going to tear stuff. And what they showed in multiple studies starting in 2017, all you have to do is do 35% full effort, four sets of 25, with a 30-second rest in between. You can't take a long rest because that short rest allows for an increase in pressure inside the muscle that shuttles blood out of the muscle, like squeezing a wet sponge.

That forces you to recruit your fast-twitch muscle fibers, which are the only fibers that can get by without oxygen. And it's recruitment of fast-twitch that produce muscle repair and remodeling. So it's a really simple technique that, you know, they once studied the elderly where they had them do a protocol like that. There were 90, almost 90 people in the study, only two dropped out because no one gets hurt. And at 30% full effort, most of the protocols take five minutes to do. So, you know, and it's just easy. And if you look at that graph, I put that graph in another paper I can send you. Once you hit 50, it starts at 0.5 to 1% per year loss in your mid-30s.

But once you hit 50, it's this downward spiral that's frightening, especially for me. So when you hit 50 on your 50th birthday, what muscle group or what exercise did you think, I need to do this because I don't want the spiral to happen? It's funny. I'm working on that right now, but I've been too lazy to put it together. It's a series. I want to make it so you can do it without cables and stuff. After reading everything I read, some people do these four-second holds. One person said it's not the force you use. It's the total contraction time. So in one week, you had people do these five-second holds, and you had them hold.

Like, total for the week was 22 minutes, so like five minutes, five days. But I do this routine where I take, like, a deadlift cable, and I want to use multiple muscles at the same time. So I'll do, like, a straight leg deadlift, but I'll start with knees bent, and then I'll have the rope with the two balls on the end of it low. I'll do 30% full effort. So I'll raise it over my head 25 times, and then I'm moderately exhausted. I wait 30 seconds, and I do it again. I wait 30 seconds. I do it again. I do that four times. And that hits all my lifters, and then I'll put the cable up high, and then I'll do pushdowns.

So I'll get my triceps. I'll get my lats. And then one paper, they had people do one set of 60 at 15% full effort, so light, and then one set of 12 with no rest at 40% full effort. So then I use that TowPro thing I have. I put it far away from a wall, and I hold on, and I'll just do 60 raises. And after 60, you're fatigued. Most people couldn't do 60, so they have to do it next to a table. But that fires every muscle in your foot and ankle, flexor digitorum longus, brevis, bronius longus. And then I have them lean forward into a wall and then push. As they push forward and up, they push back at the wall at the same time so that they go to 40% full effort to get 12.

And that little program I just described, it's just three exercises. It does every muscle of the leg, every muscle of the back, misses a few forearm muscles, and doesn't do rotator cuff, which I like doing rotator cuff. Like sideline, you take the Indian club that's off weights, it's like the weight is on one side. And then while your arm is straight up, you lower it like it's a follow-through of a tennis stroke. And that works infraspinatus, teres minus, superspinatus, and lower trap, because most of our society is upper trap dominant. So I try to find lower trap exercises. So I'm right in the middle now of making a video.

I've sent that article off to be published, and the publisher wanted images of specific exercises that people could do. But the problem is, there's people in their 30s and 40s, and people in their 50s and 60s, like me. If you've exercised your whole life, you don't want one of the protocols that people in their 80s are doing. Right. Because they're so boring, and there's nothing to them. So the goal is, pick the muscles that you want to keep, and four times a week, do four sets of 25% to 30% full effort. And you know it's 30% full effort, because you'd have a hard time doing a 26th or a 27th. 15% full effort, you can do 60.

90% full effort, you can do 10. Full effort is the amount of way you could just lift one or two of. I'm thinking, did you grow up younger when you would look at the sky, and you're like, I don't know what makes the sky blue. And then you would figure it out. Yeah, I've been making stupid stuff my whole life, but that's what you're asking. Well, it's just like figuring things out. Yeah, I've always tried to figure it out. And in fact, that's what I love about this profession. That's how the human body works is fascinating. And in fact, for 30 years, I've been saying to myself, this four sets of 10 stuff is just nonsense.

