Plantar Fasciitis and Foot Pain: Look Beyond the Fascia

This is session number 53 of the Performance Place Sports Care Podcast. Chip, I'm going to come at you like a spider monkey. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everybody. It's Dr. Sebastian Gonzales again with the Performance Place Sports Care Podcast. And today, we have a guest on. And the guest is going to be Dr. Justin Dean. Dr. Dean was actually referred, I was referred to speak with him by quite a few sources, actually, a couple colleagues. And he's actually going to have some really, really good advice and just more of like a mental mindset, I believe, for how to deal with and reevaluate really how we look at injuries, not only as clinicians, but also athletes as well.

I listened to a couple of the podcasts he was on just this morning before we are doing this podcast here. And I really, really like what he had to say. And I'll definitely ask him a few questions about everything. He did create a technique called Yap. And let's see, I forget what the website is called specifically. I think it's yapawaypain.com. Yep. Oh, yankawaypain.com. He's also the executive director of rehab2performance.com. So that's R2P. If you're in the industry in sports medicine, a lot of people have gone through R2P, which is kind of like a whole, I don't want to say group, but it's mainly a form of people who put together these great seminars.

And they educate DCs and they educate DCs, PTs, all the sports medicine people, how to practice very evidence-based and kind of take different things from different people, different professions. They might have a strength coach and they might have an MD and they might have a DC and they might have all these different experts in the field. And I know they have McGill in there and Liebenson who are really, really big names within our industry. But Justin Dean is the, again, the executive director of that. And I know a couple more people who also work within that group and they're all very smart.

And I thought today that having him on to mainly talk about that whole mindset and also to kind of change our perspective on how to deal with mainly running injuries, what we'll talk about first his website is back to runny.com. He's in China currently, and we're going to be doing a Skype call. And I believe it's early, early morning there. So if he's not perky, that's probably the reason why it's the afternoon here. We're about 16 hours behind him. So this was a really hard one to set up, but I'm really excited to do it. I think we've been talking about it for a month now, but we're going to talk about running specific things.

We might tangent a little bit, but for the most part, you have to understand that a lot of movement-based disorders, which is probably what we're going to talk about here, they have common mechanisms of injury. And I know each subset, each person, each sport, each athlete within the sport thinks their injuries are unique to them, which a lot of them are. They're kind of unique, but also, too, like most athletes run. Most athletes change direction. In that basketball, football, soccer, running, running is more of a straight line. But we all do that same kind of thing. So a lot of times, we get those lower extremity, leg, hip, knee, ankle injuries from a lot of the same faults, at least from my opinion.

So we'll see what he has to say on this, and hopefully we echo the same thing. Or also, maybe I'll have to redo this whole intro. But let's have on Dr. Justin Dean. He'll tell you all about himself, and we're going to learn lots and lots of gold nuggets here. So let's have on Justin Dean. Everyone have a pinky round of applause. All right, everyone, here's Dr. Justin Dean. And Justin, say hey. Hello, everyone. Hey. Welcome from China. What time is it in China? It is 7 a.m. on Thursday, so I'm about 16 hours ahead of you in California. Yeah. When did you go out there, actually? I have been in China since December 5th of last year.

And tell us, since everyone's going to, we're going to talk about running specific topics today. What are you doing there, and why should they listen to what you had to say, really? Well, currently I work for an American-based company called Altus, and I was hired to come over to China. Because in China, every four years, there is a competition known as the Chinese National Games, which in their culture is essentially more important than the Olympics. Really? So, yeah. So it's every single sport that there is, and they get together for like three weeks, and it's set up exactly like the Olympics.

So you have more people than you can possibly imagine come to this event. So it's a very big deal. It's very prestigious in their culture to do well at these games, and they get paid really well to do it. I think that's a bit of that. So my job, essentially, is to work for the providence of Shanghai to prepare some of their national team athletes for these games. So that's what I'm doing here in China. So how did the, you said the providence of China? How did they get a hold of you? Of Shanghai. Well, Altus contacted me because they contacted Altus, because Altus trains and work coaches and does medical for most of the top track and field athletes in the world.

And they needed somebody to go out to the satellite in Shanghai. And they called me, and I was like, well, at a time, 28 single. Why not? Let's go. I'll probably, yeah, I'll have to ask you a little bit later about some good stories, probably from China. But let's start on, yeah, do you have some good ones? Oh, yeah, definitely. Yeah, let's talk about how cab drivers steal cell phones next. Right. So tell us about then, so everyone's probably listening because they want to hear about, I told them that you were going to be a good one to listen to about how to change the mindset of their running injury.

And I'm sure you see a bunch of running injuries there. Let's just go straight down and just see that maybe the top three that you see, and then we'll go into each one individually. Well, to give a little bit of a background context, particularly for a runner, I was a college distance runner myself. So I competed at a, I wouldn't say I was great, but I was national level for small colleges. So I have about eight years of high-intensity training in me. So that gives me a little bit of a different background. So I understand what it's like to run 90 miles a week, that sort of thing. So the top three most common injuries that I see are obviously probably knee pain and anything related to the lower foot, such as plantar fasciitis.

