We're going to try not to talk about highly technical things,
but once again, thank you for giving us this half hour.
So first a little intro why we're each going to kind of tell
a little story of a patient that we have and I find we both of us
with physical therapy and and in Podiatry, treating people every
single day with plantar fasciitis.
And I want to give an example of a woman that I was seeing
recently. She's a 35 year old female.
She came in and she had been dealing with heel pain for three
years and she kept on hoping that it would go away.
Initially started when she was trying to work out for exercise
to shed a little bit of weight after having a couple of
children and it never got a never went away.
And so part of her reason for keeping active is, she was
trying to lose weight. And when you have really bad
healing, you can't do anything. It's debilitating.
So for me, when I was able to treat her, send her over to
physical therapy. Therapy, do some different types
of treatments. I think she had some shock wave
therapy and things like that getting her into Orthotics, she
could be active during her recovery.
So that's kind of why I like to help people.
And Joe you had a marathon patient right recently.
Yes I have a marathon patient right now she's at the mid
14-mile running to distance. It's just I'm becoming having
foot pain. She's in physical therapy, were
taking care of the foot pain, but we still going to keep her
cardio up. So we're having our do things
like swimming getting on the bike.
For that two hour mark and keeping that heart rate where it
is, so she can keep her cardio while she's still training and
still getting better so she can get back into the Running part
of it. Yes, I think that's key is
keeping people active so they can either lose weight or run
their Marathon or you do not have to switch boards.
But I do tell people once in a while, you know, if you have a
for example, other things like a stress fracture.
That might be a good opportunity to kind of learn another sport
like swimming or something else like that.
If it's to debilitating So let's get right into it.
The two types of heel pain that we're talking about I would say
90% maybe 95% are something called plantar fasciitis and
achilles tendonitis. Now the reason we're talking
about heel pain generically is because both of these, if you
look this is the heel bone or the calcaneus both of these
insert into the heel, the plantar.
Sure inserts into the bottom in the Achilles inserts into the
back. So in my opinion, to pretty much
the same thing and they're treated very, similarly y, you
get one versus the other, maybe a flip of the coin, there might
be some what we call biomechanics, or how your foot
structure is or how tight you are, but a lot of people they
come in with plantar fasciitis and then maybe later on.
They'll develop achilles tendonitis and I think the big
culprit is the back. Back of the calf and no one ever
complains of back of calf pain. And when I bring up, you know,
working the back of the calf or working your core, or working
your quads, or your glutes, or your other things more up, or
more proximal, everyone wonders. Why?
It's because the foot is just a symptom of what's Happening,
higher up. And so that's why it's
essential. If you really want to get rid of
it and avoid injury, you have to work on everything else.
Hi Up. And you're all it is is how your
body moves over your foot. So if your body is moving over
abnormal, abnormally, that needs to be fixed specifically in your
pelvis. That's a big area or hip range
of motion. Another thing that people should
know of some they actually have degeneration of the tendon.
So you can see here this is a thickened tendon and it develops
Scar Tissue. That's called a bulbous.
Looks like a bulb. A bulbous change in the
Achilles. Now if you think about it, if
you have a A piece of string and you tie a whole bunch of knots
in it that string is going to reduce in length because it
takes up space those knots and it's the same thing in the
Achilles and the same thing of the fashion you're going to see
later on when I talk about the ultrasound it gets thicker if
it's thicker it inherently gets shorter when it gets shorter,
it's going to put more strain on those on those tissues.
So in my opinion I think about 80 percent is due to tight.
Tightness in the back of the calf that then leads to Achilles
tendonitis, or plantar fasciitis, for some patients
that can be caused by flat feet over pronation increasing your
activity. The big, the big story I get is
people, they go to Disney and they don't have plantar
fasciitis, and they come back with plantar fasciitis,
basically, because they've been on their feet for six or eight
hours a day and they're in flip-flops.
And then the, yeah, and on cement and they're walking a
whole bunch, or they're starting to Work out there trying to do a
marathon or half-marathon and then they get it and it never
calms down if you get help right away, it can calm down and it
can you can get help. What I was talking about in
terms of the Imaging, you can either do an ultrasound or an
x-ray. We always get x-rays first to
see if there's any bones for, but it's not as important in my
opinion, if you have a Spur, not a Spur shows that you have
traction on either the faccia or on the Achilles.
So basically this is an example of the right plantar fascia.
