Latest / Hurdle with Emily Abbate / 276. Plantar Fasciitis: Navigating Foot Pain With Dr. Adam Tenforde

Transcript

276. Plantar Fasciitis: Navigating Foot Pain With Dr. Adam Tenforde · Hurdle with Emily Abbate

0:00
Speaker 1: This isn't a condition that you just need to live with,
0:02
Speaker 1: or that you need to give up activities or footwear
0:05
Speaker 1: that you enjoy wearing. Hopefully those listening in feel empowered
0:09
Speaker 1: that there are ways that their pain can actually be addressed.
0:27
Speaker 2: What is going on everyone, Emily A Body Here. You
0:30
Speaker 2: are listening to episode two hundred and seventy six of Hurdle,
0:34
Speaker 2: a wellness focus podcast where I connect with everyone from
0:36
Speaker 2: your favorite athletes to top experts and industry CEOs about
0:40
Speaker 2: their highest highs, toughest moments, and everything in between. We
0:45
Speaker 2: all go through hurdles in life, and my goal through
0:47
Speaker 2: these discussions is to empower you to better navigate yours
0:50
Speaker 2: and move with intention so that you can stride towards
0:53
Speaker 2: your own big potential and of course have some fun
0:57
Speaker 2: along the way.
0:59
Speaker 3: For today's convo, I am chatting with.
1:01
Speaker 2: Doctor Adam ten forty of Mass General Bringham Sports Medicine
1:06
Speaker 2: Say that five times fast. Doctor ten forty is also
1:09
Speaker 2: an assistant professor in the Department of Physical Medicine and
1:13
Speaker 2: Rehabilitation at Harvard Medical School.
1:15
Speaker 3: And we are talking about something super.
1:17
Speaker 2: Sexy today and that is feat specifically Planter Fascia Idis
1:23
Speaker 2: Now if you have been following along with my personal
1:25
Speaker 2: journey over the last year, I have been dealing with
1:29
Speaker 2: and can confidently say at this point I beat planter
1:34
Speaker 2: fasci idis. Now, for those of you that are not
1:36
Speaker 2: aware of what planter fasci idis is is an inflammation
1:40
Speaker 2: of the planter fascia on the foot, and doctor ten
1:43
Speaker 2: forty really dives into what it is today, what causes it,
1:47
Speaker 2: and so many other things. But like I said, I
1:50
Speaker 2: really dealt with a bad case last year, and in
1:53
Speaker 2: dealing with bad planter fasci itis, I experienced a ton
1:57
Speaker 2: of discomfort, notably in the morning throughout my day. I
2:01
Speaker 2: had to change the way that I was active, how
2:04
Speaker 2: I worked out, adjust the way that I like to move,
2:06
Speaker 2: specifically pertaining to running. I invested tons of money in
2:10
Speaker 2: physical therapy and working with the diatrist, all different treatment
2:14
Speaker 2: options which I speak about today with Doctor ten forty,
2:18
Speaker 2: and I also realized just how many people are truly
2:22
Speaker 2: struggling with this. It is so frustrating to get up
2:24
Speaker 2: in the morning, put your feet on the ground and
2:25
Speaker 2: the first thing that you experience is pain. It's something
2:28
Speaker 2: that no one should have to deal with, and that
2:30
Speaker 2: is why I brought this expert in. I wanted to
2:34
Speaker 2: finally have an in depth conversation that I could point
2:36
Speaker 2: people to when they messaged me about struggling with this issue.
2:41
Speaker 2: And that's what we're doing here. We're talking all about it.
2:44
Speaker 2: So do me a favor. Maybe you don't have plant
2:47
Speaker 2: for fascia it is, but someone you know is struggling
2:49
Speaker 2: with it that too. This episode is for share it
2:52
Speaker 2: with a friend, send it to someone that you care
2:54
Speaker 2: about their help and well being. We all deserve to
2:58
Speaker 2: live a pain free life. You do not have to
3:00
Speaker 2: accept living with pain. That is something that we really
3:03
Speaker 2: get into today, as well as so many other things.
3:05
Speaker 2: How do you doctors diagnose planter fasciitis, how is it treated,
3:09
Speaker 2: what are the home remedies?
3:10
Speaker 3: And so much more. Make sure you're following along over
3:14
Speaker 3: on social.
3:14
Speaker 2: At Hurdle podcast. I am over at Emily a Body
3:17
Speaker 2: And with that, let's get to it. Let's get to hurdling.
3:28
Speaker 3: Today.
3:28
Speaker 2: I'm sitting down with doctor Adam ten forty of Mass
3:32
Speaker 2: General Brigham Sports Medicine.
3:34
Speaker 3: How are you doing today?
3:36
Speaker 1: I'm doing well. Thanks for having me on your show.
3:39
Speaker 3: Thanks for making the time.
3:40
Speaker 2: You know, there has been a thirst for knowledge when
3:44
Speaker 2: it comes to one of the sexiest topics that we
3:46
Speaker 2: can talk about, and that is planter fascia itis. Now,
3:50
Speaker 2: like I said, you work in sports medicine at Mass
3:53
Speaker 2: General Brigham. Tell me a little bit about how you
3:55
Speaker 2: got into this area of expertise.
3:58
Speaker 1: We commonly see a number of overuse injuries, and my
4:03
Speaker 1: focus is on the management of acute and overuse injuries,
4:07
Speaker 1: particularly in runners. But when you see some of these
4:11
Speaker 1: conditions that affect runners, you can oftentimes extrapolate how they
4:15
Speaker 1: would affect other athletes that participate in land based sports
4:19
Speaker 1: or even individuals that are physically active in other methods. So,
4:25
Speaker 1: plantar fasciitis represents a very common overuse injury. We commonly
4:30
Speaker 1: think of it as heel pain, but the more we
4:33
Speaker 1: learn about it, there's a number of advances in our
4:37
Speaker 1: understanding for effective ways to rehabilitate this injury and even
4:42
Speaker 1: some targeted interventions that I commonly do in practice.
4:46
Speaker 2: Right, and you specialize traditionally in non surgical treatment.
4:50
Speaker 3: Is that correct?
4:52
Speaker 1: That's correct? And one of the things that is oftentimes
4:55
Speaker 1: a challenge, and I think it's wonderful, wonderful to be
4:59
Speaker 1: on your show is understanding that there are many different
5:02
Speaker 1: avenues to receiving care for muscular scull injuries. So oftentimes
5:07
Speaker 1: individuals are looking for a foot ancle surgeon or someone
5:11
Speaker 1: in orthopedics, and oftentimes that will will lead to discussions
5:16
Speaker 1: on whether this is an injury that requires surgery. The
5:19
Speaker 1: good news is for all those listening in plantofasciitis is
5:24
Speaker 1: a treatable condition. It's an overuse injury, but it very
5:29
Speaker 1: rarely requires surgery.
5:31
Speaker 2: Yeah, now, I think that first and foremost, let's just
5:34
Speaker 2: lay the foundation that although it is an overuse injury,
5:37
Speaker 2: and we did talk about you specializing working with runners,
5:40
Speaker 2: anyone can develop plantar fasciitis. It's not just limited to
5:44
Speaker 2: someone that identifies as a runner. When we use the
5:48
Speaker 2: term overuse injury, it beckons the question why do some
5:53
Speaker 2: individuals develop this versus others, considering maybe they may move
5:58
Speaker 2: the same amount.
