Speaker 1
If your clinic is anything like mine, you see heel pain constantly, right? We're talking about more than a million visits per year in the US alone. And historically, what have we done? We've kind of thrown the kitchen sink at it, right? Rest, ice, NSAIDs, maybe a generic calf stretch or rolling on a frozen water bottle, something like that. But if you're honest with yourself and you look at the long-term data. You've probably noticed that the kitchen sink often fails people. They constantly have this heel pain, they come back to you. The pain comes back, the patient gets frustrated. And today, I want to update that framework for you. So, we need to shift our thinking from simply suppressing inflammation, which is what we're good at, right? And we're told, like, hey, Just takes men's heads, you're fine to actually rebuilding the tissues capacity and fixing the underlying problem. That's the big paradigm shift we want today. So, we're going to move from band-aids to building a better foot. Let's dive into it right now. So, first things first, I'm going to nerd out here for just a second and update some vocabulary for you. So, when it comes to this condition, it's important. I know it seems pedantic and it seems stupid, but it'll make sense as why I'm spending time on this. So. We used to call this planar fasciatis, and planar fasciatis still does exist. I will be clear about that. Fasciatis still exists, but itis, right, implies that something's on fire or in flame, right? So that itis is pretty classic for that. But when we look at the actual histology or the cells affected in the actual plantar fascia, we don't see inflammatory cells for a while, right? So I think about it as itis is like usually for six weeks. So, you might see some misinformation if you've just developed pain. So, you just had pain, or your patient said, Hey, I've just had this for a couple weeks. Yes, you may see some information there. But most people come to us to the doctor after it's been quite a while, right? Weeks or maybe months. And so by that time, it's not really what we're looking at. We don't see that. What we actually see are degenerative changes, right? We see collagen fibers in disarray. And think of it like this: like, It's not burning wood. It's almost like rotting wood. Obviously, I'm not saying your planner fascia is rotted by any means. But why does this matter? Well, it's important because. It explains why steroid shots and ibuprofen are often just temporary fixes, right? We aren't fighting a fire. We're trying to repair a crumbling structure. So you can't fix a crumbling structure by just putting ice on it. That's my general explanation. I tend to tell people that overall we think of degenerative changes, meaning, hey, usually, like nice, we have nice compact tendons and fascia here are like really well built together. But once we have this pain for a long time, we start to have more disarray and it doesn't look normal. So, like, when you look at the histology, it's different. And the reason I say that is because itis was the old term. I will say plantar fasciopathy or plantar fasciosis. That's the kind of the new term. But it's letting you know that we are no longer thinking about this as inflammation. And once we change that paradigm and treat it for what it actually is, we tend to get better results. And so, to understand this fix, we have to understand the underlying biomechanics first. So, the fascia isn't just a passive sheet of tissue, right? Most people think that's the case. It plays a really, really important role in distributing force throughout the foot. So, the big concept here is something called the win-last mechanism, which I'll explain. So, when you dorsiflex your toes, like when you're pushing off, when you're walking, you're running, this tightens the planar fascia. And then the plantar fascia wraps around the metatarsal head and physically pulls the arch up. It turns the foot from a loose bag of bones to a rigid lever for propulsion. Obviously, I'm talking in hyperbole and kind of simplifying things here, but the windlass mechanism tensions that planar fascia when we get endorsiflection. And so, for an example, if you look at the diagram here, we'll use a bridge kind of as an example to hopefully make it a little easier to stick. The bones of your foot form that arch structure, right, of the bridge, and the planar fascia is the straight cable that runs across from the bottom connecting the heel to the toes. And its job is to hold the bridge together. When you step down, gravity pushes down on the arch and tries to flatten it. That creates massive tension in the bottom of the cable. And now, this is why we think we get pain. It's kind of a simple demand exceeding capacity. That's most of our chronic issues that we have in the sports medicine world. When I say, why do you hurt? It's usually because our body's not ready for the load it's receiving. That's usually what it comes down to. But if you think about it, maybe the mechanism is compromised. Maybe the calves are too tight, or the intrinsic muscles of the feet are too weak, anything like that. If that is leading to the planar fascia taking more load with every single step, then it could lead to issues after thousands and thousands and thousands of steps. And so if we are thinking