We'll discuss whether or not that's actually a diagnosis or not later. Yeah, I figured you're hesitating on calling a diagnosis, right? Yeah, it's a common term used for foot pain. So we'll go ahead and use that common term so everyone knows what we're talking about. So foot pain, knee pain, and actually low back pain, actually, for the running population. So would you say that they are in high-level runners? Are they the same injuries that, like, lower-level, recreational? They all get the same kind of thing, or is there different things? I would say it's pretty much universal, yeah. I don't see the same kind of overuse injuries, nerve-related pain, which we'll probably definitely go into.

Yeah. If you're going to ask me about that. I'm sure it will. But in reality, I always tell people a common thing is, oh, professional athletes, you have to treat them differently. And in a little bit, you do. But they have the same bodies. They're just higher performers. From a genetic standpoint and training standpoint, you can treat them relatively the same. So it doesn't matter if you're getting off the couch and training for your first 5K or you're preparing for the next Olympics. You can treat them relatively the same pain pattern to show up. Yeah. Do they have different thought processes with it?

I know there's a little bit more urgency with higher-level rather than recreational. Oh, well, sure. A high-level athlete is going to be more in-tuned with their bodies and more worried about pain than traditional. I guess this is just my observation. But if you're more of a casual runner, you can run through a little bit of knees discomfort. You don't think too much of it. You think, I'm running down hills too much or whatever. But a more high-end athlete, that little bit of discomfort from their perspective decreases their performance. So they're more likely to report pain. So can they feel differences then with – so not necessarily pain as the indicator.

Can they notice like, hey, my gait is off. I'm not generating power out of this leg. Is there other things that they're noticing because they're in tune? Oh, absolutely. A very common complaint that I've seen throughout the years is they're an athlete that has no pain at all, but they just feel like maybe they don't have any spring in their step and like one leg. So they can't drive off their foot. Or – and often what I hear is I feel like I'm dragging my left – usually it's the right leg. But like I'm dragging it. And the left leg is doing all the work. Well, we might as well just go down that road.

How come always the right leg, you think? I mean, I don't know for sure. This is just – I mean, this is just my own personal experience. It could be – oh, man, it could be so many things. It could be for track athletes that we go around – when we go around the track, it's always in the same direction. We're always turning to the left. Yeah. So that right leg ends up kind of – the pelvis tends to hike on that right side. And over time, we use different structures differently, and we don't allow proper loading for the right leg. It could be that. It could be that the liver is on the right side. Go into a posture restoration idea where the right pelvis is the problem child.

The right hemipelvis is the problem side of the pelvis, and you need to correct that out, if you will. It's not that fecal baby in the descending colon. Could be. Who knows? Like, this is – I've just – I've just seen it on the right side and not the left. So I would – my main theory would be around going around the track to the left for 10 years. I did it the same. Yeah. I was just curious. I'll probably ask you a couple, like, prodding questions, mainly because, like, listening to the podcast that I heard you do, like, you seem like you're very – you're okay with thought-provoking, but also, too, like, you're always thinking about the mechanics and, like, how things work.

So, yeah, I want to – even if you don't have the right answer, I'm down. I just want to hear it. Now, let's go back to that plantar fascia thing because you said it's a garbage term or it's a catch-all. You don't really want to say it. Tell me. Let's just start with plantar fasciitis. Well, just assuming that this is a very general – let's go with what the word plantar fasciitis actually means. Fasciitis. Plantar means foot, the bottom of the foot. Fasciitis means inflammation of the fascia, of the plantar side of the foot. And to have – like, a lot of times people come in with three months of foot pain, plantar fasciitis pain, and it's been there for three months straight.

Well, if it's an inflammatory condition, then it wouldn't last three months. Like, when you sprain your ankle, most of the time, you're not going to have swollen ankles in three months. And not only that, when we study this from a histological perspective, which means the cells, there's not that many inflammatory cells in the plantar fascia itself in any ways. Yeah. So – and indeed, in the plantar fascia, when you dissect it, it's a very thick, dense structure. So – and it gets deeper and deeper. So when people think they have heel spurs, from my understanding of what Thomas Machaud's work's done, is when you cut a calcaneus in half of the heel spur, it's actually the flexidigitorum brevis underneath that is calcified, causing the heel spur, and not necessarily the plantar fascia itself.

Well, how does a muscle calcify, become more like bone, from lack of use? Yeah. So it just means you're not using the small flexors of the foot. So that comes down to how strong you are, how well you control your foot, and how well you use your foot. Yeah. So the majority of people then with plantar fascia, or foot pain, I guess we'll say then, I mean, do a lot of them commonly have weakness of the muscles around the toes and the arches of the foot? Or, I mean, is that something they can test? Oh, they certainly can test. The easiest way is can you – and this goes into – Andrea Espina has a good video on this online.

But basically, how well can you control your feet? Can you push your big toe into the ground and lift up all the second, third – second through fifth toes? Can you lift those separately and do vice versa? Can you splay your feet, which basically means spread your toes out and send – and set one toe down at a time, like you're playing the piano? Mm-hmm. Can you fully flex – so can you balance on one leg with your eyes open and closed? Because you need to be able to do that, you know, that's a good – that's a decent test. So it was just simple things like that. But if you're wearing very supportive shoes throughout your entire life, these muscles naturally are not going to work as much.

