Inner arch pain and plantar fasciitis: what treatment works

Is plantar fasciitis the beginning stages of this or is it caused from that nerve issue too? And I think some of the stuff that I was finding is like there's specific nerves that you have to take into consideration in the foot that can end up causing inflammation in that area, which then can lead to plantar fasciitis as well. So if we're just treating the plantar fasciitis, this may be some of the reasons why you're not feeling better or things of that sort. 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 everybody, I'm Dr. Sebastian Gonzales with Restoring Human Movement. This is the podcast. Thanks for doing... I'm terrible at the intro today. Thanks for being part of the movement movement. I feel like I get this one down. I mean, I can almost do my sleep now. I feel like after this many episodes. So, but this podcast is about a 45-minute to an hour-long format where everybody just improves the way they understand what's going on in their body and how healthcare providers can really help patients just find a nice roadmap into getting better. I think a lot of us realize at this point that we just are guiding the people to the solution.

The solutions are things that they can do on their own, and we believe the patient should be very much empowered to be a big part of the solution. And so, this podcast is much more of a general conversational style for the most part. So, it is friendly to clinicians who want to improve their communication with their patients, but also, too, it's friendly to patients to listen to, such as this one today. This topic is going to be great just for lay public to understand. We're going to cover a topic that we have talked about during the past. We just never really got to. It was inner arch or basically plantar fasciitis or plantar pain of the foot, foot pain on the bottom of the foot, and a little bit into the inner arch and towards the heel.

So, we've alluded to talking about it multiple times, but we just never really hammered it down. So, we're going to go over it today, and I know that a lot of you who have been suffering from this feel like you've tried everything. You've tried every sock and stretch and medication in the book. And just to let you know, you have not tried everything. You just tried things that have not worked yet. So, we're going to start exploring today some of the possibilities of things that might work and maybe some considerations you might not have taken in mind yet or maybe you have not been proposed yet.

So, hopefully, this is eye-opening to you guys, and hopefully, it's a good way to venture into the right type of care. So, I'm going to have Dawne Costantino on again today. She works with me at Performance Place, and so it's always nice and easy to get more information, I think, out of conversation. And it's more engaging, too, rather than just doing a solo podcast, so I'm thankful for having her on. Now, as always, we are going to start with, I tend to share a little bit of a short story about myself as a host because I don't think people like following hosts they don't like. So, hopefully, you guys like me and get to know me a little bit more throughout the months and months you're probably going to be listening to this podcast.

So, hit the subscribe button and share. We'll get into that personal story and then write into the information about the plantar fascia region, bottom of the foot pain or heel pain, especially with people who like to do endurance sports. Let's get into that story. Now, when I was younger, I had a waterbed. So, I don't know how many people actually had waterbeds out there at the teenage age, but I did have a waterbed. I couldn't imagine ever sleeping in a waterbed again, really. Like, that was probably the worst invention in the entire world. But, around the age of 15, I had some back pain from baseball and I had to get rid of the waterbed.

And so, we got rid of the water bolus in the bed and we eventually got just a nice firm mattress that would get in there too. I actually slept on the ground for about two months when I was recovering from it. I couldn't sleep in that waterbed. It was just too soft. But, man, I remember when the dog would jump in that bed. Like, that bed was just like sloshed around. And I don't even know how many waterbeds you think they have to go through to actually make a bed that was resilient enough so that dog claws and whatnot don't poke into it. Anyways, I had a waterbed when I was a kid. So, that's maybe something you'll get to know about me.

So, let's get into the information and hope you learn a lot today. All right. So, we have on Dawne Costantino, Dawne Costantino again. Well, better. You're getting better at it. Costantino. Perfect. Is it? Not really. But, it's better for you. If everyone didn't hear the other podcast, Dawne Costantino is a colleague. She works in the same office as me. We both do the same thing. And so, she agreed to be on and help out with kind of volleying questions back and forth about plantar fascia, bottom of foot pain, inner arch. And we attempted to hit this before. And then we just, all we talked about was Achilles and heel.

So, we need to try to stay away from that today. But if you have questions on that stuff, we have a whole other podcast about it, number 191. Dawne Costantino, what do you want to start with today? What do we want to start with today? Well, like you said, let's move away from Achilles. Let's just get down to the bottom of the foot and talk about just medial arch pain or arch pain in general. And I think that just starting with that topic and idea of plantar fasciitis is a good one to discuss. Okay. So, I think we should first clarify what medial means since medial is inner inside of arch, like not outer foot.

If you're talking outer foot, then we should be talking other things. Maybe that's a whole other podcast. But inner arch, I think it'd be fair to say most people kind of have it in and around the backside more towards the heel and right into the meat of the arch. Is that about fair? I think so. It's a good way to say it. Okay. Maybe what are some – tell me an experience of someone that you've talked to about this. Like what are their concerns typically? What are they – what have they investigated? What do they feel like it is? What kind of questions do they have? Um, so a lot of times I think what they talk about is that they've been diagnosed with plantar fasciitis and they just kind of need that area where they're feeling the pain to be massaged out or rubbed out or even do I need arch support?

There's just tons of different, you know, treatment approaches for plantar fasciitis out there. And when they try these, it doesn't seem to be working. I would agree with that. I think that, um, yeah, some of the stuff they've tried, they've tried rolling. I remember back 10 years ago, 15 years ago, they started rolling on frozen water bottles. That was like the craze. And then golf balls became a thing. Uh, and then, uh, working on the fascia behind the calf and even into the leg was a thing, um, scraping tools or tool assisted, uh, soft tissue techniques. And even like, so Strasburg socks was something where people were sleeping with these like sock splints, you know, that would kind of tie their foot up into a, uh, cocked back position.

Cause they want to keep the plantar fascia stretched, you know? Um, so there's a people, I know people have tried a lot of things, but I think, I think we mentioned this in the last podcast is that just as a general rule, like some of these things do work and even just staying off the foot does work, but it should, it doesn't work for you. And, um, whatever you're trying, if it is not really sticking for more, more than a day, and it continues for a couple of weeks, you're probably trying the wrong things. And, um, those things work for some people. So I'm not going to like bash on them. They just don't work for everybody and don't be one of the people that suffer because you're trying something that someone else had success with.