This is the heel in, this is the fashion, this little fibrous
thing. If you pull hard enough on this
bone, it's going to create a Spur out here, that's called
Wolff's law, your body, it responds to pulling over a
period of time. So the goal is to reduce that
polling or that traction but what happens with the faccia, if
it's been there for a while, you can see this thickness, the
distance between the two A's and then the distance right here
between the two ways, this it looks darker looks black and
it's thicker. That's chronic.
Your fashio says it gets thick and over time if you're looking
at an ultrasound in a patient that just has plantar fasciitis,
it's going to look the same thickness in the same color.
If it's been there for a couple of months, it's going to get why
it's going to get black and it's going to get thicker.
And that means there's chronic effusion or swelling inside of
that tissue. And you may need a different
type of treatment to get rid of that.
The longer it is, I usually use three months, if you've had it
for three months, you're going to probably need some of the
more advanced treatments, if it's less than three months.
You know, you came in sooner but most people don't come in right
away. This is a lengthwise evaluation
of an Achilles. You can see this little black
line. So it's looking right down the
Achilles and this has a little bit of a tear right in that area
and then it's thicker. Once again this thickness is
kind of like scar tissue in that doesn't allow it to be as
flexible and that needs treatment and you know, get
kill. He's is a hard area because you
can't really do a cortisone injection to that because it
could cause a rupture. And so that's those are kind of
the Yeah, they aspects of the energy so just going to talk a
little bit about stretching here.
So stretching is key and that's what we kind of promote.
When the patient comes in will ask them what they're stretching
program is. And they're probably have
nothing at all. They just know, I just go
running. I just go exercise and I don't
have time for stretching so most of the patients that are here
from physical therapy because they don't stretch.
So we'll go over a nice routine of good stretching will make
sure that they know the stretching, they have the
stretching of the pictures word, so they can work on their own
stretching along with that, we do the foam rolling.
Make sure their pelvis is aligned, make sure all the
joints are working, so that the whole leg is working for the
foot and the foot is working for the legs.
So, Joe talked a little bit about your habits.
Let's say someone has Achilles or plantar fascia.
How many minutes do they need to dedicate to stretching or here's
an example of a foam rolling? How much time are they gonna
have to? We usually film about two
minutes per muscle area. So they're going to get on their
Catholic and go back and forth and get to work it out for a
good, two minutes different angles so they can take their
foot. They're going to Is the foot
angle back and forth like their Comic-Con was like running in
and out. Try to hit the different fibers
of each of those muscles. How many times a day it's up to
them. At least once or twice.
But if you know they're exercising, run, we want to do
before and after would just to keep everything nice and loose
and shouldn't hurt. Is it okay to hurt?
It's Gonna Hurt, it's just that determining.
What kind of heard it is a bad hurt that we have to hold off?
If it's a good working her that's still okay?
And after we can ice and stem or whatever they want to do to kind
of calm down, And then how about those those those the the people
run pushing against the wall, the runners stretch here,
letting your heels go. Down the E Centric, contracture,
explain that a little bit, those types of stresses of nice.
Good, lengthen and stretch. I usually tell them not to
stretch to the point where it's painful.
It shouldn't be too painful, but should get a good comfortable
stretch out of it. Yeah, I think a lot of times you
go to see a doctor and they'll just recommend stretching
Primary Care. You go to your primary care.
They're going to recommend a shoe insert, maybe a new shoe
and then stretching and time. Andres icing and fed doesn't get
better. Then the probably send you to
physical therapy or to see a podiatrist, I think foam rolling
is in deep tissue, work is key. And then if so, I basically foam
rolling, is that two to three minutes on each muscle group.
Maybe I say ten minutes in the morning, ten minutes at night,
that's what eyes. And then during the day you can
do your stretches like if you're at work or if you're at a stair
or something else like that. But you have to become part of
your routine. Now, even when they recovered,
do they have to continue doing this?
Yeah, they'll keep them out of the doctor's office and other
PC. Keep working.
Keep stretching keep foam rolling.
Yeah I think a lot of people all the time and you can speak
better to that but everything gets kind of tight and then
people start working out. I go to Disney or something like
that. And they Wonder well how come I
developed heel pain or something like that for sure?
Yeah. Okay, talk about this here,
what's this? All right, so another way we can
adapt the tissue or a kind of break up that strategy called
fiberglassing. So, we have tools and see the
tools up here. Use the tools that people love
to hate because they hate it when we do it, but they love it
after it, because they feel so much better.