Delorme came up with it in 1945. He did rehab on people after World War II. No one's questioned it. When that guy showed that four times 25 at 30% produced bigger strength gains, that was like 2016. And they did CTs to measure muscle volume. He said, how come nobody studied this? This is the first paper where they've actually looked at it. And the injury rates, you can't have someone in their 50s and 60s. I always had this thing that I had to be able to bench press a certain amount on my birthday. Two years ago, I tore my rotator cuff because I got a label injury because I was trying to bench press the 200 pounds that I've always been able to do.

I'm like, this is stupid. So then I started looking into how can you build muscle mass at light weight. And that paper that was four times 25, they built more muscle mass with that protocol. And again, it just requires kind of like strangling a muscle. Speaking of strangling a muscle, the blood flow restriction protocols, I don't know if you've heard about those at all. They're phenomenal. You just put a strap on someone. Say you want to build up a quad. Right. You take a nylon strap, put it on the quad, have them do four sets of 15 at 30% full effort. Massive increases in hypertrophy because without blood, you use your fast twitch fibers, which stimulate satellite cells, which convert to myoblasts.

They're like the body stem cells of muscles. And as myoblasts, they rebuild. Did you just reveal to me how to win the Arnold next year? Is that what I'm hearing? What did you say? You just revealed to me the secret about how to win the next bodybuilding competition. Yeah. Put straps around your arms. It's really popular now. If you look it up, blood flow restriction. The problem is that the original researchers that did it, most of the data now is showing you only have to decrease blood flow to like 70% or 90 millimeters mercury if you were using a spig cuff. The early guys completely occluded blood flow with like tourniquets, and it was a little scary.

Right. But, you know, subsequently, I just use the Nylatec straps that you use in office to put pads on people's, you know, muscle stim machines. Oh, that's pretty simple. You are the master of just using the small things that you already have. Yeah, that's why with that protocol to stop age-related muscle loss, I'm trying to come up with a way you could do with a backpack and a bag of rice. You know, put two bags of rice in a backpack. And if someone's not fit, raising it over their head a hundred times is going to be fatiguing. Yeah, right. Well, I'm sure that when you created like the TowPro, you're like, well, this is going to fix my problem, but everything against me, like my being, makes me feel like I want to have someone buy something else that they can't make their own.

Exactly. Well, in fact, I just did an article on the TowPro, and at the end of it, I said, if you can't afford the $45 for a TowPro, you could do this. And it was this elaborate thing of pulling your leg down. I'm like, you know, it'd be easier just to get it. Yeah, I had a patient one time that like he, we had some TRX one time hanging in the office, and he was a smart dude. He's like, I can make that. I'm like, dude, you just buy it for a hundred bucks. And so he came back about two weeks later, he made it all out of PVC pipe and straps, and he left it in the office. I'm like, what am I going to do with this?

He's like, well, I don't want it. I just want to prove I can make it. I love it. I had a bull-legged master's runner who had all these problems with his legs, and I was describing Varus posts and all this stuff. And he said, and he's an engineer, and he said, I could just make that in my shop. And he did. He machined this tilt and then poured in this silicone material, and it was perfect. I was like, yeah, that's it. It's a little messy, but it certainly worked. Yeah, not too many people know how to make stuff anymore, which is a shame. Yeah, it's a good deal. But making the silicone molds, the prototypes were tough.

You had to put a vacuum mold on the silicone to degass it and then go to 100 PSI when the plastic's pouring for the early models. But it was enjoyable. I'm definitely looking at the dynamometer as well as the powder. Very interesting to me. I'm going to probably get it. You'll see my information come through your website pretty quickly here. So I'm going to go play with it too. Yeah, that dynamometer, I just love. Of all the stuff, the thing I like, I mean, the dynamometer is great if you treat athletes because you see the score, they see the score, and it's surprising. When a woman was in, she had a tibial stress fracture, and like usual, eight weeks, ten weeks of mobilization, no one gives them intrinsics.