6:00
Speaker 1: I think it's a great question, and I oftentimes will
6:03
Speaker 1: joke with patients when I get that question, because we
6:07
Speaker 1: may be doing the exact same amount of activity we've
6:10
Speaker 1: historically done, but for a number of different factors, probably
6:15
Speaker 1: a number that we have not been able to identify,
6:18
Speaker 1: individuals will develop this injury. So overuse really refers to
6:23
Speaker 1: excessive demand to a tissue in which the tissue is
6:26
Speaker 1: not able to repair itself. So we've moved away from
6:30
Speaker 1: using the term itis for everything like tendon itis fasci itis.
6:35
Speaker 1: I'll commonly use that term when I'm talking to my
6:38
Speaker 1: patients because I want to use terms that are familiar.
6:41
Speaker 1: But now that if we start to think of this
6:43
Speaker 1: as an overuse injury, which may not necessarily be purely
6:48
Speaker 1: driven by inflammation, we understand why some of our traditional
6:52
Speaker 1: strategies around icing or taking over the counter anti inflammatory
6:56
Speaker 1: medications don't successfully treat this condition.
7:00
Speaker 2: Before we get into the treatment for this, let's talk
7:04
Speaker 2: about what some of the signature signs might be that
7:08
Speaker 2: you are indeed dealing with plant or fascy itis.
7:12
Speaker 1: Yeah, so, with plantar fasci itis, the most common issue
7:16
Speaker 1: than individuals will have is pain in their heel, and
7:20
Speaker 1: that will oftentimes be when you first wake. Those first
7:24
Speaker 1: couple of steps can be very painful. There oftentimes is
7:27
Speaker 1: something called a warm up phenomenon, which means that as
7:30
Speaker 1: the tissue gets more blood flow from demand, it will
7:34
Speaker 1: feel a little better. But we'll have those transition times.
7:38
Speaker 1: For example, after sitting for a while, where the first
7:42
Speaker 1: steps will be very painful. The pain is usually localized
7:46
Speaker 1: to the to the plant or heel, so right under
7:50
Speaker 1: the sole of the foot, but this injury can evolve
7:54
Speaker 1: a larger span of the foot. Because the plantar fascia.
7:58
Speaker 1: As much as it's very annoying and most of us
8:00
Speaker 1: take it for granted until we have an injury involving
8:03
Speaker 1: the plant fascia, it serves a number of critical roles.
8:08
Speaker 1: It actually starts at the base of the heel. It
8:12
Speaker 1: has three bands and then five slips that will actually
8:16
Speaker 1: go to each of each of the toes. So this
8:21
Speaker 1: spans almost the entire length of the bottom of the foot.
8:25
Speaker 1: So when it's injured, it's very difficult to avoid overloading
8:30
Speaker 1: that tissue and as a result, a lot of individuals
8:33
Speaker 1: will have pain and they will try number of things
8:35
Speaker 1: to support their foot to try to take the pain away.
8:39
Speaker 2: Right understandable, and I can speak as someone who really
8:42
Speaker 2: dealt with the gnarly case of this last year. I
8:46
Speaker 2: feel like there are almost like two different places you
8:49
Speaker 2: can be in. It's like I might feel plantro fausci
8:52
Speaker 2: itis every so often, but it's not something that is
8:55
Speaker 2: truly debilitating for you, versus being in a place where
8:58
Speaker 2: plantra fauci itis really is. As you spoke about that
9:02
Speaker 2: early morning starts from the moment you wake up. Might
9:04
Speaker 2: feel a little bit better throughout the day, but it's
9:07
Speaker 2: there every single day. For those that are in the
9:11
Speaker 2: first camp, the area where it only presents every so often,
9:14
Speaker 2: I would imagine that they want to do everything they
9:17
Speaker 2: can so they don't end up in the second camp.
9:21
Speaker 3: Where do they begin?
9:24
Speaker 1: So this injury does sometimes start with pain just during activity,
9:30
Speaker 1: and it's actually been described as one of the more
9:33
Speaker 1: common running related injuries. So you'll have individuals that feel
9:37
Speaker 1: okay most of the day and it's only when they
9:40
Speaker 1: run or they do activities which involve a lot of
9:43
Speaker 1: hopping where their plan of fashion hurts. And I think
9:47
Speaker 1: when you're in that stage, really the goal is to
9:50
Speaker 1: figure out what is it about the demands on the
9:54
Speaker 1: feet that are causing that pain. So this is where
9:57
Speaker 1: physical therapy can be very helpful. Recognizing that the planner
10:01
Speaker 1: fascist spans the length of the foot, but there's actually
10:04
Speaker 1: four layers of muscles that make up the arch of
10:07
Speaker 1: the foot as well. So this if this fashi is
10:10
Speaker 1: under chronic stress from activities. Perhaps there's a rule for
10:16
Speaker 1: actually strengthening the muscles in the feed to take the
10:18
Speaker 1: stress off of the planner fashion, And you're right, it
10:22
Speaker 1: can sometimes progress to becoming more of a daily nuisance.
10:26
Speaker 1: Whenever you take a step, you feel it. So what
10:31
Speaker 1: we're really trying to do is treat this injury as
10:33
Speaker 1: early as possible, and there are some studies suggesting that,
10:38
Speaker 1: you know, the first year can be can be a
10:41
Speaker 1: really good window to have better outcomes. Although I've taken
10:44
Speaker 1: care of individuals with this condition that have had this
10:47
Speaker 1: pain for years and we're ultimately able to get them
10:50
Speaker 1: better and not having pain. So I also don't want
10:54
Speaker 1: people to become discouraged if they've had this condition for
10:58
Speaker 1: a long time, or if it's affecting them at all times.
11:01
Speaker 1: I think there's still a lot that can be done
11:04
Speaker 1: to help address this injury, and again it's oftentimes not
11:09
Speaker 1: necessarily a surgical solution, but it does require a number
11:12
Speaker 1: of different considerations.
11:15
Speaker 2: Yeah, I'm like sitting here nodding my head, because there
11:18
Speaker 2: are many different things, many different ailments that can be
11:22
Speaker 2: quite the hassle on the body. But when standing alone
11:26
Speaker 2: is the thing that brings you pain from the moment
11:29
Speaker 2: you wake up.
11:29
Speaker 3: It really does get to be truly exhausting.
11:34
Speaker 2: Now I know personally, a big cause for my planto
11:37
Speaker 2: fasci it is was a lot of calf tightness. So
11:40
Speaker 2: let's segue here into talking about some of the different
11:44
Speaker 2: root causes Aside from as we talked about an overuse injury,
11:47
Speaker 2: what are other things that can cause planto fasci it is.
11:51
Speaker 1: Yeah, it's a great question. So it may not necessarily
11:56
Speaker 1: be just from overload. Again, the the risk factors that
12:01
Speaker 1: have really been you know, clearly demonstrating the literature, there
12:05
Speaker 1: are very few. There's there's concerns that perhaps you know,
12:09
Speaker 1: being overweight, age, certain conditions like diabetes might might predispose
12:16
Speaker 1: the development a planar fasciatis. But again that's not to
12:19
Speaker 1: say that that's that's predestined, because you have arguably a
12:23
Speaker 1: number of runners that are normal body weight who will
12:26
Speaker 1: also develop the condition. And I also don't think it's
12:29
Speaker 1: it's the most helpful for for individuals to hear those
12:32
Speaker 1: risk factors and assume that they're going to receive uh,
12:36
Speaker 1: you know, suboptimal care just because of medical come morbidities.