about Increased load over time after lots and lots of steps. That's why we tend to think that we're having pain, not because it's necessarily inflamed, although it probably was at one point, but because overall the capacity is just not there. And so we kind of have to rebuild things and build it up. And I'll explain what that looks like here. And I like to explain this to patients using a bucket analogy. So, everyone has a bucket in life. That's your tissue's capacity to handle load. And the water filling the bucket is the overall load. And when the water overflows, you get pain. Obviously, it's not that simple. It's never that simple. But just for the analogy, it works here. And so we kind of have two choices, right? We can either stop pouring water in or we can get a bigger bucket. And so obviously it's both things, you know. Stopping pouring water in is what we traditionally do say. Oh, it hurts, like, stop doing it. That's the classic advice you get from your doctor, right? Like, oh, something hurts, don't do it. That's not an option for people who are athletes or Want to exercise and want to be active, our job is to figure out how do we build a bigger bucket. So, that is what we're talking about today: is how can we make you more ready to handle this load? So, that's the big thing. And I did mention before what causes this, and really comes down to multiple factors as to why planar fasciosis happens. There's different things. A big overarching theme, though, as I mentioned before, is that we're doing too much for that planner fashion to handle at this time. So that's kind of how I think about this load. Going higher than the capacity. And it's not that simple, but there are some risk factors as well. So there are things called intrinsic and extrinsic. Intrinsic are the things that Have kind of anatomical basis. So, the things that are risk factors there are elevated BMI, limited ankle dorsiflexion, and over-pronation, or like someone who has flat feet of the foot, those are risk factors. But also, there are these extrinsic factors: things like training errors, meaning doing too much too fast, maybe not wearing the correct footwear for you. There's debate on what that is, but we'll just leave it at that. And not being used to that, that may also be a factor. If you change footwear, that can be a factor. And on top of that, abrupt changes in how much you're doing may also lead to this. But the weird thing is, we see two main distributions, right? We see people who are very active and doing lots of running, and then we also see people who are sedentary. And so it's not quite as easy as doing too much. But rather, I think about it as for whatever reason, our body is just not ready to handle that load right now. So, two different buckets, but we're going to treat them pretty much the same. The diagnosis here is usually a clinical diagnosis, right? We don't need a million-dollar workup. We just need to look for a few things. And the absolute hallmark: The thing that should make the light bulb go off in your head is what I call startup pain. It's the sharp, stabbing pain on the very first step out of bed or after sitting for a long period of time. And it usually warms up as they move on, right? That's the big thing. Usually that first step, terrible, and then gets a little better. That's pretty pathodemonic for planar fasciopathy. Their pain is typically located on something called the medial calcaneal tubercle, on the medial aspect of the calcaneus, right in this illustration where they are palpating. That's the big thing. You can also use ultrasound if you have it in your office. You can throw the probe on there. We're looking for thickness of the planar fascia greater than four millimeters, and you might see. Dark hypochoic changes. That is not something I'd expect you to look or do, and you certainly do not need to do that to make a diagnosis. Patients love seeing it, though. It's very helpful to get the buy-in. And on top of that, it's cool, it's fun. I do ultrasound, so it's very fun, but strictly not necessary by any means. You can make a diagnosis. They have startup pain, they have tenderness, right, the medial tubercle. You've got your diagnosis, you do not need ultrasound, but that's something that you can also offer for corroboration as well. And so, now though, we have to think about Yeah, we have heel pain, right? We have to be judicious. Heel pain is a bucket, not a diagnosis. So we don't want to miss something bigger. If the patient tells you that the pain gets worse the more they run and really never gets better with warm-up. Well, then we have to think about something else. Or if you squeeze the calcaneus, the heel bone, and they jump off the table, well, that might be something like a stress fracture. And it pretty much is a stress fracture until proven otherwise. And maybe the pain is burning, electric in nature, or radiates. Then maybe we think about a nerve issue, specifically something like a Baxter's nerve entrapment. And on top of that, If they're walking, like I said before, we're having lots of pain, never gets better on the bottom of their foot. You might have something called fat pad atrophy. So, all those things. So, how do we differentiate those? Well, it can be hard sometimes, but first thing would be checking the