She had like a 70% strength deficit. She would have gone on to get plantar fasciitis. But when she sees one side she can generate 12 pounds, the other side two pounds, then when you push down and you can't stop the dynamometer from being pulled out, it's disturbing. That's where you go. It's like I'm paralyzed, and you didn't even know it. Yeah. Yeah, it definitely helps drive a point home. So people are more consistent with their protocols. Yeah, I'm very interested in that. There's some dancers that come in that I'm kind of curious to see what they're going to have on theirs. Yeah, they just did an interesting study on muscle volume in gymnasts, dancers, and other athletes where they have different degrees of wearing, like being shod.

And they did an MRI study of volume of intrinsic muscles. And I would have guessed that the gymnasts had thicker abductor halisus muscles, but they didn't. They all had the same amount, which was surprising because I think of gymnasts and dancers as having much stronger intrinsic muscles. Why do you think they're not? Well, oddly enough, there's not that much of a correlation between volume of a muscle and strength. In fact, some recent studies have come out that have shown that runners who get hip abductor, hip rotator problems, and valgus collapse of the knee have weakness of the hip abductors, but no difference in muscle volume.

So volume and strength don't always correlate. You know, I haven't spent the dancers I've seen where I measure their toe strength, they're significantly stronger. But you can be strong without a lot of muscle bulk. I think a lot of muscle bulk is just genetic. I want to be respectful of your time, so I do have one more question, and then I'll let you go. Does that sound fair? Sure. Of the work in writing, or all the writing on content that you've put out over the years, what is the one thing that people have misinterpreted frequently? Oh, that would be a tough one. I mean, I wouldn't even say they misinterpreted.

The first book I wrote in the 90s, I kind of went with the root paradigm for a function. In fact, the JOSPT just came out with an article saying it needs to be let go when people incorrectly reference it. And they had me as someone who incorrectly references it. But I wrote that book in 93, and the book I wrote in 2012, I completely got rid of it. You know, I would just say that based on the time period, you learn as you go. And especially in the last five years, it's been a great five years. Three-dimensional imaging, you can see how muscles move, you can do an intervention on someone. For example, we were talking about orthotics.

Everybody thought orthotics decreased how the navicular move, decreased tibial rotation, decreased calcaneal eversion, and it turns out they don't. They decreased velocity, they improved proprioception. Really fascinating stuff, and, you know, that's just what happens with time. You know, it's just you adapt to the new research. Okay. Actually, I take about one last question. Since there's DCPT, ATC listeners, what is a word of advice for them as they first get out of school or the first couple years? Oh, that is the best. I spent my first few years, you know how some people go to practice management courses?

Right. If ever I had a free minute, I just studied. And I felt like if I knew more than anybody else in the world, I would be really busy and I'd be happy. And I would say that was true. I just studied a lot. And I would try to, anything I could get, I would just read. You know, you've got to get certain, having now spent 35 years reviewing the literature, find authors you like and follow their stuff and contact them. If I see a paper that I like that comes out, I'll send the person an email and ask them questions. You know, Anthony Kaye, as a researcher from the United Kingdom, just published a paper showing if you are isometrically tense with an ankle at a 90-degree angle and then for five seconds and then stretch for 10 seconds and then go back to the starting point.

Always apply the isometric load with the joint in a neutral position. You've got almost 20% increases in tendon resiliency, much higher than anything else. So I started emailing them to see if you had anything else going on. Then the guys from Belgium with the vibrating motors, I'd say, how did you do it? They helped me through it. So the researchers out there are kind of on their own and they don't get a lot of feedback. So if you find somebody that you find interesting, don't hesitate to contact them. You know, people email me about questions and stuff. And if it's about a patient, I will always get back to them.

You know, if they're asking me about their particular problem, I'm not as quick to get back to them. But if they're asking about how to become better as a practitioner, I always get back to them because that's what it's all about. Nice. Where can everyone find a contact for you? I know you have human, is it humanlocomotion.org? Yeah, humanlocomotion.org. If you just do contact the office, my wife usually does a lot of the front desk stuff there, but she'll forward stuff to me. And I get back to people usually within one to two weeks. You know, if I didn't work full time, I'd get back to people the next day.