12:42
Speaker 1: So so those tend to be. Some of the factors
12:44
Speaker 1: we'll look at though, is if someone has been gaining
12:48
Speaker 1: weight that that may be part of the strategy is
12:51
Speaker 1: thinking about what is that individual's healthy weight to get
12:54
Speaker 1: back to UH if if it's a change in activity
12:58
Speaker 1: or training, it's recognizing that any change in activity can
13:04
Speaker 1: sometimes acutely overload the tissue. And then there's a number
13:08
Speaker 1: of different aspects of footwear that we have to think
13:10
Speaker 1: about as well. And you know, women will wear shoes
13:15
Speaker 1: that are you know, have a high heel. The way
13:18
Speaker 1: that may contribute to development a pleno fasciitis or some
13:21
Speaker 1: of the other foot ankle injuries is that the use
13:24
Speaker 1: of a lift a heel will actually take some of
13:28
Speaker 1: the stress, the stretch off of the tissues. So that
13:32
Speaker 1: going from having a lot of heel support to having
13:36
Speaker 1: no heel support, which is what we typically have in
13:40
Speaker 1: most athletic footwear, that that acute change might be very
13:45
Speaker 1: challenging for the feed And again, I think it's important
13:48
Speaker 1: to understand the goals of the individual and I certainly
13:51
Speaker 1: have no qualms about individuals getting back into whatever footwear
13:55
Speaker 1: they want to wear, but it's just understanding what are
13:59
Speaker 1: the things that could potentially cause the foot to be
14:01
Speaker 1: painful in the first place, where we can help help
14:05
Speaker 1: to address that early on and then build up the
14:08
Speaker 1: strength and the function so that individuals can get back
14:10
Speaker 1: into whatever they want to wear.
14:12
Speaker 2: Yeah, you know, it's funny because I would definitely go
14:15
Speaker 2: through phases even when at the height of my planter
14:19
Speaker 2: fasciitis that going from something flat like a sneaker into
14:23
Speaker 2: a heel almost felt good because it was just a
14:25
Speaker 2: different angle for my foot.
14:27
Speaker 1: Yeah, that's exactly right. So you intuitively, we're doing something
14:32
Speaker 1: that was temporarily taking the stress off of the foot,
14:36
Speaker 1: so by being in a heel that can sometimes provide
14:39
Speaker 1: some relief, and that's why we oftentimes will we'll see
14:44
Speaker 1: runners and other active individuals get a shoe that goes
14:47
Speaker 1: from having a zero drop meaning that the sole of
14:50
Speaker 1: the shoot has no difference between the heel to the forefoot,
14:54
Speaker 1: to getting something that has a little bit of a drop,
14:57
Speaker 1: because that will take a little bit of the stress
14:59
Speaker 1: off of the heel. But to your point, when your
15:03
Speaker 1: calves feel tight, that can also be a sign that
15:05
Speaker 1: those tissues are fatiguing. So another reason that people can
15:10
Speaker 1: be tight is not just that their bodies are built
15:13
Speaker 1: a certain way where their tissues are going to tighten up.
15:15
Speaker 1: But that tightening or that cramping can be a sign
15:18
Speaker 1: of fatigue. And that's why physical therapy and rehabilitation exercises
15:24
Speaker 1: can be so effective for this.
15:25
Speaker 2: Condition definitely, And we'll get to those treatment options in
15:29
Speaker 2: just a second. I want to make sure that we
15:31
Speaker 2: reiterate here that generally speaking, most sneakers will see something
15:36
Speaker 2: between an eight to ten millimeter drop when it comes
15:38
Speaker 2: to running sneakers. When we talk about zero drop, the
15:41
Speaker 2: shoes that are flat from toe to heel, that doesn't
15:44
Speaker 2: necessarily mean that they're completely minimalist, completely flat on the ground.
15:48
Speaker 2: Those shoes could have what we often talk about to
15:51
Speaker 2: be a stack height, which is the thickness supposedly of
15:56
Speaker 2: the foam that's under your foot. So a lot of
15:59
Speaker 2: different buzz where it's when we talk about shoes and
16:01
Speaker 2: all the things that come with them, the bells and
16:03
Speaker 2: the whistles, it really is about finding what feels best
16:07
Speaker 2: for you and your foot, whether or not you're dealing
16:09
Speaker 2: with a condition like this.
16:11
Speaker 1: Yeah, I agree with that the stack hite versus the
16:16
Speaker 1: actual drop. That's a common question that individuals will bring up.
16:21
Speaker 1: You can have a shoe that has a lot of cushioning,
16:24
Speaker 1: but that cushioning is evenly distributed under the foot, and
16:27
Speaker 1: that might that might be a zero drop shoe. Or
16:31
Speaker 1: you can have a traditional minimal shoe that has no
16:33
Speaker 1: cushioning under the foot and is also a zero drop,
16:37
Speaker 1: and both of those can put acute stress through the foot.
16:41
Speaker 1: So that's a really important consideration when individuals think about
16:46
Speaker 1: what footwear they've changed when they developed this injury, so
16:49
Speaker 1: that they don't necessarily assume that their footwear didn't play
16:53
Speaker 1: a role.
16:54
Speaker 3: Right.
16:54
Speaker 2: I think it's really important to evaluate all the different
16:57
Speaker 2: things that might be happening, and that's why seek out
17:00
Speaker 2: one on one advice with an expert like yourself, like
17:04
Speaker 2: a physical therapist, like another physician, is really important.
17:08
Speaker 3: Granted, yes, we are providing some insight in here. Let's
17:12
Speaker 3: consider this a beginner primer. So then after.
17:16
Speaker 2: Listening this to this, you can take matters into your
17:18
Speaker 2: own hands.
17:20
Speaker 1: Yeah, that's exactly right. I think the important thing for
17:24
Speaker 1: the listeners to understand is this isn't a condition that
17:27
Speaker 1: you just need to live with, or that you need
17:29
Speaker 1: to give up activities or footwear that you enjoy wearing.
17:33
Speaker 1: It's really hopefully those listening in feel empowered that there
17:38
Speaker 1: are ways that their pain can actually be addressed.
17:41
Speaker 3: Right.
17:41
Speaker 2: It's not something that you just have to say, Okay,
17:44
Speaker 2: this is my life now, although admittedly I've definitely gone
17:47
Speaker 2: through phases where I was like, well, this is how
17:51
Speaker 2: it is now.
17:51
Speaker 3: So before we get to those treatment options that we were.
17:55
Speaker 2: Hinting at, why don't we just confirm how does a
17:59
Speaker 2: doctor diagnose plantar fasci itis.
18:02
Speaker 1: Yeah, so the diagnosis is primarily based on the history
18:07
Speaker 1: and the physical exam. So that history of where the
18:10
Speaker 1: pain is, what makes the pain worse, and the general
18:14
Speaker 1: sensation of a warm up phenomenon. Those tend to favor
18:18
Speaker 1: it being a soft tissue over you overload injury to
18:22
Speaker 1: the plantar fascia. And then on physical exam it's usually
18:26
Speaker 1: identifying pain right where that the plantar fascia attaches, but
18:31
Speaker 1: also looking at the foot to see if there's foot weakness.