location, right? So, planar fasciopathy lives on the medial side or on the inner edge of the calcaneus. Fat pat atrophy typically hurts at the dead center of the heel, kind of more diffusely, so it's not as pinpoint. And the second thing to differentiate is asking about timing, right? So fasciopathy hates the morning startup, right? That's usually the worst thing. Fat pad atrophy hates the mileage. Usually gets worse at the end of the day after doing more. And if you press into the center of their heel and it feels like you're pushing straight into a hardwood table instead of a firm pillow, Then maybe we have fat pet atrophy. As I mentioned before, with the nerves for Baxter's neuropathy, anytime you think of like you know tingling, Radiation and stuff like that, then you think maybe more nerves. And then stress fracture is going to be their hysteria. They do lots and lots of running. They're kind of diffusely tender in that calcaneus, or just the picture kind of fits better. You should have those on your differential. It's not a slam dunk, but I don't want you to just think its heel pain has to be planar fasciopathy. Although, spoiler, usually it is. But I want you to be judicious thinking about that as well. Now, let's move on to the treatment. So, phase one is very simple: calm it down by whatever means necessary. This typically includes things like taping, orthotics, or stretching to start. I tell patients we can't train an angry tissue, right? So, our goal is to kind of calm it down. Also, people will commonly ask about ice, and I tell them that it's neither right or wrong, right? So, this is a very controversial thing. People talk about ice now. It's just probably not doing anything long-term to fix it. But it may help you feel better. And so I'm okay with it. So it's really up to you. I don't think it's going to be delaying. You know, if you've had this for months, right? I don't think it's any problem to ice if it feels good for you, but I don't think it's going to speed up your recovery by any way. But that's okay. And so. I tell my patients that first we need to evaluate how much they're doing in terms of exercise, right? If it's a ton of exercise, then the first thing we need to do is just pull back on the training a little bit. It's kind of simple and see if that helps right away. Another thing we can also try is orthotics. So inserts into your shoe. And they can be worth a shot for some patients, but I tell my patients: pretty much save your money. Don't buy customine orthotics off. Like initially, just do over-the-counter. And data shows that high-quality over-the-counter orthotics tend to work just as well as customer orthotics for most people. And so You can use those to offload the tissue for maybe a few months while we're kind of fixing the unknowing issue. This can be helpful for some people. This kind of goes counter to another idea we'll talk about, but it may be helping. And another thing that's mentioned in literature is something called low die taping. It's where you can apply some heavy-duty tape to your foot. And so theoretically helps support the arch a little bit. It's cheap, it's fast. You do have to have some expertise in taping it. It's kind of a specific way. And so, a lot of times you have to go see a physical therapist for this. So, it's not as easy as just going to buying some orthotics, but it's another fix that we have. You know, it's kind of. Bolster you through this process, right? So, when we are getting people offloading, we're just trying to calm things down. If we can calm things down, that's wonderful. Then we can get them back to being loaded and getting healed. That's what we're going for. But stage one is just really calming it down however we want to. And then, including stage one, I want to talk about some stretching that patients can do. So, if you know me, most of the time I say stretching is not the primary thing we should be doing for rehab. And I still agree with that. But overall, this is one of the cases where the evidence shows that. It seems to be pretty darn helpful. So I recommend this. And there's one specific type that has been shown to be particularly helpful, and it's called the Di Giovanni protocol. So most patients are usually just leaning up against a wall, stretching their calf, and that's fine. But this stretch seems to be better when compared directly. So, how we do this is we have the patient, and you can see the image here, usually sitting down on a chair or whatever. Before their feet hit the floor in the morning, we want to do this. So, to hopefully kind of prime the planar fascia, that's helpful. Hopefully, it kind of prevents that huge shock in the morning. And this is something we can do. You can do this whenever, but this is what I typically said. On top of that, all a patient has to do is cross their leg onto their knee, pull their toes back into dorsiflexion, and that is tensing up the plantar fascia. And you can feel in the image you show, they're feeling that you can make sure you can feel this tightness. If you feel the tension on the bottom of the foot. Then you're doing it correctly. And then you're just going to do 10 reps for 10 seconds. That's pretty much it. And you can do this multiple times throughout the day if it's helpful. But this is a good way to stretch that planar