Achilles tendon and heel pain that won't go away

And I don't necessarily know. I mean, I think that flat feet can play a role. And I think it's just because of the biomechanics of the foot and ankle and the way that they walk on it and things of that sort. But sometimes we try to, just correct me if I'm wrong, sometimes we try to fix people's normal anatomy too much. Like they're born with it. And that's just how their anatomy is. Like, do we really want to be fixing what they're born with or what, you know, what they're given? And I don't think that that is necessarily the issue. I think it's more what muscles are engaging and how is your movement and things of that sort that we should be more addressing rather than do we need to fix this flat foot?

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. It's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the movement, movement. If this is your first time, welcome. It's about a 45-minute, hour-long format where we discuss how to make people feel better, really, and how to improve our communication with our patients. So, this podcast is targeted at clinicians and movement professionals to really help us help our patients.

Now, can patients listen to this too? Yeah, sure they can. There's certain topics, especially certain podcasts such as this one, which are more for general conversation and just general understanding. So, remember, the whole point is to make it easy to understand for everybody. So, we try not to make things too complicated or at least use analogies as you'll see today. Today, I am having on a co-worker of mine or a colleague, a doctor who works in my office. This is Dawne Costantino. I always say her name wrong. Constantino. She corrects me all the time. Costantino. Anyways, we're going to discuss Achilles tendonitis or Achilles regional pain as well as some stuff into the heel, specifically in people who run or are endurance athletes.

This is a really hot topic that I think a lot of people have some misunderstandings of the things that are helpful and not helpful, or at least there's a lot of confusion about the kind of the problem where everyone's like, I've tried everything and nothing has worked. So, we're going to try to help unravel some of the possibilities of things that you might have not tried today and some super easy wins that you can have. Before we get into that, I tend to start off this podcast with a general format of sharing a little bit about myself so you guys can understand who I am as a person. And so, hopefully, you like me and follow me through this journey of podcasting that I'm on.

It's been about almost 200 episodes now. So, we'll get right into that short story, then we'll get right into the content about heel and Achilles. Now, when I was younger, I had this little black pillow. Like, it was kind of like a, it was like a suede type of pillow. It was really old and mushy. I don't even know where we got it, really. But this pillow, it was like my favorite pillow. And, like, the dog slobbered on it, but it was just nice and soft, and it was great. It was my favorite. But, during hot summer nights of Southern California, I would put it in the freezer for about, you know, 15 minutes, and then I would use it in the bed because it's just so damn cold.

So, if you ever heard the term, as cool as the other side of the pillow, you should change it to as cool as the pillow that came out of the freezer. So, that was epic. So, I don't know what happened to that little black pillow. I'm pretty sure it got just destroyed and thrown away. But, that was a good experience. If you haven't tried it already, you probably should do that. Now, let's get into the show. Okay. So, everybody, me and Dawne Costantino are on now to talk about ankle pain. We'll talk about some foot heal as well for running populations. And, I know it's really hard to go through and find all the information on the internet and, you know, dissect it down because there's a lot of different, well, if this, then that.

And so, we're going to cover a couple things in their own right and spend time where probably most people have most of their problems, like in the Achilles and inner heel area. We'll talk about some shin splints as well as things like tarsal tunnel and peroneal tendonitis, kind of the oddities. But, we're going to dissect down wherever this conversation goes. We're going to take it that way. And, we're just going to discuss a little bit. Say hi, Dawne Costantino. Hi, guys. Dawne Costantino's another doc at the office. So, we both work together. Yeah. It's been fun. So, Dawne Costantino, why don't we, we'll just kind of volley these things and just so we can cover a lot of ground.

And, I know you're going to have different opinions than me on some things. But, why don't we start with first, is it normal to have, how long is it normal to have a heel problem? Say, like Achilles tendonitis, how normal is it to, how long should somebody have it to say that, oh, it's going to go away? How long should somebody have it and say it's going to go away? I mean, from the people that I've heard talk about Achilles tendonitis and just tightness in that area and things of that sort, it seems like they deal with it for a really long time and it's really hard for them to find people who can even help fix any of the issues that are going on in that area.

I don't think that it should be lasting as long as most people are suffering with it. I don't think that, you know, it's one of those lifetime things that most people just try to, oh, if I just wear certain foot gear or if I just stretch a little more, oh, I'm just tight and I'm not stretching enough. Like, a lot of people have that type of mentality and I think that they're thinking a little bit wrong when it comes to that aspect. I don't think it should be lasting as long as they're told or what they're just accepting. Yeah. Yeah, I would agree with that. I think that there's a lot of people that just kind of hang on and they just kind of suffer through it, think it'll go away.

And they try things like changing their mileage and changing shoes and maybe I have flat feet and maybe I need to do this. I think one thing that probably one really important marker that people should probably note if they really do true have Achilles tendonitis and it's a new thing and it's like something that needs to be quote unquote rested is that the tendon itself would be swollen. Like, it would feel boggy, it would look different from side to side. And so, like when that is the case, that's more of like, yeah, there's going to be a definitive timeline, like a short timeline where it's probably going to get much better than what it is right now.

But if it's like not noticeably swollen, it looks like the other side, you can't really tell, like passerbys couldn't really tell which side was hurting you. And it just kept going for months at a time. I think they're missing something really easy here. And even though they may feel like they tried everything, they probably missed some really easy critical wins in there. Yeah, absolutely. I mean, a lot of times too with Achilles tendonitis, would we say, because some people are always saying, oh, I feel it on both sides. Like, I don't think that Achilles... You just drop yourself off the call, Dawne Costantino.