Yeah, absolutely. Let's define, uh, plantar fasciitis in the first place, a true plantar fasciitis. Is that one mine or you'd want that? I think, oh, I just want to hear what, how you would define it. Oh, then I'm going to ask you to find it later. Okay. So plantar fasciitis, I don't know where the double I is, by the way. Is it in the beginning before the T or after the T? It's before the T. F-A-S-C-I-I-T-I-S. I think like, so I was trying to spell Achilles earlier and every time I'm like, I know this is probably wrong. And I Google it and I'm like, damn it, it always corrects me. How would you spell it?

I think I put an I after the L-L or something. There's just never, like, it's just never right. Um, anyways, so, oh, I don't know if I told you. I've only gotten one B ever in my life in, uh, actually, sorry. I've gotten two B's in my life. Uh, one was in English. That doesn't surprise me. Yeah. Yeah, I know. It's text message madness in grammar. Yeah, it's pretty bad. Um, so anyways, yeah, my friend actually asked me, he's like, is English your second language? Cause your texts and emails are just madness. I'm like, no, I just, I just don't see, I just don't see theirs. So, plantar fasciitis is going to be an inflammation of the plantar fascia structure.

The plantar fascia structure goes from the base of the heel to the slips of the toes. Uh, and actually there's stuff underneath it too. It's probably important to note that too. There's other things that attach in the same region as the plantar fasciitis on the bottom part of the heel. But, um, I actually saw, so I have a diagnostic ultrasound at the office. And one time I had this lady who just had searing foot pain. And so the ultrasound sees the structures that are especially close to the surface, such as the IT band and parts of the shoulder and things like the plantar fascia. It's like there, you can see it literally swollen up like a balloon compared to the other side, like difference of size.

I think it was like three times the width, um, because of just the, because it was actually like there was swelling in the area of that structure, um, versus the other one. And so that would be, yes, this is a issue of an itis, which is a really acute inflammatory process of the plantar fascia. Um, I think someone mentioned before, or they were talking to me about, do you know the difference between an itis and an osis? And I said, no, I don't really know. And they said, uh, there's, uh, neovascularity or new blood supply, which creates the, that swelling process. And like, basically if you're looking at an image and you see that it's just, it's like, there's no vessels in the area.

Like, cause ultrasound can see vessel formation. It's not really an itis. So is that, it's not a plantar fasciitis. So technically that's the definition of the plantar fasciitis. Don't look at me like that. What do you, what do you got now? You're going to say foot pain. No, no, no, no. That was really good. No, but you, what I just didn't know. So you're saying neovascularization, um, is in the osis? Is that what you're saying? No, it's in the itis. Neovascularization. Okay. I believe it's all might correct me if I'm wrong on that, but, but there's a vascular supply issue and there's a swelling.

Cause there's a, there's the, the inflammatory response is different with acute versus chronic and chronic could be more of the osis. The osis. Yeah. Makes sense. Yeah. Um, by the way, everybody, Dawne Costantino's really good at making things simpler than me. So what do you got? Um, I just, I actually think that that was great. I mean, the plantar fascia and like the, the, the spot on the foot that really is the issue when it's a true plantar fasciitis is a, is a, like a ligament and fascia and tendon that runs from like the heel to the toe, like the base of the first toe until all the base of all the other toes.

Um, and it can get inflamed and it can cause swelling and it can cause a lot of pain when walking, um, for people. I think a lot of times what people complain of is that first step in the morning is when they notice it the most. Um, and a lot of times people say it has to do with certain biomechanics of the foot and the way that they walk. Um, and then even just stretching that area can cause pain, but the more and more that I learn, I don't necessarily know if I can truly differentiate. Well, not that I can't truly differentiate, but like, I think that one thing that we, I need to notice is a lot of, okay, what am I saying here?

Let me start over. What I am trying to say is those things that the people are complaining of that I just mentioned also can be true when it is a nerve related issue as well. And so trying to figure out in office and when you're with people, how do you differentiate the two things? And so when you said that you saw that ballooning and that swelling in the foot, you saw that through the ultrasound or did you see that just by looking at the foot too? I, I, I noticed it was a little bit like boggy, kind of like bigger, but I saw it through the ultrasound. I think I might still have the picture somewhere.

Actually I've showed to you. Yeah. Um, we did. So we, um, we were reaching out to a podiatrist. Remember we were talking to that podiatrist one time and we were talking to him about plantar fasciitis and things of that sort. Um, and the podiatrist and us, we were all just sending research articles back and forth. And one of the things that we noticed is, is plantar fasciitis the beginning stages of this or is it caused from that nerve issue too? And I think some of the stuff that I was finding is like there's certain specific nerves that you have to take into consideration in the foot that can end up causing inflammation in that area, which then can lead to plantar fasciitis as well.

So if we're just treating the plantar fasciitis, this may be some of the reasons why you're not feeling better or things of that sort. Yeah. I think, uh, I'm actually going to see if I can pull that, I have that article here somewhere. There was a part of it that I thought was interesting. Um, that wrote some of it down as of the one from the neurodynamics. Is that what you're looking for? No, no. This one is the one from the, this is Dr. Pham sent it. Um, Oh yeah. But there was, but there was something about like, so he was, um, this doctor was, um, he's very like, we walked in, we're like, look, we're not good at plantar fascia cases, like true ones.

I actually had to, uh, refer that lady out to a podiatrist. Um, and he was like, Hey, great. We actually, we actually know that a lot of, a lot of foot pain can be nerve or back related. And so here's, here's the, it was a consensus study, I think. Or so, yeah, the American College of Foot Ankle Surgeons, uh, clinical consensus statement diagnosed the treatment of adult acquired, uh, infracalcaneal heel pain. And there was a section here where it basically talked about like, look, we're, we're regional specialists. We can't deal with stuff up the chain even further, but you should have a good referral network from it.

And I think you'd mentioned that like a strong, a strong amount of them, like an overwhelming percentage of them were from a referral. Do you remember something like that? A strong percent of, wait, say that again. They're like a lot of the foot people where, where they weren't foot pain or sorry, they weren't foot. The foot wasn't the problem. It was, uh, it was upward. It was like a hip or a, or a nerve or something like that. Ones that he would find. Is that what you're saying? Yeah. Well, I'm saying in the, in the article. Uh, consensus study or the clinical consensus statement, uh, I'll, I'll peruse through next time you're talking and I'll see if I can pull up the statement.