fascia. And it seems to decrease pain when compared to just traditional stretching. So, once again, that is calming everything down. That is great. That is step one. But if you just stop there, then we're either not going to get the bottom, or maybe we'll feel a little better and it'll come back. So, the key here is calm it down so then we can phase two build it back up. And this is where we pivot. So, the most important slide, probably the entire deck. Once the acute pain is managed, we need to stop protecting and start building, right? So, the evidence specifically for this Rathcliffe in colleagues' study that I read in 2014. I don't read it in 2014, but it's from 2014. It tells us that heavy, slow loading beats stretching at the three-month mark. So, saying, hey, for pain and overall function. Loading it seems to be helpful. And so we need to load the tissue to signal the body to lay down all the repair mechanisms it needs, right? Laying down new collagen, doing all that stuff. And so, to do the Rathclip protocol, you just need a step, a towel, and eventually some weight. And so, the crucial detail, though, as you can see in the image, is that we want to have that rolled-up towel under the toes. It engages that win-last mechanism, so we're able to load the fascia, not just the calf. And the tempo is slow and deliberate. So three seconds up. Two seconds hold at the top, and then three seconds down again. This is really important. It's going to feel like it's taking forever, right? So, one, two, three, one, two, one, two, three. That seems painfully slow, and because it is, it's wonderful. So we do that. That's the tempo. And then we progress them by adding weight. Literally, like in this study, they put a backpack, right? So a backpack of books. And they did this every other day for 12 weeks. Typically, this would be progress, and in weeks one through two, you're probably just doing body weight at 12 reps, give or take. Then, week three to four, you add some weight in a backpack or something like that, and you decrease it down to 10 reps. So, you're trying to get to like at a weight where you can do 10 reps max. And then at weeks five plus, we're adding more weight and getting down into the eight rep range, which means we're just adding more weight, and it should be challenging. And obviously. There's lots of variability how you can do this. You can start with two feet if you want to. Eventually, the goal is to work to single legs, so you're really loading it. But that's the beauty of exercises. You can scale them almost infinitely. And so, this is the progression I'll give. I'll tell people: hey, let's start. If you need to with two, that's great. If you knew one, that's great. But starting slow, body weight gets used to it, and then gradually building up weight as we're doing these every other day. That's the general rule there. And one thing I did want to show is you can see from this is that paper, and this is a table from that paper showing at about three months, we see that we have a significant improvement in foot function index, which is a measure of a patient's pain, disability, and activity restrictions. And you can see a big difference at three months. However, I do think it's worth mentioning that the difference seems to go away at six to twelve months. And so, a lot of times I counsel patients and say that: hey, You know, I think overall, if you do nothing, it'll probably get better in six to 12 months. That's like what the data kind of shows. However, if they're coming to see me, usually it's been multiple months already. And so I want to help them move along faster. And so. But you can see a patient in primary care, and if they're unable to do anything and you did nothing and just gave them some stretches, they're probably going to be okay, like at Six to 12 months. That's the overall goal. But that being said, my job is to get people better as fast as possible. And so, for this, this is helpful because it does improve pain faster, it seems like. And then, also, for me, this is more intuitive. Like longer term, I'm trying to build a more robust foot so they can handle more, do more. And that's my overall goal. But I do want to be honest and say Yeah, it seems to be better in the short term and long term, it's similar. But overall, I think if you're similar while also being stronger, I think it's a net win. But that's just my personal preference. And so I do want to mention, though, I kind of have this stop lysism. It's very, you know, people talk about this in the rehab literature all the time, but patients can get scared to load a painful anything, right? Knee. Ankle, Achilles, you know, plantar fascia, all that stuff. So, we have to kind of guide them. I usually give them the pain rules, is what I call. This means that I want the patient to keep track of pain during exercise and then the next 24 hours after. Some pain during exercise is fine. That's just the tissue being stressed, and that's okay. I usually allow for anywhere from a three to five out of 10. It depends on the person and whatnot. But the big thing is that I want them to watch for the rest of the day and then into the next morning. So if they wake up worse than usual the next day, we back off from what we're doing before. So that's the big thing. If they are doing it. I feel