You just dropped the phone. You just dumped your own call. I was, it was like balancing on my laptop and I just moved my knees and I don't know. It's just a little bit of a disaster right now. It's okay. I also didn't realize we were doing video and I was just like lounging in my bed. Oh, oh. I looked down at my phone and saw your face and was like, oh. Yeah, well, yeah, I just, well, I had my video on and then I just, I'm like, oh, the thing's not open. We don't share these videos, right? No, we won't share these videos. Just audio. So, your question was people, oh, bilateral. Is it common to have bilateral or was that your question?

Yeah, I don't feel, I mean, I don't think that it's not, I don't think that it's, what am I trying to say? Like that it's not possible. But I think a lot of times when it comes to Achilles tendonitis, you know, it's most likely you're going to see it one-sided because it's like an overuse type of thing. And a lot of people, when they're complaining of Achilles pain, I feel like I hear them a lot of times say it's bilateral too. Yeah, I have seen people with some bilateral, but usually they'll comment a little bit more up into like the calf area. So, it won't necessarily always be like, I guess we should differentiate with, there's the tendon on the backside itself.

There's the heel, which sometimes people relate to Achilles tendonitis. And then there's the calf, the muscle area. I feel like when people are talking about both sides, they relate a little bit higher up into the calf. Which in that case, like I found that some of those people, like they're just vertical runners, like they're up and down versus forward propulsion. And in that case, like an easy one for them would be just creating, let's just say if you're doing a long jump, a long jump requires a hip hinge movement. For forward movement, like a squat is just, you reverse a squat and go straight vertical.

But if you do a long jump, it's a hip hinge, which means they just have to improve their hips ability to function better. And so, they don't have, they don't have that, that calf dominance, I guess. But in regards to bilateral heel pain, what do you think about that? Like in maybe in the inner part of the arch, just in the inner part of the foot around the heel point. What do I think about just heel pain? Just the general topic of heel pain? Yeah. What do you think about, like what's your, what are some thoughts on that? Like when someone comes in with that and they've had it for a very long time, they've tried everything.

So, a lot of times when people are coming in with heel pain, I think, I mean, one of my first questions is like, what part of the heel? The heel is not like a super huge, you know, part of the, or it's not like a really big area. But a lot of times when they're complaining of heel pain, it's like a specific part of the heel that they're complaining of. And so, a lot of times they're coming in and they're like, oh, my, my heel pain is because of my Achilles. Or another option that they usually come in with is, I'm having heel pain because of my plantar fasciitis. Like a lot of times it's like that specific part of the heel and they're complaining of that.

And they have been told it's plantar fasciitis that's causing it. Yeah. That's what I've noticed. And I know that there was a, there was a push a while back where they're talking about the fascial connection between the plantar fascia and the Achilles and the backside of the body and the deep fascial line and all that kind of stuff, which, which there is. And, but there was, I think when that came around, people started to kind of combine the plantar fascia pain, the heel pain, the Achilles problem, and then stuff all the way up into their leg and calves and back relatable to this deep fascial line.

I don't see that quite as much. And so when they would remedy that, it would just roll. They, a lot of them just roll their whole body and they would roll their foot a lot, but it doesn't always resolve. Now, when something doesn't resolve, maybe into the inner foot, the heel area, say someone came in with plantar, the quote unquote plantar fascia in your heel pain, plus the Achilles actual area. And so a little bit of the calf, what are some thoughts like when they're not resolving, but they've been stretching it a lot? Like, what are some thoughts that maybe we can add in? Well, one of my first thoughts is I'm wondering if the, uh, the nerve issue has been, has been considered at all with these patients.

And even as you're talking about that, that fascial line and following it up all the way to the back, like, that's funny because I remember learning about that in school and I never really put these two things together. But like, just the idea of all of that being connected, like it absolutely is. But like, the nerve can also refer to all of those areas as well. So you're talking about the foot's connected to the calf, connected to the hamstring, connected to the back. Well, it's also another structure that runs along those areas as well. And it's the sciatic nerve from the back, down the glute, down the hamstring, into the calf and into the foot.

So are we considering that nerve as well, instead of just saying that all these muscles are connected? I think there's just a lot to consider when it comes to this specific pain and we got to make sure that we're looking at all of those structures. Because if it's not resolving, then something's being, something's missing. Yeah, I would agree. And, and, you know, like I was just, I was talking to someone actually the other day. He was, he, he, he was an urgent care medical doctor. So he worked at urgent care. And so we were, he had something going on in his leg and we kind of talked about like, he's like, what do you think it is?

I'm like, I'm like, let's just call it a low grade sciatica. And he's like, you know, like it didn't really follow the common classifications that people would think when they have a nerve problem. Cause it was, it was a situational ache or pinchy feeling. And like, most people think numbness, shooting, stabbing, electricity, like excruciating. And so when we're talking about then heel pain, it's like, oh no, it just aches a little bit. Like, how can this be a nerve? You know, it's just a little bit aching. It feels tight. And it's stretching takes it away. How can this be a nerve thing? I think it's more fascia, you know, and it kind of just begs that question of like, um, it's, it doesn't feel like what you would expect a nerve to feel like if that was part of the equation.

Can you say that one more time? I don't know if I understand what you're talking about. Yeah. So I don't know if it was a question or just a statement. So what I'm saying is I think, uh, I think a lot of people, so you mentioned the nerve following that path. And it's like, I'm guessing some of the listeners probably thinking like, well, it feels tight though. I feel it's a muscle. I feel it's a soft tissue structure because it feels tight. It doesn't feel like shooting, stabbing. Cause I looked up on Dr. Google about what sciatica is like, and it's not that. And yes, this is a soft tissue structure, but then when they keep addressing the soft tissue structure in a really, in really good way, a productive way, a way that should work, then it doesn't get better.