18:36
Speaker 1: One thing will commonly do, and it's kind of an
18:38
Speaker 1: interesting exercise for viewers is see what it's like to
18:42
Speaker 1: try to balance on one foot and even balancing with
18:45
Speaker 1: your eyes closed that can give you a sense for
18:48
Speaker 1: your ability to balance, which if your balance is off,
18:52
Speaker 1: of course you're going to put more demands through the
18:54
Speaker 1: plantar fascia to try to maintain stability. But then the
18:58
Speaker 1: other feature is if you're standing in front of a
19:01
Speaker 1: mirror and you can see the arch of the foot
19:05
Speaker 1: when you go into a single leg squat, it's seeing
19:08
Speaker 1: whether that that that arch deflects down and that could
19:12
Speaker 1: be a sign that those four layers of muscles are
19:15
Speaker 1: not working as well to stabilize the foot and might
19:19
Speaker 1: also represent some features that can be targeted through physical
19:24
Speaker 1: therapy or other interventions. In terms of other diagnostic testing,
19:29
Speaker 1: we will sometimes get an X ray. X rays can
19:32
Speaker 1: be helpful for looking if there's presence of a bone spur,
19:36
Speaker 1: and the idea on why we look for bone spurs
19:41
Speaker 1: is we can sometimes target those through different interventions. But
19:46
Speaker 1: the way I look at a bone spur is this
19:48
Speaker 1: is probably more a sign that there's been chronic traction
19:53
Speaker 1: of the planar fashion up against the bone, and the
19:55
Speaker 1: body will oftentimes respond by trying to put down calcium
20:00
Speaker 1: deposits to try to reinforce the tissue or as part
20:03
Speaker 1: of the inflammatory process. Rarely we'll get MRIs, and MRIs
20:07
Speaker 1: can be helpful if there's concern for an overuse injury
20:11
Speaker 1: to bone, such as a stress fracture, which again the
20:15
Speaker 1: history will oftentimes give us a clue if that's a
20:18
Speaker 1: bigger concern, and with certain procedures that are done, an
20:23
Speaker 1: MRI can be helpful. But oftentimes I'll have patients come
20:28
Speaker 1: to me and they're very concerned that they've had chronic
20:32
Speaker 1: pain and one of their goals is to get an
20:35
Speaker 1: MRI to understand the injury. The good news is that
20:38
Speaker 1: when we've looked at the evidence for how to diagnose
20:43
Speaker 1: plantar fasciatis, there's very limited role for MRI upfront, and
20:49
Speaker 1: that oftentimes will add cost. So it's identifying ways to
20:53
Speaker 1: get our patients better and to use our resources the
20:56
Speaker 1: most efficient is possible.
20:58
Speaker 2: Yeah, And if someone comes in and they think they
21:01
Speaker 2: might have plantro fasci itis but it's actually something else,
21:05
Speaker 2: what would you say some of the something else things
21:08
Speaker 2: might be.
21:10
Speaker 3: Yeah.
21:10
Speaker 1: So at the local level, the other features that overlap
21:15
Speaker 1: with plantar fasciitis would be keel pain, which which could
21:19
Speaker 1: in fact be from an overuse injury such as the
21:21
Speaker 1: stress reaction stress fracture in the more advanced cases, there
21:25
Speaker 1: are other tendons that attach in the hind foot, the
21:29
Speaker 1: peronial tendons the tibi alis posterior. When the tibi alis
21:33
Speaker 1: posterior is chronically irritated, oftentimes individuals will feel like their
21:38
Speaker 1: foot is flattening out, though, so that that would be
21:42
Speaker 1: perhaps a clue. And then to your earlier point, we
21:46
Speaker 1: sometimes will find, as I like to joke with my patients,
21:49
Speaker 1: a close cousin of plantar fasciitis can actually be overload
21:53
Speaker 1: to the Achilles tendons, so people can develop an Achilles tendonitis,
21:58
Speaker 1: or as I like to refer to, an Achilles ten
22:00
Speaker 1: and opathy. And the reason to understand that relationship is
22:04
Speaker 1: to know that when someone's had a history of an
22:07
Speaker 1: Achilles injury, that's oftentimes there's increased demands that have been
22:12
Speaker 1: put through the foot and ankle, or perhaps weakness that
22:15
Speaker 1: contributed to that injury or other biomechanical factors. And some
22:20
Speaker 1: of those fibers that contribute to the Achilles ten and
22:23
Speaker 1: actually wrap around the heel, and so that tightness from
22:26
Speaker 1: the calf muscle can actually pull on the plannar fascia
22:30
Speaker 1: and make it more vulnerable to injury.
22:36
Speaker 2: Taking a break from today's episode to give some love
22:40
Speaker 2: to something that's been in my personal wellness toolbox for
22:45
Speaker 2: years now.
22:46
Speaker 3: That is a g One.
22:49
Speaker 2: It's my all in one daily greens powder that's got
22:53
Speaker 2: seventy five vitamins, minerals, and whole food sourced nutrients in
22:58
Speaker 2: one convenient daily serving with the anti accident equivalent of
23:03
Speaker 2: twelve servings of fruits and vegetables, as well as probiotics, probiotics, adaptagens,
23:07
Speaker 2: and superfoods. It's hard for me to think about what
23:10
Speaker 2: my life was like before I was regularly incorporating.
23:14
Speaker 3: Ag one into my routine.
23:16
Speaker 2: No matter what is going on with my diet, how
23:19
Speaker 2: often I'm eating out, especially with the holidays, this can
23:22
Speaker 2: get a little bit nutty this time of year. I
23:24
Speaker 2: know that beginning my day with ag one is me
23:27
Speaker 2: doing something really good and investing in my own personal
23:31
Speaker 2: health and well being. With ag one, I have notable
23:35
Speaker 2: benefits to my energy levels.
23:36
Speaker 3: I feel more.
23:37
Speaker 2: Motivated, and it actually tastes good. And I don't say
23:41
Speaker 2: that like it tastes good for a greens powder like
23:44
Speaker 2: I look forward to drinking my ag one every single
23:48
Speaker 2: day as a stand alone product. Of course, ag one
23:52
Speaker 2: has a deal for you. If you want to get
23:54
Speaker 2: in on the gang today. Cannot recommend it enough, head
23:57
Speaker 2: on over to drinkag one dot com slash hurdle to
24:01
Speaker 2: get five free travel backs and a year's supply of
24:04
Speaker 2: Vitamin D absolutely free again. Head on over to drinkag
24:08
Speaker 2: one dot com slash hurdle to get a year's supply
24:12
Speaker 2: of Vitamin D as well as five free travel backs
24:15
Speaker 2: with your orner. Also got to give some love to
24:19
Speaker 2: my sponsor at Element. Element makes an electrolyte drink mix.
24:23
Speaker 2: It's got everything you need and nothing you don't. Tons
24:27
Speaker 2: of flavors ranging from watermelon and raspberry to citrus, and
24:32
Speaker 2: my favorite right now, my go to in the chilly
24:34
Speaker 2: winter months, there chocolate. I heat it up just like
24:38
Speaker 2: you would hot chocolate, water, a little bit of warm milk,
24:42
Speaker 2: and top it with some coconut whipped cream. Oh my goodness,
24:46
Speaker 2: to know that I'm doing something good for my body
24:48
Speaker 2: that tastes this good, feels like it should be It
24:52
Speaker 2: feels like it should be illegal anyway. Electrolytes, why do
24:55
Speaker 2: you need them? Well, I'm so happy you asked.
24:57
Speaker 3: Let me tell you.
24:59
Speaker 2: Along with water, your body also needs sodium, calcium, magnesium, potassium,
25:03
Speaker 2: and chloride. These minerals, which are called electrolytes, regulate a
25:08
Speaker 2: staggering number of processes in the human body like fluid balance,
25:12
Speaker 2: blood pressure, muscle contraction, heart function, and even anxiety. In
25:17
Speaker 2: other words, they are massively important for you to intake
25:21
Speaker 2: to feel good in your body.
25:24
Speaker 3: And that is why I cannot get enough element.
25:27
Speaker 2: Now, of course, they are offering you a sample pack
25:29
Speaker 2: so you can try all of the flavors with your purchase.
25:32
Speaker 2: Head on over to drink Element dot com. That's drink
25:35
Speaker 2: lmnt dot com slash hurdle to get your free sample
25:38
Speaker 2: pack Today again drink lmnt dot com slash hurdle to
25:43
Speaker 2: get your free sample pack with purchase.