Um, but yeah. So on that, on that note then, cause you mentioned that all these things can be caused by other things. I actually pulled up Dr. Google here to see what are the common symptoms that people would know about with quote unquote plantar fasciitis. And so maybe if I propose them to you, tell me what else this could be sharp heel pain. What else could it be? Yeah. I mean, is this only, could this only be plantar fasciitis? No, absolutely not. Okay. So the medial calcaneal nerve can also affect that too. Uh, pain after prolonged rest. It says pain is typically noticeable when getting out of bed in the morning and getting out of a car after sitting down for prolonged periods of time.

What do you think on that one? I think that that sounds a lot like disc and nerve as well. Yeah. That sounds like sciatica, you know, which does innervate into that area. Um, pain after prolonged activity. So just as prolonged rest can cause plantar fascia to tight, to tighten, prolonged activity can strain the plantar fascia and cause it to weaken, uh, resulting in pain. Yeah, absolutely. I mean, activity is very general. It really depends on the activity and that's where history comes in. But, um, that can still, if we're going to focus on sciatica, cause sciatica kind of runs down and can't go into the foot.

Yes, absolutely. That can be a sciatica issue as well. And I, and I think if we're like, if, say, if, say if we had that lady with that swollen plantar fat or plantar fascia, um, probably loading that plantar fascia in that state would like, if we just had her do simple things like heel raises, it would probably piss it off and that one's a little bit more like that one would be more of, maybe this is the actual plantar fascia too, but it's all dependent upon what else they say. Pain when flexing, flexing the toes and foot upward towards the shin or dorsiflexion, maybe uncomfortable or painful.

This is a symptom that it's, or this symptom may be worse if the person has a tight Achilles tendon. What do you think when you see that one? Sounds like an SLR to me. Yeah. It sounds like a nerve tension test. Uh, basically a sciatica again, this one's good foot tingling or burning. Occasionally people report tingling or burning sensations of the affected foot, possibly indicating nerves being irritated or squeezed. Nerve. Okay. So not necessarily predominantly fascia, uh, limping, limping. Anything. A tack in your foot. Um, yeah, I mean, those are all things that very much could be like, especially the first step out of, at a bed in the morning.

Like that one's really, I think it'd be, if you like thoroughly test these people, other than just looking at the foot, I think you'd probably find a lot of other like a positive, like explain, while I look up this, uh, on this article, can you explain the, the nerve tension test that I think would be a really good way for people to understand what we're talking about with this? Yeah. So the nerve tension, she want me to, okay, well, yeah. So nerve tension test, nerve tension test being that we are applying tension to the nerves that come out of the back and supply the lower extremity. And so the way that we do that, we can do it a bunch of different ways.

Um, you start by bringing the toes and the ankle, like we said, dorsiflexion or bring those towards your head, keeping the leg and knee extended and starting to slowly raise it up. And we're causing, it's kind of like you're stretching your hamstrings in a way it's, it would look like that. And so a lot of times that puts more tension on the leg that supplies the nerve all the way down into the foot. And then the way that we would differentiate, um, so with this one, if we're specifically talking about plantar fasciitis, we'd keep that dorsiflexion in the toes and in the ankle, keep that leg extended.

And then let's do some head movement and see if that even causes any sort of difference with that pain or tingling or burning sensation that you're feeling in the foot at all. Um, so that's some of the ways that we would differentiate whether it's nerve or whether it's truly a foot issue. So a lot of what we were saying is a lot of the nerve related things that we're talking about symptom wise and what people will complain of sounds a lot like plantar fasciitis cases as well. So how do we differentiate the two? Well, nerve tension tests, like what I just explained, and then movement of the head should not affect the foot.

So if we move the head, extend it, it slackens that nerve a little bit. And all of a sudden that pain you're feeling in your foot feels a little bit better than we should probably chase the route of a nerve related issue more than anything. If it doesn't cause pain, then maybe we should, or if it doesn't change it at all, then maybe we can dive a little bit deeper into that foot. But it really is just a cluster of examinations that we would need to do to try to figure out what the next best step is. I would agree if I was listening, I was reading, sorry. I figured. No, I heard parts of it. No, I think you're right.

Now, so we've kind of talked a little bit about the possibility that it is not actually a foot issue or a plantar fascia issue. I think we should make sure that we're clarifying with people that when it's actually a plantar fascia case, like an actual swollen, like notice that we referred that one lady out. There's a lot of things that we're not good at. But when, when this is a nerve related or referred related one, or even something's not a really active itis, we're actually pretty good at it. So we don't want to say we're good at everything. But this is, and this is why we talked to the podiatrist.

But I think as you're talking, Donna, I was reading through this a little bit. I didn't see the part that I wanted to really quickly, but I realized there's some really nice points in here. I think that we should maybe address because this is the, this was consensus statement was in, I think it was recent, uh, 2017. So it's not that old. Uh, I think these are actually nice points that people should know about when they're actually dealing with the plantar fascia. Um, just keeping into consideration that it might not be from the pain that might not be from the actual plantar fascia, but I'll, I'll, I'll hit a couple of these points.

And if you want to chime in and talk about it, just stop me. So number one, plantar fasciitis is diagnosed in most cases by history and physical exam findings alone. I like that. Meaning you don't need much more routine use of radiographs is not necessary for the diagnosis of non-traumatic plantar fasciitis. So you don't need x-rays. The presence of a calcaneal spur will generally, uh, will not generally alter the treatment course. So I know a lot of people will be concerned about their calcaneal spur. Don't worry about it. Number four, advanced imaging such as MRIs and ultrasonography is not necessarily necessary for the diagnosis or the guidance of treatment of non-traumatic plantar fasciitis.

