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Speaker 1: This isn't a condition that you just need to live with,

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Speaker 1: or that you need to give up activities or footwear

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Speaker 1: that you enjoy wearing. Hopefully those listening in feel empowered

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Speaker 1: that there are ways that their pain can actually be addressed.

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Speaker 2: What is going on everyone, Emily A Body Here. You

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Speaker 2: are listening to episode two hundred and seventy six of Hurdle,

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Speaker 2: a wellness focus podcast where I connect with everyone from

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Speaker 2: your favorite athletes to top experts and industry CEOs about

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Speaker 2: their highest highs, toughest moments, and everything in between. We

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Speaker 2: all go through hurdles in life, and my goal through

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Speaker 2: these discussions is to empower you to better navigate yours

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Speaker 2: and move with intention so that you can stride towards

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Speaker 2: your own big potential and of course have some fun

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Speaker 2: along the way.

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Speaker 3: For today's convo, I am chatting with.

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Speaker 2: Doctor Adam ten forty of Mass General Bringham Sports Medicine

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Speaker 2: Say that five times fast. Doctor ten forty is also

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Speaker 2: an assistant professor in the Department of Physical Medicine and

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Speaker 2: Rehabilitation at Harvard Medical School.

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Speaker 3: And we are talking about something super.

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Speaker 2: Sexy today and that is feat specifically Planter Fascia Idis

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Speaker 2: Now if you have been following along with my personal

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Speaker 2: journey over the last year, I have been dealing with

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Speaker 2: and can confidently say at this point I beat planter

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Speaker 2: fasci idis. Now, for those of you that are not

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Speaker 2: aware of what planter fasci idis is is an inflammation

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Speaker 2: of the planter fascia on the foot, and doctor ten

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Speaker 2: forty really dives into what it is today, what causes it,

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Speaker 2: and so many other things. But like I said, I

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Speaker 2: really dealt with a bad case last year, and in

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Speaker 2: dealing with bad planter fasci itis, I experienced a ton

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Speaker 2: of discomfort, notably in the morning throughout my day. I

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Speaker 2: had to change the way that I was active, how

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Speaker 2: I worked out, adjust the way that I like to move,

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Speaker 2: specifically pertaining to running. I invested tons of money in

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Speaker 2: physical therapy and working with the diatrist, all different treatment

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Speaker 2: options which I speak about today with Doctor ten forty,

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Speaker 2: and I also realized just how many people are truly

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Speaker 2: struggling with this. It is so frustrating to get up

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Speaker 2: in the morning, put your feet on the ground and

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Speaker 2: the first thing that you experience is pain. It's something

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Speaker 2: that no one should have to deal with, and that

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Speaker 2: is why I brought this expert in. I wanted to

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Speaker 2: finally have an in depth conversation that I could point

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Speaker 2: people to when they messaged me about struggling with this issue.

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Speaker 2: And that's what we're doing here. We're talking all about it.

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Speaker 2: So do me a favor. Maybe you don't have plant

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Speaker 2: for fascia it is, but someone you know is struggling

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Speaker 2: with it that too. This episode is for share it

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Speaker 2: with a friend, send it to someone that you care

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Speaker 2: about their help and well being. We all deserve to

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Speaker 2: live a pain free life. You do not have to

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Speaker 2: accept living with pain. That is something that we really

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Speaker 2: get into today, as well as so many other things.

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Speaker 2: How do you doctors diagnose planter fasciitis, how is it treated,

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Speaker 2: what are the home remedies?

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Speaker 3: And so much more. Make sure you're following along over

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Speaker 3: on social.

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Speaker 2: At Hurdle podcast. I am over at Emily a Body

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Speaker 2: And with that, let's get to it. Let's get to hurdling.

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Speaker 3: Today.

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Speaker 2: I'm sitting down with doctor Adam ten forty of Mass

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Speaker 2: General Brigham Sports Medicine.

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Speaker 3: How are you doing today?

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Speaker 1: I'm doing well. Thanks for having me on your show.

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Speaker 3: Thanks for making the time.

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Speaker 2: You know, there has been a thirst for knowledge when

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Speaker 2: it comes to one of the sexiest topics that we

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Speaker 2: can talk about, and that is planter fascia itis. Now,

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Speaker 2: like I said, you work in sports medicine at Mass

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Speaker 2: General Brigham. Tell me a little bit about how you

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Speaker 2: got into this area of expertise.

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Speaker 1: We commonly see a number of overuse injuries, and my

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Speaker 1: focus is on the management of acute and overuse injuries,

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Speaker 1: particularly in runners. But when you see some of these

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Speaker 1: conditions that affect runners, you can oftentimes extrapolate how they

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Speaker 1: would affect other athletes that participate in land based sports

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Speaker 1: or even individuals that are physically active in other methods. So,

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Speaker 1: plantar fasciitis represents a very common overuse injury. We commonly

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Speaker 1: think of it as heel pain, but the more we

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Speaker 1: learn about it, there's a number of advances in our

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Speaker 1: understanding for effective ways to rehabilitate this injury and even

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Speaker 1: some targeted interventions that I commonly do in practice.

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Speaker 2: Right, and you specialize traditionally in non surgical treatment.

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Speaker 3: Is that correct?

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Speaker 1: That's correct? And one of the things that is oftentimes

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Speaker 1: a challenge, and I think it's wonderful, wonderful to be

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Speaker 1: on your show is understanding that there are many different

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Speaker 1: avenues to receiving care for muscular scull injuries. So oftentimes

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Speaker 1: individuals are looking for a foot ancle surgeon or someone

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Speaker 1: in orthopedics, and oftentimes that will will lead to discussions

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Speaker 1: on whether this is an injury that requires surgery. The

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Speaker 1: good news is for all those listening in plantofasciitis is

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Speaker 1: a treatable condition. It's an overuse injury, but it very

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Speaker 1: rarely requires surgery.

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Speaker 2: Yeah, now, I think that first and foremost, let's just

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Speaker 2: lay the foundation that although it is an overuse injury,

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Speaker 2: and we did talk about you specializing working with runners,

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Speaker 2: anyone can develop plantar fasciitis. It's not just limited to

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Speaker 2: someone that identifies as a runner. When we use the

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Speaker 2: term overuse injury, it beckons the question why do some

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Speaker 2: individuals develop this versus others, considering maybe they may move

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Speaker 2: the same amount.

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Speaker 1: I think it's a great question, and I oftentimes will

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Speaker 1: joke with patients when I get that question, because we

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Speaker 1: may be doing the exact same amount of activity we've

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Speaker 1: historically done, but for a number of different factors, probably

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Speaker 1: a number that we have not been able to identify,

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Speaker 1: individuals will develop this injury. So overuse really refers to

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Speaker 1: excessive demand to a tissue in which the tissue is

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Speaker 1: not able to repair itself. So we've moved away from

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Speaker 1: using the term itis for everything like tendon itis fasci itis.

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Speaker 1: I'll commonly use that term when I'm talking to my

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Speaker 1: patients because I want to use terms that are familiar.

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Speaker 1: But now that if we start to think of this

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Speaker 1: as an overuse injury, which may not necessarily be purely

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Speaker 1: driven by inflammation, we understand why some of our traditional

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Speaker 1: strategies around icing or taking over the counter anti inflammatory

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Speaker 1: medications don't successfully treat this condition.

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Speaker 2: Before we get into the treatment for this, let's talk

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Speaker 2: about what some of the signature signs might be that

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Speaker 2: you are indeed dealing with plant or fascy itis.