But, you know, I get back to them pretty quickly, especially about this stuff. You know, the stuff on that site is really cool. We didn't even get into it, but those vibrating motors, they're freakish. When you put them on someone's calf and then they almost fall over backwards and you know that their muscle spindles in their core aren't working because of that, I find that fascinating. And I wrote an article that went to 70,000 chiropractors on that. I didn't get a single email saying, what are these things? I found that. I found that one. It was in Dynamic, wasn't it? Yeah, yeah. It predicts future injury, like 4.5-fold.

And it distinguishes low-back pain patients from non-low-back pain patients. Nobody does that. Yeah. You know, and I'm amazed. Kurt Claes and all those guys from Belgium. To me, this stuff should be changing musculoskeletal medicine, but nobody seems to be paying attention to it. I don't know why. Like, because you maybe, like, you use words like annulospiral. I don't know. Type 1A receptors. It's just, it's not complicated. Like, it is if you're not familiar with it. But once you figure out what a spindle does, everybody in this profession, in every healthcare profession, should know what muscle spindles do.

Because they determine whether we get injured or not. And if you could put a little motor on someone's calf to evaluate whether their spindles are functional, why you wouldn't do it is beyond me. How do we get those? Because I know, I looked, actually, I was looking up 60 cycles per minute, and I couldn't find anything. I kept looking. No, you, you, the only place that makes them is my site, and it took me, it took me two months to make those. You think making that Topro was hard? I had to use high-speed cameras because the researchers in Belgium had engineering departments make those. And, you know, they used Maxon motors that cost $1,000.

Oh, I see. And then they had to be set up to a computer, so you're looking at a $10,000 investment for these things. So I just played around with all the different motors I could find. I found one motor that was 5,000 RPM at 12 volts. I dropped it down to 9 volts, put it on a high-speed camera. I got it at 360 RPM, which is 60 cycles per second. Then I just took the weight in the center. I drilled the center core differently, and then I balanced it with a grinder. Each one takes about an hour to tune. Oh, I see. Yeah, yeah, it's something. I didn't know this was on your site, actually. I was looking around for it, and I didn't realize it was on your site.

Oh, yeah. Nobody sells them. I tried to get, because I didn't want to make them. I got other things to do. I tried to get the guys from Belgium to see if they could market them, because I wanted them. But, in fact, I made them, right? And it was a lot of time, a lot of money. I finally made the prototypes. The first person I put it on was this high-level athlete, and she didn't budge. And I thought, oh, these things stink. And then I put it on a woman who had a multi-level spinal fusion. And I was really glad I talked to the authors of the study, because they said, be careful. Some people, their proprioception is so bad, you should stand behind them.

So I happened to be standing behind her. It looked like she was diving off a platform. Like, I caught her. But I was really surprised. And I did her after I did that first high-level athlete, who didn't even budge. And she kind of looked back at me like, what are you putting the little vibrating things on my cast for? But most people, if they've had a history of back pain, will go back four or five centimeters. All right. Yeah, they're a blast. And if I could get more interest in those things, I could subcontract out the manufacturer of them, so they wouldn't even be that expensive. I think I'm charging $175.

I could probably get them down to $75 if I could get, like, a couple hundred people interested in it, and I could subcontract it out. But they're phenomenal. And I tried to get other people to make them, but I couldn't. So that's when I just said, oh, I'll make them. And I'm glad I did, because I use it on every new patient. Okay. You will check the spindle activity in 20 seconds. And, yeah, it's something. Yeah, I see you got the video here, actually. Yeah, put that video on. Watch the person sway back. It looks like you hobbled a lady, and you're taking her for a walk. It's like you're hypnotizing them.

And it happens fast. And the funny thing is, if you turn it on and off, you can kind of make them move however you want, because their spindles are saying, we're falling forward. So they shoot themselves back. So the spindles in their calves, when you vibrate them at that specific frequency, the gastroc sends a signal, and soleus sends a signal saying, we're lengthening, and we're lengthening fast. So the upper body tilts back to compensate for it. But if they have good spindle sensitivity in their core, they just completely ignore it. They'll go, I feel it, but I know we're not moving, because I have a functional core.