25:53
Speaker 3: So now we have our basics.
25:55
Speaker 2: We know what characterizes plantrofasciitis, we know what might cause it.
25:59
Speaker 3: Now well let's talk about how do we treat it.
26:03
Speaker 3: Where does someone even begin?
26:05
Speaker 1: Yeah, so oftentimes by the by the time I see
26:09
Speaker 1: a patient, they've they've tried a number of different strategies.
26:14
Speaker 1: So I certainly understand the tendency to try something over
26:19
Speaker 1: the counter, like an anti inflammatory medication. And for those
26:23
Speaker 1: that don't have a history of kidney or stomach issues
26:27
Speaker 1: or cardiovascular uh, you know concerns. You know, a few
26:31
Speaker 1: weeks of an anti inflammatory is oftentimes a reasonable thing
26:36
Speaker 1: to try, or something like tile and all. And what
26:41
Speaker 1: that will do is that will provide some pain relief
26:44
Speaker 1: and oftentimes will allow individuals then to be able to
26:47
Speaker 1: do some of the rehabilitation exercises. Practically speaking, I actually
26:52
Speaker 1: don't prescribe anti inflammatories because I find they have a
26:55
Speaker 1: very limited use in this condition. So what what I
26:59
Speaker 1: consider to be the mainstay is to get the individual
27:02
Speaker 1: into physical therapy. So again, some of those earlier features,
27:06
Speaker 1: can you balance on one foot? Or how how does
27:09
Speaker 1: someone look when they do a single legg squat can
27:12
Speaker 1: point to some of the weakness, especially if the condition
27:15
Speaker 1: is on one side and the individuals finding it a
27:17
Speaker 1: lot harder to do those tasks on that side. It
27:20
Speaker 1: represents something to target and ensure that people feel like
27:24
Speaker 1: there is actually something to work on and it's not
27:26
Speaker 1: just going through a process. In terms of other strategies,
27:30
Speaker 1: early on, if someone has first morning step pain, so
27:34
Speaker 1: that pain getting out of bed, use of a night
27:37
Speaker 1: splint or a Strasbourg sock, which is which tends to
27:41
Speaker 1: be a little better if you're if you're sleeping next
27:43
Speaker 1: to someone, because it really hurts if you get kicked
27:46
Speaker 1: by a boot. But a Strasbourg sock is essentially a
27:50
Speaker 1: long stocking which which puts a chronic stretch through the
27:54
Speaker 1: plantar fashion and might help with that first morning step.
27:57
Speaker 2: Pain.
27:58
Speaker 1: Orthotics are another thing that individuals will try. I'm not
28:03
Speaker 1: a huge proponent for orthotics long term unless someone really
28:06
Speaker 1: has an advanced structural foot deformity, but something over the
28:11
Speaker 1: counter that provides a little bit of our support will
28:13
Speaker 1: sometimes allow for some pain relief. Now, if those strategies
28:20
Speaker 1: don't work, that's where we start to think about other interventions.
28:25
Speaker 1: So in terms of those strategies for treatment, one option
28:28
Speaker 1: that is commonly offered is a steroid injection. And the
28:32
Speaker 1: theory is that if steroid is put right next to
28:35
Speaker 1: the planar fascia and there is a component of pain
28:39
Speaker 1: and inflammation which is limiting the individual, by applying an
28:43
Speaker 1: anti inflammatory, you might get pain relief. Now, while that's
28:48
Speaker 1: a reasonable strategy, there are a number of concerns around
28:51
Speaker 1: the use of steroid. One is that individuals that have
28:55
Speaker 1: diabetes or have other issues affecting their over all health.
29:01
Speaker 1: The steroid itself can actually cause a spike in blood
29:04
Speaker 1: sugar or can affect people's mood. They sometimes have difficulties sleeping.
29:10
Speaker 1: But the other issues are what steroid can do structurally.
29:14
Speaker 1: So if steroid gets deposited into the heel pad, it
29:18
Speaker 1: can actually cause a condition called fat atrophy where the
29:21
Speaker 1: fat actually will will be permanently injured, and then that
29:27
Speaker 1: we don't have a really effective treatment for the other
29:32
Speaker 1: is that the steroid itself. The more we learn about steroids,
29:35
Speaker 1: the less I like them. The main concern is that
29:38
Speaker 1: steroid actually suppresses the normal turnover proteins in the plantar fascia,
29:44
Speaker 1: so people can actually tear their planar fascia by having
29:48
Speaker 1: steroid deposited next to it. So if someone is going
29:51
Speaker 1: to have a steroid injection, we recommend the use of
29:54
Speaker 1: ultrasound guidance. And we didn't talk about ultrasound as an
29:58
Speaker 1: evaluation tool. Ultrasound has actually been shown to be quite
30:02
Speaker 1: effective under when we review the literature for detecting this condition,
30:08
Speaker 1: because you can actually look for thickness of the plantar
30:10
Speaker 1: fashion and you can look for the presence of tearing
30:13
Speaker 1: and what ultrasound guidance allows for is putting the steroid
30:17
Speaker 1: right next to the tissue, as opposed to putting the
30:21
Speaker 1: steroid directly into the planar fascia or into attendon where
30:24
Speaker 1: it could cause those tissues to get weaker. So that's
30:28
Speaker 1: something that we commonly will do at MASS. General Brigham
30:30
Speaker 1: is use image guidance if we're going to provide an
30:34
Speaker 1: injection like steroid. Now, looking at the systematic reviews, so
30:42
Speaker 1: the evidence that steroid will work even though it's covered
30:45
Speaker 1: by insurance, it's been suggested by Cochrane, which is a
30:50
Speaker 1: big review group, that it might have low evidence that
30:53
Speaker 1: it will help for one month of pain relief. So
30:56
Speaker 1: while it may be covered by insurance, and if someone
31:00
Speaker 1: and you know, doesn't have the financial means to try
31:02
Speaker 1: some of these other strategies and physical therapy is and working,
31:06
Speaker 1: that is something that could be considered should be done
31:08
Speaker 1: under ultrasound guidance, but we have to recognize that may
31:11
Speaker 1: not be a good long term strategy. So in terms
31:15
Speaker 1: of the other interventions, there's one other form of injection
31:19
Speaker 1: that will commonly consider, which is called platelar rich plasma
31:23
Speaker 1: or PRP, and PRP is really you know, kind of
31:28
Speaker 1: a hot topic in sports medicine. What we believe PRP
31:34
Speaker 1: can do is that by taking someone's own blood, spinning
31:39
Speaker 1: it down, and taking the platelar rich layer, we're isolating
31:44
Speaker 1: some of the growth factors that might help the body
31:46
Speaker 1: to repair our own tissue. So the upside with this
31:51
Speaker 1: is this is our bodies owned cells, and what we're
31:53
Speaker 1: trying to do is we're trying to reinitiate a healing response,
31:57
Speaker 1: So very very little argue with that strategy. The main
32:02
Speaker 1: downsides with playlar rich plasma are that insurance won't pay
32:06
Speaker 1: for it, and we also need to recognize that if
32:09
Speaker 1: an athlete is in season, or if you're you know,
32:13
Speaker 1: you have an upcoming running event, you may not want
32:16
Speaker 1: to take the traditional time off that's required after a
32:21
Speaker 1: PRP injection to effectively rehabilitate the tissue.
32:26
Speaker 3: And what does that time off classically look like.