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Speaker 1: Yeah, so, with plantar fasci itis, the most common issue

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Speaker 1: than individuals will have is pain in their heel, and

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Speaker 1: that will oftentimes be when you first wake. Those first

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Speaker 1: couple of steps can be very painful. There oftentimes is

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Speaker 1: something called a warm up phenomenon, which means that as

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Speaker 1: the tissue gets more blood flow from demand, it will

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Speaker 1: feel a little better. But we'll have those transition times.

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Speaker 1: For example, after sitting for a while, where the first

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Speaker 1: steps will be very painful. The pain is usually localized

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Speaker 1: to the to the plant or heel, so right under

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Speaker 1: the sole of the foot, but this injury can evolve

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Speaker 1: a larger span of the foot. Because the plantar fascia.

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Speaker 1: As much as it's very annoying and most of us

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Speaker 1: take it for granted until we have an injury involving

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Speaker 1: the plant fascia, it serves a number of critical roles.

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Speaker 1: It actually starts at the base of the heel. It

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Speaker 1: has three bands and then five slips that will actually

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Speaker 1: go to each of each of the toes. So this

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Speaker 1: spans almost the entire length of the bottom of the foot.

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Speaker 1: So when it's injured, it's very difficult to avoid overloading

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Speaker 1: that tissue and as a result, a lot of individuals

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Speaker 1: will have pain and they will try number of things

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Speaker 1: to support their foot to try to take the pain away.

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Speaker 2: Right understandable, and I can speak as someone who really

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Speaker 2: dealt with the gnarly case of this last year. I

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Speaker 2: feel like there are almost like two different places you

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Speaker 2: can be in. It's like I might feel plantro fausci

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Speaker 2: itis every so often, but it's not something that is

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Speaker 2: truly debilitating for you, versus being in a place where

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Speaker 2: plantra fauci itis really is. As you spoke about that

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Speaker 2: early morning starts from the moment you wake up. Might

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Speaker 2: feel a little bit better throughout the day, but it's

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Speaker 2: there every single day. For those that are in the

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Speaker 2: first camp, the area where it only presents every so often,

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Speaker 2: I would imagine that they want to do everything they

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Speaker 2: can so they don't end up in the second camp.

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Speaker 3: Where do they begin?

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Speaker 1: So this injury does sometimes start with pain just during activity,

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Speaker 1: and it's actually been described as one of the more

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Speaker 1: common running related injuries. So you'll have individuals that feel

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Speaker 1: okay most of the day and it's only when they

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Speaker 1: run or they do activities which involve a lot of

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Speaker 1: hopping where their plan of fashion hurts. And I think

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Speaker 1: when you're in that stage, really the goal is to

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Speaker 1: figure out what is it about the demands on the

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Speaker 1: feet that are causing that pain. So this is where

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Speaker 1: physical therapy can be very helpful. Recognizing that the planner

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Speaker 1: fascist spans the length of the foot, but there's actually

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Speaker 1: four layers of muscles that make up the arch of

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Speaker 1: the foot as well. So this if this fashi is

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Speaker 1: under chronic stress from activities. Perhaps there's a rule for

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Speaker 1: actually strengthening the muscles in the feed to take the

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Speaker 1: stress off of the planner fashion, And you're right, it

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Speaker 1: can sometimes progress to becoming more of a daily nuisance.

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Speaker 1: Whenever you take a step, you feel it. So what

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Speaker 1: we're really trying to do is treat this injury as

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Speaker 1: early as possible, and there are some studies suggesting that,

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Speaker 1: you know, the first year can be can be a

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Speaker 1: really good window to have better outcomes. Although I've taken

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Speaker 1: care of individuals with this condition that have had this

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Speaker 1: pain for years and we're ultimately able to get them

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Speaker 1: better and not having pain. So I also don't want

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Speaker 1: people to become discouraged if they've had this condition for

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Speaker 1: a long time, or if it's affecting them at all times.

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Speaker 1: I think there's still a lot that can be done

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Speaker 1: to help address this injury, and again it's oftentimes not

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Speaker 1: necessarily a surgical solution, but it does require a number

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Speaker 1: of different considerations.

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Speaker 2: Yeah, I'm like sitting here nodding my head, because there

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Speaker 2: are many different things, many different ailments that can be

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Speaker 2: quite the hassle on the body. But when standing alone

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Speaker 2: is the thing that brings you pain from the moment

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Speaker 2: you wake up.

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Speaker 3: It really does get to be truly exhausting.

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Speaker 2: Now I know personally, a big cause for my planto

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Speaker 2: fasci it is was a lot of calf tightness. So

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Speaker 2: let's segue here into talking about some of the different

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Speaker 2: root causes Aside from as we talked about an overuse injury,

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Speaker 2: what are other things that can cause planto fasci it is.

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Speaker 1: Yeah, it's a great question. So it may not necessarily

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Speaker 1: be just from overload. Again, the the risk factors that

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Speaker 1: have really been you know, clearly demonstrating the literature, there

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Speaker 1: are very few. There's there's concerns that perhaps you know,

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Speaker 1: being overweight, age, certain conditions like diabetes might might predispose

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Speaker 1: the development a planar fasciatis. But again that's not to

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Speaker 1: say that that's that's predestined, because you have arguably a

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Speaker 1: number of runners that are normal body weight who will

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Speaker 1: also develop the condition. And I also don't think it's

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Speaker 1: it's the most helpful for for individuals to hear those

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Speaker 1: risk factors and assume that they're going to receive uh,

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Speaker 1: you know, suboptimal care just because of medical come morbidities.

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Speaker 1: So so those tend to be. Some of the factors

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Speaker 1: we'll look at though, is if someone has been gaining

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Speaker 1: weight that that may be part of the strategy is

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Speaker 1: thinking about what is that individual's healthy weight to get

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Speaker 1: back to UH if if it's a change in activity

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Speaker 1: or training, it's recognizing that any change in activity can

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Speaker 1: sometimes acutely overload the tissue. And then there's a number

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Speaker 1: of different aspects of footwear that we have to think

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Speaker 1: about as well. And you know, women will wear shoes

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Speaker 1: that are you know, have a high heel. The way

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Speaker 1: that may contribute to development a pleno fasciitis or some

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Speaker 1: of the other foot ankle injuries is that the use

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Speaker 1: of a lift a heel will actually take some of

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Speaker 1: the stress, the stretch off of the tissues. So that

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Speaker 1: going from having a lot of heel support to having

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Speaker 1: no heel support, which is what we typically have in

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Speaker 1: most athletic footwear, that that acute change might be very

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Speaker 1: challenging for the feed And again, I think it's important

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Speaker 1: to understand the goals of the individual and I certainly

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Speaker 1: have no qualms about individuals getting back into whatever footwear

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Speaker 1: they want to wear, but it's just understanding what are

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Speaker 1: the things that could potentially cause the foot to be

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Speaker 1: painful in the first place, where we can help help

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Speaker 1: to address that early on and then build up the

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Speaker 1: strength and the function so that individuals can get back

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Speaker 1: into whatever they want to wear.

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Speaker 2: Yeah, you know, it's funny because I would definitely go

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Speaker 2: through phases even when at the height of my planter

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Speaker 2: fasciitis that going from something flat like a sneaker into

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Speaker 2: a heel almost felt good because it was just a

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Speaker 2: different angle for my foot.