So, basically, we are digging into the muscle.
We're breaking up while the fibers and we're stretching it
out, so we'll do it at different angles at different points, it
will do it action, but movement, sometimes just so we can break
up those five or so we can get The muscle working better.
It's what technologically, what is it doing to the tissue?
Is it lengthening? It?
Is it helping it to repair? Or what is it?
Doing all the mom. So basically we're breaking up
the scar tissue, increasing the blood flow, and we'll do it at
different points of the joint angles so that we can hit
different areas of the muscles. Yeah, and so what Joe's talking
about on that ultrasound when I showed you that it was thicker,
I guess you could call that scar tissue or a thickened tissue and
then he takes this any, any rubs it on that area.
What I find is that when you do treatment such as this or shock
wave, it can actually thin down over time, that swelling goes
down from within that tissue and it can thin it down to more of a
normal level. But just like, scarring,
anywhere else. For example, if you have a
surgery or if you have a cut it's going to be initially,
swollen thick and scarred. And then over about six months
to a year it's going to remodel and it's going to get That
thinner little line, you're always going to have a scar but
the whole goal is that it's not as swollen and part of the
problem is we never stopped in a.
We are always busy, I find especially kids.
You know, we don't see this as much in kids but like we're
going from one sport to another sport.
Were either sitting down or very active and no one gives anything
a chance to kind of rest and recover.
So it's an issue. How important our shoes Joe She
was our key. So we have pronate and supinate
has in neutral feet and most Runners.
Even there if they've been doing multiple marathons, really don't
know about their feet. You'll find a particular sneaker
and they'll just go with it and more likely are in pain.
But once we see them will evaluate their foot to see if
which, what type they are. And there's different shoes that
fit for different kinds of fees, especially for runners on the
top, right? You'll see the new balance, you
see the yellow band in there and that's a guys, it's a pronated.
So it's an anti pronate. So it's a bar It's somewhat like
let your foot came in as much and that will cause the
pronation pain cause deep and right up to the hip pain for
these Runners. The one on the bottom is more of
a neutral, you can see where it's just basically nice, good
Soul, nice cushion, soft as someone that has it more neutral
foot and needs that needs to be able to select just like through
when they're going through the running process and that's after
afterwards when you feel nice. And so again it's a nice good
sandal like that. It just makes you feel good.
Yeah, I keep it real simple. One asked me.
Hey Doc, am I gonna have to wear ugly shoes?
The rest of my life. I say.
It's for now. It's not forever, okay?
And I say when you're at home, if you don't want to wear shoes,
I like either a new foe or there's a Hoka sandal something
with a really good arch support when you're when you're at home
or it's a better alternative to a flip-flop.
Now, you can tell something's good when you give it to your
mom. So when my mom came and visited
me, she had bunion surgery and I put her in these things and she
absolutely love them. It could be from the cushion,
could be from the arch, but there's a lot of things.
These shoes are great. Now, specifically, I want to
talk a little bit about a little to get a little technical here,
a lot of shoes. You can see here, it's thicker
at the heel than it is at the toe.
And it has this little curvature thing here.
So, this is kind of like a little rocker in the front of
the foot. And this is a probably, a five
to seven millimeter drop what that Ins is the height here,
down to there is about five millimeters.
This works well with someone, with Achilles tendonitis and
finer fasciitis, because if you have a group called a zero drop
shoe or it's exactly the same height that's going to put more
pressure on the back of the Achilles now.
Even though I do recommend a lot of shoes that are zero drop, I
find that when you're recovering from one of these conditions,
you tend to do better with the shoe with a little bit of a heel
in it. Is that what you find as well
for sure? Yeah.
Some of my achilles patients I'll ask them.
Have they changed their shoes and then someone will go from
the zero drop two and another sneaker or Nike sticking with a
higher heel bed and that's what's probably given the issues
are going to a higher arch for actually lower.
Look down and see where you're at, in terms of shoes.
Can they go to? Like I said O, My People sneak
around Mama, we have a script will write down the script, it
will validate the foot. They look at the script.
They look at the sneakers, they'll choose they'll give them
three or four options and that's how we usually do it.
Yeah, the real key is you want to go to a place that We're
going to watch you walk and they'll be able to get something
that's appropriate for you. You know.