32:28
Speaker 1: With PRP, it oftentimes will take a minimum of three
32:32
Speaker 1: months to really get back into full running, and so
32:36
Speaker 1: for a lot of individuals that's not an acceptable amount
32:39
Speaker 1: of time. But I do think it's a reasonable strategy,
32:42
Speaker 1: and oftentimes we will get an MRI before offering PRP
32:47
Speaker 1: because we want to understand the extent of the injury
32:50
Speaker 1: and to make sure that the treatment is as targeted
32:53
Speaker 1: as possible. And oftentimes the individual will have more than
32:57
Speaker 1: just planar fasciatis. There may be some involvement and of
33:00
Speaker 1: other soft tissue which then could also be targeted with
33:03
Speaker 1: the injection at one time. So the other injection two
33:09
Speaker 1: that has a little less evidence would be something called
33:12
Speaker 1: prolo therapy, and prolo therapy is becoming very there's a
33:19
Speaker 1: lot more advertising for it. Prolo stands for proliferation. So
33:24
Speaker 1: what prolo therapy is is it's using a substance, oftentimes
33:29
Speaker 1: dextro solution or sugar water that can be put around
33:33
Speaker 1: a tissue and basically triggers a local inflammatory response. So
33:39
Speaker 1: oftentimes we hear, you know, fascy itis, and we assume
33:42
Speaker 1: that that is an inflammatory response. But getting back to
33:45
Speaker 1: our earlier definition, most of the time individuals do not
33:49
Speaker 1: have a primary inflammatory response causing their pain. What they
33:53
Speaker 1: have is they have tissue that's thickened where the body
33:57
Speaker 1: put down tried to repair but that repair did not
34:00
Speaker 1: successfully happen. So what prolotherapy does is it reinitiates that
34:06
Speaker 1: healing response. So the upside with prolo therapy is that
34:10
Speaker 1: can be used for an n season athlete or someone
34:12
Speaker 1: who has a competition coming up by changing the concentration
34:17
Speaker 1: of the dextro solution. The downside with prolotherapy is similar
34:21
Speaker 1: to play the rich plasma. It does have an out
34:23
Speaker 1: of pocket cost and oftentimes with prolo therapy, individuals will
34:29
Speaker 1: get multiple injections to see the full effect, as opposed
34:33
Speaker 1: to PRP where we typically start with one followed by
34:36
Speaker 1: a structured rehabilitation program. Outside of injection based treatments, the
34:42
Speaker 1: intervention that I commonly perform in my clinic is something
34:45
Speaker 1: called shockwave. Now, shockwave has been around for a long time.
34:51
Speaker 1: It actually was first developed for the treatment of kidney stones,
34:56
Speaker 1: and it was observed that it actually had effects and
35:00
Speaker 1: other tissues. So not only could you dissolve a calcific
35:03
Speaker 1: stone or a mineral stone in the kidneys, but you
35:07
Speaker 1: can actually use these these sound waves or these pressure
35:11
Speaker 1: waves from this device to essentially reinitiate a healing response.
35:17
Speaker 1: So some of the early work outside of treatment of
35:21
Speaker 1: kidney stones, which we refer to as lithotripsy, was in
35:24
Speaker 1: plantar fasciitis where they were finding that by targeting those
35:29
Speaker 1: those heel spurs, they were actually giving patients pain relief.
35:32
Speaker 1: And then it was determined that not only was it
35:34
Speaker 1: treating the mineral deposit, but it was actually treating the
35:37
Speaker 1: length of the plantar fascia that was giving individuals that
35:41
Speaker 1: long term pain relief they were looking for. So there's
35:45
Speaker 1: been a number of studies and again, you know, super
35:49
Speaker 1: nerdy thing, but if you really want strong evidence, you're
35:53
Speaker 1: looking for studies that are randomized, have a placebo, and
35:57
Speaker 1: are controlled studies. And this is actually where shockwave has
36:02
Speaker 1: some of the strongest evidence for treatment is in the
36:05
Speaker 1: treatment of planner fasciatis. So the upside with shockwave is
36:11
Speaker 1: it's a non evasive procedure. It's called extracoporeal shockwave because
36:15
Speaker 1: it's delivered outside of the body. You have a device
36:19
Speaker 1: that either will strike the tissue and that's what we
36:22
Speaker 1: refer to as radial shockwave or radio pressure wave, or
36:25
Speaker 1: you'll have a device that oftentimes will create kind of
36:28
Speaker 1: a burning sensation and that's what we refer to that
36:30
Speaker 1: as focused shockwave. The downside with shockwave is the treatment
36:34
Speaker 1: itself is painful, and you know, it is truly as
36:38
Speaker 1: some of my patients say, it is no pain, no gain.
36:41
Speaker 1: If the treatment's being done correctly, it will induce pain.
36:45
Speaker 1: Studies that have been done where people would get a
36:47
Speaker 1: nerve block actually found that it was less successful for treatment.
36:51
Speaker 1: So we believe that shockwave works to actually stimulate tissue
36:55
Speaker 1: remodeling through inflammation, but it may also disrupt pain signals
36:59
Speaker 1: between our brain in our spinal cord, so so you
37:03
Speaker 1: will have pain during the treatment that we'll say is
37:06
Speaker 1: typically five to seven out of ten. It does have
37:09
Speaker 1: an out of pocket cost, and similar to other treatments,
37:13
Speaker 1: there is no one singular treatment that's one hundred percent effective.
37:17
Speaker 1: But I've looked at outcomes for my patients and have
37:20
Speaker 1: seen you know, upwards a seventy five percent of individuals
37:23
Speaker 1: with good functional improvement after receiving shockwave treatment, and a
37:28
Speaker 1: typical protocol should include three weekly sessions with structured rehabilitation
37:34
Speaker 1: with a follow up at three months. I see a
37:37
Speaker 1: lot of variability in how shockwave is delivered, where some
37:41
Speaker 1: people say, you have a really bad case and you need, like,
37:44
Speaker 1: you know, some random number of sessions. But if you
37:48
Speaker 1: really look at the literature and you're not necessarily driven
37:52
Speaker 1: just by a financial component of charging for every session.
37:57
Speaker 1: I do believe that the best standard practice is to
38:00
Speaker 1: do three to four initial session separated by a week,
38:04
Speaker 1: do the structured rehabilitation, and then, based on the studies,
38:08
Speaker 1: it's usually a three to four months where you're going
38:10
Speaker 1: to see a good response to the treatment, and that's
38:13
Speaker 1: where you might consider more shockwaver. You might consider combining
38:16
Speaker 1: it with other types of strategies such as platelar rich plasma.
38:20
Speaker 3: Two things to double click on here.
38:22
Speaker 2: First, I do want to go back to us talking
38:24
Speaker 2: about the steroid injections. When we talk about that, are
38:28
Speaker 2: we talking about a cortizone shot.
38:31
Speaker 1: Yeah, thank you so much for having me clarify that,
38:35
Speaker 1: so we hear cordicas steroid cortizone. That's essentially what we're
38:40
Speaker 1: referring to is the use of steroid which is oftentimes
38:43
Speaker 1: mixed with a numbing medication like lytocane, and both of
38:48
Speaker 1: those are actually been shown to be potentially toxic to
38:51
Speaker 1: the cells that they exposed to.
38:54
Speaker 2: Right now, I know, at least in my case a
38:56
Speaker 2: concern and why we didn't go that route was not
38:59
Speaker 2: only do we want to act fix the root cause
39:02
Speaker 2: of what was giving me this problem, but also more
39:05
Speaker 2: often than not, what will happen is that the cortizone
39:09
Speaker 2: injection dulls the pain in the area but doesn't rid
39:12
Speaker 2: the issue, and so you may not be aware to
39:15
Speaker 2: your point that people might tear their planter, that you
39:19
Speaker 2: could be doing more damage than good. Now, understandably, people
39:23
Speaker 2: are like, oh, but I don't want to feel the pain,
39:25
Speaker 2: so they're hoping to find someone to give them a
39:27
Speaker 2: cortizone injection. And so I bring all this up because
39:31
Speaker 2: it's helpful to know that although it may lessen your
39:34
Speaker 2: pain in that moment, you might be doing yourself a
39:37
Speaker 2: disservice in.