And so you're bringing up this possibility of, of maybe this thing is like a nerve. And my listener point of view here is like, no, I've read Dr. Google. It's not a nerve. Can you convince me why that could be? I see what you're saying. Yeah. And I mean, one of the things that we learned too is, is, you know, you learn that people use specific words to describe specific structures in the body. So like, like deep and boring could be a bone issue and achy could be a muscle issue and sharpened shooting can be a nerve issue. But clinically what you see a lot of times too, is nerve related issues can just cause aching into the muscles that they supply.

So although sharpened shooting can be, you know, correlated with nerve issues, it doesn't always have to be sharpened shooting. It really could just depend on how bad it is, what's causing it, how long it's been going on, how your body's adapted. There's just so much to take into consideration. And we're not saying that it's not a soft tissue, you know, injury or whatever it may be. Depending on how long it's been going on, the soft tissue could be affected as well by that nerve and supplying it. So over time, like you, nerves can, can cause inflammation in those soft tissue areas. So you address the soft tissue, maybe it gives you temporary relief, but it just keeps coming back.

We've got to get to the root cause of what's causing it in the first place. And there's actually, um, uh, like, um, Cody used a saying where he's like, is it tight or does it just feel tight? And so like clinically you can test to see range of motion. And, and I know that, um, there's, there's self-tests for like ankle mobility, Achilles length and so on, where it's like, you put your, you put your foot, like you're kind of facing a wall. You put your foot about a fist distance from, from the wall, your own fist. And then you try to touch your knee on the wall without actually lifting your heel and see how close you can get.

And it's like, Hmm, well, I can't touch the wall. It's just, this is tight. But if you check the other side, it's the same thing. And only one side maybe hurts. So clinically, is it actually shortened or quote unquote tight, or is it, does it just feel tight? And I think a lot of people, when they, they relate the two together and they're not necessarily that. So if it feels tight, but it's not actually tight, then I would consider more of the nerve aspect maybe because us, a real soft tissue structure, like a muscle tendon, even I think fascia would create a physical loss of range of motion. And that's not always the case with these people.

I mean, don't you even think that physical loss of range of motion from the soft tissue structures could still even be just your muscle and your body's way of protecting that irritated nerve? That's kind of where my mind goes with that all the time too. Yeah, it can be, it definitely can be, but you know, like I, like I think from some people that I've seen, this is not everybody either. Like they'll come in and say, they'll talk about their hamstrings, always feeling tight. And then you check them and their hamstring on the side where they're talking about is light years, more mobile or more has more range than the other side.

And then I've concluded over the years, it's like, you spend a lot of time stretching the sand string, haven't you? And they say, yeah, I spend, I spend quite a bit of time because it always feels tight. So in that case, there's more motion in the side that is the problem than the other side. So in that case, the soft tissue structures are kind of a little bit less, the soft tissue structures are a little bit less on the radar. If that side of that hamstring has more range of motion, because you spent more time stretching it, you know, you've already kind of addressed the tightness, quote unquote, and the range of motion change, which is fine.

But the problem didn't go away. Yeah, I get what you're saying. It always just depends. I hate that answer, but it always just depends. I like it. I don't know why everyone like complains about it. Because everybody wants those like specific answers to things and then you just get the, well, it depends. But it really always just depends with the human body. There never is really a definitive answer. Yeah. It depends on a lot of things. Yeah. It's a, yep. I never really think it's really that complicated. It's just, you just need a little bit more facts to make that answer. Yeah, absolutely. So let's, so before we, before we get away from Achilles tendonitis, let's just say, we should probably talk about the other aspects that people find in combination with it.

Like when they look on Dr. Google and they say, oh, well, maybe it's a heel spur. Maybe it's fat pad syndrome associated with it. Maybe I do have overuse of the tendon. Maybe tendon degeneration or a tendon, a tendinopathy or a tendinosis. You want to pick any of these topics and we'll start dissecting them away before we get too far. My goodness. Okay. Let's start with just, I know, I'm trying to remember even what you just said. We'll just start with tendinopathy because we're talking about the tendon itself. So let's go with that. Okay. Yeah, where should we start with that? You want to, you want to leave?

Well, so how would someone maybe know it's a, since we talked about the possibility of being fascia or nerve or tendonitis, which has a swollen appearance or a tendinopathy now or a whatever, maybe what it's a classified, like a nice critical data point with something like that. What is a nice critical data point with something like that? Yeah. Well, it's like one thing where maybe that is like unique or maybe something, how about this? Why would someone be led to believe that they have a tendinopathy versus the other things? Like what, what may be experience have they had? Imaging. Oh, I think of imaging when, when we talk about tendinopathies and things of that sort.

I mean, a lot of times if it is a true tendinous issue, you will see it on imaging, especially with the Achilles tendon. And if nothing's coming up on imaging for that specific tissue, then maybe there's something else to consider. Does that kind of go where you're headed with this? I think so. Yeah. Remember, you can always, you can always say, I don't know, shitty question. You answer that. Well, no, I know what you're saying. I kind of just need to get the juices flowing. It's still early. Yeah. So earlier, earlier I was about to do an Instagram story and I, and I turned the thing on and I reversed the thing.