I can't emphasize when you're when you're starting to deal
with heel pain. If you're if you're just in the
beginning it's about its shoes as key.
And you may say oh I have tons of shoes.
I particularly don't like some of these cuter shoes, the
Skechers, the Nikes, the things like that, they have really kept
up with the technology, whereas the New Balance, the Saucony,
the A6 and things like that. They have a better shoot.
Now, for those patients doing to come in and say, you know, you
know, Joe, I tried I'd 10 shoes in my heel, still doesn't feel
better. What do you tell them?
That's when I you should promote doctor Pelt, 04 Orthotics.
And, you know, we'll take them, see how the taping feeling if
that feels. Well, go see, dr.
Kelso for Orthotics, and we're from there.
Yeah, Joe that's the key is like if you've tried 20 pairs of
shoes and the shoes of hurts, and it only hurts on your right
foot because your right foot as pain pressure to the problem
isn't the shoe don't go buying more shoes and don't you can
spend like thousands of dollars on Amazon trying to buy every
single thing don't do that. Save a lot of time and a lot of
money by seeing someone. So, how about activity,
modifications, if your want to stay active?
Sure. So, if the running or the
walking part hurts, this other ways of doing it.
So, you're walking or running on the cement or Tire, you can get
you onto a treadmill or you can go to a track.
That's a lot softer. That'll help out a little bit.
You can do some cycling cycle, will keep you going but I won't
put a lot for stir that through your foot.
Strengthen your core is always key and then for some people if
they're running, if they're doing a marathon and they can't
really put a lot of weight, we'll get him, the pool and
we'll do some In the pool that will burn them out real quick.
We'll give them the all the exercise but it won't put all
that force on that foot and there's a special pred know that
they make right. The that was a cup of G-Force if
you're for yeah and you're pretty much sit in a saddle and
then it you can take off 50% of the way, 30 percent of the
weight. And you can still get that
cardio that you like that's a good option if you're having a
lot of pain. Now, how about if someone let's
say Joe someone has pain when they get up in the morning but
when they do their stretches and things like that, everything
goes Away. Can they be as active or how do
you determine how active you can be?
Yeah, they can be a source is the pains gone.
Let them do what they're workout.
It is and it's all by space on the pain.
If the pain increases that we have to slow down a little bit.
Yeah, I always say if you're limping and if you're changing
your gate, or if you're going to injure yourself because of
because you're a cheap accommodating, how you're going
to injure yourself, you're gonna have to go see Joe, you're going
to throw your hip off. You're going to throw something
else off because you're changing your gate.
If it's that level you're going to have Switch your activity
temporarily until you get calm until you calm down.
So I'm going to talk a little bit about some of the initial
treatments. I'm not going to go into detail
about all of those like hundreds of treatment, but a few things,
if you're trying to deal with this, something that you may not
have heard of is something called a contrast bath, and
everyone knows about like taking the bottle of water and rolling
on the bottom of the foot or a bottle on the back of the calf
of ice water. But a contrast bath, if you've
never tried it, you take a bucket of ice water in a bucket
of hot water. You know, you don't want to burn
yourself and You five minutes in the ice water, five minutes in
the hot water, and then 5 and Ice.
You always start and end in the ice water and what that does is
it, basically restarts reboots the computer.
So it's going to cause the ice is going to cause
vasoconstriction. Meaning it's going to shrink
down the the hot water is going to vasodilate, it's going to
swell and then it's going to shrink down again, it's kind of
shocking the area to help increase the blood flow, all of
its blood flow getting to that area.
So if you want to think about it, if you want your body to
heal itself, you have to have adequate blood flow and there
are things that can restrict the blood flow.
Okay. And that's what we're going to
talk about anti-inflammatories. I don't do more than two weeks
of an anti-inflammatory. It can be used temporarily.
If you like okay I II once in a while you do a prednisone, not
too much. I'm not too much of an
anti-inflammatory person. I think you should work on the
treatments of getting rid of the pain.
I want to talk a little bit about offloading.
Now, the reason I want to talk about this is because if you
want to stay active, you're going to have to take the
tension off the faccia or off the Achilles and there are
different levels of pain reduction.
I'm going to start with the kind of the most severe so if your
pain level is 8 9 or a 10, what we call an on that visual analog
scale. Basically you look at the
frowning face and a happy face. And if you're if you're
basically a limping around, you're going to probably need to
be in a walking boot for a short period of time or if you have a
tear or something else like that.