Oh shit. I was wrong. Wasn't I? Did you say that earlier? No, no, no. No. I just know that I did it. Like I did it because I didn't know what it was. Like I want, I want to confirm what it was. So, um, number five, in most cases, infracalcaneal pain, uh, is a soft tissue based disorder and calcaneal spurring is most likely not a causative factor. So I think, uh, it's important to hit on Dawne Costantino, do you get, do you get a lot of people who talk about their arthritis and all that kind of stuff? Yeah. They like to, they like to, uh, blame their arthritis for a lot of what they're experiencing. Oh, I have arthritis.

That's why. Yeah. So this, I mean, this is, if, if everyone has known a consensus statement is it's, it's one of the, it's one of the things that you would, uh, as we would look at as clinicians, it's like, oh, this is really pretty relevant information. It's not like, you know, a case study of one person. Like this is, this is pretty good stuff. So this is kind of like the plan of attack, like that everybody should be taking if, if they're at least, and this is the podiatrist, uh, this is the journal of foot ankle surgery. So this is kind of what they're saying. So, uh, the public is the ones that believe that the arthritis is the problem.

We don't. So, and there's not a big reason to based upon what this is saying, right? Mm-hmm. Okay. Uh, let's see. What's another important point? There's a bunch in here. Stretching is safe and effective treatment for plantar fasciitis. Corticosteroid injections are safe and effective treatment of plantar fasciitis, uh, shockwave as well. Um, and then it talks about some, uh, uh, in, in interventions that are going to be for surgical stuff. Um, so there are, um, there are treatments that are there that you guys can do on your own, such as stretching and so on, um, injections if you need them. But, um, we all kind of say like, this is like, if things aren't going well on your own with less invasive care, but also too, if those don't work, you have to consider, were you screened for the other thing yet?

Yeah, absolutely. I think one, my mind keeps going towards this idea of like swelling and inflammation, like really being the only difference, but can nerve also cause inflammation in a specific area? I remember one of the articles I was reading, the neurodynamic solutions ones, is it just talked about how like nerve ends can trigger inflammation in the same area as plantar fasciitis. So say it's that medial calcineal nerve or interior nerve or whatever. I'm just curious, like what would be your first plan of attack? Like you have someone been complaining of this, like what would you do first?

Yeah, that's a good question. Um, so yeah, I do. I mean, I think that I wouldn't know all the physiology of, of how the, of how the nerve will create that, but I did hear there was a study. I think they were, they, there was inflammation, inflammation within a region and they snipped the nerve and all the inflammation stopped basically. And I think it was a cat model, if I recall. Um, but, um, in that case, it's like the nerve, if you make the nerve healthy, it might, it might just self resolve the problem. Um, so maybe then I would probably try to pick something as an intervention that somebody feels is for the foot, but is actually to cover the other basis too.

And, uh, the reason I say this is because say if you came in and we did that, we did that, that test that you talked about and the head movement bothered, bothered your foot and you were texting a lot. And I said, just don't text. I want you to use, I want you to sit proper posture and then I'll make your foot pain go away. And you're like, dude, this person sucks. Like they didn't even cut, like I went to their office. They didn't even dress my foot. They told me to have better posture. Like it doesn't make any really clear sense to the patient, although it could work. So maybe in that case, uh, I would tell the person to, you know what?

Um, let's take, like, there's a pot, like if I don't see any swelling in the, swelling in the area and it really doesn't test, like it's really a true itis. I'd say, you know what? Loading of the foot, if this is a tendon problem or, or a fascia problem, actually loading the foot is actually pretty good if we do it in a scaled way. So what I want you to do is I want you to walk every, every hour for about like, you know, 10 minutes and we're going to slowly start to put weight upon the foot. And if it's, if it's, if it's painful, I want you to stop and take a short break and then continue again.

Um, and then we're going to try to build some load and get some adaptation of the area because the tendon or the, sorry, the, in this case, the fascia will start to help remodel. And that's what we want because loading will help the, the tendon. I keep saying tendon, the fascia in this case and every other stuff in the foot. And we want to strengthen the foot too. And so what that might do is then if we think that if there was a disc driving the nerve pressure to create that problem, we also had them walk, which is a good intervention for the disc, but we're not going to scare them away by thinking that we're just giving them only some postural exercise.

That'd probably be step one with it. Nice. Um, but it really depends on too, how, how much you trust me as a patient. If you just say, whatever you say, doc, I'll do it. Then I can give you whatever I want. But if you're new, I think I need to nurture that. I think one thing that I haven't really been able to explore very much with you in office and stuff like that is actual like foot treatments. So say we screened out the back, we screened out the sciatic nerve and it's not that, and maybe we're going down the route of, it is like a Baxter's neuropathy or something of that sort. Like what would be your like plan of attack for just the specific foot local issue?

For local foot? Yeah. So I think based upon, you know, just the general muscles turned on, muscles turned off type of tonic phasic type of thought, you know, um, and even with the hand, this kind of goes to is like the intrinsic hand, I think does not necessarily the small muscles of the hand tend to not work as much or they tend to become lazy. And then the muscles that cross say the ones that are, have a higher affinity becoming tight tend to become overused and work and they become a little pissed off. And, um, I did this with a lady recently where she had a De Quervin syndrome, which is a symptom of the, of a tendon of the hand.

It's like a, um, um, tenosynovitis of a tendon. Um, I know it's a big word, but let's just say the tendon was pissed and so she couldn't pick up a pot. So we were doing a video session like this. And so she couldn't pick up a pot because it, it hurt right around the base of the thumb or that base of the thumb side of the hand. And so I had her really do, I did her do one exercise, which all it used was her, was her a dinner table chair. And so I made her squeeze it so hard that her, the small muscles of her, of her hand worked harder than the other, uh, the big tenant. Um, and I want you, I said, I want you to go into your, your muscles feel like, like your hand's going to cramp.

Um, and then, so after that we tested and she can move the pot. No problem. Um, she had no symptoms for the next, uh, well, she didn't have a recurrence. So it went away within, within under a week. And all we did was one exercise. So for a foot, we might take the same approach. Um, so the intrinsic or small muscles of the foot are probably where I would start. Um, but the only issue is how do you do it without pissing off, um, or stretching the plantar fascia? Although some of the suggestions of how to get better is to only stretch the fascia. I think if you have a tendon or a ligament or a fascia that's pissed, I don't think I'd stretch it.

