Tim Mulholland

They arrive with a scan report. An exercise sheet. Three pairs of runners, each bought with great hope. There might be orthotics in the bag, a mental list of things that have been tried and a very firm opinion from someone at the gym.

Mostly, they arrive with effort.

By the time someone comes to me for a second opinion, they have usually done plenty of sensible things. They rested. They strengthened. They changed shoes. They reduced their running, built it back up, flared again and wondered whether they were right back where they started.

That effort was not necessarily wasted. The scan may be useful. The exercises may be good. The shoes may change load in exactly the way they were designed to.

But sensible treatments can remain separate pieces. Nobody has yet made them answer the same question.

What is actually sore? Why is it struggling with this load now? What can it tolerate? Which lever matters first? How do we build from here towards the thing you actually want to do?

That is the part of sports podiatry I find most interesting.

Take a common Achilles pain story.

Rest calms it down, so rest appears to work. The person starts running again and the pain returns, so running appears to be the problem. They are given calf exercises, which are a sensible way to build capacity, but the exercise is too easy to create much adaptation or too deep for an irritated insertional tendon. A new shoe feels better for a fortnight, but training rises and the tendon complains again.

None of those decisions is ridiculous.

They simply do different jobs.

Rest can reduce an irritating load. Exercise can build capacity. Shoes, heel lifts and orthotics can redistribute load. Imaging can clarify an important diagnosis. Trouble starts when we cannot explain which job each treatment is doing, how much is needed or what should happen next.

A technically good exercise at the wrong dose is not a good programme for that person. A beautifully made orthotic prescribed for the wrong loading problem is still the wrong orthotic. A scan finding may be real without being the main reason someone hurts.

The treatment pile gets taller. The plan does not get clearer.

When pain hangs around, it is tempting to keep moving along the treatment menu: shockwave, another shoe, a different exercise, more rest, different orthotics, an injection or another scan.

Sometimes the next item is exactly what the case needs. Persistent pain can reflect slow biology, an incomplete diagnosis or a condition that deserves imaging, medical treatment or surgical opinion.

Still, adding a treatment before improving the question creates more noise.

I would rather ask:

• What diagnosis best explains the pattern, and what else still needs consideration?
• Which loads from training, work, footwear or daily life are actually relevant?
• What can the tissue and the person tolerate today?
• What changed with each previous treatment?
• What is the smallest useful change we can test?

Those questions turn the treatments you have already tried into evidence.

Complete rest is sometimes necessary. More often, it is simply the easiest instruction to give and one of the hardest to live with.

If running, football, lifting or being active is part of how you feel like yourself, removing all of it has a cost. It can also reduce the capacity you will eventually need when you return.

Useful load management asks a more practical question: what can we keep, what needs to change and what response tells us the dose was appropriate?

For one runner, that may mean keeping two shorter runs while removing hills. For another, running may need to pause while cycling and strength work continue. A painful tendon may tolerate heavy calf work in one range and hate a seemingly gentle stretch in another.

The plan should respond to the tissue, the risk and the person in front of us.

I love shoes. This is useful occasionally and mildly embarrassing at other times.

Shoes can alter pressure, stiffness, heel height, cushioning and how an orthotic interacts with the foot. They can make a meaningful difference. They cannot tell us the diagnosis, and a new pair cannot build tissue capacity.

Orthotics are similar.

I do not think of an orthotic as something that fixes a collapsed or defective foot. It is a tool that pushes on the foot while muscles pull on it. When a little external push reduces stress in the right place, it can make walking, work, rehabilitation or running more tolerable while we build capacity.

The dose matters. The shoe matters. The activity matters.

Some people need a device. Some need a different shoe or a better strength progression. Plenty need a thoughtful combination, introduced in the right order.

I cannot promise that every difficult injury has one hidden answer.

Bodies are not that tidy.

What I can aim to give you is a working explanation that connects your symptoms, activity, footwear, capacity and goals. You should know what I think is happening, what remains uncertain, what we are changing first and what result would make us continue, adjust or escalate.

You should also understand what you can keep doing.

A consultation should leave you with more agency, not a longer list of things to fear. If the first plan does not work, we should already know what question comes next.

I graduated from La Trobe University with a Bachelor of Podiatry in 2010. I am a Clinical Educator and Course Advisory Board Member at La Trobe, and I have taught and clinically supervised podiatry students there since 2012. My background also includes four years working in acute hospital podiatry.

That range matters in a second-opinion consultation. It brings experience with clinical risk, practical rehabilitation, teaching and clear explanation into the same room. I am comfortable saying, "I do not know yet, but here is how we can find out."

Running has given me a personal appreciation for the gap between knowing what good rehabilitation looks like and fitting it into an actual week. It has also given me an unreasonable interest in running shoes. We all need hobbies.

I have also managed Achilles tendinopathy in my own running. That does not make my experience identical to yours, but it has made the gap between understanding a rehabilitation plan and getting a tendon to tolerate the next run feel very familiar.

At Pride Podiatry, that clinical reasoning is only part of what I optimise for. A technically correct plan is table stakes. The person needs to feel heard, understand the problem, see or feel why the plan makes sense and believe they can carry it out.

Bring the scan report. Bring the shoes. Bring the orthotics that live in the cupboard. Bring the exercise programme and tell me what happened when you actually tried it.

They are not evidence that you failed.

They are evidence we can use.

If your sports injury, running pain, heel pain or Achilles problem has become persistent, confusing or resistant to the plan you have already tried, you can book a sports podiatry assessment with me at Pride Podiatry, 80 Collins Street in Melbourne CBD.

We will start by working out which question needs a better answer.