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Speaker 1: Yeah, that's exactly right. So you intuitively, we're doing something

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Speaker 1: that was temporarily taking the stress off of the foot,

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Speaker 1: so by being in a heel that can sometimes provide

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Speaker 1: some relief, and that's why we oftentimes will we'll see

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Speaker 1: runners and other active individuals get a shoe that goes

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Speaker 1: from having a zero drop meaning that the sole of

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Speaker 1: the shoot has no difference between the heel to the forefoot,

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Speaker 1: to getting something that has a little bit of a drop,

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Speaker 1: because that will take a little bit of the stress

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Speaker 1: off of the heel. But to your point, when your

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Speaker 1: calves feel tight, that can also be a sign that

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Speaker 1: those tissues are fatiguing. So another reason that people can

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Speaker 1: be tight is not just that their bodies are built

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Speaker 1: a certain way where their tissues are going to tighten up.

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Speaker 1: But that tightening or that cramping can be a sign

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Speaker 1: of fatigue. And that's why physical therapy and rehabilitation exercises

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Speaker 1: can be so effective for this.

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Speaker 2: Condition definitely, And we'll get to those treatment options in

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Speaker 2: just a second. I want to make sure that we

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Speaker 2: reiterate here that generally speaking, most sneakers will see something

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Speaker 2: between an eight to ten millimeter drop when it comes

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Speaker 2: to running sneakers. When we talk about zero drop, the

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Speaker 2: shoes that are flat from toe to heel, that doesn't

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Speaker 2: necessarily mean that they're completely minimalist, completely flat on the ground.

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Speaker 2: Those shoes could have what we often talk about to

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Speaker 2: be a stack height, which is the thickness supposedly of

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Speaker 2: the foam that's under your foot. So a lot of

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Speaker 2: different buzz where it's when we talk about shoes and

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Speaker 2: all the things that come with them, the bells and

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Speaker 2: the whistles, it really is about finding what feels best

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Speaker 2: for you and your foot, whether or not you're dealing

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Speaker 2: with a condition like this.

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Speaker 1: Yeah, I agree with that the stack hite versus the

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Speaker 1: actual drop. That's a common question that individuals will bring up.

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Speaker 1: You can have a shoe that has a lot of cushioning,

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Speaker 1: but that cushioning is evenly distributed under the foot, and

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Speaker 1: that might that might be a zero drop shoe. Or

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Speaker 1: you can have a traditional minimal shoe that has no

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Speaker 1: cushioning under the foot and is also a zero drop,

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Speaker 1: and both of those can put acute stress through the foot.

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Speaker 1: So that's a really important consideration when individuals think about

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Speaker 1: what footwear they've changed when they developed this injury, so

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Speaker 1: that they don't necessarily assume that their footwear didn't play

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Speaker 1: a role.

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Speaker 3: Right.

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Speaker 2: I think it's really important to evaluate all the different

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Speaker 2: things that might be happening, and that's why seek out

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Speaker 2: one on one advice with an expert like yourself, like

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Speaker 2: a physical therapist, like another physician, is really important.

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Speaker 3: Granted, yes, we are providing some insight in here. Let's

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Speaker 3: consider this a beginner primer. So then after.

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Speaker 2: Listening this to this, you can take matters into your

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Speaker 2: own hands.

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Speaker 1: Yeah, that's exactly right. I think the important thing for

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Speaker 1: the listeners to understand is this isn't a condition that

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Speaker 1: you just need to live with, or that you need

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Speaker 1: to give up activities or footwear that you enjoy wearing.

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Speaker 1: It's really hopefully those listening in feel empowered that there

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Speaker 1: are ways that their pain can actually be addressed.

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Speaker 3: Right.

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Speaker 2: It's not something that you just have to say, Okay,

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Speaker 2: this is my life now, although admittedly I've definitely gone

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Speaker 2: through phases where I was like, well, this is how

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Speaker 2: it is now.

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Speaker 3: So before we get to those treatment options that we were.

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Speaker 2: Hinting at, why don't we just confirm how does a

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Speaker 2: doctor diagnose plantar fasci itis.

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Speaker 1: Yeah, so the diagnosis is primarily based on the history

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Speaker 1: and the physical exam. So that history of where the

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Speaker 1: pain is, what makes the pain worse, and the general

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Speaker 1: sensation of a warm up phenomenon. Those tend to favor

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Speaker 1: it being a soft tissue over you overload injury to

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Speaker 1: the plantar fascia. And then on physical exam it's usually

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Speaker 1: identifying pain right where that the plantar fascia attaches, but

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Speaker 1: also looking at the foot to see if there's foot weakness.

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Speaker 1: One thing will commonly do, and it's kind of an

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Speaker 1: interesting exercise for viewers is see what it's like to

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Speaker 1: try to balance on one foot and even balancing with

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Speaker 1: your eyes closed that can give you a sense for

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Speaker 1: your ability to balance, which if your balance is off,

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Speaker 1: of course you're going to put more demands through the

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Speaker 1: plantar fascia to try to maintain stability. But then the

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Speaker 1: other feature is if you're standing in front of a

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Speaker 1: mirror and you can see the arch of the foot

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Speaker 1: when you go into a single leg squat, it's seeing

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Speaker 1: whether that that that arch deflects down and that could

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Speaker 1: be a sign that those four layers of muscles are

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Speaker 1: not working as well to stabilize the foot and might

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Speaker 1: also represent some features that can be targeted through physical

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Speaker 1: therapy or other interventions. In terms of other diagnostic testing,

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Speaker 1: we will sometimes get an X ray. X rays can

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Speaker 1: be helpful for looking if there's presence of a bone spur,

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Speaker 1: and the idea on why we look for bone spurs

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Speaker 1: is we can sometimes target those through different interventions. But

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Speaker 1: the way I look at a bone spur is this

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Speaker 1: is probably more a sign that there's been chronic traction

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Speaker 1: of the planar fashion up against the bone, and the

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Speaker 1: body will oftentimes respond by trying to put down calcium

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Speaker 1: deposits to try to reinforce the tissue or as part

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Speaker 1: of the inflammatory process. Rarely we'll get MRIs, and MRIs

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Speaker 1: can be helpful if there's concern for an overuse injury

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Speaker 1: to bone, such as a stress fracture, which again the

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Speaker 1: history will oftentimes give us a clue if that's a

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Speaker 1: bigger concern, and with certain procedures that are done, an

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Speaker 1: MRI can be helpful. But oftentimes I'll have patients come

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Speaker 1: to me and they're very concerned that they've had chronic

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Speaker 1: pain and one of their goals is to get an

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Speaker 1: MRI to understand the injury. The good news is that

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Speaker 1: when we've looked at the evidence for how to diagnose

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Speaker 1: plantar fasciatis, there's very limited role for MRI upfront, and

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Speaker 1: that oftentimes will add cost. So it's identifying ways to

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Speaker 1: get our patients better and to use our resources the

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Speaker 1: most efficient is possible.

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Speaker 2: Yeah, And if someone comes in and they think they

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Speaker 2: might have plantro fasci itis but it's actually something else,

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Speaker 2: what would you say some of the something else things

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Speaker 2: might be.

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Speaker 3: Yeah.