I was looking at it. I'm like, I still have like Sandman in my eyes and everything. I'm going to wait an hour. I know when you, when you told me we were going to do this earlier than expected, I was like, oh my God, I got to get outside and just like go run and do some squats real quick and wake up. I was still in bed. Yeah. It wasn't as planned, but yeah. So, I mean, I think image is an important thing because a lot of people will probably go through the ringer on imaging. They'll try x-rays, which x-rays will not show anything really. I consider x-rays kind of useless in most ankles. Although you can see things like spurring of the heel, which is not always related to the problem.

I've seen enough people that have heel spurring that have no pain whatsoever. And you can see signs of other big, bad, scary things. You can see fractures and things like that. But MRIs are the gold standard for seeing the quality of the soft tissues in the area, which if you're looking to rule out Achilles tendonitis, that would be nice because you can certainly see a lot of swelling around the tendon if it was an itis. If it was a nerve thing there, you probably wouldn't see it because it'd be coming from somewhere else. If you're looking to see if you had plantar fasciitis, yeah, you would see inflammation in the structure there.

But if there's nothing to see, if there's nothing there, it's probably not really that. It's a pseudo type of presentation. It's not like you really have an issue with the structure. And I think the one thing that people, which they don't do, they usually don't do these, but bilateral both side MRIs is I think when you have actually a sign of tendon degeneration, I think you should investigate the other side, and I bet you're going to find that they're probably the same. But the cool thing is, at least with the quote-unquote degeneration of the tendon, is that the thing that actually helps a lot, according to the standard of care, is you load it.

You start to supply load into the area, such as walking, after you get past a certain critical point. And you can start doing eccentric raises, who have been shown to work all across the board. Because the body, it remodels, but it needs some type of stimulus to remodel. But if you don't challenge the area, if this was a tendon problem, then it will probably continue to not change, because you haven't challenged the area. Now, if you challenge the area too much, you might have a flare-up, but the caveat is, if you didn't challenge the area at all, then it wasn't going to get better anyways. So, I guess that's my thought on imaging.

And I think people get hung up too much on imaging, and they're looking to see physically what's wrong. A lot of times, just like a sunburn, you won't see any positive imaging on a sunburn. It hurts the high L. So, pain is an experience. It's not necessarily structural-dependent. Yeah, absolutely. And I think a lot of times too, it's like, okay, well, once we get that imaging, and there is or isn't something shown there in that will stick to the Achilles tendon tissue specifically, is your treatment approach really going to change all that much? I mean, we're still going to load that area. We're still going to make sure that that area is being, that we're moving the area so that we can just cause better healing in general.

Right. Yeah, it doesn't really change it much. And I know that people want to see what's wrong, but the reason we would get imaging is because we want to see what we've missed and see if our course of action changes. If it doesn't change our course of action, you're basically, like, your insurance company probably won't pay for that image if you don't have a need to investigate further. If you want to pay for the image, I know I paid for my own image because I want to see, that's your right. You can do that, but it doesn't change what we're doing. And even, you can start care. Most people start care, and they should start care, without having an image.

It doesn't stop you from doing anything. I think that's a critical point is because people are like, I don't know what's actually wrong, so I can't do anything. It's like, I think that's an incorrect way of thinking. Yeah, I had somebody the other day I was talking to that was kind of like that, and I just let her know, like, listen, I think one of the things is, the beautiful thing is, is we just start conservative care treatment first. Like, we don't need imaging. That's never really one of our, at least for us at Performance Place, it's not one of our first things we go to. If we don't think that it's anything any crazy, bad, and scary underlying causing the issue, we're going to just start conservative care and see what happens.

And we'll do our job to make sure that if you're not progressing the way that we think you are, then we're going to refer you out and see if we can find something that maybe we've missed through imaging or somebody else that can help you better. Yeah. And if you consider the cost, too, of an image, like, I think MRIs now are like, they're going to cash it. They're going to be right around $500 to, you know, probably a little bit more than that, give or take a couple hundred dollars. For all that money that you spent because you just wanted to know what it was or what it wasn't, you could have paid for nearly all of your care.

Yeah. So, it's like you're taking a gamble on, I just want to see because I'm curious versus, you know, I just want to get better. And you're probably going to be surprised after the first week or two. You're like, you know what, I feel so much better. I don't even care what it was anymore. I just wanted to feel better and I was scared about what was in there. And I think if people can admit that to themselves, then I think they'll get further than what they, where they would if they actually voted for the image. Yeah, absolutely. I understand it and just give it a chance first. Give it a chance.

Now, let's talk about timeline, Dawne Costantino. What are your, maybe do you have some suggestions on timeline for people of how quick they should expect any changes? You know, maybe talk about some adaptations through loading, what's happening, how long should they be in pain, how long should it take to actually fully rehab through, something like that, or whatever you feel comfortable answering. I was, we're sticking with tendon, like actual tendonitis, tendinopathy. You can pick whatever, I know what you're thinking. You can pick whatever route and I'll take the other one. I could pick whatever route. Oh, okay.

Well, in that case. Well, because, because remember, we're talking about, we're talking about regional Achilles pain. So whatever's driving it, just make sure to frame what you're talking about. Okay, well, here's my answer. It depends. Oh, welcome back. I didn't do anything that time. So your answer is it depends. My phone didn't like that answer. Yeah, they're like, screw you. I want you to answer more thoroughly than that. I feel like I'm just like living in old times with all the technology I have. Okay, so it depends. Yes, it depends because it depends on really what truly is causing that, that issue in that area.