Now the key I you see so many people they come in with the
boot but then they complain of hip pain or back pain or
something else like that. That's why I just want to take a
moment to talk about this thing. This is called an even up.
So if you ever get a boot or if you ever see someone that has a
boot in there, limping around you have you can use an even up
or you can use your shoe with a little bit of a heel so you can
just Mine on Amazon is called even up.
So that's the worst amount of pain, the next, the next kind of
the if you're if you're only in moderate pain, there are two
options. What is called an air cast in?
The other one is called a velocity brace and I want to
explain both of these. The purpose of these are to be
used temporarily, okay? Just like the boot.
You're not using these forever, the are past.
It has a bladder of are in the bottom and a bladder of are in
the Back of the Achilles. So as you're walking, it's
pushing the air back and forth with a little tube and it's
massaging the back of the Achilles to increase blood flow.
And it's as you push here, it's taking pressure off the heel so
it can be used both for plantar fasciitis, and achilles
tendonitis, this isn't my first go to that.
These are for people that have quite a bit of pain and you do
this, I would say for two to four weeks, For patients that
that need more stability to avoid pronation.
This is called a velocity brace. It's kind of like an afo.
An afo is an ankle, so it involves the ankle and a foot
and it's an orthotic. So it has a little orthotic
piece in the bottom, and it also has an ankle brace.
So this won't allow people to invert or E vert.
It won't allow that pronation to happen and it puts less strain.
So specifically patients. Have posterior tibial,
tendonitis or tendinitis on this tender on the inside or a lot of
flattening, they're going to work.
Well in this, another reason that this works well is because
it works in one unit. And what I say is my expectation
is about 30% of the pressure is going to go into the lower leg.
So it's going to attenuate or take the pressure off the back
of the Achilles and off the faccia, input it into the lower
leg. It's a lot easier to get used to
this. That it is a big bulky boot.
These are both. 'The only used I would say two
to four weeks when you're in the recovery period, I don't use it
for a long, long time. Once people are feeling better
than I'm going to transition them to an orthotic.
In the way I use Orthotics is I use it to correct posture?
Okay. Go ahead.
So our thoughts are different types.
You can try an over-the-counter insert and there are different
ones once again, if you're going to get an insert, please don't
hope dr. Scholl's isn't listening but
don't get a doctor, Scholl's. They're overpriced, and they're
not doing anything where I would recommend is going to sneak
around mama. And what you're going to find is
you're going to find an over-the-counter insert.
There's like a spend Co something that's more rigid
because when it's rigid, it's actually doing something
patients, can start with an over-the-counter one.
But the main key, and I want to explain this for everyone is,
when you have an orthotic, they did some research and they found
that with the faccia, the higher, the orthotic Contours,
as to the foot, the better, it takes the strain and stress off
the fashion and what you'll find is a normal.
Insert is going to be a big gap between there in that Gap.
Still allows pronation and it doesn't take as much strain off.
That's the reason we do a custom one because it basically sits
right with the arch and it that takes more of the strain off and
you just can't do that with an over-the-counter because you
don't have an over-the-counter foot and no one does.
But for a lot of patients in over the counters, a good way to
start. And if that's not enough, then
we'll move some Into a custom orthotic.
And that's, and that's, and they're made to be used, maybe
not the rest of your life. Everyone asked me to have to
warm the rest of my life. Probably not.
You're going to wear them until you feel better.
And then for certain types of activities that could aggravate
your plantar fascial, anything else you want to say about
these? How about a patient that has the
Orthotics. But there's still having pain
and if I tape them, they feel better.
Yeah. I think taping is great and I
don't tape you guys tape. I think what taping does is it
holds everything in proper Ian, I a lot of a lot of doctors what
they do is if they have a custom orthotic already, then that
custom orthotic isn't contouring enough so you may need something
that's even higher. Yeah in the big problem for us
going to high is that it's not going to be comfortable.
But doing a higher one is going to feel even better.
That's why that taping feels good that extra support but you
can't take for the rest of your life.
No. Do you still have to kind of get
that, get that area down. You may need a higher contouring
or thought because there are a lot they are there.
A lot of places around the they say it's a custom orthotic.
But it's really not. They see how it's made for you.
You step in a box or something else like that, the way we do it
as perfect a 3D scanner and we make it specifically for you.
