Introduction: Why We Need a Better Model Than "Normal vs. Abnormal"
In the world of podiatry and musculoskeletal medicine, many clinicians still rely on outdated biomechanical models that try to define what is "normal" and what isn’t. But the truth is, people can move far outside those so-called normal ranges without ever developing pain. At Bayshore Podiatry Center in Tampa, we take a more functional, individualized approach based on what’s called the Tissue Stress Model.
Rather than forcing every patient into a biomechanical mold, this model focuses on what structure is hurting, why it’s being overloaded, and how we can reduce that load while rebuilding its strength. It’s how we keep patients active, pain-free, and out of surgery—especially those who’ve failed more generic treatment approaches in Tampa, Florida.
What Is the Tissue Stress Model?
"I explain the Tissue Stress Model to patients as a problem of tissue insufficiency. In plain terms, your tissue is currently too weak to handle the amount of force you're putting through it—so it becomes inflamed, irritated, and painful. The goal of treatment is twofold: first, we need to rest the tissue by offloading it in some way, usually through a splint, support, or modification in activity. Next, we strengthen the tissue through proper rehabilitation exercises. This allows the tissue to tolerate that stress or load again without breaking down.”
— Dr. James Repko, DPM
Why We Don’t Rely on Root Biomechanics Alone
"I find the Tissue Stress Model far more useful than traditional Root biomechanics because biomechanics tends to force everyone into a narrow definition of what’s ‘normal.’ But there really is no universal normal. People can function perfectly well outside of textbook biomechanical limits and never develop pain. That’s why I believe the predictive model of Root biomechanics is flawed."
"If restoring people to a defined ‘normal’ range of motion was all it took to prevent injuries, then custom orthotics designed under that philosophy should have massive prophylactic benefit—but research doesn’t show that. Instead, I focus on assessing the injury or pain itself and working backward to determine why the tissue is failing under stress."
How I Came to Embrace the Tissue Stress Model
"I first adopted this model about five or six years ago while talking with my brother, who was going through his orthopedic residency in physical therapy. We had a lot of conversations around pathology, biomechanics, and how real people recover from injuries—not just what textbooks say. Those discussions really challenged how I thought about pain and movement. It had a big impact on how I evaluate, treat, and think about patients today."
Why Most Approaches Fail—and What We Do Differently
Many clinics focus on treating foot and ankle pain by addressing what they see on the surface: inflammation, flat feet, "overpronation," or alignment issues. While those factors can play a role, this often leads to a one-size-fits-all approach—like prescribing the same generic orthotic or stretch routine to every patient, regardless of what tissue is actually involved.
The problem? These treatments don’t address the root cause of pain. They may reduce symptoms temporarily, but they don’t improve the tissue’s capacity to handle stress. In many cases, the pain returns, or worse, the tissue continues to deteriorate quietly until surgery becomes the only option.
At Bayshore Podiatry Center, we use the Tissue Stress Model to flip that approach on its head. We start by identifying which specific tissue is breaking down, then ask why that tissue can’t handle its load. From there, we match the treatment to the tissue’s current state—whether that means offloading, strengthening, or both. Every decision is individualized, and every treatment plan is rooted in restoring long-term function, not just chasing symptom relief.
We believe our patients deserve more than short-term fixes. They deserve a plan built around their actual injury, activity level, and goals—and that’s what this model allows us to deliver.
How This Model Helps Us Avoid Surgery
"If I can understand a patient’s tissue load patterns—how stress is being applied to their body—I can then apply corrective therapies to manage that load. Sometimes that means using external tools like orthotics or bracing to offload the area. Other times, it’s about building internal capacity through strength training. The goal is always to use a multifaceted, tiered approach to help people avoid surgery and get better long-term."
"Whether we emphasize offloading or strengthening depends on several factors: the physical exam, the patient’s tolerance to exercise, the chronicity and severity of the injury, and sometimes imaging—like MRI or in-office ultrasound—to assess the state of the tissue."
Analogies That Make It Click
"One of my go-to analogies is a piece of twine rope. In healthy tissue, fibers are aligned like strands of rope twisted in one direction. When there’s tendinosis or plantar fasciopathy, those fibers knot up and scar down, like a tangled necklace. Scar tissue and disorganized collagen make the tissue weak and inefficient. That doesn’t fix itself—you need targeted intervention to remodel it."
"Another analogy is a car out of alignment. You can replace the tires and it might feel better temporarily, but if you don’t fix the alignment, the new tires will wear down fast. Pain might not show up where the actual problem is."
"Another way I explain it is by comparing the tissue to a bank account. If you keep making withdrawals (stress) without making deposits (recovery and strengthening), eventually you overdraft. Pain is often the body's way of telling you you’re overdrawn."
"Finally, I sometimes talk about blistered skin. If you were to go run a marathon in brand-new shoes without conditioning your skin, you’d end up with blisters—not because your foot is abnormal, but because the tissue wasn’t prepared for that kind of stress. Tendons and fascia behave the same way."
How It Shapes My Orthotic Prescriptions
"Once we identify where the pathologic tissue is, we use orthotic design to strategically offload that tissue or make it easier for it to do its job under load. That mechanical offloading gives the tissue the chance to heal while we simultaneously work on strengthening it through rehab. That combination—offloading plus progressive loading—resolves pain at its source and delivers lasting results."
"What’s different about how I approach orthotics through the lens of the Tissue Stress Model is that I’m not trying to ‘correct’ someone into a textbook ideal. I’m designing a device to meet the patient’s current tissue needs. If a tendon is failing, we support that specific tissue. If a joint is collapsing or overloaded, we shift the stress elsewhere to allow healing. And most importantly, the orthotic is always part of a bigger plan—one that includes rehabilitation, strength training, and patient-specific guidance."
"I usually recommend a custom orthotic when an over-the-counter insert has failed to provide sufficient offloading or relief, or when the patient’s anatomy or condition doesn’t lend itself to a prefabricated device. Some cases need more precise control than a store-bought device can offer. Another major consideration is duration—if someone needs support for more than 6 months, a custom orthotic is often more economical, as it lasts 3–5 years or longer."
"In some cases, the orthotic is a short-term intervention to break the pain cycle. In others, it’s a long-term tool for managing chronic issues or preventing re-injury. The key is that it’s never a one-size-fits-all fix. The orthotic must match the tissue problem—not just the foot shape."
Conditions Best Explained by the Tissue Stress Model
We routinely apply this model to:
In all of these cases, understanding why the tissue is breaking down—whether due to overload, poor recovery, or mechanical imbalance—is more clinically useful than simply labeling someone “overpronated” or “flat footed.”
The Tissue Stress Model allows us to precisely match the treatment to the underlying cause: reduce strain where it’s excessive, rebuild tissue that’s underprepared, and ultimately restore durable, long-term function. why the tissue is breaking down is more useful than simply labeling someone “overpronated” or “flat footed.”