great. That's wonderful. But the next morning are really sore, then that was probably too much. We need to pull back from what we're doing. However, if they're back to their baseline in the morning, we can keep progressing. I also remind people that healing looks like the stock market, right? You have oughts, ups, and downs, but hopefully, the general trend is what we're going for. That's the big thing. So, you're going to have good days, you're going to have bad days. And that's the nice thing about the system: on a bad day, it's okay to scale back a little bit. And then on good days, it's okay to push it a little bit. So, this allows that guidance that, hey, pain's okay, a little bit of pain is fine. I always tell people if you have that take your breath away pain, like, ow, that's probably too much and not helping us. But overall, some discomfort is expected and totally normal and fine in the rehab process. And next, I want to talk about the musculature of the foot. So, we talk about core strength all the time, right? Core is so important for your back and anything. Well, the foot kind of has a core too. And the intrinsic muscles of the feet, if they're weak from years of Rigid shoe use or disuse, the fascia may have to kind of pick up the slack for the muscles not doing their job. That's kind of generally how I explain it. It's not that easy, but that's what it is. A way we can do this is using something called short foot exercises, which is where having a doming of the arch without curling the toes. So essentially, you're trying to Pull the joints, the toes without the actual curling. You're trying to pull them towards your heel without curling them. So you'll kind of feel this dome in your foot. That's the goal. The goal is to wake up these muscles, work them a little harder, and building the kind of internal strength of the foot to give yourself a, you know, quote-unquote internal orthotic, right? Not necessarily so that I don't have to wear orthotics forever. Give yourself the strength of the foot so I can kind of maintain that arch better. Another thing you'll see commonly recommended is towel curls, which can be okay, right? And if that's like what we do, that's much better than doing nothing. But typically, these activate the bigger muscles that originate from the lower leg and not necessarily the foot intrinsic musculature. So. Short foot has been shown with an EMG to be better at activating that instead. So, on top of that, there are other exercises people can do, things called toe yoga, where you take turns trying to lift up each individual toe. So, you start by lifting up the big toe and then putting that down, and then a lot of people can just do the other four together. But that's very helpful, and you're just going to do that a couple times. And the same principle applies, right? We're trying to get the foot stronger so. We're trying to get the planar fascia more robust. We're trying to get the muscles more robust. So it's an overall process to try to get your foot just to be ready to handle load. And then I also want to have a quick word on shoes and shoe width. So, specifically, if you have a wider toe box in your shoe, this helps the Abductor hallysis muscle be more active, which can help pick up some of the slack, once again, being placed on the plantar fascia. And this kind of goes hand in hand with toe spacers as well. People have talked about toe spacers have been very helpful for their plantar fasciopathy. The idea is that you put them between your toes and it spaces out your toes to give your foot a more anatomical alignment. You know, a lot of times the shoes we wear are very, very narrow and We're not meant to necessarily. We can't splay our toes out. Like normally, if you step down, your toes will splay out when they're barefoot, but years and years of just tight shoes make it we're kind of walking our toes together. So that's what we're trying to do here: give space and do that. The spacers just kind of let you walk around, and they can be used on your own, just walk around your house, or even with shoes if you have wide shoes. But it can be a powerful adjunct to restoring foot musculature. There's actually been data showing that just walking around barefoot or with spacers actually increases potentially some of the. The strength of the muscles, and so kind of goes hand in hand with the next topic we're going to talk about right here, though: zero drop shoes. And this is another thing where it's been not controversial, but kind of controversial. And that traditional model has said, hey, Wear supportive shoes, wear insoles, do all those things like traditional. And then now there's another side saying, actually, don't do that. Go barefoot, wear spacers, wear a zero-drop shoe. So people are confused. And the answer is. Both of these can work for the right patient. It just depends on the patient and their preference and all those things. But you might hear about this, so I wanted to mention it. And so People do talk about minimalist or zero drop. What this means, zero drop, is that the heel is at the same height as the front of the shoe, meaning there's no real heel protection. No, and also these zero-drop shoes are usually minimalist footwear, which are typically wider. So a classic minimalist shoe will have a zero-drop. With