I think I just let it be. And so maybe step number one is allow it to settle. So about five days of you can put someone in a boot or, or, or like a, like an air cast, just let them, let it settle, let nature do its job. And then we can start loading the small muscles of the foot with single leg stance exercises. You can do even all the, the ones that you probably seen on YouTube, like smearing peanut butter and grabbing a towel and stuff like that. Um, I tend to like single leg stance ones because you really have to work hard to keep your foot buried into the floor. Um, or there's other ones where you can cue in like, um, tripod foot, um, type of holds or even shit.

Like you ever gone on a paddleboard? That is exhausting on your foot. I mean, like your foot almost cramps. So there's a lot of different ways to do it, but I would, um, I think, I think that when we're talking about the toe flexors in particular, like the intrinsic small muscles of the foot, adding a load into a extended position is ideal. So like running, pushing a sled, um, trying to push a wall over, um, sitting up onto your haunches, like heels up, um, kind of like you're into like that only on your toes position and just staying there. Like we have that exercise called pennies in a fountain.

Um, all those will work, but if your plantar fascia is still a little pissed, then maybe we don't do that yet. It's just a little too soon. We cool the plantar fascia down. Then we start working the small muscles of the foot. So that would might be thought one thought two is you'd go from above and maybe make sure that, um, the hips and the core are working well, which it's a, again, from a patient perspective, are they believing you on this BS your hand? Like, does it seem like BS to them if you're going at the core? So I tend to start with the foot a little bit local if I need to. And then if they start warming up to the idea, I'll start working on single leg stance, which you'll get a little bit more of, of, of upper part involvement anyways.

Yeah, absolutely. I just think that there's, I mean, with what we talked about in the last one on Achilles and all your other podcasts that you have and things of that. So there's just a common trend here of it's not just always focusing on that local issue of where it's at. You always have to go up the chain. You have to take the whole body into account because the foot reacts to the knee, which reacts to the hip, which reacts to the core. Like everything is connected. So it's important to just note that although we may not be focusing specifically on the foot, it's because a lot of other things play a role in how well your foot can work and the biomechanics of it.

And so we have to take, take the whole body into account. Yeah. And just a, maybe an exercise, if you guys want to play with it right now, or a little test, maybe not on the foot that bothers you, but if your foot's on the ground right now and you're sitting, try to, if your shoes are off, try to scrunch your toes on the ground, like you're trying to pull the carpet and don't use your hamstring. You trying to try that. Let's try that. I'm barefoot. So now I'm going to try it. I just thought of it. Don't use your hamstrings, but try to rip the carpet off the ground. You feel your hamstring starting to, it's trying to, it's trying to help.

Yeah, kind of. Yeah. I mean, I think if you're really good at like, if you're really good at activating short foot, then you probably could. But even, even with that, like you still feel that like bottom part of your hamstring near the knee, like just turn on. Yeah. It's really trying to help. So I guess the point, the point is it's really hard to only help a foot if you're not willing to do the other part because everything works together. So. Yeah, absolutely. All right. What else should we hit on this plantar fascia thing? Well, let's talk about maybe some orthotics or arch support or something of that sort.

Okay. What's your take on orthotics? I think that's a, that's a talking point. I think I'm always the type of person who can see both sides to things. So like when it comes to like orthotics or arch supporter, like things that are probably going to do the job that your foot or muscles or tendons or ligaments or whatever should be doing on their own. Like I'm not a huge fan of long-term. So when it comes to foot support and things of that sort, if it's going to be something that maybe is going to help calm down the body for a short period of time in the beginning of treatment, I'm all for it. If it helps, it helps.

But I don't think that they should be relied on. I think a lot of people are like, oh, let me just insert this into my shoe and it's going to fix all of my problems. And I think that that's a terrible mindset. And I think if it's a temporary relief, cool, but let's work on what needs to be worked on that caused this in the first place. Like working the intrinsic muscles of the feet, working the glutes, working the core, working with biomechanics and movement patterns so that we can get those orthotics out of your shoe and get you to just be able to activate those muscles long-term and keep you out of pain.

Yeah, I think it's important to note that for the most part, I think your body has all the tools it needs to feel better. You know, like just all the braces and stuff, they're nice aids, they're helpful. I was actually against orthotics for a very long time, just thinking like, you know, it's kind of useless. Even like heel lifts, I'm not like, like if people have them in, I'm like, does he like it? And they're like, yeah, I'm like, great, keep it. But if they're like, should I get one? I'm like, no, like, like there was, there was something I saw where, um, it was, I forget the number. It was some absurd.

It was like, you have to have like a distance difference of foot length of like, I want to say it was like five centimeters. I'm sure I'm wrong. I have, I have a post on my website somewhere about it, but it's, it's like, I was like, damn, that's huge. You know, basically most of the population has abnormal leg length and there's no problems whatsoever. Um, but I interviewed Tom Michaud, uh, who his family, his family had an orthotic company for a lot of years and he's, he wrote the book, human locomotion. So, uh, he's like a, he's got a bunch of research articles at the, you know, the back of his hand.

Um, he's an advocate. And so I trusted judgment and, but it's basically like, I think what basically he said was, um, they're, they're kind of like helpers. And if you invert, uh, or if you pronate what with using orthotics, you're going to pronate or sorry, without, you're going to pronate with them. Like it doesn't change much. It's just, um, I thought it, I forget the actual terms he used, but he said for the most part, like, it's not going to make a big dramatic change, but, um, it can, it can be very helpful for symptoms and, um, they would be a really good first start for some people. Interesting.

Like he's, he's, he was the, one of the hardest people to get on, but, uh, he was so, he was so nice and he talked for longer, but he's like, like his terminology is like so specific. He's like, Oh, so you want to take the foot and go like 10 degrees, extra rotation, a little bit of pronation, maybe like two and a half degrees in this. And you're like, dude, I don't want to think about this anymore. And all of a sudden he breaks into a nice story about his friend running. And you're like, Oh, like that was just brain break. Yeah. He was good at like, it was just always, it was like, Oh, that's too much.