It's going to get cast. So are you wearing like – you're wearing like five-fingered toe shoes right now? Or you got flip-flops on? No, I generally wear – Slippers? Right now, I'm wearing no shoes. I mean, what I'm – right now, right now, in my room. But when I run, I wear – I wear actually regular training shoes. What do I wear? I wear Brooke Newbelt. I wear Brooke's Adrenaline. But when I train – cross-training, I train a more freeze. There's a big movement now to get into the Vibrams. But in reality, the progression – when we look at this from Irene Davis research, I believe – the progression to get you into a Vibram five-fingers takes like three years, like changing your shoes.

And most people go straight into them. And that's how we get like stress fractures and people that get foot pain and stuff like that. And those are the things we don't really talk about. I mean, I myself went into just – I mean, I trained 90 miles a week through college, which is quite a bit. And I changed to a minimalist-like shoe just one day because I – this is in chiropractic school, like my first year. And I bruised my foot. And my feet are indestructible. I'd never hurt my feet. I'd climb mountains. I wasn't – I went to a small school up in the mountains and I'd bang my feet on rocks all the time and be completely fine.

And then just one month of training in minimalist shoes and I bruised my foot. And so, you know, and that's just one example. But if my foot gets bruised up, that's obviously – You got like a club of a foot over there or something? It's like it's got hair on the bottom? You have a hairy bottom foot? No, it's okay. It's calloused up. It used to be. Now I'm starting – now I'm starting to get – my feet are not warriors anymore. But I don't run as much anymore. Now I strength train. Yeah. Actually, on a personal note then, do you like strength training more than running now? Or is it like – did you just kind of get over it?

Or is it – I mean, do you still like it and miss it? Well, I do both. But I was a very odd athlete in college. I was a very big boy for a distance runner. I raced college at 170 pounds, which is very big for a distance runner. I was actually – my nickname in college was actually the caveman because I was so big and muscular. So now – so my constant – I was always trying to be lighter as a college athlete. So now I've got about 190 pounds and, you know, running that far, that weight isn't as much fun because I can't run as fast because I'm not as efficient. So I kind of just do a little bit of mileage and strength training.

Yeah. Because I'm trying to – trying to see if I can get up to about a 400-pound deadlift. Yeah. You're pretty close there? I've done it on a tripod. I can only imagine, like, you doing, like, a cross-country meet. Like, you just – say you fell behind, loops around, all of a sudden everyone thinks you're a Sasquatch walking out of the forest. Yeah, but – well, I did pretty well. You know, for the big guy, I was about a 228 marathon at 170 pounds, which is pretty – which is pretty odd looking out there, let me tell you. Yeah, right. Everyone else. If there was a fight afterwards, like, you'd totally win that wrestling match.

Right, right. If there was a dispute about who leaned who at the line, I'd win. Yeah. So going back on that foot thing, so I'm sure a lot of people have read Born to Run and the whole theory that we shouldn't be wearing shoes and you wear those little strappy shoes. Remember those were in style? Yeah, right, yeah. You have thoughts on that or, like – because I've had some patients that have really – like, they've talked about it. They're like, oh, I want to go this route. I really want to do, like, barefoot. And I don't know. Like, my mindset is that I feel like all those people, too, they were probably running on some type of packed dirt.

And, like, if we're running on concrete and asphalt, I think we need a little bit of a – but I don't know. I'm always afraid to just run on glass or, like, things of – like, beds of nails on the street. So what are your thoughts on the book, anyways? Well, I love the book. It's definitely one of my favorite books from college. I love that and Once a Runner. Once a Runner is the best-written book ever. But, yeah, no, I agree with what they're saying in the book from a naturalistic standpoint. We shouldn't be wearing the shoes that we are, necessarily. But you look at the population that they studied.

We're talking about runners in Mexico that grew up without shoes at all. And they only put these little tire-based sandals on their feet to protect them from the jagged rocks that go running up in the hills. So that is a completely different way of being raised. There's a completely different adaptation of forces of the foot than the common American does that's raised in, let's say, L.A., where you're at in Huntington Beach. You have to wear shoes because if you go to the park and some guy was doing, some druggie was doing some needle-based drugs last night. Definitely heroin. Step on the needle.

Yeah. Oh, yeah. I said heroin. I don't know. I didn't want to say it. But you step on that needle, now you're worried about some kind of contagious disease. That's a very dramatic, exaggerated example. But it's that thought, when you're a parent and your kids running around outside, not that I'm a parent, but your kids running outside in the grass, these are the things you think of. So we're not going to have kids run, if you're in a really big city, you're not going to run around barefoot, even though it would be better. And then there's the whole idea, well, these Mexican runners also didn't have to run on concrete, which if you bounce a golf ball on concrete and you see how high it bounces, that gives you an idea of the amount of forces that are going into your foot when you run.

And when you run on one leg, it's three times gravity, three times your body weight every time you step. Because all of your weight, it's a controlled fall. So you run, your leg hits the ground, three times your body weight, and as far as energy goes through your leg. It's a good visual, actually. Yeah, so if you have three times your body weight going into the cement, and it's hard, so it bounces back at you faster, now we have all this peak of forces, just like the ocean smashing on rock into your leg. So that's why it takes three years then to progress into these minimalist shoes, right? Right, I don't really see, unless you have a really long-term goal and you want to run outside.