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Speaker 1: So at the local level, the other features that overlap

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Speaker 1: with plantar fasciitis would be keel pain, which which could

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Speaker 1: in fact be from an overuse injury such as the

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Speaker 1: stress reaction stress fracture in the more advanced cases, there

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Speaker 1: are other tendons that attach in the hind foot, the

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Speaker 1: peronial tendons the tibi alis posterior. When the tibi alis

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Speaker 1: posterior is chronically irritated, oftentimes individuals will feel like their

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Speaker 1: foot is flattening out, though, so that that would be

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Speaker 1: perhaps a clue. And then to your earlier point, we

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Speaker 1: sometimes will find, as I like to joke with my patients,

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Speaker 1: a close cousin of plantar fasciitis can actually be overload

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Speaker 1: to the Achilles tendons, so people can develop an Achilles tendonitis,

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Speaker 1: or as I like to refer to, an Achilles ten

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Speaker 1: and opathy. And the reason to understand that relationship is

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Speaker 1: to know that when someone's had a history of an

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Speaker 1: Achilles injury, that's oftentimes there's increased demands that have been

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Speaker 1: put through the foot and ankle, or perhaps weakness that

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Speaker 1: contributed to that injury or other biomechanical factors. And some

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Speaker 1: of those fibers that contribute to the Achilles ten and

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Speaker 1: actually wrap around the heel, and so that tightness from

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Speaker 1: the calf muscle can actually pull on the plannar fascia

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Speaker 1: and make it more vulnerable to injury.

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441
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Speaker 3: So now we have our basics.

442
00:25:55,160 --> 00:25:59,399
Speaker 2: We know what characterizes plantrofasciitis, we know what might cause it.

443
00:25:59,720 --> 00:26:02,959
Speaker 3: Now well let's talk about how do we treat it.

444
00:26:03,000 --> 00:26:04,280
Speaker 3: Where does someone even begin?

445
00:26:05,680 --> 00:26:09,440
Speaker 1: Yeah, so oftentimes by the by the time I see

446
00:26:09,480 --> 00:26:13,879
Speaker 1: a patient, they've they've tried a number of different strategies.

447
00:26:14,560 --> 00:26:19,360
Speaker 1: So I certainly understand the tendency to try something over

448
00:26:19,400 --> 00:26:23,760
Speaker 1: the counter, like an anti inflammatory medication. And for those

449
00:26:23,840 --> 00:26:27,160
Speaker 1: that don't have a history of kidney or stomach issues

450
00:26:27,280 --> 00:26:31,240
Speaker 1: or cardiovascular uh, you know concerns. You know, a few

451
00:26:31,280 --> 00:26:36,120
Speaker 1: weeks of an anti inflammatory is oftentimes a reasonable thing

452
00:26:36,200 --> 00:26:41,400
Speaker 1: to try, or something like tile and all. And what

453
00:26:41,440 --> 00:26:44,480
Speaker 1: that will do is that will provide some pain relief

454
00:26:44,560 --> 00:26:47,480
Speaker 1: and oftentimes will allow individuals then to be able to

455
00:26:47,560 --> 00:26:52,040
Speaker 1: do some of the rehabilitation exercises. Practically speaking, I actually

456
00:26:52,119 --> 00:26:55,199
Speaker 1: don't prescribe anti inflammatories because I find they have a

457
00:26:55,280 --> 00:26:59,280
Speaker 1: very limited use in this condition. So what what I

458
00:26:59,359 --> 00:27:02,280
Speaker 1: consider to be the mainstay is to get the individual

459
00:27:02,280 --> 00:27:06,360
Speaker 1: into physical therapy. So again, some of those earlier features,

460
00:27:06,400 --> 00:27:09,560
Speaker 1: can you balance on one foot? Or how how does

461
00:27:09,560 --> 00:27:12,040
Speaker 1: someone look when they do a single legg squat can

462
00:27:12,040 --> 00:27:14,960
Speaker 1: point to some of the weakness, especially if the condition

463
00:27:15,080 --> 00:27:17,960
Speaker 1: is on one side and the individuals finding it a

464
00:27:17,960 --> 00:27:20,560
Speaker 1: lot harder to do those tasks on that side. It

465
00:27:20,600 --> 00:27:24,359
Speaker 1: represents something to target and ensure that people feel like

466
00:27:24,400 --> 00:27:26,520
Speaker 1: there is actually something to work on and it's not

467
00:27:26,600 --> 00:27:30,399
Speaker 1: just going through a process. In terms of other strategies,

468
00:27:30,440 --> 00:27:34,440
Speaker 1: early on, if someone has first morning step pain, so

469
00:27:34,480 --> 00:27:36,880
Speaker 1: that pain getting out of bed, use of a night

470
00:27:37,000 --> 00:27:41,680
Speaker 1: splint or a Strasbourg sock, which is which tends to

471
00:27:41,720 --> 00:27:43,760
Speaker 1: be a little better if you're if you're sleeping next

472
00:27:43,760 --> 00:27:46,359
Speaker 1: to someone, because it really hurts if you get kicked

473
00:27:46,359 --> 00:27:50,000
Speaker 1: by a boot. But a Strasbourg sock is essentially a

474
00:27:50,040 --> 00:27:54,600
Speaker 1: long stocking which which puts a chronic stretch through the

475
00:27:54,640 --> 00:27:57,080
Speaker 1: plantar fashion and might help with that first morning step.

476
00:27:57,119 --> 00:27:57,359
Speaker 2: Pain.

477
00:27:58,359 --> 00:28:02,960
Speaker 1: Orthotics are another thing that individuals will try. I'm not

478
00:28:03,000 --> 00:28:06,320
Speaker 1: a huge proponent for orthotics long term unless someone really

479
00:28:06,359 --> 00:28:11,320
Speaker 1: has an advanced structural foot deformity, but something over the

480
00:28:11,359 --> 00:28:13,720
Speaker 1: counter that provides a little bit of our support will

481
00:28:13,800 --> 00:28:20,240
Speaker 1: sometimes allow for some pain relief. Now, if those strategies

482
00:28:20,280 --> 00:28:24,560
Speaker 1: don't work, that's where we start to think about other interventions.

483
00:28:25,080 --> 00:28:28,640
Speaker 1: So in terms of those strategies for treatment, one option

484
00:28:28,880 --> 00:28:32,520
Speaker 1: that is commonly offered is a steroid injection. And the

485
00:28:32,520 --> 00:28:35,919
Speaker 1: theory is that if steroid is put right next to

486
00:28:35,960 --> 00:28:39,680
Speaker 1: the planar fascia and there is a component of pain

487
00:28:39,720 --> 00:28:43,640
Speaker 1: and inflammation which is limiting the individual, by applying an

488
00:28:43,640 --> 00:28:47,960
Speaker 1: anti inflammatory, you might get pain relief. Now, while that's

489
00:28:48,000 --> 00:28:51,480
Speaker 1: a reasonable strategy, there are a number of concerns around

490
00:28:51,480 --> 00:28:55,000
Speaker 1: the use of steroid. One is that individuals that have

491
00:28:55,080 --> 00:29:00,800
Speaker 1: diabetes or have other issues affecting their over all health.

492
00:29:01,200 --> 00:29:04,400
Speaker 1: The steroid itself can actually cause a spike in blood

493
00:29:04,400 --> 00:29:09,720
Speaker 1: sugar or can affect people's mood. They sometimes have difficulties sleeping.

494
00:29:10,440 --> 00:29:14,120
Speaker 1: But the other issues are what steroid can do structurally.