So you have to go to a place. Yeah.
Are they going to be more expensive?
Yeah. But these over-the-counter ones
the last maybe six months and you have to change it.
So and then I want to talk a little bit about questions about
doing a cortisone injection and then there's a new type of
therapy called Shockwave. So, the way I think about it is
it, if you're in a lot of pain, if you're limping around, if
you've had this and you just can't function in life.
And so basically, if you're looking at an eight, nine or ten
pain, You can't tolerate Shockwave, you can't tolerate
Physical Therapy, you're going to be living around.
You can't do anything. So for patients, like that, if
it's in the heel, I will do a cortisone injection, okay?
If it's under eight, if it's seven or below and then if I do
an ultrasound and I see that it's thicker, that's where I'll
recommend the shock wave now, I don't do this.
Usually first line meaning. What I do first is I say, change
your shoes, try the inserts, try the ice, You can try the
anti-inflammatories if that doesn't work, then what I tend
to do is I switch to the shock wave, and the physical therapy,
okay? People start with the foam
rolling and then if that doesn't work, then they go into the
shock wave in the physical therapy.
What? How this works?
There are two types of shock waves.
But you see, this little thing that looks like a bullet.
This bullet runs back and forth, and it hits this piece of metal
in a create something called radial shockwaves, okay?
There's two different devices we have One that's focused in one.
That's radial, I'm just showing you the radio one, this is the
one that we've had for a number of years.
But what does it do? Basically areas that are
chronically, injured like the fashion in the Achilles tendon,
they get thick and they get scarred.
And if you know anything about Scar Tissue, it doesn't have the
best blood flow. The flow is bad.
And what what, you try to do with your breasts and technique,
or there's another Physical Therapy modality called dry
needling, and That, what that does is that tries to increase
the blood flow to the area. So your own body heals it.
Okay. And that's what this does.
I whack the heck out of it and it increases the blood flow.
So during the course of treatment with shockwave, you
can't do any anti-inflammatories Motrin ibuprofen.
You can do Tylenol, two days before and two days after, and
we do between three and six sessions in what that does is
that increases the blood flow to the area.
And it's Matt, it's almost like magic and it takes away the
pain. There are some other Advanced
ones. Well like platelet-rich plasma
or amnio injections, we might do those if there's a tear or
something else we specifically see on the ultrasound but this
is our go-to for treating. I used to do ton of cortisone,
but what I found with cortisone, I had a patient today.
I did a cortisone, he had a four weeks ago and he was feeling a
little bit better for about two to three weeks.
And then all of a sudden, all the pain came back.
The reason for that is cortisone, only lasts about
four. Four to six weeks depending on
what type you put in. We do a combination of a
short-acting and a Long acting and then what I find is, what it
wears off. If you don't change the tissue
or the structure with the foam rolling and the physical therapy
in the offloading, it can come back, not for everyone but it
can come back. But what this does is it
actually heals the tissue. What's been your experience?
With this drone we're seeing a lot more patients, those truck
where they usually like it. They'll come in will do the
stretching and the check out the pelvis, getting all the joints
working, and we're just work with their pain level and
getting them better. Yeah, I think it's A real
practice changer, especially in the Achilles on the back and the
Achilles you can't do cortisone because it could cause a
rupture. So we really didn't have any
options besides doing a surgery. If there's a big bump back there
or something else. Now with patients that are not
coming from a podiatrist that have heel pain.
What I'll do is I'll show them the book by Don Pelt.
Oh and open up the page which Shockwave so they can read about
shock wave that I'll do you give them the card so they can called
on and see if they can do the shockwaves for them.
Yeah. I I can't, I can't it's really
been a practice changer. There's been an only a few
things subbing in this remote on over 10 years now.
But this has been a practice changer and it's something
that's it tended to start. I'll tell you a little history
of it. Shockwave, it started in Germany
and it was used to break up kidney stones.
So what they did is they put people in big things of water
and they still use it to this day and they shoot these sound
waves with his huge shock wave machine and it broke up the
kidney stones. But what they found is that
people with chronic back I mean, because a lot of times back pain
is caused by the tightness in the muscles, their back pain
went away and they're like, hmmm.
I wonder why their back pain went away when were treating
their kidneys and then the machines got smaller and
smaller, and instead of putting people in water, now we put
ultrasound gel on it and what we're finding and it's not just
using the foot. It's used pretty much everywhere
in your body for area of chronic inflammation to help it
naturally reduce it and I think the reason they do it more in
Germany, is it might because I think it's covered by Insurance
there and they're more natural than we are here.