If somebody was primarily a trail-based runner, I would be like, yeah, go ahead. That's a fantastic goal to eventually get into five rooms, say, half the week, and then still wearing a little bit more supportive shoes half the week, too, to give your feet a rest. But if you run exclusively on sidewalks, I would say you can do it with the proper progression. But at what cost? Because you're going to, those are not natural forces. And if we talk about, I mean, let's just talk about human evolution in general. How long have humans lived, generally, the average life expectancy before the common era?

People only lived about 35, 40 years old. It was like an old man. Yeah, they were probably getting still their peak bone density before they died. Right, exactly. And if you look at the, there's a spring. If you look in your heel of your foot, in the fat pad there, the way that the fascia is organized, it's a spring. So when you hit the ground, that fat pad deforms, and it springs you back up. So it's like free energy, essentially. Well, if humans were only, just the environment we lived, it only lived to about 40, then that, it doesn't make any sense that that heel pad was designed to last until you're 80.

Yeah. Yeah, I always wonder how long we were really actually designed to even last. The frustration of getting older and then thinking that you're still going to have the same athletic abilities, it's kind of primed for just being depressed half the time. Well, I'm nearing 30, and I'm starting to see that I'm slowing down, which is kind of not a lot. I mean, I still have energy for days, but not as much as I used to. I get tired now. Yeah. Well, I can see that shirt you got on right there. It looks like there's a, you got a nice little bacon collar going on right there. You got like a little loose neck.

Oh, yeah? Yeah, it's great. You remember that Michael Jordan commercial where he's on a plane, he's looking at, the guy looks like Jeff Foxworthy. He had a bacon neck. No, I don't remember. Oh, I'm going to have to send it to you then. I guess I don't get your reference. It's okay, it's okay. I'll send it to you. You'll like it later. I'll have a good chuckle. What was that? I'll have a good chuckle later, I'm sure. Yeah. So, going on to back to plantar fasciitis then, talk about how like someone who has plantar fasciitis, or sorry, we'll say plantar fasciitis again, but we mean foot pain. Sure.

So, what then, what were the corrective measures you would take? Actually, just someone walked into your office, or you got one of these runners that has it. Explain how you kind of go down the process of correcting that for them. Well, first thing you have to do is, I like to establish what is the pain generating tissue. So, that's first and foremost, because there's a lot of movement assessments out there that kind of tell you abnormal motor control. It gives you a category of why this is happening, but it doesn't really tell you why it's happening, because you don't know what the tissue is that is generating the pain based on the best evidence that we have.

So, I take a neurocentric approach, which basically means that I assume it's the nervous system generating the pain, which the nervous system is what reads the pain. But I assume it's a nerve irritation until proven otherwise. So, with the foot, the two big nerves that you need to consider is the tibial nerve, which is what a surgeon will go in and release on these chronic plantar fasciitis cases. So, they'll go in and loosen up that tibial nerve. Why can't I think of a wound there and there in the heel? Like a medial calcaneal or something? Yeah, that's what I'm thinking of, which is a branch of the tibial there.

At 7 in the morning, I need more coffee. And then the one that I have particularly been trying to push in the social media in the last couple of years that I've got ridiculed for is the saphenous nerve. Most of the anatomical textbooks that we use show the saphenous nerve ending, say, mid-calf. And the saphenous nerve is a cutaneous nerve that, if you look at nerve block research and surgical anatomy literature, it can go all the way down to the base of the first metatarsal or the first big toe. So, it needs to be considered an arch pain and ankle pain on the medial side of the inside. So, those would be the two areas that I would look at first.

Because if you have a nerve that's irritated, it's going to alter the way you move. So, it's going to give you – you're going to waste a lot of time doing, say, something like the SFMA. Because you're going to see a protective movement pattern that may not be present once you relieve or remove, in theory, the thing that's causing the protective movement pattern in the first place. So, I would have limited all that first prior to doing something like the SFMA. So, how would you explain – because I know people are probably thinking, well, we're still talking about plantar fasciitis. We're talking about the plantar fascia.

What does the nerve have to do with it? And then explain how you address the nerve before testing movement. Well, what does the nerve have to do with it? Well, let's look at it from a running-specific perspective. Runners tend to be skinnier. They tend to do repetitive stress. And they tend to do an exercise that is in the anaerobic state, which means – I mean, sorry, aerobic state, which means they are constantly using oxygen. Well, nerves get irritated in certain specific instances when there's a high tensile or compression load and when there's lack of oxygen. Well, when you're running, your nerves are constantly being stretched and compressed, which is one mechanism that gets them irritated, such as, say, a disc herniation on the nerve root causing – and the low back causing sciatica.

That's the easiest one that everyone knows, sciatica, pain down in your leg, and the low back. Well, if we're looking at it from the foot, that same thing happens. If you have poor control of your foot, you're going to have a rapid stretch and compression of the – let's say the nerves on the inside of the foot, the tibial nerve and the saphenous nerve. So – and then you have lack of oxygen. So you have rapid stretching from poor control of the foot, potentially, and you're not – and the nerves not getting that much oxygen because you're running up the side of a mountain. And then compound that with how do nerves protect themselves from compression and stretching – well, compression mainly.