Oh, good. He's telling a story. He just knows how to time it. Yeah. Okay. So, or thought, um, well, you want you to tell him about heel lifts? Cause I think those, those are actually different. So, um, heel lifts. Yeah. Heel lifts. That's with leg length discrepancies mainly. What are your thoughts on heel? Actually, what's your thoughts on leg length discrepancies? I don't think we've ever talked about this. Oh, leg length disc. Wow. You just throw that one at me. I have, I have some thoughts on it. I know we don't, we don't really talk about it. We don't talk about it as with patients, nor do we really.

Yeah. So it's not. It's funny that you bring that up though, because when people talk about leg length discrepancies, people tell me that I feel like it's almost majority of my patients are like, Oh yeah. So I've been told that like one length longer than the other. And it's kind of just one of those things where I'm like, okay. And in my head, I'm just like, yeah, probably not. But I'm not going to try to just like tell you you're wrong or right. You know, I'm not here to do that. I'm just here to like fix what you're here for. I, but it's my cause. It's my cause. Yeah. I don't, yeah. I don't think so.

I don't, I don't know. I mean, we learn, we learn so many different ways of just like learning how to measure the leg lengths in school and things of that sort. I just think that the ways that are shown in school are just so open to human error when it comes to that. So when it comes to measuring leg length, measuring like, you know, the height of the heel when you're laying on your stomach and bringing the legs up and that sort of thing, and then adjusting a certain area and then coming back. And now it looks like it's normal again. I'm not going to say that's right or wrong. I don't know. I haven't done the research to see, you know, whether it is or isn't right or anything of that sort.

I don't really have an opinion on it. Like I said, it's just one of those things that I'm, I just take note when people say it. And, uh, I kind of just move forward. I don't, it's yeah, that's a mental note kind of thing for me. Yeah. I remember, uh, like they're like, no one's asked me in a while, but there, I would just, I'd explain it to him in this, in this way. And so I'd stand there and I would hike my hip and I'd say, I just made my foot or my foot one inch from the floor. Is there any like, but that that's because of, uh, of, of this case, voluntary, you know, muscular change. And so I'm like, you have a lot of different reasons why you can have a difference of leg length.

And, um, this is just one, but I'm like, if you're ever in a car accident where you broke your femur and it never really got back to the same length again, because you had a surgical procedure and rods and so on. I'm like, you could have a structural leg length discrepancy. It's not going to change. And it doesn't, it doesn't ebb and flow. It just, it's there because your bony structure is different. You had a trauma, but a functional one is like, I just changed it at will. And so some of the stuff you're experiencing, maybe it's your hip or back or whatever you're here, uh, here for, um, even like limping.

And it's like, I don't want to put my weight on that leg. It's like, it would make complete sense that over time, the muscles would adapt to like, just put your pelvis in a different position or hike up your whatever and make it. So things measure abnormal. It's really hard to, I couldn't imagine like laying someone down on their belly. or on their back and measuring them. It's like, okay, a hundred percent relax, just relax. You know, like you can't get them to turn that stuff off, no matter how you fuss with them. Like they're still providing an air factor. So I don't put too much weight into it, but, uh, I just thought I'd bring it up since we didn't talk about it yet.

Did you ever, did you ever, um, use leg length in like when you were going through school or when you first got out of school or anything of that sort? Like, was that a part of your examination at all? No, someone had, no, there was a workshop that kind of taught me about, or they kind of taught us like the flow of it and stuff. And it was, and maybe it takes a keener eye than I have or whatever, but like we were doing, we were kind of looking at and stuff and, and the instructor came over. And so he was like, uh, he's like, you see, like he would put up, I'll show you cause you got on the camera.

And so he's like, you see, they're different. And so I, he put them down and I said, let me, let me do it. And I said, no, they're not there. They look the same to me. And I'm like, and he does it again. He's like, you see, they're different. And so I keep shifting. Like, I'm like, we did this like five, six times. And I'm like, okay, maybe I'm not getting it. But what that tells me is there's so much air. Like if he kept seeing the difference and I didn't, and it's the same person, you know, no, we didn't change anything, but how are you going to teach that? So I had a real, I had, I had trouble with it, nor did I really put much weight into it anyways.

So I just didn't bother, but that was my only real big experience with someone telling me about it. So, yeah, yeah, that type of approach. I mean, I've seen it work for people. I mean, I, I never really, truly adopted that treatment style or anything of that sort, but I mean, I've heard it work for people. I've seen it work for people. I think there's a bunch of different ways that you can go about, you know, treatment and things of that sort. So we're going to talk about leg length and, and that being the reason for your pain, I think, uh, there's just a lot of tools out there for fixing it. And so we don't necessarily do use leg length as a, as an approach, but I'm not saying it's right or wrong.

Well, I think something that we should maybe talk about then is like, so let's just say if I think it's a data point, I think it's good information to have. If you truly see it there and it's, and it's easily, you can tell. Um, but do you want to accommodate it more? Like, do you want to, do you want to actually put a wedge there to keep it there? You know what I mean? Like, so I don't know if like, if it's, if it's like a structural one, I think the, I would say yes. Uh, meaning the bone length changed or you had like, say some disease, which didn't allow your bones to grow or the growth plates had had a problem.

Um, but if it's one that's adapted because of your pain, I don't think I would, I don't think I would add to it is all. So I think, I think we have to think logic on each person, you know? What do you mean by add to it? Add to it in what way? Well, I mean like you put something under it to keep it at the altered height. You know what I mean? Like just during the treatment or are you talking about like through daily activity too? No, daily activity. So, so, so, so some people. Oh, oh, okay. So you're talking, cause we were on the topic over orthotics. Yeah. Cause we're like, so I don't bring it back now.

Well, or that, but orthotics would be different than a heel lift is, but I, I, the reason we're bringing up the topic is because we're talking about plantar fascia. Cause those are common things that people will have talked about. And sure, obviously like just like everything else, if they work for you, go by all means keep it. But if you're struggling and you have that really reconsider, is that right for me? And we tell people in the office too, if we're doing something and it's, and it's been a couple of weeks and they're not seeing a change we picked wrong, you've done it poorly, or maybe this is just the wrong treatment for you.