We're Like running the surgery there.
They do everything they can to avoid surgery because they have
public health and it takes forever to get a surgery.
So that's why they have some of those other options.
There were a few questions that people ask.
So I'd like you, if you're listening here and you have any
other questions, put it in the chat box right now and we're
going to start answering the questions that were sent over
previously and then we'll answer the other ones that people are
putting it to us right now. So I'll ask you Joe, is it best
to avoid impact exercises? Like aerobic exercises, while
you're healing it all depends on your pain level.
If you're able to do the exercise without causing
increased pain, then it's okay if you're doing the exercise and
causing more pain, that means you the tissues being
overwhelmed, you got to cut it down and that's where we can go
to the cycling. You get the swimming, you got
the elliptical. That's not pounding as much, but
still give me an aerobic capacity.
Yeah, and I would say, try doing the shoes And the the offloading
with, either an orthotic, or something else to see how it's
doing, or even one of those braces like that are cast, that
you mentioned to me, that perfect, you could probably stay
being active with that. So how do you know what the
balances between pain and exercise therapy for achilles
tendonitis. I don't, if you have any ideas
here, the pain. So it's there's good pain in
this bad pain. If you're in that bad pains
Zone. Once again, you're over texting
that tissue and it's not going to get better.
So we going to cut it back here with otix global you're
stretching. The scraping, comment down in
the build from there. Perfect question, 3 plantar
fasciitis versus achilles tendonitis treatment, any major
differences any studies and this was a saint by one of the
colleagues from physical therapy.
I usually treat them pretty similar in terms of PT
treatments in terms of plantar, fasciitis.
I think there are almost exactly the same.
The only difference is, I think plantar fasciitis responds, much
better to orthotic therapy than achilles tendonitis.
Achilles tendonitis, there's no, not really Many studies about
responding to to orthotic therapy.
I find that Achilles tendinitis tends to respond a little bit
better to heal lips. So putting a he lifts in there.
Taking the pull off temporarily, that works for Achilles
tendinitis also treatments in terms of what I do.
I don't do cortisone on Achilles, I can do it on plantar
fasciitis, the Shockwave is all the same, all the other icing
anti-inflammatories, PT is pretty much the same, anything
else that you do different for both of you.
I usually go after the hip if the hip has really poor range
emotion when they're walking or running their always hitting in
that same spot on the heel. So I Really Work the hip get
that range of motion better. So they have multiple angles
when they're walking, they're moving to different spots.
Perfect. So, Joe which shoes are better
or worse for it. We can address that but yeah,
there's so many shoes out there. Once we evaluate the foot, we
figure out your opponent is super neutral.
And we sent you over to the Seeker stuff, they'll get the
shoe on for him and from there we can evaluate, which you can
works for best for you. Yeah, and Joe, does it ever go
away? Does it ever go away?
It should. But if you don't do your
stretching, you don't do all your exercise.
You don't do what you're supposed to do.
It's going to creep back and basically just going to keep on
doing it or you can come back to us and we can figure out again.
Yeah, I so I guess there's two ways of thinking about this
question. It might go away and then come
back. If it's Coming back.
It tends to be something structural that you're going to
need physical therapy for meaning.
You may have a pelvic issue, you may have a stability issue, it
might be a tightness issue. That's not addressed, maybe new
orthotic issue, something else like that, but it should go
away. So, long away coming back, it's
usually because of that, I usually say, it's like an
incident meaning, you went to Disney, you went on a long walk.
You're starting to train for something very commonly people
at train or starting to be more active, trying to lose weight,
the Cavs, get tight, not usually day one.
Wanted to day three. But after a few weeks and they
start to have foot pain, it's because the tightness normally
and then the other for you if you're listening to this and
you've had this for years and it's never gotten better.
It's probably because you haven't had treatment or the
right kind of treatment. I find many patients.
They come as a second opinion, they've like seen a doctor a
number of times, but they just say, okay, I'll do 3 cortisone
injections in an orthotic and if you can't get better, you can't
get better. You know, you have to really
advocate for yourself. There are some Advanced
treatments, but I do have a certain Number of patients that
just might need a surgical procedure or something more
involved. I think I've done this maybe one
surgery in the last three years. There's not really surgery isn't
the option, okay? Isn't the best option but there
are other people that can help you.