Fat. Runners tend to have less fat. And if we look at it from cancer, a lot of people that have cancer, late-stage cancers, have a lot of neuropathy pain because they don't have that much fat. So there's not that much cushion around the nerve, and we have more neuropathies in a patient that has cancer. So it's all these things that kind of – go ahead. Well, this probably leads into the – we're looking at your stuff with the yanking, yank-away pain. So you're working into more of that realm of the superficial cutaneous nerves right along the surface that – is that then how you would address these superficial nerves or like the nerves close to the surface a lot of times?

Well, that is one way to give some background. Yank-away pain, or YAP, as it's known on the street, is a superficial nerve flossing technique that I co-invented, co-conspiracy, with my mentor, Dr. Philip Snell up in Portland, Oregon. And essentially what we did was we extrapolated on David Butler and Michael Shacklock's research on neurodynamics of macro nerves, such as the tibial nerve – I mean, such as the sciatic nerve and spinal cord, and thought, what would happen if we did the same thing to cutaneous nerves, which are closer in the skin? So the only way to stretch a cutaneous nerve that we could think of was to pull on the skin.

So essentially what you do is you pull on the skin, something hurts, you have a painful movement, you pull on the skin, and then you move again. So that would be – so that would be the idea. So if you start rubbing the skin just above your medium malleolus, the bone on the inside of the ankle, and it's really tender on the side that you have pain in your foot, and it's not tender on the asymptomatic side, the side that doesn't hurt, and you start rolling that skin up the inside of your leg, and it's all really tender, but it's not on the other side. So that could be your saphenous nerve going down into the arch of your foot, and you may just need to mobilize the skin of the inside of the leg.

And that could be a very quick and easy fix for – and in fact, one of the most common reasons that I see pain on the plantar fasciitis, pain in the foot. So this is the top three most common. So you were getting ridiculed for the saphenous nerve because everyone believed by Netters that it didn't go down that far? Is that what happened? Yeah, definitely. Miss Frank Netters did it. Well, but he was trying to make artistic, pretty pictures, and it's not really his fault. It's just that the saphenous nerve is so small. Yeah. And you can't dissect it out very well. And in fact, when you use a nerve block study, they don't even look for the saphenous nerve because you can't see it on a skeletal ultrasound.

They inject the antiseptic or like the lidocaine around the saphenous vein to get the saphenous nerve. They just hope it goes, right? Because they run together, the saphenous vein and the saphenous nerve. It's a neurovascular bundle that runs together on the medial leg. So they look for the vein and inject around it, and you get the nerve, and you kill pain in the arch of the foot. So Netter was just going off what he could see. And Netter's too, like the – if everyone doesn't know who Netter's is, it's a book that a lot of us reference. We all had it in school. It was an anatomy book, and it was an MD – MD, right?

Yeah. That just drew a bunch of badass pictures. But, I mean, that was like 60, 40, 50 years ago. I couldn't imagine he thought like his images were going to be the end all forever. You find more and more all the time. Oh, for sure. Most of the stuff I'm talking about – go ahead. No, go ahead. Go ahead. I was going to say most of the research I'm related to in the saphenous nerve is from like the last 10 years. Yeah. Because it wasn't a structure that most people paid attention to until recently. Well, so when the – so you're talking about being able to get rid of at least plantar fascia pain or foot pain by stimulating and releasing some of the nerves that are higher.

And I would imagine at this point some people are thinking, well, what the heck? I've been rolling my foot out for months now. Is this typically what happens then? People just kind of like start bashing on the foot and they're just looking for – they're going where it hurts and they're not thinking above it? Oh, exactly. I mean, it's very – it's like here in China where it hurts, you hit it. So if you have – they say tom tom, which means pain in Chinese. And what they do is like if my quad hurts, I'm just going to hit it with my hand, my fist, I'm just going to punch myself. And that's just their cultural way of dealing with pain, which is no different than us rolling out with a foam roller.

So, yeah, it's very – in our minds, we always think it hurts right there. So the problem has to be right there where I put my finger. And the body is just way more complex than that. If it was that simple, man, pain would be easy. Yeah, right. Because you just work right there and then you're done. And it should be fixed, right? Yeah. I've always told people with like – no one ever questions the arm pain and the heart attack like anymore. Like at least it's common knowledge. But when it comes to the musculoskeletal condition, don't think so about it really, you know? Right. Exactly. And I mean often the example I make is like people – especially if they've had this before.

A lot of people have had low back pain with leg pain. And you treat the back and the leg pain goes away. If they've had that, then they know automatically what's going on there. So it's like when you treat the back to get rid of the leg pain, it's the same idea. Or if you're pulling on an extension cord to unplug it out of the wall, you don't have to go right next to the plug of the wall to unplug it. You can like be 20 yards off and yank on that thing. You're going to pull the plug out of the wall. I think you're more stylish when you do that anyway, just a real quick yank. Way more stylish. It looks real cool.

It does look cool. So when you're – so now we've already kind of addressed how the person feels, then what do you do? Then let's start going into more of a corrective exercise mindset. So first I try to eliminate the pain-generating tissue, whatever is causing that. And then I'll go more into exercise-based. Now it could be the exercise that relieves the pain-generating tissue as well. I stick with whatever works. I'm just saying a general format. So I would go into the foot intrinsic exercises or maybe I established that the foot pain isn't foot pain at all and it's from the low back. It's referral from the low back.