a wide toe box, and usually it's a pretty flexible material to give your foot as natural movement as possible. And there is research that foot intrinsic strength can be increased just by wearing them, so it can be a powerful tool potentially. But they can be dangerous if rushed. So, going from a super cushioned running shoe, like some of these running shoes we see now, have enormous heels. So, like enormous heel drops. So, just tons of padding on the heel. So, if you go from that, To zero drop quickly, that could be a big issue, right? So one of the big issues I have seen is when people say, hey, I bought into the minimalist idea and we're going for it. And they just start wearing them, that can be a big issue. It can lead to lots of problems, specifically on the Achilles, right? Because you go went from this angle before to now flat. Your Achilles is not used to that being that long and lengthened and just a lot of stress. And so. I've definitely had patients have great success with though, but I've also had people have issues. And so I just wanted to talk about it because it does kind of fit with the underlying pathophysiology, and it's not as common in the literature yet. It's getting there. We're starting to see more and more. But the big thing is, if you want to do this, it can be helpful. Like for me, my starting point for this would be like wear some spacers at home while you're walking around barefoot if that feels okay. I understand sometimes this might not be great during the phase one where we're calming it down, but after that, when we're building it back up, maybe it feels a little better. That's where I would start. And then, if you want to incorporate a wider toe box, there's zero drop while you're working out, that's fine. But we have to be careful and probably going to do it over the course of like 10 to 12 weeks. And so, this is an example. I'm just going to fly through this because it's way too detailed. But This is how you might do that, you know, in terms of increasing going to a zero-drop shoe, because if you go too fast, it will be a problem. On top of that, it's really important to continue to work on foot intrinsic strength and dorsiflexion mobility of the ankle as well. So, like, weeks one through two would be just wearing zero drop shoes for short walks, 10 to 15 minutes, or just around the house using your traditional shoes for all their running, long-duration activities, anything like that. Week 3, maybe start introducing some short jogs, a 10-minute walk followed by a 5-minute rung twice a week while wearing the minimalists. And week 4 and 5. You can start running maybe for 20 minutes with your minimalist two to three times a week. However, you should still use your traditional shoes for longer efforts or recovery days to give you your foot kind of a break. And then going up through weeks six through nine, gradually increase up to 75% of your weekly mileage in the minimal shoes. And week 10 plus is full-time use, provided that your body feels good. And just remember to listen to your body, and too much too soon can lead to additional problems as well. The big thing for me is: if we're doing something new, I do not rush. I'm just very conservative. We're going to go slow because if you go too fast, then we're going to lead to another injury and then we're going to have just more delays in our training. And so I want to be very slow with this. It can also lead to things like stress fracture if your running form hasn't changed. Because if you go from really cushioned heel, To a zero drop, and you're usually a heel striker, that's going to be a bad time for your heel. And so, we usually these people are going to land more midfoot as well, and so yeah. This can all happen. I want you to be aware. This is probably too much detail, but patients are going to talk about this or are going to have questions, but I wanted to include it to let you know that. It's probably best to work overall with a physical therapist to do this hand in hand if you're worried. That's always the answer from rehab: like, go see a qualified professional who does this all the time. That's always the right answer. But I thought I'd include this for completeness. And now we've done all the conservative things, right? So that's where that's the base of everything. I always tell people that is like where I start. The base of everything is Physical therapy, building resilience, that's the key. But sometimes that's not enough. And so, I did want to touch on injections because that's something that can be done in clinic, and a lot of doctors can do this, right? But we have to be judicious. That's the whole thing. And the old way of doing it is kind of not what we do anymore. So you can see I have a pyramid here. We basically have three main options, and the pyramid goes from cheapest to most expensive. Not necessarily the best injections, right? It's not like, hey, this is the perfect injection on top. It's just saying cheapest to most expensive. So, first, let's talk about steroids. Like most things in orthopedics, this used to be the only option, right? You got a steroid, but that's no longer the case. I kind of call this the grenade approach, right? It stops pain fast, you know, provides a decent amount of pain relief usually for people, but it also stops