So really, I think that stuff is fascinating. And every now and then, I'll sell one of those to someone, and they're the only people I send them a note. It's like, this is how you do it, if you have any problem. In fact, I was throwing lasers in with them when people first ordered them, because there's not a lot of interest in it. And again, I'm not sure why. Because those things are, if you saw them in action, besides that video, they're just phenomenal. And they're quick. You strap them on. It literally takes 10 seconds to put them on, and 20 seconds to test. I'm going to have to play with these things.

They did really, really interest me. And now I know where to get them. And you already got a video to show how to use them. Yeah, and I only have a few of them, and they take forever to make. And right now, I'm the one who has to make them, because I can't get anybody to make them, because you have to put on high-speed cameras with magnifying glasses. It's a pain. So I actually don't even care if I sell them, because it's too much work. But if I could get people interested, I could find somebody. Because it costs a lot to get engineers to do things. And they have to do it in a certain volume, otherwise it's not worth their while.

Just like injection molding this Topro thing. I mean, it costs a small fortune, because you've got to do runs of 1,000, and you've got to make aluminum molds. And I didn't want to have it done in China. I had everything manufactured in the U.S. Well, I think this is definitely something that we could, instead of doing alignment screenings anymore, you could just stick these on people at local CrossFit gyms and see which ones are going to get hurt. You could. In fact, you could probably just apply it to people really fast. I mean, I wanted to come up with a smaller pod that could go on really quickly, but it's so fast as it is.

Yeah. Yeah, I like them a lot. Of all the things on the site, that's the thing I personally like the most, even though someone else discovered it and made them. I just think the people who did that early research were just geniuses. You're just going to be the one to bring them to America, is all. There you go. Well, I won't take any more of your time. I might email you to get some of the, maybe some links of things that we talked about, but for the most part, I'll dig and find as much as I possibly can. Absolutely. So, yeah, if anybody from any of your sites even wants discounts on these things, just let me know.

I'll come up with a discount link for anybody affiliated with your site. Well, I definitely can't tell them about the motors yet because there's only like two left, so I've got to get the one. Yeah, there's only two left, so yeah. Yeah, I might have to hold. I should prolong this podcast about a month or so. Yeah, exactly. Give me time to make some more. But again, you know, it's not the kind of thing people seem that interested in, and for the life of me, I don't understand it. Yeah. Well, we'll get them interested. We just need to do a little marketing with it, I think. Beautiful. Well, awesome.

Thanks, Tom. This was wonderful. Yeah, it was a lot of fun. I enjoyed talking to you a lot. Yeah, absolutely. Good talking to you as well. Yeah. And if you want to do this again in the future, just shoot me an email and we can figure it out. I definitely do. We're going to find the people. I'm going to find some people that I'm just going to jiggle their leg at 60 seconds per minute and send you some videos a little bit just to show you. Hey, what do you think about this one? Yeah, good luck with that. It's 60 cycles per second. Oh, per second? That's some fast jiggling. If you could do that, you could make a living some other way.

But yeah, that worked out well. All right. Hey, good talking with you, Tim. Good talking with you, too. I'll talk to you soon. All right. Sounds good. Take care. Bye. Okay, so that was an interview with Tom Machad. If you're looking for the show notes, go to p2sportscare.com. There is a – I'm really refraining from giving the direct links because I want people to go through the site and really use the search function. Look up Tom. Look up Foot Ankle. Look up Machad if you know how to spell it. And you'll find the show notes for it. And it's transcribed. There's a player on there as well as some quotes and so on.

So it's really good. It's all the stuff that you missed on the audio version. I will put some links also to his – the references to his products on there. I don't like being the product promotion dude. But honestly, the stuff that he's got in his site, you can hear the passion with it. And he's a really smart guy. A lot of references in what he says. So I would strongly suggest take a look at these. The Toe Pro we're going to be getting. The Toe Strength Dynamometer we're going to be getting. And he has those focal muscle vibration, those motors that he referenced. He actually has a video straight through the page.