So the treatment would actually be something for the low back or it'd be balance or it'd be – it could be one of like 20 or 30 things. Yeah. Well, yeah, I figured it would be hard to pin it down to one thing. But with the – so let's talk about mechanics then because – so this person came in with foot pain. And we don't know if it's from the back of the foot or so on, but with the – what are the typical degrade process? I mean, is there a mechanism of injury that's pretty common that most runners will get that we should be aware of? Or is it just unluckiness of one left foot or the right hip or whatever you said, you know?

I would say that if you're going to – the most common that I would – you can never point it on one thing because it's a dynamic system that's always changing. But usually lack of foot strength and intrinsic mobility. The big – they don't know how to – when you're running and you don't know how to essentially push off your first metatarsal, your first head. You don't know how to end the foot strike at the end of the first metatarsal using adequate big toe extension. That's an issue. But also, if you just don't have a proper, I would say, core endurance, core coordination, that's a good place to start as well.

I mean, if you can't do a – if you can't do a side plank for a minute and a half, then you're not going to be able to control your body after 30 minutes of running, you know? Yeah, yeah. So you have to have – you have to have foundation before you go out and run, I would suggest. So you should be able to do, I would hope, two minutes of side planks and front planks before you even started running. Oh, good. I'm glad you said that because I would imagine that – I mean, I really think people should test that too because it lets – at least have something measurable. Like you talked about dexterity of the foot, which is an awesome thing people can try.

I'm sure they're just wiggling their toes and they have no idea how to separate them. But the core function – and so when you said side plank, why did you choose side plank more so than a front plank or say a sit-up then? Well, the side plank specifically because let's say that your pelvis, which is basically your belt line, needs to be – it's an oscillating movement. But from a relative standpoint, it needs to be somewhat level. So if you're running and we go back to that right leg that you're dragging, hypothetically, and your pelvis is basically dipping, so it's falling much lower than the left side with a high energy peak, then that's going to transfer down into your foot.

So you're not going to be able to push off that right foot nearly as hard. And one of the basic – the most easy ways of addressing that, at least starting to address it, is just to make sure that you can side plank – you have adequate endurance to do the activity that you're requesting of your body. So if you want to save your time at the doctor's office, just make sure your side plank's up to two minutes. Yeah. Before you go see – you know, because – Go ahead. I'll do a lot of fancy stuff in the office to, like, you know, release the saphenous nerve, tibial nerve, do some stecofascial manipulation, ART, make them think that I know what I'm doing, and then I'll give them side planks and they'll be like, really?

Yeah, yeah. I did hear you say on the podcast before that you kind of got to wow them a little bit because you've got a baby face and you're younger. I'm kind of the same way. I actually wore a tie and all that stuff to my own office for a long time because I thought people wouldn't respect me unless I did, and I just wore a T-shirt. But you said you got to wow them a little bit, and then you give them, like, the brass knuckles of it, you know? Right, well, this is going to be an audio version, but now I'm rocking a full beard. That might help. I don't know. I think it just makes you look a little hipster now.

If you were in Stunner Shades at the same time, I would really – I don't think I'd credit you for any of the stuff you said. Oh, yeah? Well, here they are. Oh, my God. I'm just going to wear these shades for the rest of the podcast. Yeah. If you can put your pinky finger in the side of your mouth, I think I should – I'm going to take a screenshot of that. Oh, where's my phone? Oh, you stay right there. I'm not moving. Here we go. Perfect. Okay. So I'll post that when actually we have the – when we're going to release this session, actually. Go for it. But, yeah, so the – yeah, so explain that again, actually, because I know there's a psychological reason why you're bringing out the fancy stuff and then you throw in the side plank, is there – because the side plank is the main thing you care about, right, the most.

Well, it's kind of like – when you build a house, the first thing you do is lay down the foundation so that the house doesn't fall down later. So you can put it in your fancy granite countertops and, like, your Da Vinci painting, I don't know. And then – but if you don't have a foundation, the house is just going to crumble in X amount of years. So, I mean – and it's just dirt simple. It's an easy exercise to teach. It's highly effective in the research. It shows in the research, the McGill, that if you don't have it, you're more likely to have low back pain from asymptomatic controls. So it's just, like – it's low-hanging fruit.

It's easy. It's easy for everyone. Yeah. So maybe someday on my website, if I don't see much of it, I'll be like, make sure you have – you can do two minutes of side plank before you come see. Well, there was that – are you affiliated with the website, Fix Your Own Back? Was that it? Or is that just no? Oh, I'm affiliated in – I mean, I'm not really affiliated except for, like, Phil's, like, one of my best friends. Yeah. And I promote it. And I help him film stuff. I guess I'm somewhat affiliated with it. You were doing the camera work on him mainly? And some of the later stuff I'll help him, yeah.

Yeah. Well, I think it makes a lot of sense to do the, like, side plank. Like, I usually test a bunch of that stuff, too. And it's – I always find it really – I don't want to say frustrating. As a provider. But it does take a lot of conversation a lot of times for me when I test the entire knee. Say we're talking about knee. You test the entire knee. It looks fine. It looks stable. Everything looks like it's intact. They still have knee pain. Then you see grossly that they can do a 10-second side plank, you know. And then you suggest a side plank, and they're like, well, when are we going to do something for my knee, you know?