So you have to kind of advocate for yourself and try to get
help. Yeah.
And there are some other questions were going to address
here before we finish up here for patients, who get custom
orthotics. How long do they usually last?
What do you tell them? So custom orthotics.
Once again, you have to have the sneaker and shoe to fit with it,
if you have the wrong shoe with the Orthotics, that's not going
to help as much. What we're talking three to five
years, depending on how it was built, how was made?
And you have to where you have to do.
All your stress is all the stuff you do to keep it going.
Yeah. Orthotics are kind of like
glasses, right? I can't I don't wear my glasses
when I'm doing the webinars, but I'm not wearing these.
I can't see far away but if I'm wearing them, I can see far away
it. So it corrects for mechanical
instability in the foot and it's the same thing with an orthotic
in the way I kind of explained. It is if you're doing Out of
walking, a lot of standing, you're probably going to feel
better in them. Now, you may only need them for
a period of time to heal that injury, though, once you're
better, if you're an athlete, you can probably try to ditch
them. But if you have a really really
collapsing foot, you're just going to feel better in them,
some patients just feel better because they're so collapsed for
them. There was some comments here
about a book, I'll show you guys how you can get these books if
you want. I have them as a download and
then in the at the PTA Greendale, they have them
sitting there as well. So when patients are getting
shopping, this is a question here, when patients are getting
shock wave therapy in an attending Physical Therapy.
Should they modify the exercise and all my opinion, if they're
getting Shockwave? It's usually for, let's say, for
the heel, I'll have them. That session work, more on the
calf region, okay? Or working on the poor stability
or something else like that because if it's way too painful.
But frankly, if you do Shockwave that day, Would just the next
day, you should be better. Shockwave doesn't usually have
much pain for a few days after it doesn't another thing about
Shockwave, Shockwave is an instantaneous, like, cortisone
injection of cortisone, you get the cortisone, you're better
Shockwave to. It actually has to create new
blood vessels, and blood flow to the area and that takes six to
eight weeks. So, just for you.
So, you know, so from day one of shock wave to you actually start
seeing the results is six weeks. And so if we do three sessions
as you six weeks after that's when it started, And it works
for like three or four months afterwards and it's not
instantaneous. So that's where you have to
control the load so people can kind of Be Active with that as
well. Another question here, I wear
slippers at home, I think that may be part of my problem.
Can you be more specific on what I can wear?
What can they wear at home? So a good sandals of once again
I said I'm down to see Grandma. They have always good sandals
over there, they have good arch. Support a lot of cushioning them
in the much better in the house. You come into the house, you
take your shoes off, you're going to do sandals and you
could pick out. Yeah I think there's a couple of
Brands Spangled hasn't okay. One who follows have a good one.
Hoka has a good one and you can just wear shoes though.
If you have a you get a second pair of shoes, I have a whole
shoe and wear that at home, and I think you're going to be,
you're going to be much better with that.
So I think we answered all the questions.
I put a little link here for the the replay and resources.
So if you're watching this, we're going to post this.
You can use your phone and kind of scan it and it'll go to a
blog post. And then you can also go to the
Greendale PT and contact them. They can give you a copy of this
video. If you want to listen to it
afterwards. There's a couple of resources I
make available on my blog after build a.com.
It'll there's one thing on a heel and wanting to kill.
He's the one that Joe was referring to.
I'm just going to open it up right here.
Look at that. Doesn't even open up.
You have to have an Achilles with a capital A and it's a
little course, I put together. So it basically has a book.
You can download a quick start guide, icing and contrast oofos,
shoes recommendations and then basically down here it's kind of
cool because I put your how do you treat achilles tendonitis,
deep tissue, massage and loosening exercises actually
recorded this at Greendale PT a number of years ago.
Trigger point tools. What To do when you get up in
the morning this is kind of fun. So it patients we talk about
core belly, breathing, doing a stretching routine before you
get out of bed. This is to help that first step
out of bed. Talk about Shockwave or E Pat
and amnio injections and then things like that.
So there's other resources. So I take a lot of pride in
doing these things. It's been a lot of fun and I
really appreciate all the help over at Greendale PT.
So it's been great. I think we've answered all the
questions. I don't really see any other
questions here. If you guys have any more, you
can post it. Otherwise we're going to stop
this.