But I don't think, you know, the madness of keeping doing the same thing over and over again and just expecting it to changes and saying you've tried everything is really the best call action, you know? Yeah, absolutely. No, I agree with that. I forgot that that's what we started that conversation with. Oh yeah. Yeah. Orthotics and heal. But so again, I guess we'll reiterate cause we were just, I felt like we were bashing on it. Like by all means, if it works for you, great. We don't tend to recommend them too much. I will say with orthotics, I think based upon what Tom Michaud said in episode 93, I think I would trust his judgment.

He's a very smart guy, but I haven't really seen anything compelling leading me to think that heal lifts are a way to go for plantar fasciitis. Yeah. Nice. Good. What else we got? Yeah. One thing actually my mind was going towards like, what about the idea of like tarsal tunnel or something of that sort? Yeah. Treatment approaches for it, diagnosing it, something like that. That's a good question. I haven't, I haven't seen a tarsal tunnel in probably a lot of years, to be honest with you. Um, I've seen people with pain into that heal area from like a nerve thing. Like you might find a positive nerve test similar to what you're talking about earlier.

There, if there was an issue with the nerve itself, cause it's kind of the same nerve. So, or the same like nerve root or nerve innervation. So, um, I think I talked to someone about the idea of a double crush. So double crush is when the nerve is kind of, uh, smashed and not, not deformed, but just pressurized in one spot and also another somewhere else that it's going. And I think someone had said that, uh, uh, that they thought that most nerve conditions are actually probably double crush because the nerve is one cell and it can swell. And so it doesn't allow itself to pass through normal size tunnels.

And so logically it's like, yeah, like the whole thing is kind of, but you just, you just have to make sure that you find like the high payoff points and reduce it from those points. But I'm sure that I'm sure we've seen more tarsal tunnels than we know. I just, but reducing it from the furthest point of the nerve, I don't know if it's the best idea addressing it at the tunnel. I think we should start at the spine or the hip and see if that produces fruit and then maybe just the tarsal tunnel goes away. Yeah. If not, do you have like a specific mobilization you like to use or would you just go into exercise for tarsal tunnel or, cause I know like tarsal tunnel, a lot of times it comes from that.

It's always like that topic of pronation of the foot. So in pronation of the foot is a lot of just like, like, um, movement patterns and like things of that sort and exercise. So what would you do? Well, in that case, something like if we're really concerned about the, uh, if, if we are talking about a true tarsal tunnel, a single enchantment at the tarsal tunnel of the nerve, then, um, we're worried about compression of the nerve as it passes through the retinaculum. Um, or as the tenants through the, through the area becomes swollen and also decrease the space, similar to carpal tunnel, but at the foot.

Um, so in that case, a taping technique would work probably really well. You just allow, allow the two points where the retinaculum attaches, which is the bony area of the foot. Um, or sorry, the bony area of the ankle and the inner side, as well as the heel, just approximating them together. And it'll, it's kind of like, it's kind of like creating a fort, you know, like it creates some air space under anything and allows the nerve to breathe. So I'd probably just give them five days of tape it, let the opening happen, let the nerve de-swallow and let it do its thing. Uh, and then you can start reloading the foot.

Hmm. I like it. What if holding it into supination for a minute throughout the day? That'll work. Would work. That'll work too. Allow just swelling that way. That might be a cool approach too. I feel like you've been to the neurodynamics course already. Just thinking that way now. Are you? Yeah. That's actually part of that. There's, there's a protocol in there. Oh, is it? Yeah. You just opened the tunnel. Um, yeah, that's just, that just seems to be what we do. It's like, okay, well this specific movement causes your pain. Let's just do the opposite and see how it works for you. And so many times it's just like, oh, that helped.

Just do the opposite. It's like when somebody comes into your office and they sit down and they're like, my back hurts and they're sitting in like a C shape. And you're just like, okay, let's try one thing. Just sit up straight for me and they sit up straight. I'm like, how do you feel? Oh, that feels better. Yeah. It is nice when they're easy like that. Yeah. I know that when you get into foot or ankle area, it's, it's not as we got to think in a little bit more different, like multiple planes of movement. So it's a little bit harder for people, I think, to, to see the relative thing. But I think you're right.

Like, yeah, you just open the tunnel. That's one, two. Um, and yeah. Uh, but I think passively opening the tunnel, meaning that you do it with your own hand, uh, versus having the muscles do it. Cause when the muscles do it, they might kind of can, I don't remember if the, if the, the tenants going, if the tent, it's the tenants going through. So yeah, it is, it's not the actual muscle bellies unless I think we're talking about the one muscle, the, the big toe, the, uh, flexor hall is just longest. Through that tunnel? Yeah. I think cause there's, cause when the muscle contracts, it would fill up full of blood when it would balloon, which would relatively decrease the space of the tunnel, you know?

So I think that's why passively it's a little bit more controlled. So you just kind of do it on your own. You looking up the Tom, Dick and Harry? Yes, I am. Oh, that's the saying. I'm trying to remember the saying. Yeah. Tom is, uh, what's Tom? Uh, tibia, uh, tibialis, uh, digitorum, uh, halysis. Um, I think, you know, I think halysis is the muscle going through it. If I recall from the ultrasound, so. It's really bad, but I like it when you sound like a fool sometimes. Is that right? Yeah. The Tom, Dick and Harry? I don't know. Is it? What runs through the tarsal tunnel? I mean, it's poster. Is it?

Oh, whatever. It doesn't matter. The posterior tibialis is the flexor digitorum longest. The flexor hall is just longest. And I think, uh, I think, well, there's the vein artery nerve in there too. Um, 10 and the posterior tibialis, flexor digitorum, flexor hallysis. Yeah. And then the vein artery nerve of the. Yeah. Is your tibial nerve. Yeah, but I think there's only one that becomes meaty in there. And I think it's the hallysis. Anyways, I'm sure, I'm sure the general population doesn't care about this conversation anymore. Um, but you're, but you're right. You're right with the tarsal tunnel.

If by the way, uh, you'll know it's more tarsal, tarsal tunnel nervy thing because of the burning and the nervy feelings that, I mean, or, you know, it's just an easy payoff thing. You just kind of try it. And if it works, like Dawne Costantino said earlier, it might just decrease the swelling. So it's something super simple. There's like no real contraindications to doing it other than if your foot hurts when doing it, but it doesn't really, it's like, it's a really simple thing to do. It's like a quote unquote hack, you know? Yeah. I just think, uh, I mean, when we, when it comes to like foot issues, a lot of times, like if people are coming to us for the foot issue, cause when people think foot issues, they're going to go to the doctor who specializes in the foot.