There's a severe lack of understanding, I think, from people about the foundation, like you said. Right. And that helps when you start doing – you've got to do the fancy stuff sometimes first, especially when you've got a baby face. I hate to make it sound like you're selling yourself, but you kind of are. You have to establish trust and saying, hey, just doing the manipulation and go home and do some side plank isn't really going to establish that trust. And also, other therapies are very highly effective for relieving my knee pain, and they should be done. I just happen to do them first to try to really quickly help the patient understand tissue, what tissue is being sensitive, explain it.

And then once I've explained it from a movement-based perspective, show them how a simple exercise like a side plank can help them with a movement-based perspective that I just showed them. So – Go ahead. I'm sure you're going in or out. Go ahead and continue. All I was going to say is I try to make a full circle with it. I try to show them the irritated tissue generated, and then I try to do something to reduce that generated – that tissue – whatever is generating the pain, whether it be a neuro-based – whether it be manual therapy, neurodynamics, or exercise. And then from that, I try to show them how the way they're moving is causing that tissue irritability in the first place, and this is why we're giving you this particular exercise.

Say it's the side plank, or say it's something else. And that way they understand 360 degrees of how this all relates together and how my treatment is actually addressing 360 degrees from irritated tissue to source of the problem. Yeah. I like it. Does anyone ever have – say you work on their saphenous nerve. The arch pain goes away. You tell them to do the side plank. They've hit two minutes. Does this then equate that they can move better, or that they have – do they just only have the strength to lay the foundation of better movement? Is there some type of thing that you give them later for that, or?

Oh, sure. We're just like – everything we've been talking about is like the first time I meet a person kind of thing. Oh, got it, got it. Okay. So, yeah, there's always more, and you can get as sports-specific as you want. Over here in China, I have the opportunity to work with athletes every single day so I can monitor their progress, and I don't have to worry about insurance reimbursing me or something like that, you know? Do you have to take notes, actually, in China? Or just – because you could probably remember them all off the top of your head. Should I say yes? Well, yeah, you're right.

I don't know. Just not – we're not on video, so just nod at me. This is for my own. Okay, so no one knows what that was, but just in case everyone does know, note-taking sucks. Note-taking really sucks, but it does help the writers out, remember. But I would imagine, like – go ahead, go ahead. I work with the same athletes every single day, day in and day out, so it's like there's not – I mean, it's really hard to forget what you did. Oh, yeah. Because it's every day. It's like hanging out with somebody every day. That's what I do. Yeah, you probably know their bowel movements and, like, who they're dating and what they drink for – what kind of coffee they get and all that stuff.

Well, Chinese don't really drink coffee. They're weird like that, but – I'm always like, coffee, coffee, coffee. And they're like – they look at me like I'm weird. You are a foreigner. This is true, and I am from the country, but they drink their tea, which is good, which is good as well. So I'm guessing that since we're about almost 15 minutes in here in the podcast, I started with saying that we're going to talk about three things. We're not going to. I think we're just going to finish off with this foot – we haven't done a foot podcast yet, or I haven't anyways. Is there anything you want to add on foot pain really or, like, any other thing that you've been noticing that, you know, like some nuggets?

I know all the chiro students and PT students are probably going to say, I want something that's takeaway. I want something real good. What have you been stealing on? I would say that foot pain – if you want some nuggets, here's two nuggets, two things that I would say will address 80% of every foot pain you've ever seen. I like the number 80. It's good. It's not everything, but it's, like, 80% of the time. If you eliminate these two things, you're going to get some kind of positive treatment effect. Okay. One – first off, let's just assume that the foot is not the problem because most of the time it's not.

Clear and screen the low back via McKenzie protocols. So repetitive end-range loading into extension. Okay. You will be amazed at the amount of foot pain that clears up if you just treat the low back. I'm guessing especially both-sided foot pain. Not even necessarily. Oh, okay. Got it. McKenzie protocols. Everyone, I'll put the show notes – I'll put McKenzie protocols on there, too. Yeah. That's a big secret. I always wow people with other seminars. Okay. Number one, McKenzie. Second nugget. Second nugget is screen that saphenous nerve. If you have somebody that comes in and they've been to Graston, they've had ART, they've had some decent rehab, it's probably either what I said before, a referral from the low back, where it's the saphenous nerve talking to them.

And the easy way to do that, really, is just to check for skin sensitivity in the medial leg and do a saphenous nerve flossing, which is basically just a lateral lunge. Go to tension anywhere in the tissue in the medial leg and then back off immediately and then do that 10, 15 times and then recheck the foot pain. Okay. I like that. If you guys want to – if you want to know more about the yank away pain stuff, which I have the entire body – Phillip and I have the entire body mapped out all over the body. The foot is just one example. But the headache stuff and the neck stuff is unreal. But they can check that out at yankawaypain.com.

So when you guys are showing this stuff, is it mainly actually hand-on skin? Because you described a movement right there, which is kind of the same mobilization, right? Right. All you're doing is pulling on the skin in very specific locations where the nerves are known to be close, very close to the skin. So you can get traction on them very easily. Okay. I like it. I'll put that in the notes too, everybody, so in case you're looking for it. Okay. So give me a couple more things too of what are two things that runners with foot pain could check on themselves besides – well, because we just talked to the clinicians.