495
00:29:14,320 --> 00:29:18,440
Speaker 1: So if steroid gets deposited into the heel pad, it

496
00:29:18,480 --> 00:29:21,200
Speaker 1: can actually cause a condition called fat atrophy where the

497
00:29:21,560 --> 00:29:26,680
Speaker 1: fat actually will will be permanently injured, and then that

498
00:29:27,800 --> 00:29:31,520
Speaker 1: we don't have a really effective treatment for the other

499
00:29:32,000 --> 00:29:35,280
Speaker 1: is that the steroid itself. The more we learn about steroids,

500
00:29:35,280 --> 00:29:38,120
Speaker 1: the less I like them. The main concern is that

501
00:29:38,200 --> 00:29:44,120
Speaker 1: steroid actually suppresses the normal turnover proteins in the plantar fascia,

502
00:29:44,680 --> 00:29:47,880
Speaker 1: so people can actually tear their planar fascia by having

503
00:29:48,000 --> 00:29:51,760
Speaker 1: steroid deposited next to it. So if someone is going

504
00:29:51,800 --> 00:29:54,800
Speaker 1: to have a steroid injection, we recommend the use of

505
00:29:54,960 --> 00:29:58,640
Speaker 1: ultrasound guidance. And we didn't talk about ultrasound as an

506
00:29:58,640 --> 00:30:02,280
Speaker 1: evaluation tool. Ultrasound has actually been shown to be quite

507
00:30:02,360 --> 00:30:07,560
Speaker 1: effective under when we review the literature for detecting this condition,

508
00:30:08,240 --> 00:30:10,640
Speaker 1: because you can actually look for thickness of the plantar

509
00:30:10,720 --> 00:30:13,000
Speaker 1: fashion and you can look for the presence of tearing

510
00:30:13,800 --> 00:30:17,680
Speaker 1: and what ultrasound guidance allows for is putting the steroid

511
00:30:17,880 --> 00:30:21,080
Speaker 1: right next to the tissue, as opposed to putting the

512
00:30:21,080 --> 00:30:24,880
Speaker 1: steroid directly into the planar fascia or into attendon where

513
00:30:24,880 --> 00:30:28,120
Speaker 1: it could cause those tissues to get weaker. So that's

514
00:30:28,160 --> 00:30:30,800
Speaker 1: something that we commonly will do at MASS. General Brigham

515
00:30:30,880 --> 00:30:34,520
Speaker 1: is use image guidance if we're going to provide an

516
00:30:34,560 --> 00:30:40,800
Speaker 1: injection like steroid. Now, looking at the systematic reviews, so

517
00:30:42,560 --> 00:30:45,240
Speaker 1: the evidence that steroid will work even though it's covered

518
00:30:45,280 --> 00:30:50,000
Speaker 1: by insurance, it's been suggested by Cochrane, which is a

519
00:30:50,000 --> 00:30:53,160
Speaker 1: big review group, that it might have low evidence that

520
00:30:53,240 --> 00:30:55,800
Speaker 1: it will help for one month of pain relief. So

521
00:30:56,720 --> 00:30:59,880
Speaker 1: while it may be covered by insurance, and if someone

522
00:31:00,040 --> 00:31:02,800
Speaker 1: and you know, doesn't have the financial means to try

523
00:31:02,840 --> 00:31:05,800
Speaker 1: some of these other strategies and physical therapy is and working,

524
00:31:06,200 --> 00:31:08,320
Speaker 1: that is something that could be considered should be done

525
00:31:08,400 --> 00:31:11,880
Speaker 1: under ultrasound guidance, but we have to recognize that may

526
00:31:11,920 --> 00:31:15,200
Speaker 1: not be a good long term strategy. So in terms

527
00:31:15,200 --> 00:31:19,800
Speaker 1: of the other interventions, there's one other form of injection

528
00:31:19,920 --> 00:31:23,600
Speaker 1: that will commonly consider, which is called platelar rich plasma

529
00:31:23,720 --> 00:31:28,720
Speaker 1: or PRP, and PRP is really you know, kind of

530
00:31:28,720 --> 00:31:34,080
Speaker 1: a hot topic in sports medicine. What we believe PRP

531
00:31:34,360 --> 00:31:39,320
Speaker 1: can do is that by taking someone's own blood, spinning

532
00:31:39,360 --> 00:31:44,160
Speaker 1: it down, and taking the platelar rich layer, we're isolating

533
00:31:44,200 --> 00:31:46,920
Speaker 1: some of the growth factors that might help the body

534
00:31:46,960 --> 00:31:51,239
Speaker 1: to repair our own tissue. So the upside with this

535
00:31:51,400 --> 00:31:53,640
Speaker 1: is this is our bodies owned cells, and what we're

536
00:31:53,640 --> 00:31:56,800
Speaker 1: trying to do is we're trying to reinitiate a healing response,

537
00:31:57,720 --> 00:32:02,320
Speaker 1: So very very little argue with that strategy. The main

538
00:32:02,440 --> 00:32:06,640
Speaker 1: downsides with playlar rich plasma are that insurance won't pay

539
00:32:06,720 --> 00:32:09,320
Speaker 1: for it, and we also need to recognize that if

540
00:32:09,360 --> 00:32:12,760
Speaker 1: an athlete is in season, or if you're you know,

541
00:32:13,200 --> 00:32:16,880
Speaker 1: you have an upcoming running event, you may not want

542
00:32:16,920 --> 00:32:21,880
Speaker 1: to take the traditional time off that's required after a

543
00:32:21,920 --> 00:32:25,760
Speaker 1: PRP injection to effectively rehabilitate the tissue.

544
00:32:26,120 --> 00:32:28,440
Speaker 3: And what does that time off classically look like.

545
00:32:28,960 --> 00:32:32,720
Speaker 1: With PRP, it oftentimes will take a minimum of three

546
00:32:32,760 --> 00:32:36,120
Speaker 1: months to really get back into full running, and so

547
00:32:36,200 --> 00:32:39,280
Speaker 1: for a lot of individuals that's not an acceptable amount

548
00:32:39,280 --> 00:32:42,880
Speaker 1: of time. But I do think it's a reasonable strategy,

549
00:32:42,920 --> 00:32:47,080
Speaker 1: and oftentimes we will get an MRI before offering PRP

550
00:32:47,760 --> 00:32:50,760
Speaker 1: because we want to understand the extent of the injury

551
00:32:50,880 --> 00:32:53,360
Speaker 1: and to make sure that the treatment is as targeted

552
00:32:53,400 --> 00:32:57,400
Speaker 1: as possible. And oftentimes the individual will have more than

553
00:32:57,600 --> 00:33:00,280
Speaker 1: just planar fasciatis. There may be some involvement and of

554
00:33:00,400 --> 00:33:03,760
Speaker 1: other soft tissue which then could also be targeted with

555
00:33:03,880 --> 00:33:09,200
Speaker 1: the injection at one time. So the other injection two

556
00:33:09,280 --> 00:33:12,320
Speaker 1: that has a little less evidence would be something called

557
00:33:12,320 --> 00:33:19,560
Speaker 1: prolo therapy, and prolo therapy is becoming very there's a

558
00:33:19,600 --> 00:33:24,600
Speaker 1: lot more advertising for it. Prolo stands for proliferation. So

559
00:33:24,720 --> 00:33:29,760
Speaker 1: what prolo therapy is is it's using a substance, oftentimes

560
00:33:29,880 --> 00:33:33,360
Speaker 1: dextro solution or sugar water that can be put around

561
00:33:33,400 --> 00:33:38,440
Speaker 1: a tissue and basically triggers a local inflammatory response. So

562
00:33:39,000 --> 00:33:42,680
Speaker 1: oftentimes we hear, you know, fascy itis, and we assume

563
00:33:42,800 --> 00:33:45,600
Speaker 1: that that is an inflammatory response. But getting back to

564
00:33:45,640 --> 00:33:49,120
Speaker 1: our earlier definition, most of the time individuals do not

565
00:33:49,280 --> 00:33:53,560
Speaker 1: have a primary inflammatory response causing their pain. What they