Right. Um, and so they try things and they try things and something's not working. So a lot of times if we see people with foot and ankle issues, it's probably because what there's been the one thing that hasn't been looked at yet. And so that's why we find success with those types of people is because we look at the one thing that hasn't been addressed, which is usually the nerve coming out of the low back down the leg and supplying that area. And we address that and all of a sudden their symptoms go away. Yeah. And I think that, uh, I don't recall anything that I know I had a couple of podiatrist referrals for a growth plate fracture.

Um, there was actually, there was two fractures that, um, I don't re I'm trying to think of something in the area that would be a common fracture or some type of other oddity that they would have to see a podiatrist for. Um, certainly in the injections, like the cortisone injections, if they want to do that, that would be, that'd be something that would, you'd have to go to. Um, can you think of anything else that would be, there's no real bursa in that area. There's no real, um, major fractures that we typically see other than it was like a large trauma. Um, yeah, that's kind of, um, I know we, did we talk about flat feet or was that last time?

That was last time. We did not bring that up in this one. I think say what you said last time. I think, cause that's good. I think cause people are going to be concerned about maybe their flat feet was as a reason for this, but I think you hit on the head last time. Yeah. So a lot of people like to, uh, blame their flat feet for the reason for these issues. Um, and I like to think of it in a sense of you're born with those flat feet and we don't necessarily want to fix what your body was already naturally designed to be like. So just because you have flat feet doesn't necessarily mean that you're prone to this more or that this is your reason why I think it would just necessarily be, we need to look up the chain and see if there's something else going on first before we blame your flat feet for it.

Cause that's your normal anatomy and we don't want to, we don't want to mess with people's normal anatomy. That shouldn't be causing issues. Yeah. And you, something like that. Yeah. And it's like, and also too, like the, the flat feet were there before your pain was so that you can obviously exist without reducing your flat feet. Um, I don't recall that we'd ever talk about the rich kids and flat feet before. No, last time you were talking about people's flat feet and being good swimmers. Oh no. So this one I'd have to find out where this was, but, um, they, I think it was an observational thing back in, I think I want to say like the forties or 50, like it was like when, you know, when kids weren't wearing shoes all the time, but so all the, all the rich kids are the well-to-do kids would have flatter feet because they were shoes and all the kids that were the poor kids had nice arches.

Um, so I guess you can tell their socioeconomic background based upon their foot feet. I don't know if it still holds weight anymore. That's interesting. Well, I like to think that like, I have really good, so I'm one of those people that can control like each individual toe differently. Like I have really good control over my like toes and stuff like that. And I was barefoot a lot as a child. I was always out front, like just running around barefoot and things of that sort. So that's kind of interesting. I would wonder, I wonder if that plays a role at all. I was not barefoot. I have flat feet.

You have flat feet? Pretty flat, I think. Yeah. And you wore shoes a lot. Yeah, I wore shoes a lot. Interesting. But my feet don't hurt. A little rich kid. Yeah. I grew up on the other side of the boulevard. Are you making, is that me? Are you making fun of me? Isn't that something I said? Yeah. I already know. I know about, I know about that area. Above the boulevard and below the boulevard. That's right. Anything you think we should cover before we close up? We have a couple minutes. As far as that, I can't really think of anything. I feel like it's just with that specific area of the foot. I mean, we covered most of it.

Yeah. It's a really common thing people have. So I'm glad we did a full podcast on this today. How would, what if people are living somewhere where they don't have help? What do you think you want to tell everyone about that whole thing? Sure. So we have put together and have been spending a lot of time putting together these programs for specific areas of the body and what we have found to have helped people with pain in those areas of the body. And so these programs are online. They can be done virtually. We have a bunch of different pricing options and different lengths of time that you want to commit to it, depending on who you are.

And so because this topic is ankle and foot, we are putting together an ankle and foot one as well. And so if that's something that you're interested in, you're not in Huntington Beach, California where we're located and you can't, you can't come see us. We have put together these programs in a way that we would approach it if you were in person. And so you can always reach out to us and let us know a little bit about more about what you're feeling and questions that you have. And then we can always discuss with you our pricing options and our time commitment options and just kind of go forward from there.

Sounds good. May you always make it simpler than I do. Cool. Right on. Thanks for being on then. We'll close the podcast. Right on. Dawne Costantino, thank you for being on and helping me through the podcast. Again, Dawne Costantino, again, she works with me. I'm very happy to have her as another provider to work alongside with. And as you see, we get along pretty well. So if you guys are suffering with foot pain as well as inner arch or either or, and you don't know where to go and you feel like, hey, all this information is all good and everything, but I still don't know what to do with this thing. Like I need someone to help me.

What do I got to do? You can contact us. Okay. We're available. Distance is not a problem. So feel free to email us, info at p2sportscare.com. Just tell us, hear the podcast and say what you liked and didn't like and tell us your story. So we're on the mission to help people find the answer wherever they're at. And I know that with distance, people think, well, they're across the world. I don't think they have any guidance for me. You'd be surprised. We've had people call from the other side of the country like New York, and we've been able to refer them even to somebody who was able to help them there locally just around the corner and they just didn't know they existed.

So be open to the experience of maybe finding a solution. All right. It's your guys' choice. As always, you have the right to choose and you can still do what you're doing and maybe not have any change, or you can try something different. And I'd always advise trying something different if you've shown that the things in the past haven't worked. But again, it is your choice. So please be happy with your decision. Now, as always, thank you for being part of the movement. I appreciate any shares and likes and comments that you guys give me about this podcast. Share it with your colleagues. Share it with your friends who are experiencing foot or ankle or heel pain.

This is the only way this podcast gets out. I don't have a large marketing company. I don't have people reaching out to other podcasts asking if I can be a host in there like a lot of people do. I don't have any of that stuff. All right. This is grassroots. This is literally in my bedroom right now. And in the past when we're open at the office, it's out of the utility closet that I've made into a studio. So this is grassroots shit. So support local. Thank you for being part of the movement. I'll see you guys next week.