39:37
Speaker 3: The long haul.
39:39
Speaker 1: I'm really glad you're bringing up that point, because again,
39:43
Speaker 1: often we oftentimes are responding to the fact that we
39:46
Speaker 1: have pain. So I have unfortunately seen patients where I've
39:51
Speaker 1: taken care of them or they are seeking care from
39:55
Speaker 1: other providers in addition to me, where they've received a
39:59
Speaker 1: sterid injection and subsequently torn their planar fascia. So it's
40:05
Speaker 1: not a pleasant experience, and that in itself is going
40:09
Speaker 1: to require a prolonged time to recover from from tearing
40:14
Speaker 1: the plantar fascia as well. So yeah, both of us,
40:18
Speaker 1: it's very disheartening when you do happen. And then the
40:22
Speaker 1: other thing too is that people will sometimes be given
40:25
Speaker 1: oral steroids. And my concern with oral steroids is, you know,
40:29
Speaker 1: it's it's like trying to hose off a forest fire
40:32
Speaker 1: when you could just dump a bucket of water right
40:34
Speaker 1: on the flame. So if someone's going to get a
40:37
Speaker 1: steroid injection, I would much prefer that it be targeted
40:41
Speaker 1: very locally, as opposed to taking oral steroids, which we
40:44
Speaker 1: know will will actually have more profound effects on the
40:48
Speaker 1: endocrine system, can cause people to have trouble with sleeping,
40:52
Speaker 1: but can also have effects long term on bone health
40:55
Speaker 1: or even a rare condition called a vascular necrosis, which
40:59
Speaker 1: can cause a long term damage to join some bones.
41:03
Speaker 1: So I think a big takeaway for all the listeners
41:07
Speaker 1: is to understand that steroid is commonly used, but it
41:13
Speaker 1: may not be the best long term solution for someone's.
41:16
Speaker 3: Health, definitely.
41:17
Speaker 2: And then the last thing that I wanted to mention
41:20
Speaker 2: here the second point to double click on. I know
41:22
Speaker 2: we talked about shockwave therapy, but something we haven't talked
41:25
Speaker 2: about just yet.
41:26
Speaker 3: Is light therapy. That is a route that I went down.
41:29
Speaker 2: I did the led Red light therapy essentially an application
41:33
Speaker 2: of red and near infrared light goes to your injury
41:37
Speaker 2: area i e. The Planter fascia and in my case,
41:40
Speaker 2: I did I believe three treatments aiming to accelerate that
41:44
Speaker 2: tissue healing and reduce the inflammation and pain. For me,
41:48
Speaker 2: that worked. It might not work for everyone. What do
41:50
Speaker 2: you say about the light therapy.
41:54
Speaker 1: Yeah, so I'm glad you're bringing up light therapy because
41:57
Speaker 1: this is an area where we're actually doing some active research.
42:02
Speaker 1: And the theory on how this light therapy may work
42:06
Speaker 1: is that oftentimes what we're using is something close to
42:09
Speaker 1: a near infrared, so it'll be it'll be more of
42:13
Speaker 1: like a red based laser. It requires a lot of
42:16
Speaker 1: a lot of safety precautions because a true laser can
42:19
Speaker 1: actually cause permanent vision damage blindness, so that treatment. The
42:25
Speaker 1: theory is that the light therapy might actually increase metabolic activity,
42:31
Speaker 1: and unlike shockwave in some of these other interventions, it's
42:34
Speaker 1: largely a painless experience. Oftentimes it just feels like a
42:38
Speaker 1: dpeat is being applied to the tissue. There have there
42:42
Speaker 1: have been some limited studies showing that light therapy may
42:45
Speaker 1: help with plantar fasciitis, where right now studying combining light
42:50
Speaker 1: therapy with shockwave in the treatment of achilles tendinopathy. So
42:56
Speaker 1: and and in my system as General Brigham, there's actually
43:00
Speaker 1: a whole center for what's referred to as photo medicine
43:03
Speaker 1: or phototherapy. So I think there is something There is
43:08
Speaker 1: definitely something too light therapy, and whether it's done as
43:12
Speaker 1: a singular treatment or in combination with other treatments that
43:16
Speaker 1: can provide some help. I think for those listening, it's
43:19
Speaker 1: just understanding that things like phototherapy shockwave play the rich plasma.
43:26
Speaker 1: They oftentimes will have an out of pocket cost. So
43:29
Speaker 1: it's trying to understand what's going to be the best
43:31
Speaker 1: individualized treatment. And for some that's going to be informed
43:36
Speaker 1: by understanding, you know, evidence based medicine, which describes groups
43:40
Speaker 1: of patients not necessarily an individual. But for others it's
43:45
Speaker 1: going to be about choice and understanding how things should
43:48
Speaker 1: be done safely.
43:49
Speaker 2: Yeah, and you know that's definitely a frustration point for
43:53
Speaker 2: so many. Right you pay so much for insurance, it
43:55
Speaker 2: doesn't get you what you need. You're trying to make
43:57
Speaker 2: the right decisions for your body and then under standarably.
44:00
Speaker 2: So that is why more often than not, some people
44:03
Speaker 2: may go down a path that might not ultimately be
44:06
Speaker 2: in their best interest. So again this goes back to
44:09
Speaker 2: that concept we were talking about before, patients patients, patients,
44:14
Speaker 2: which when you've got regular pain, it's not exactly easy.
44:18
Speaker 1: Oh, I one hundred percent agree. And again that's also
44:23
Speaker 1: why it's important to have you know a physician or
44:26
Speaker 1: a medical provider that you trust and that you feel
44:29
Speaker 1: is really listening to you and understanding how this injury
44:34
Speaker 1: is affecting your overall health, because, as you were mentioning earlier,
44:38
Speaker 1: these injuries, you know, pain can really affect a number
44:41
Speaker 1: of things. Can affect someone's physical health, but it also
44:44
Speaker 1: affects their mental health and their quality of life. So
44:47
Speaker 1: that's why I think it's a really important injury to
44:51
Speaker 1: think about targeting, and for those that have dealt with
44:55
Speaker 1: this injury that are listening in not to give up
44:58
Speaker 1: hope that there can't.
44:59
Speaker 2: Be a Now, there are two things I want to
45:02
Speaker 2: touch on before I let you go. The first thing
45:05
Speaker 2: is getting back to regular activity. We're talking about maybe
45:09
Speaker 2: seeing a little bit of a light at the end
45:11
Speaker 2: of the tunnel. The symptoms are lessening a little bit,
45:14
Speaker 2: maybe there's a little bit of lingering pain, but it's
45:16
Speaker 2: not like it was before. Do you have any golden
45:19
Speaker 2: rules of thumb when it comes to getting back into
45:22
Speaker 2: activity where you should be at if you're on a
45:25
Speaker 2: pain scale, what should we expect?
45:28
Speaker 1: I'm really glad you asked. There's actually been some work.
45:32
Speaker 1: And again this is extrapolated from the treatment of overuse
45:35
Speaker 1: injury to tendon, where there's a pain scale based on
45:41
Speaker 1: zero to ten and three zones of pain. So I
45:45
Speaker 1: really like this analogy of a green zone, a yellow zone,
45:50
Speaker 1: and a red zone. So this is the way that
45:53
Speaker 1: I'll handle the management of planar fasciitis and runners. And
45:57
Speaker 1: again this is outside of something like rich plasma, where
46:01
Speaker 1: there may be a specific timeframe before starting back into activity,
46:05
Speaker 1: but for individuals after shockwave treatment, we oftentimes will talk
46:09
Speaker 1: about the green zone being any activity you can do
46:13
Speaker 1: with zero to two out of ten pain is desirable.