566
00:33:53,560 --> 00:33:57,120
Speaker 1: have is they have tissue that's thickened where the body

567
00:33:57,160 --> 00:34:00,760
Speaker 1: put down tried to repair but that repair did not

568
00:34:00,920 --> 00:34:06,160
Speaker 1: successfully happen. So what prolotherapy does is it reinitiates that

569
00:34:06,200 --> 00:34:10,160
Speaker 1: healing response. So the upside with prolo therapy is that

570
00:34:10,239 --> 00:34:12,680
Speaker 1: can be used for an n season athlete or someone

571
00:34:12,680 --> 00:34:17,240
Speaker 1: who has a competition coming up by changing the concentration

572
00:34:17,400 --> 00:34:21,280
Speaker 1: of the dextro solution. The downside with prolotherapy is similar

573
00:34:21,320 --> 00:34:23,879
Speaker 1: to play the rich plasma. It does have an out

574
00:34:23,880 --> 00:34:29,040
Speaker 1: of pocket cost and oftentimes with prolo therapy, individuals will

575
00:34:29,080 --> 00:34:32,960
Speaker 1: get multiple injections to see the full effect, as opposed

576
00:34:33,000 --> 00:34:36,000
Speaker 1: to PRP where we typically start with one followed by

577
00:34:36,000 --> 00:34:41,480
Speaker 1: a structured rehabilitation program. Outside of injection based treatments, the

578
00:34:42,560 --> 00:34:45,640
Speaker 1: intervention that I commonly perform in my clinic is something

579
00:34:45,680 --> 00:34:51,800
Speaker 1: called shockwave. Now, shockwave has been around for a long time.

580
00:34:51,960 --> 00:34:55,880
Speaker 1: It actually was first developed for the treatment of kidney stones,

581
00:34:56,600 --> 00:35:00,120
Speaker 1: and it was observed that it actually had effects and

582
00:35:00,360 --> 00:35:03,680
Speaker 1: other tissues. So not only could you dissolve a calcific

583
00:35:03,840 --> 00:35:07,080
Speaker 1: stone or a mineral stone in the kidneys, but you

584
00:35:07,160 --> 00:35:11,000
Speaker 1: can actually use these these sound waves or these pressure

585
00:35:11,000 --> 00:35:16,960
Speaker 1: waves from this device to essentially reinitiate a healing response.

586
00:35:17,760 --> 00:35:21,200
Speaker 1: So some of the early work outside of treatment of

587
00:35:21,320 --> 00:35:24,440
Speaker 1: kidney stones, which we refer to as lithotripsy, was in

588
00:35:24,520 --> 00:35:27,759
Speaker 1: plantar fasciitis where they were finding that by targeting those

589
00:35:29,360 --> 00:35:32,360
Speaker 1: those heel spurs, they were actually giving patients pain relief.

590
00:35:32,800 --> 00:35:34,759
Speaker 1: And then it was determined that not only was it

591
00:35:34,840 --> 00:35:37,360
Speaker 1: treating the mineral deposit, but it was actually treating the

592
00:35:37,840 --> 00:35:40,840
Speaker 1: length of the plantar fascia that was giving individuals that

593
00:35:41,000 --> 00:35:44,960
Speaker 1: long term pain relief they were looking for. So there's

594
00:35:45,000 --> 00:35:49,000
Speaker 1: been a number of studies and again, you know, super

595
00:35:49,040 --> 00:35:53,040
Speaker 1: nerdy thing, but if you really want strong evidence, you're

596
00:35:53,080 --> 00:35:57,319
Speaker 1: looking for studies that are randomized, have a placebo, and

597
00:35:57,600 --> 00:36:02,640
Speaker 1: are controlled studies. And this is actually where shockwave has

598
00:36:02,680 --> 00:36:05,360
Speaker 1: some of the strongest evidence for treatment is in the

599
00:36:05,400 --> 00:36:11,000
Speaker 1: treatment of planner fasciatis. So the upside with shockwave is

600
00:36:11,120 --> 00:36:15,560
Speaker 1: it's a non evasive procedure. It's called extracoporeal shockwave because

601
00:36:15,760 --> 00:36:19,440
Speaker 1: it's delivered outside of the body. You have a device

602
00:36:19,520 --> 00:36:22,319
Speaker 1: that either will strike the tissue and that's what we

603
00:36:22,360 --> 00:36:25,799
Speaker 1: refer to as radial shockwave or radio pressure wave, or

604
00:36:25,840 --> 00:36:28,200
Speaker 1: you'll have a device that oftentimes will create kind of

605
00:36:28,239 --> 00:36:30,680
Speaker 1: a burning sensation and that's what we refer to that

606
00:36:30,760 --> 00:36:34,480
Speaker 1: as focused shockwave. The downside with shockwave is the treatment

607
00:36:34,520 --> 00:36:38,279
Speaker 1: itself is painful, and you know, it is truly as

608
00:36:38,320 --> 00:36:40,640
Speaker 1: some of my patients say, it is no pain, no gain.

609
00:36:41,280 --> 00:36:45,080
Speaker 1: If the treatment's being done correctly, it will induce pain.

610
00:36:45,560 --> 00:36:47,759
Speaker 1: Studies that have been done where people would get a

611
00:36:47,760 --> 00:36:51,160
Speaker 1: nerve block actually found that it was less successful for treatment.

612
00:36:51,800 --> 00:36:55,320
Speaker 1: So we believe that shockwave works to actually stimulate tissue

613
00:36:55,320 --> 00:36:59,360
Speaker 1: remodeling through inflammation, but it may also disrupt pain signals

614
00:36:59,400 --> 00:37:03,440
Speaker 1: between our brain in our spinal cord, so so you

615
00:37:03,480 --> 00:37:06,200
Speaker 1: will have pain during the treatment that we'll say is

616
00:37:06,239 --> 00:37:09,120
Speaker 1: typically five to seven out of ten. It does have

617
00:37:09,160 --> 00:37:12,960
Speaker 1: an out of pocket cost, and similar to other treatments,

618
00:37:13,840 --> 00:37:17,120
Speaker 1: there is no one singular treatment that's one hundred percent effective.

619
00:37:17,719 --> 00:37:20,080
Speaker 1: But I've looked at outcomes for my patients and have

620
00:37:20,160 --> 00:37:23,200
Speaker 1: seen you know, upwards a seventy five percent of individuals

621
00:37:23,239 --> 00:37:28,360
Speaker 1: with good functional improvement after receiving shockwave treatment, and a

622
00:37:28,480 --> 00:37:33,880
Speaker 1: typical protocol should include three weekly sessions with structured rehabilitation

623
00:37:34,520 --> 00:37:37,600
Speaker 1: with a follow up at three months. I see a

624
00:37:37,640 --> 00:37:41,200
Speaker 1: lot of variability in how shockwave is delivered, where some

625
00:37:41,239 --> 00:37:43,799
Speaker 1: people say, you have a really bad case and you need, like,

626
00:37:44,520 --> 00:37:48,040
Speaker 1: you know, some random number of sessions. But if you

627
00:37:48,080 --> 00:37:52,720
Speaker 1: really look at the literature and you're not necessarily driven

628
00:37:52,920 --> 00:37:57,160
Speaker 1: just by a financial component of charging for every session.