You can see how it works. It does look like he has a person hobbled there. But yeah. So I think I'm going to be using a lot of these because I really do think the focal buy-in or the really quick buy-in is important because patients, a lot of times they just focus on pain aspect and they don't really look at dysfunction or things that we can see through like basic tests like this muscle vibration one. So if we're able to predict and prevent some of these conditions for them, they're going to be happier. And whether they have – whether they say it or not, they really don't want to age poorly. They don't want to get aches and pains.

They don't want to lose the sport they love. And they don't want to be hindered, you know, throughout life. They want to have a good life. So – and for any patients listening out there, I'm sure you're going to resonate well with this. The book that he – that we were talking about, Human Locomotion, they actually – he did a ton of drawing. He did all the drawings in. I have it on my desk at work. And actually, I have my amazing intern, Jeremy. I had him take a look at it. And he opens it and he's like, whoa. And his eyes got all big. And he's like, why don't we learn this in school? And I really think – I was thinking about this.

I really think it would just take too long. I think it would take like two terms of full class to get into it as deep as you could. It's a very heavy read. It's very technical. There's lots of planes of movements. There's lots of directions of human movement, which – so it's definitely not consumer-based. I hope Tom releases – I bet he could do it real quick – releases a consumer-based one, kind of like Dr. Stu McGill did with Back Mechanic. I think it would help everyone out a ton. So, Tom, I think that's something that people would definitely like. Because people tend to like the Back Mechanic one a lot.

So, yeah, go onto his site, Human Locomotion, and buy those things. The book, again, it's a really great read and it's a great price as well. Lastly, I think just go onto the website and check out everything that I have for you guys. We are going to be making a series of books coming up by the time this podcast release. I really hope that we have them out already. We're working on mainly Disclaimer because I – although it's targeted at young clinicians learning some treatment theories as well as ways to rehab and creating buy-in and so on, there's exercises in there. And it's written in a lingo.

I think that I'm speaking to both. So, if patients do pick them up, I want to make sure that you guys understand that you still got to go see somebody. Because misdiagnosis is a big problem. A lot of people misdiagnose themselves and I'm sure I've done it in the past too. And I realized two months later, I'm like, holy crap, I could have – you know, I should have just gone to someone, which I did for my back thing, and I found that I have a solid plan of attack, you know. So, those books are going to be coming out. We do have a foot-ankle one coming out. That will probably be one of the last ones to come out.

For Young Docs, we have YouTube – the YouTube guide for the Young Doc, basically. In so many words, I'm going to show you how many – or how I built my practice based upon YouTube videos and how it builds – how it shuttles people into my office. Also, I have another book that is – it's basically the things that – when I was on a plane, I was coming back from a conference in Colorado, and I saw a bunch of Young Docs there, and I thought, man, if they knew the things – if they knew the things that I wish I would have done differently or they don't make some of the same mistakes I did, they would be so far ahead.

So, I just was on the airplane, and I just wrote this – the outline for this book, and I cleaned it up for the last couple months, and it's about 40 pages. And I sent it to one of my friends, and he's like, wow, that's really good. I sent it to all my interns, and they said, wow, that is extremely valuable. So, that's going to be something available for you guys, too. For consumers, the ulnar nerve one, or the numbness into the fourth and fifth finger, is going to be probably live first. That's the one we're mainly working on the disclaimer for. But all these things are – I'd love to say we're going to make a killing on it, and I'm going to pay off my house with it, but it's really that we can only help so many people one-on-one.

And as Ryan DeBell said, it's like you're able to help people more on a surface level, at least in the basic foundations of their understanding. And you help more people, but those people still probably got to go to someone to get it cleaned up. So, it's not intended to replace the clinician. It's just a supplementary thing. Now, lastly, be good to each other. Talk to you soon. Get some coffee. Have a good day.