So two-minute plank – or sorry, two-minute side plank? I would say two-minute side plank is very easy and everyone can do that. There's no real argument on how to test that. And then I would say, honestly, make sure you can lift your big toe. If you don't know how to lift your big toe just standing there, then that's like doing the side plank. I mean, that's like low-hanging fruit. If you can't lift your big toe, you're not going to be able to use what we call a windlass mechanism that integrates the foot into the calf, to the hamstring, to the glutes. So if you can't lift your big toe, that's a big – here's an example.

I was working with Paul Chalimo in Portland, and he's having Achilles pain. And Paul Chalimo ended up getting the silver medal in the Olympics in the five game. And he couldn't lift his big toe. He gave me permission to share this information, just so we all know. He couldn't lift his big toe. I'd squeeze his Achilles. It would hurt. I'd lift up his big toe, squeeze his Achilles again. It wouldn't hurt. I taught him to lift his big toe. This is the second-fastest runner on the planet at the Olympics. And his Achilles pain went away. He trained that for a bit. His Achilles problem was no longer an issue.

So he was only just – he was only lifting it actively. He wasn't passively lifting it, or was he doing both? He couldn't actively lift his toe. He didn't know how to lift his toe off the ground. But he had passive motion, though, on that, right? Oh, yeah. I'd lift it myself, and it'd be just – it'd be 70 degrees, no problem. Okay. Got it. So he just – he didn't know how to actively do it with his own brain. So he didn't – later on, just to recap on that one, too, is – so did he ever – they were just mainly him sitting there practicing to lift his toe. He didn't load it with a band or anything like that.

He didn't play with sand. Not that – I only worked with him a few times, so we never got that far. He started doing traveling and meet schedules after that. So next time I saw him, he was in the Olympics. Okay, cool. Playing the silver medal. Cool. Play with people's toes. Got it. Okay. Cool. I guess we'll just – I guess we'll wrap it up here. Is there anything that you want to add? How can – are you going to – when are you going to practice in the States again? I don't know. You might not come back, huh? Well, actually, I'm considering going back to – I'm considering coming down to California afterwards.

We'll see. Maybe L.A. or San Diego or something. But I've gotten – I've gotten interest or job interest in working with the Filipino national team and other jobs in China. But I'm kind of sick of China, so. Yeah. You must be a minimalist, too. Do you have any – like – do you have like five T-shirts and like two pants on that computer? Kind of. No, I got more – I got like a suitcase full of stuff that I wear. Only five T-shirts and two pairs of pants. But yeah. Yeah, I'm a minimalist kind of guy. I like it. They had a – there was a documentary they did recently on Netflix. It was on – it was called The Minimalist.

It was amazing. Like homeboy, like he like walked around with I think only two – I mean, they almost come and look like mercies, like man purses. There was only like two of them. I don't know how he got around with that. Really? Yeah. If you haven't seen it, you should watch it. You'll like it. If you just do your laundry every day, you can definitely figure it out. I learned to be a minimalist over the last few years because of doing – teaching seminars and going to seminars. Last year, before I moved to China, without December, I flew or went to 34 different seminars last year, 2016. Jeez. Yeah.

It was crazy. So being on the road that much – and I was working in the clinic four or five days a week too. You just do weekend ones? Yeah, yeah. I was hustling. Yeah, you learn how to basically be a minimalist doing that because you have to. You don't get attached to one toothbrush because you probably left it in a hotel room somewhere. Actually, speaking of that, yeah, I have like – just here in China, I have like seven toothbrushes. Like as I look at my desk, I have two next to me right now. Wow. Well, I'm pretty sure it's safe to say that if you're not – if you are a minimalist, you're a hoarder of toothbrushes then.

Yeah. That's the only thing I'm not a minimalist. Like I have a toothbrush – it's like you know, you've got to have a toothbrush in your car. You've got to have a toothbrush in your backpack and your bathroom. Well, I really want to hear the other four spots really because I agree with those three. I don't agree with the other ones you're going to come up with. Yeah. At the girlfriend's house, you know. I don't know. I'm just making stuff up now. I don't know. Yeah. Well, cool. Then let me – then I'm going to close the podcast out real fast here and just stay on for a minute. We'll talk after real fast, okay?

Yeah, no problem. Cool. All right. So, everybody, that was Justin Dean. Again, I will put all of his links on the show notes there. I know we only went into foot stuff, but he's got a lot, a lot more information to share. So, again, go to p2sportscare.com slash podcast, and I'll put all the show notes there, and I'll put how to contact him as well. Yeah, if you end up being in L.A. and San Diego, everyone should go see him. He's got a lot of good big toe stories I'm sure to share with everybody. So, cool. Yeah, so thanks for listening in. And, again, p2sportscare.com. If you have not listened to it on iTunes, please do so.

Subscribe, and please share with friends. So, a lot of these people I have on are really, really good. They're really knowledgeable. And I think to further everybody's education in sports injuries and in pain, then we really, really need to share podcasts like this and other good ones with good interviews on it. So, I'll talk to everybody soon.