629
00:37:57,760 --> 00:38:00,360
Speaker 1: I do believe that the best standard practice is to

630
00:38:00,440 --> 00:38:03,600
Speaker 1: do three to four initial session separated by a week,

631
00:38:04,000 --> 00:38:08,239
Speaker 1: do the structured rehabilitation, and then, based on the studies,

632
00:38:08,400 --> 00:38:10,319
Speaker 1: it's usually a three to four months where you're going

633
00:38:10,400 --> 00:38:13,520
Speaker 1: to see a good response to the treatment, and that's

634
00:38:13,520 --> 00:38:16,719
Speaker 1: where you might consider more shockwaver. You might consider combining

635
00:38:16,800 --> 00:38:20,600
Speaker 1: it with other types of strategies such as platelar rich plasma.

636
00:38:20,680 --> 00:38:22,279
Speaker 3: Two things to double click on here.

637
00:38:22,480 --> 00:38:24,480
Speaker 2: First, I do want to go back to us talking

638
00:38:24,520 --> 00:38:28,839
Speaker 2: about the steroid injections. When we talk about that, are

639
00:38:28,880 --> 00:38:30,560
Speaker 2: we talking about a cortizone shot.

640
00:38:31,440 --> 00:38:35,040
Speaker 1: Yeah, thank you so much for having me clarify that,

641
00:38:35,160 --> 00:38:40,160
Speaker 1: so we hear cordicas steroid cortizone. That's essentially what we're

642
00:38:40,200 --> 00:38:43,759
Speaker 1: referring to is the use of steroid which is oftentimes

643
00:38:43,840 --> 00:38:48,120
Speaker 1: mixed with a numbing medication like lytocane, and both of

644
00:38:48,160 --> 00:38:51,080
Speaker 1: those are actually been shown to be potentially toxic to

645
00:38:51,160 --> 00:38:53,239
Speaker 1: the cells that they exposed to.

646
00:38:54,040 --> 00:38:56,799
Speaker 2: Right now, I know, at least in my case a

647
00:38:56,880 --> 00:38:58,960
Speaker 2: concern and why we didn't go that route was not

648
00:38:59,000 --> 00:39:02,000
Speaker 2: only do we want to act fix the root cause

649
00:39:02,200 --> 00:39:05,719
Speaker 2: of what was giving me this problem, but also more

650
00:39:05,800 --> 00:39:09,080
Speaker 2: often than not, what will happen is that the cortizone

651
00:39:09,120 --> 00:39:12,479
Speaker 2: injection dulls the pain in the area but doesn't rid

652
00:39:12,920 --> 00:39:15,839
Speaker 2: the issue, and so you may not be aware to

653
00:39:15,920 --> 00:39:19,080
Speaker 2: your point that people might tear their planter, that you

654
00:39:19,120 --> 00:39:23,200
Speaker 2: could be doing more damage than good. Now, understandably, people

655
00:39:23,280 --> 00:39:25,200
Speaker 2: are like, oh, but I don't want to feel the pain,

656
00:39:25,480 --> 00:39:27,600
Speaker 2: so they're hoping to find someone to give them a

657
00:39:27,680 --> 00:39:31,560
Speaker 2: cortizone injection. And so I bring all this up because

658
00:39:31,600 --> 00:39:34,239
Speaker 2: it's helpful to know that although it may lessen your

659
00:39:34,280 --> 00:39:37,080
Speaker 2: pain in that moment, you might be doing yourself a

660
00:39:37,080 --> 00:39:37,719
Speaker 2: disservice in.

661
00:39:37,680 --> 00:39:38,279
Speaker 3: The long haul.

662
00:39:39,320 --> 00:39:42,720
Speaker 1: I'm really glad you're bringing up that point, because again,

663
00:39:43,120 --> 00:39:46,200
Speaker 1: often we oftentimes are responding to the fact that we

664
00:39:46,280 --> 00:39:51,160
Speaker 1: have pain. So I have unfortunately seen patients where I've

665
00:39:51,200 --> 00:39:55,279
Speaker 1: taken care of them or they are seeking care from

666
00:39:55,360 --> 00:39:59,120
Speaker 1: other providers in addition to me, where they've received a

667
00:39:59,200 --> 00:40:04,279
Speaker 1: sterid injection and subsequently torn their planar fascia. So it's

668
00:40:05,680 --> 00:40:09,880
Speaker 1: not a pleasant experience, and that in itself is going

669
00:40:09,920 --> 00:40:14,120
Speaker 1: to require a prolonged time to recover from from tearing

670
00:40:14,160 --> 00:40:17,040
Speaker 1: the plantar fascia as well. So yeah, both of us,

671
00:40:18,280 --> 00:40:22,400
Speaker 1: it's very disheartening when you do happen. And then the

672
00:40:22,480 --> 00:40:25,000
Speaker 1: other thing too is that people will sometimes be given

673
00:40:25,160 --> 00:40:29,359
Speaker 1: oral steroids. And my concern with oral steroids is, you know,

674
00:40:29,400 --> 00:40:32,640
Speaker 1: it's it's like trying to hose off a forest fire

675
00:40:32,719 --> 00:40:34,879
Speaker 1: when you could just dump a bucket of water right

676
00:40:34,920 --> 00:40:37,680
Speaker 1: on the flame. So if someone's going to get a

677
00:40:37,719 --> 00:40:40,840
Speaker 1: steroid injection, I would much prefer that it be targeted

678
00:40:41,120 --> 00:40:44,799
Speaker 1: very locally, as opposed to taking oral steroids, which we

679
00:40:44,880 --> 00:40:48,680
Speaker 1: know will will actually have more profound effects on the

680
00:40:48,800 --> 00:40:52,120
Speaker 1: endocrine system, can cause people to have trouble with sleeping,

681
00:40:52,360 --> 00:40:55,280
Speaker 1: but can also have effects long term on bone health

682
00:40:55,920 --> 00:40:59,200
Speaker 1: or even a rare condition called a vascular necrosis, which

683
00:40:59,239 --> 00:41:02,960
Speaker 1: can cause a long term damage to join some bones.

684
00:41:03,600 --> 00:41:07,480
Speaker 1: So I think a big takeaway for all the listeners

685
00:41:07,560 --> 00:41:13,080
Speaker 1: is to understand that steroid is commonly used, but it

686
00:41:13,120 --> 00:41:16,720
Speaker 1: may not be the best long term solution for someone's.

687
00:41:16,320 --> 00:41:17,840
Speaker 3: Health, definitely.

688
00:41:17,960 --> 00:41:20,040
Speaker 2: And then the last thing that I wanted to mention

689
00:41:20,239 --> 00:41:22,600
Speaker 2: here the second point to double click on. I know

690
00:41:22,640 --> 00:41:25,280
Speaker 2: we talked about shockwave therapy, but something we haven't talked

691
00:41:25,280 --> 00:41:26,440
Speaker 2: about just yet.

692
00:41:26,400 --> 00:41:29,239
Speaker 3: Is light therapy. That is a route that I went down.

693
00:41:29,280 --> 00:41:33,520
Speaker 2: I did the led Red light therapy essentially an application

694
00:41:33,840 --> 00:41:37,000
Speaker 2: of red and near infrared light goes to your injury

695
00:41:37,080 --> 00:41:40,840
Speaker 2: area i e. The Planter fascia and in my case,

696
00:41:40,920 --> 00:41:44,640
Speaker 2: I did I believe three treatments aiming to accelerate that

697
00:41:44,760 --> 00:41:47,960
Speaker 2: tissue healing and reduce the inflammation and pain. For me,

698
00:41:48,320 --> 00:41:50,920
Speaker 2: that worked. It might not work for everyone. What do

699
00:41:50,960 --> 00:41:53,080
Speaker 2: you say about the light therapy.