I think that when it comes to like loading and tissues and things of that sort, I'll let you take that path. I'm going to go down the nerve path. What we see in office specifically with nerve-related issues. So, you know, you're having tightness in the calf, tightness in the Achilles, tightness down into the foot, the bottom of the foot, the sole of the foot. If we find that it's a nerve-related issue, we can actually reduce the pain on the first visit if we find the right first aid for you. So a lot of times we'll pick a specific movement that causes your pain. We will try the first aid that we think is going to work for you and then retest it.

And a lot of times people are looking to find improvement, at least 30% improvement in the first visit. From there going forward, depending on your consistency and how hard you're willing to work with the exercises and things that we've prescribed for you. I mean, with a nerve-related issue, I think within three, four visits, which could be spread out over a month or so, we can get you feeling at least 50% better with just that. If it is a nerve-related issue that we're talking about here. Okay. So what I heard was, great, I'm going to feel really good after four visits or so. I'm done. Is that what you're saying?

There's nothing else left to do? Absolutely not. Okay. No, absolutely not. What do you want to add to that? So we always talk about getting to the root of the problem. So yes, we're getting to the root of the problem being, hey, it's the nerve-root-related issue, right? But we can go even further than that by thinking, what is it in your daily life and your lifestyle and your movements and your activity that caused this irritation in that area in the first place? So we need to make sure that we are building buffers. We are teaching you proper movement. We are strengthening you. And we do this through exercise and movement in office.

So what we do is just build endurance and strength throughout the body. We're going to, although it is a foot and ankle issue and we will give you specific exercises for that target area, we have to go all the way up the chain and make sure that everything is working all the way up so that your foot and ankle can do what it naturally is meant to do. So if your glutes aren't firing properly, your hips aren't firing properly, your core, all of that kind of stuff, none of that is working. Like you're not even really giving your foot and ankle a chance. Yeah, I would agree. Sorry, I want to push a little bit further on that because I think that it's, I think when people, people don't always clearly understand there's a difference between reduction of pain and restoration of function.

And if somebody's goal was to, you know, run a marathon again, whenever they start running marathons again, uh, then their requirements of what their body needs to do is very different than someone that says, I just want to, um, watch Netflix and lay in my bed. Like the requirements are very different. Like you could, in theory, if walking hurt your ankle or your foot, don't walk. It's not a good long-term plan, but you can certainly feel better. You know, there's a lot of ways to reduce pain, but to restore function to whatever lifestyle you want is a different story. Um, and if I'm going to take the, uh, the actual tenderness route, then I'll, I guess I'll talk about adaptation first is that your body didn't get that way on accident.

It has adapted to become that way. Let's just say we're talking about, say you want to call it an overuse of the Achilles tendon itself or the plantar fascia or whatever, uh, that overuse has come over time and the, the body has started to, um, adapt to use more load in that area. Now, is it loading a lot in that spot because of the disuse of something else? Perhaps, uh, but you will also have to spend some time to get the body to adapt back. It doesn't happen overnight, even if the pain reduces. So a reduction of pain is really nice and it's really easy buy-in for people and they feel good. They feel good that they're on the right track, but when they're reversing their body's, uh, support systems and improve the way it's loading and get into the goal that they want.

So just like, just like working out, your workout doesn't feel painful. It feels effortful. And then you don't see any results. You don't visibly see any results for years, you know, but you feel good. You're happy about the way your life has been going. You can do everything you want to do physically. And that's kind of where most people think should be. And so from this, and this happens with, uh, conditions in various parts of the body, whether it be the nerve creating the ankle or heel pain or the actual ankle itself from a tendon issue, like a local. So you have a local tendon, uh, degeneration, let's just say, uh, loading's King in that regard.

But as I mentioned earlier, if you don't do it at all, then it won't feel better. Um, if you do it too much, it'll flare up. So there's this nice sweet spot in there. And I wish that we knew exactly what that was for everybody, but we don't. And so this really comes down to an issue of load management. Can we make it so your body is getting enough load in that area to help it repair and remodel, um, and adapt, uh, and not flare it up. We could do something simple. Like, um, let's just say if you're a runner and you'd love to, um, say you'd love to run 50 miles a week and it hurts on your 50 mile weeks, but it doesn't hurt during your thirties.

You have to be willing to scale back a little bit to allow us to load that area properly and do your three mile week, 30 mile week. Cause that's what your body has the ability to do at this point. Um, now we can add in things that will help with that area. I say like your East intercule raises and all that, all that kind of stuff, but what you do outside of your exercises is just as important as what you do within it. So if you decide to run that 50 mile week and it flares it up and then we add more load to it when it doesn't like it already, then we're not going to get anywhere. So is a little bit of intricacy in the, in the beginning of it, where we might ask you to do some changes in your habits, as well as we add in a couple of things to help out, heal up the area.

Um, I like to consider tendon, actual tendon overuse issues as issues of underutilization versus overuse. Um, and we've, we've seen a lot, uh, quite a bit of indications that people with actual Achilles problems, they load the side of complaint, meaning the other hip or other limb or other area does not work well. And when you have them squat and they squat in the mirror and look, they actually load the side of the problem and it doesn't make any logical sense. So they're actually asking the area to do a lot more work than, and we'd want them to share the load. So that's maybe situation one. Um, the second thing is, is the intricate small muscles of the foot.

A lot of times they don't help out the situation either. And they're kind of lazy in some people, which makes the areas that hurt work more. And so that'd be more of a local approach with it. Uh, however, I think from a, I think a timeline perspective is important to note on this. Again, you can feel much better over the course of a couple of weeks. If we just modify your activity and then give you some exercises to do isometric exercises are really good for a pain reduction effect too. Um, and usually when people do these, they think, Oh, I just quote unquote warmed it up. Well, there's a, there's a natural, uh, reduction of pain effect that happens with an isometric non-movement exercise.