46:18
Speaker 1: Acceptable is the yellow zone, So that's any activity that
46:22
Speaker 1: causes pain between two to five out of ten, and
46:25
Speaker 1: that's both during as well as after the activity. We
46:29
Speaker 1: call that the yellow zone. So yellow means it's okay
46:32
Speaker 1: to have that amount of pain, but we need to
46:34
Speaker 1: be cautious, and we need to make sure that that
46:36
Speaker 1: pain comes back down to baseline before we return to
46:40
Speaker 1: doing that activity. Any activity that exceeds five out of
46:44
Speaker 1: ten we refer to as a red zone, which really
46:46
Speaker 1: means stop. If we're pushing our body into pain that
46:51
Speaker 1: exceeds five out of ten, the concern is this tissue
46:54
Speaker 1: is getting overloaded and that's just going to cause more
46:58
Speaker 1: damage that the body needs time to repair. So it's
47:02
Speaker 1: just going to keep the body in this chronically irritated
47:05
Speaker 1: state where the body will not ultimately heal and get
47:08
Speaker 1: that desirable long term goal of pain relief.
47:11
Speaker 3: Again.
47:11
Speaker 2: I know when I was in the prime of my
47:13
Speaker 2: planter fasciitis diagnosis and really working back to slowly up
47:18
Speaker 2: my mileage as I was training for a marathon, the
47:20
Speaker 2: goal was always to do it a only adding ten
47:24
Speaker 2: percent each week, so no more than an additional of
47:27
Speaker 2: ten percent total mileage week over week, and then to
47:31
Speaker 2: increase the volume without changing or increasing the pain. Right, So,
47:37
Speaker 2: as long as we were in as you described that
47:40
Speaker 2: yellow zone or below, it was a safe place to be.
47:43
Speaker 2: So I think that breakdown is actually truly truly helpful
47:47
Speaker 2: in a really great way to visualize what someone may
47:49
Speaker 2: be going through.
47:50
Speaker 1: One other piece of that that I think is important
47:53
Speaker 1: is to understand how long does it take for soft
47:55
Speaker 1: tissue to heal. So oftentimes, you know, when I was
48:00
Speaker 1: growing up, when you were growing up, we were told
48:02
Speaker 1: everything was itis. Right, it's inflammatory, a couple weeks, you
48:06
Speaker 1: should be able to knock it out. But the way
48:08
Speaker 1: we're understanding soft tissue healing is we're actually there's actually
48:13
Speaker 1: belief that it may take six to twelve months for
48:16
Speaker 1: the body to fully repair a soft tissue injury. So
48:20
Speaker 1: as we talked about before, and I feel as almost
48:23
Speaker 1: insulting to my patients to tell them they need to
48:26
Speaker 1: be patient, there is something to be said for recognizing
48:30
Speaker 1: how long it takes for the body to fully repair
48:33
Speaker 1: a soft tissue area of injury. That can take six
48:37
Speaker 1: months or longer. So if someone is still having pain
48:41
Speaker 1: but they're following those guidelines of the green yellow red zone,
48:46
Speaker 1: if they stay the course, my hope is they'll get
48:49
Speaker 1: to a point in which they're not having pain.
48:51
Speaker 2: Now, before I let you go, I do want to
48:53
Speaker 2: touch on what could be some advice for home remedies
48:57
Speaker 2: when it comes to dealing with planter fascy itis. Obviously,
49:00
Speaker 2: getting in to see an expert is highly important for
49:04
Speaker 2: everyone to get back to a quality of life that
49:06
Speaker 2: feels much more enjoyable. But when it comes to ice,
49:09
Speaker 2: I know you touched about anti inflammatories. What else should
49:12
Speaker 2: someone know who's dealing with this on their own at home.
49:15
Speaker 1: Yeah, so I think icing is fine. Stretching is a
49:20
Speaker 1: little controversial. You know. While I described a night splend
49:23
Speaker 1: as a way to keep your feet from being in
49:27
Speaker 1: a passive, you know, slack state where you're going to
49:30
Speaker 1: have a lot of pain when you take steps, stretching
49:33
Speaker 1: itself in some cases will cause the tissue to be
49:37
Speaker 1: chronically irritated. So I'm not as big of a proponent
49:41
Speaker 1: for stretching as I used to be. Once someone explained
49:43
Speaker 1: the you know, the idea that that tissue might have
49:46
Speaker 1: some frame, And the analogy I use now is if
49:49
Speaker 1: you pull on a rope that's already frayed, it's not
49:52
Speaker 1: necessarily going to make the rope hole again. It's probably
49:55
Speaker 1: going to cause more damage. There are exercises the short
49:59
Speaker 1: foot exercise or toe spread exercises, which sometimes people will
50:05
Speaker 1: use toet spacers on top of it, using wider toe
50:08
Speaker 1: box shoes can also be helpful because if there's a
50:12
Speaker 1: component of having a bunion or HeLEX falgus, having a
50:16
Speaker 1: little bit more space and the shoe will allow for
50:18
Speaker 1: the toast to not be as constrained and then helps
50:21
Speaker 1: to and then doing that in combination with strengthening the
50:25
Speaker 1: feet might actually help to restore something we're referring to
50:28
Speaker 1: as the foot core, so the muscles to make up
50:31
Speaker 1: the foot and ankle complex.
50:33
Speaker 2: You know, it's funny we talk about leg day and
50:35
Speaker 2: upper body day and working on our core, but we
50:38
Speaker 2: rarely ever think about the importance of strengthening our foot,
50:42
Speaker 2: this thing that we rely on so much, day in
50:45
Speaker 2: and day out, so much really really great advice in here,
50:49
Speaker 2: truly a really in depth explainer on plant fasci itis.
50:53
Speaker 2: So I appreciate you, doctor ten forty for taking the
50:56
Speaker 2: time to go through this with me. Anything else that
50:58
Speaker 2: you want to offer the hurdlers before I let you
51:02
Speaker 2: go today, No, I.
51:04
Speaker 1: Think this is this has been been a great opportunity
51:09
Speaker 1: to share what I know on the on the planner fascia.
51:12
Speaker 1: And and again I hope for those listening who suffer
51:16
Speaker 1: with this injury. You know, seeing myself seeing one of
51:18
Speaker 1: my colleagues in mas General Brigham, or you know, seeing
51:21
Speaker 1: a provider that that has an expertise in this if
51:25
Speaker 1: if you're you're not in the Boston area and just
51:27
Speaker 1: remaining hopeful that there can be a strategy to treat
51:31
Speaker 1: this this injury and to get back to doing the
51:34
Speaker 1: things you enjoy and love.
51:36
Speaker 3: We love that.
51:37
Speaker 2: Well for those that are not in the area, or
51:39
Speaker 2: they may be but want to follow along with you,
51:42
Speaker 2: how do they keep up with you?
51:43
Speaker 3: Is there a way to hang out with you on
51:44
Speaker 3: social media?
51:46
Speaker 1: Sure? So on on x Adam ten forty MD is
51:50
Speaker 1: my is my X handle and feel free to reach out.
51:54
Speaker 1: I just want to help my fellow human beings.
51:57
Speaker 2: I love that I'm over at Emily a Badi an
52:00
Speaker 2: at Hurdle podcast Another Hurdle Conquered.
52:03
Speaker 3: Catch you guys next time.