the healing too. And on top of that, steroids can lead to a risk of fat pet atrophy. So we know steroids can. Decrease fat pads anywhere. And so, if you hurt that fat pad, you're actually trading temporary relief for permanent disability. And on top of that, we know steroid is not great around tendons or ligaments or fascia. As it has the ability to weaken the surrounding musculature. And so, overall, this really has to be used judiciously. I only use it for acute, like severe breakthrough pain. And if the patient really understands the risks, However, most times I try to discourage this because it does have its place, but long-term could be an issue. I do want to say, though, usually just doing a one-time injection, you're probably going to be fine. Like, usually a one-time store it anywhere. Is not a big deal, but this is certainly not one where I'd say, Hey, let's get an injection, come back in three weeks, get another one. I've seen some injection routines where they literally would do an injection like a steroid injection. Every month for like three or four months. And that just doesn't make sense pathophysiologically at all. And so I would strongly recommend against that. But there is a time and place, like when I had a patient said, I'm going overseas. My daughter is having their wedding in Europe, and I need to be able to walk. And he's like, Yeah, life happens. That's fine. You can do that. But something to think about. Next, we kind of have the regenerative option. So, prolotherapy is what I kind of call more of like the blue collar regenerative option. We inject sugar water or dextrose somewhere at a 12. 5 to 50% concentration, and it acts as a chemical irritant. So, we're poking a sleeping bear, trying to wake up. And the plantar fascia and the surrounding tissue to restart the healing process. This is not nearly as costly as PRP, which we'll talk about, but typically requires a series of injections. So the patient comes back. Every four to six weeks, at least three injections. This is a safe injection. It's not going to degrade the tissue. That's why I like it. It's good, but it does require that multiple injection. But this is certainly a reasonable option. Unfortunately, usually not covered by insurance. But not nearly as expensive as PRP. And finally, we do have PRP or platelet-rich plasma, which is the Cadillac option. This is where the patient's blood is taken out. Spun around in a centrifuge, and concentrated platelets are then injected back into the affected area. So you can do this at multiple different spots, but the planar fascia is no different. The idea behind it is that you're injecting platelets, which have lots of things like growth factors that help restart and kickstart the healing process, in addition to being an irritant, just like prolotherapy. So, we're trying to get that natural response. However, this can sometimes be egregiously expensive, talking about like into the thousand plus dollars for one single injection. The idea would be that you do one injection here and don't hopefully need a repeat injection, but It's there. I just want to mention that. Also, you might see information about Botox injections into the plantar fascia. And sure, those definitely are an option as well. They're not. As robustly studied in the literature, but definitely still an option for you, but they're going to be very expensive, right? So Hitz Botox, that's going to be expensive. Usually not first line. Usually you've kind of worked our way up to this, but that is an option as well. You might see that in the literature. And overall, I try my hardest really to not inject people in the planar fascia because most of the time it's just an issue with load management rehabilitation, and they don't truly need it. But also because they're not fun injections at all. The bottom of the foot is super sensitive. And I've had patients tell me that they'll never do that again because of how painful it was. All those things. I just wanted to include them for completeness. But overall, we usually don't need injections if we rehab it properly, but they're there and we can use them as long as we do it judiciously. And so, to wrap this up, Diagnosis is key, right? Once we diagnose it, we need to calm it down first and then build it back up with heavy slow resistance. We do have to address the big rocks as well if they're running on worn-out shoes. Their calves are tight if their BMI is elevated, all those things we can work on that and go around. But hopefully, we can get people back, and we don't need to give them injections, it's just a matter of understanding: hey, what is causing this problem, this load mismatch, and then slowly build them back up. But hopefully, you found this helpful. And so, hopefully, now you're an expert in plantar fasciopathy and how to rehab it. But if you want a program that is made for you to kind of help you rehab from this issue, then I have that here. The link will be in the description below.
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If you watch everything, you have all the information. But if you wanted a step-by-step kind of hand-holding way of doing it all in one place, you can go ahead and make that purchase. But hopefully, this was helpful. And hope you have a great rest of your day. We'll see you next time.