Um, when we, when you're actually returning to full bore your sport, which is, I think it's important to talk about expect if you've been not running for three months, and now you feel better and you go out and run what you did three months ago. I think you're asking for a problem is because expect that three months is the amount of time that'll also take you back, take you to return back to normal situations in the foot, bone mineralization, uh, uh, local soft tissue strength. Uh, I know you're like, maybe you've been doing cross training, so your cardiovascular fitness is high. So you've done something to nurture that system, but you haven't done as much to nurture the other ones.

And like, I've met quite a few people who have had stress reactions after returning too quickly. So just make sure that I bring all that up because the central theme is, although you feel better, you need to create a stimulus for your body to adapt. And that might be some of the exercises, suggestion, uh, suggestion, suggestions that we might make. So make sure that you understand that it is a process. You won't, you'll be able to do a lot of things during that time, but it's certainly a process. You can't speed it up really that much. Uh, just let the body start to adapt. Nicely said, Seb. That's all I got on that part.

That's, I think that's quite enough. Okay. So, uh, I guess we should touch on to the, I never like going down this, but I think it needs to be talked about. So doc, I've already tried all of the stuff you talked about. I looked at, had my MRI looked at my back. There was nothing wrong with my back. I've done, uh, exercises of the ankle and foot and none of it worked. I'm still in pain. What, why is this? It depends. So do you have an answer for that or you want, um, I'm going to let you go ahead on that one. So what exercises did you do? Like all, all rehab is not considered equal. What exercise did you do?

Like, what are ones done that you usually hear that like, maybe when someone's gone to quote unquote rehab and they're like, I've done everything. So, okay. So you start questioning them. What have you done? What are some things that you maybe hear? Um, I hear a lot of just general category of things. A lot of times they don't necessarily give specifics because a lot of times they don't remember, but they say I've done core work. Um, and if it's an ankle foot issue, it's more local exercises. They say, oh, I've done, you know, maybe toe flossing or things of that sort. Um, but it's very general and it's very, I think one of the biggest things I see a lot is people saying, yeah, I went for this amount of time and then I just stopped going and I just did it from home and now I haven't really done it as much anymore.

It was, they lost the consistency number one and it was just general core exercises and local exercises that they were doing. Oh yeah. It, yeah. I think on that note too, they usually say, well, I stopped going because I could do it at home by myself and like, they weren't doing anything. They were just watching me or something like that. Um, or they're like, I saw those on, on YouTube. I just did them on YouTube. I don't need to pay my copay, you know, things like that. Um, that's a good point. I didn't think about that. Yeah. Uh, it's important to note too, that most people should not go through their recovery alone.

Like there's a lot of value in your, in your, in the professional you work with, not just for like guidance of what to do, cause you have to do the work. They just provide the guidance, but they're also dedication and scaling and progressing the exercises or regressing. So, um, home care is not successful for a lot of people, but it does work for some. Um, you know, some people are fortunate where they have Achilles pain, they rub on it a little bit and it goes away and they're like, you know what? You're wrong. Like all the stuff you said about working at, like doing stuff at home, you're wrong.

Cause it worked for me. You're, you're right. I am in that situation. I'm wrong. But for a lot of people that, that is not the case. And I think if you, I think if you look around and read up on all the things that people have tried at home, they're super frustrated. Like their stories are like sad. It's like fuss. You can see the field of frustration and what the things they write up about how there's no answers and you know, but they're trying a lot of things at home. It's, it's not guided. It's not concise. Um, I mentioned to someone the other day, they said, well, what's the value though? They said, what's the value of having someone show you exercises?

And I said, do you ever been on a hunting trip? It's really frustrating when you go out there and there's no animals, right? So like the guide shows you where the high payoff points are. And that's why you pay somebody like you don't go to African safari and you're like, you know what, I'm just going to go on. I'm going to go on it by myself. You know, like you're, it's not going to go well. So, um, self-care is a little bit menacing. Although there are a lot of DIYers out there, um, at least if you have a good plan in place, then you're off to the best start. Go to these spots. So like self-guided tours, you know, go to these spots.

You'll probably see an animal, but if you don't even have a guide in place, like you won't, like it's probably not going to go extremely well. Yeah. Two things I wanted to say on that is number one is I know for me specifically, and for a lot of people, but maybe not everyone is that you're not willing to push yourself by yourself as hard as you do too, as well, when it comes to specific exercises, when you have somebody watching you and showing you and kind of pushing you through them and, and kind of forcing you to put in the amount of work that you should be to be getting these adaptive changes in these areas, that's the importance of having somebody guide you into the exercises.

And another thing too, is a lot of times we pick exercises that we think are going to work for you. And then once we start doing them, we realize, oh, maybe it's causing pain in this area, or maybe they just need this specific cue to allow you to do it better or to take that specific pain away. It's just like having that other person there with you and watching you move and cuing you through things and pushing you through it is, is really what you need. Yeah, I, I, I agree. Well, so give me like, so what do you mean? Let's dive more into that. So then like, what do you mean they don't push themselves enough?

Like, Hey doc, I got through the 10 reps you said. Yeah. So like, for example, I just think, I always think of when we work with people, I always think of, you know, use this as a warmup before you go into something, you know, that kind of is a conversation that's had a lot. And people think of war, like people have just different ways of warming up. Like they just do 10 squats, 10 pushups, 10, whatever. And then they're like, okay, I'm warm. I'm going to hop into it. That's not what we're looking for. We're looking for, I, I always just compare it to like a pump. We're looking for pumps in certain areas.

You need to turn certain muscles on in certain areas so that you can feel those muscles working the entire duration of your workout, the entire duration of your exercise. It's super important. It's not just, all right, I'm going to get my, you know, my heart pumping a little bit faster. Now I'm warm and I'm ready. Like we're looking for tissue tone changes. We're looking for pumps and we're looking for you to, you know, really feel fatigued. And a lot of times people can't push themselves to that type of caliber. So when you say fatigue, then is, is this supposed to hurt? Like, am I supposed to push through the pain?

No, it's not supposed to be painful. It's supposed to be effortful. That's a sub quote. That is a sub quote. How do you get a pump in the, in the arch of the foot? Like I do all these like exercises, like I'm moving peanut butter and scrunching towels. How do I get a pump in those? I feel like after the 10 reps that I do, I just don't feel a pump. Well, if we're talking about the, well, we are talking about the foot specifically, but I don't think we're looking for a pump in the foot. I think that we are trying to take the effort away from the foot, having to do the effort that it's been doing up until this point.

We're looking for you to find a pump or effort in other areas so that we can take the stress away from the area that is in pain in the first place. Okay. Got it. What would you add to that? Yeah, I think it, I think it depends. Um, so, so if we find, if we, if we find, uh, if we find that there's a certain area that, that in, in an exam really shows that it makes a, a change in somebody like say like normally squatting or hopping hurts your Achilles ankle area. Notice we're saying area right now, because there's a lot of things that can cause, like, I don't want to say it's the Achilles problem or the heels problem or the plantar fascia problem, because it could be a lot of things referring to the area.

Um, if it creates, if it creates a definitive change in your ability to do a certain task that was previously in that same session painful, then, uh, I think whatever that thing was, it should be addressed and get the pump in there. So if it's the glute do that, if it's the abs do that, if it's a quad do that, if it's the foot do that too, you know, like it, it usually isn't the area that's the painful spot. I guess an example, which is strikes comes out my mind is that a lot of people say they have tight hip flexors. And so they just continually try to get a pump in their hip flexors. And I think that's wrong.

In most cases, um, you can get that tightness to feel or the feeling of tightness to go away by getting a pump somewhere else. Um, but sometimes finding that right area is menacing because you can't really assess yourself, you know? So then it's just a crapshoot. Um, but there's been a lot of cases where the ab wall or the glutes, um, have been very helpful for reducing hip flexor tightness and you don't have to keep banging on your hip flexors to get a pump because they're just going to get, I guess, quote unquote, tighter, you know? Yeah, absolutely. I feel like we always go very general when we start to talk about things.

Do we want to go back into specifics of more ankle foot stuff? Sure. That's a good idea. So it's funny. Like we said, we're going to talk about it. Shin splints. We're not going to get to it all. We just have to do another. So why don't we just stick on Achilles heel ankle area right now? Um, or back of heel area. So, um, uh, fat pad syndrome, which is probably correlated. That same spot because it's in the bottom part of the heel is that, um, I'm 15 years old. I think I have fat pad syndrome. Do you, what do you, do you have any questions on? Man, fat pads and I just haven't dealt with fat pad syndrome a lot with people that I've worked with.

I just know that like, I think it's more in the older population that, that deals with that issue. I've never actually heard it being a younger population issue, but I could be wrong. I'm not positive on that. That was a trick question. I think you're, you're dead on. So that's, it's, it's like an IT band. Uh, it's like a, a weightlifter talking about IT band. Like it doesn't make sense. Like, is there something else, you know? Um, yeah, he'll, he'll, uh, uh, fat pad syndrome or stuff from the fat pad is probably going to be, it's usually older, you know, people over the age of 50 for the most part.

Um, okay. Let's see what else in the area. Um, do you need arch support? Let's, you stopped me on a topic maybe that we need to talk about. Arch support, flat feet, um, uh, heel stretching or strengthening exercises. Ooh, BOSU balls, balance work, um, proprioceptive exercises. Those are common things. What do you, do you have any comments on any of these yet? I mean, I'm, I feel like I have a comment on all of them. Which one do you want to go with? Whatever you, whatever you think is good. We got about, I think about five minutes here before we got to shut down. Okay. Well, I, I maybe flat feet.

Cause a lot of people say that the, you know, their flat feet is the cause of their foot and ankle issues and whatnot. Um, I don't necessarily know. I mean, I think that flat feet can play a role and I think it's just because of the biomechanics of the foot and ankle and the way that they walk on it and things of that sort. But sometimes we try to just correct me if I'm wrong. Sometimes we try to fix people's normal anatomy too much. Like they're born with it and that's just how their anatomy is. Like, do we really want to be fixing what they're born with or what, you know, what they're given?

I don't think that that is necessarily the issue. I think it's more what muscles are engaging and how is your movement and things of that sort that we should be more addressing rather than do we need to fix this flat foot? Yeah. I think you're right. I think it comes to the, it's, it's kind of like, it's like a general observation that tends to come up. You know, it's not always related. I forget what the term is. I thought it was like, um, it's like a, it's a theoretical flaw of like cause equals causation or something. I forget what it was, but it's kind of like, um, uh, you right now you're in your house, your hair is wet.

Therefore your ceiling has a hole in it, you know, or something that's like, it doesn't or, or say there's a seat, there's a hole in your ceiling, your hair's wet. It's not raining, but you're like, that's what, you know, that's why, or actually, so I think it'd be a better analogy. There's a hole in your ceiling. It's raining. Your hair's wet. That's means because your hair, it's because of the rain and water and you just came out of the shower, you know? So they don't, they don't equate each other, but there are, it makes, it would make logical sense if you didn't think of the other options.

I just think that your analogy is in the funniest thing. I think it works. I think so too. I just, we can never not have a conversation without an analogy. It's so funny. Sorry. I'm going to just start working on metaphors and similes. I'm going to start doing, I'm going to do haikus pretty soon. Haikus. I think you were talking about, is it the saying is a correlation does not equal causation. There you go. Yeah, that's it. Yeah. So there was, there was for a while I was saying, I think, um, it was, it was, it it wasn't epiphany. I was, it was like having a good idea. Epiphany was right. And I was calling it something else.

And like, Alec kept correcting me. That's wrong. Like, it sounds right to me. Um, like you say in my last name. Yeah. Constantino. No. So, but yeah, the, the flat feet, like, I think we have to consider, is that the actual reason or is it just there? And if you look at the other side, it's still like, okay, that person's got another flat foot on the other side. Maybe that's the problem or sorry, maybe that's just, that's the normal and the, uh, probably the normal thought process for, okay, so why is the, why is it collapsed? Well, maybe it's a posterior tibial tendon dysfunction. We got to fix that, you know?

And, um, there's, it's not always related, but I think one aspect of, of that, which probably is important to hit on is that, you know, if I was gonna throw another analogy out, I will. Is that, you know, if I was going to try to be in the NBA, but I'm five, seven, maybe I should not try to be in the NBA. You know, it's just going to be harder for me. Um, and for someone that has flat feet, maybe they, this kind of look like flippers, you know, maybe they're meant to swim more so than run long distance, or maybe they're supposed to be sprinters, you know? So I think that the mechanics of the body just make it harder, you know, like when people try to do weightlifting, like, like Olympic weightlifting competitions, but they're not like of Asian descent and they're like, I can't get that deep.

You know, it's like, well, you're, you don't have the, you don't have the hip anatomy for it, so you can keep trying, but it's going to be a harder road for you. Um, so I think that's the, just the thought on the flat feet. People don't stop running, but maybe be considerate of how much running is appropriate for you. Yeah, I think I agree with that. And then, I mean, it's just finding what works for you too. You know, we can just try, if that's something that's your goal, then we'll just consider, continue to go down the road of figuring out what works for you. Any last things on last pieces of wisdom or analogies or haikus for the audience?

I believe that to you, those analogies. I just, I don't have those in my head like you do. Um, I just think that, what would I want to end this on? I mean, like I said, it all depends. And it really is just figuring out, you know, let's just, I think it's just important to figure out what is your root cause. I mean, that's just what we're here for. That's what we're here to try to figure out for people is, you know, we need to get to the root cause of things. If you've been trying a bunch of things and nothing is working, something's missing. We're going to try to help you find that missing link.

What, what, in what capacity can, can we help them for people who are, you know, uh, maybe around our office or in other parts of the country or world, since this is going to be out there for a while. Oh, I think we might as well just put this on there. Oh, well, we have tons of options. Now, since this whole thing has been going on, we have virtual appointments that have been working really, really well for people who are afraid to leave their home, um, or just can't, or are too far away to come see us in office. Virtual appointments are work wonders. We don't need to put our hands on you for you to feel better.

Um, we have programs and different price options for those programs, um, for different areas of the body, depending on what the issue is. Um, and these programs vary in length and vary in price. Um, and then we also just come see us in office. If you're, if you're near here, if you're vacationing in Huntington beach, California, um, we'd be happy to see your face and to work with you and to try to help you figure out what that missing link is. Perfect. I couldn't, I couldn't have said it better with an analogy myself. Dawne Costantino, thanks for helping me out on that topic. Uh, that is, it's really hard to do podcasts on my own.

So, uh, I think we'll probably do some more and we'll probably hit the topics that we really talked about, uh, which was, or we're going to talk about, which was some of the other, um, arch based pain as well as, uh, the tendonitis around the foot and ankle and so on, which, uh, I didn't realize we'd go so far on that one specific topic, but I guess there's a lot of touch points we should probably address in there too. So, uh, thanks for hanging in there with us, everybody. And if you have questions, feel free to reach out. We, we do have, um, a lot of different ways we can help you. And we've told, we've told people multiple times throughout social media that if you really do have a problem and you want to talk to us about it, we can make it happen.

And so, um, we, you don't need people to touch you all the time to make you feel better. And I think that your solution is, is right. It's sometimes you're very close to it. You just need a little bit of guidance along the way. So if you're looking for help and you don't know where to go and you've exhausted your resources and you can't find anyone to help you, please reach out to us. And, you know, worst case, we just tell you where to go, you know, and what person we might know in that area who is really good at doing what, doing what they do in that area. So, um, it's a, it's a nice trusted group of people.

I think that we've come to meet over the years of being in practice. So, um, hopefully it's a good resource to you guys. So reach out to us, info at p2sportscare.com. Again, that's info at p2sportscare.com. And as, as always providers and listeners, thank you for being part of the movement. I'm very grateful for all the time that you spend listening to the shows. And I realized the other day, I did the math. If I've done 190 something episodes, I've spent 190 something hours talking. That is, that's, that's almost a week, isn't it? I mean, 24, I mean, that's a long time. So there's been a lot of hours I've spent on this podcast and I'm just thankful that if people are still getting good information from it and people are still enjoying it out there.

So please share with your friends and colleagues who think might get more information from this. And again, it's the only way the show was ever promoted. Thank you for being part of the movement. I'll see you guys next week.