700
00:41:54,160 --> 00:41:56,960
Speaker 1: Yeah, so I'm glad you're bringing up light therapy because

701
00:41:57,280 --> 00:42:01,640
Speaker 1: this is an area where we're actually doing some active research.

702
00:42:02,760 --> 00:42:05,879
Speaker 1: And the theory on how this light therapy may work

703
00:42:06,040 --> 00:42:09,400
Speaker 1: is that oftentimes what we're using is something close to

704
00:42:09,480 --> 00:42:13,040
Speaker 1: a near infrared, so it'll be it'll be more of

705
00:42:13,080 --> 00:42:16,279
Speaker 1: like a red based laser. It requires a lot of

706
00:42:16,480 --> 00:42:19,839
Speaker 1: a lot of safety precautions because a true laser can

707
00:42:19,880 --> 00:42:25,560
Speaker 1: actually cause permanent vision damage blindness, so that treatment. The

708
00:42:25,560 --> 00:42:30,440
Speaker 1: theory is that the light therapy might actually increase metabolic activity,

709
00:42:31,000 --> 00:42:34,000
Speaker 1: and unlike shockwave in some of these other interventions, it's

710
00:42:34,080 --> 00:42:38,560
Speaker 1: largely a painless experience. Oftentimes it just feels like a

711
00:42:38,640 --> 00:42:42,560
Speaker 1: dpeat is being applied to the tissue. There have there

712
00:42:42,640 --> 00:42:45,719
Speaker 1: have been some limited studies showing that light therapy may

713
00:42:45,800 --> 00:42:50,319
Speaker 1: help with plantar fasciitis, where right now studying combining light

714
00:42:50,360 --> 00:42:56,279
Speaker 1: therapy with shockwave in the treatment of achilles tendinopathy. So

715
00:42:56,520 --> 00:43:00,000
Speaker 1: and and in my system as General Brigham, there's actually

716
00:43:00,239 --> 00:43:03,640
Speaker 1: a whole center for what's referred to as photo medicine

717
00:43:03,680 --> 00:43:07,839
Speaker 1: or phototherapy. So I think there is something There is

718
00:43:08,000 --> 00:43:12,839
Speaker 1: definitely something too light therapy, and whether it's done as

719
00:43:12,880 --> 00:43:16,319
Speaker 1: a singular treatment or in combination with other treatments that

720
00:43:16,400 --> 00:43:19,520
Speaker 1: can provide some help. I think for those listening, it's

721
00:43:19,520 --> 00:43:26,160
Speaker 1: just understanding that things like phototherapy shockwave play the rich plasma.

722
00:43:26,480 --> 00:43:29,080
Speaker 1: They oftentimes will have an out of pocket cost. So

723
00:43:29,120 --> 00:43:31,839
Speaker 1: it's trying to understand what's going to be the best

724
00:43:31,840 --> 00:43:36,520
Speaker 1: individualized treatment. And for some that's going to be informed

725
00:43:36,520 --> 00:43:40,560
Speaker 1: by understanding, you know, evidence based medicine, which describes groups

726
00:43:40,560 --> 00:43:44,960
Speaker 1: of patients not necessarily an individual. But for others it's

727
00:43:45,000 --> 00:43:48,480
Speaker 1: going to be about choice and understanding how things should

728
00:43:48,480 --> 00:43:49,240
Speaker 1: be done safely.

729
00:43:49,880 --> 00:43:52,880
Speaker 2: Yeah, and you know that's definitely a frustration point for

730
00:43:53,000 --> 00:43:55,520
Speaker 2: so many. Right you pay so much for insurance, it

731
00:43:55,560 --> 00:43:57,600
Speaker 2: doesn't get you what you need. You're trying to make

732
00:43:57,600 --> 00:44:00,560
Speaker 2: the right decisions for your body and then under standarably.

733
00:44:00,680 --> 00:44:03,640
Speaker 2: So that is why more often than not, some people

734
00:44:03,680 --> 00:44:06,160
Speaker 2: may go down a path that might not ultimately be

735
00:44:06,680 --> 00:44:09,120
Speaker 2: in their best interest. So again this goes back to

736
00:44:09,160 --> 00:44:14,640
Speaker 2: that concept we were talking about before, patients patients, patients,

737
00:44:14,680 --> 00:44:17,440
Speaker 2: which when you've got regular pain, it's not exactly easy.

738
00:44:18,600 --> 00:44:23,040
Speaker 1: Oh, I one hundred percent agree. And again that's also

739
00:44:23,120 --> 00:44:26,200
Speaker 1: why it's important to have you know a physician or

740
00:44:26,239 --> 00:44:29,160
Speaker 1: a medical provider that you trust and that you feel

741
00:44:29,200 --> 00:44:34,040
Speaker 1: is really listening to you and understanding how this injury

742
00:44:34,239 --> 00:44:38,520
Speaker 1: is affecting your overall health, because, as you were mentioning earlier,

743
00:44:38,560 --> 00:44:41,760
Speaker 1: these injuries, you know, pain can really affect a number

744
00:44:41,760 --> 00:44:44,719
Speaker 1: of things. Can affect someone's physical health, but it also

745
00:44:44,800 --> 00:44:47,560
Speaker 1: affects their mental health and their quality of life. So

746
00:44:47,600 --> 00:44:50,840
Speaker 1: that's why I think it's a really important injury to

747
00:44:51,840 --> 00:44:55,799
Speaker 1: think about targeting, and for those that have dealt with

748
00:44:55,840 --> 00:44:58,120
Speaker 1: this injury that are listening in not to give up

749
00:44:58,160 --> 00:44:59,840
Speaker 1: hope that there can't.

750
00:44:59,640 --> 00:45:02,719
Speaker 2: Be a Now, there are two things I want to

751
00:45:02,719 --> 00:45:05,279
Speaker 2: touch on before I let you go. The first thing

752
00:45:05,560 --> 00:45:09,120
Speaker 2: is getting back to regular activity. We're talking about maybe

753
00:45:09,120 --> 00:45:11,360
Speaker 2: seeing a little bit of a light at the end

754
00:45:11,400 --> 00:45:14,080
Speaker 2: of the tunnel. The symptoms are lessening a little bit,

755
00:45:14,200 --> 00:45:16,120
Speaker 2: maybe there's a little bit of lingering pain, but it's

756
00:45:16,160 --> 00:45:18,520
Speaker 2: not like it was before. Do you have any golden

757
00:45:19,120 --> 00:45:22,520
Speaker 2: rules of thumb when it comes to getting back into

758
00:45:22,560 --> 00:45:25,440
Speaker 2: activity where you should be at if you're on a

759
00:45:25,440 --> 00:45:27,800
Speaker 2: pain scale, what should we expect?

760
00:45:28,239 --> 00:45:32,280
Speaker 1: I'm really glad you asked. There's actually been some work.

761
00:45:32,440 --> 00:45:35,840
Speaker 1: And again this is extrapolated from the treatment of overuse

762
00:45:35,880 --> 00:45:40,840
Speaker 1: injury to tendon, where there's a pain scale based on

763
00:45:41,040 --> 00:45:45,120
Speaker 1: zero to ten and three zones of pain. So I

764
00:45:45,160 --> 00:45:50,279
Speaker 1: really like this analogy of a green zone, a yellow zone,

765
00:45:50,320 --> 00:45:52,920
Speaker 1: and a red zone. So this is the way that

766
00:45:53,000 --> 00:45:57,400
Speaker 1: I'll handle the management of planar fasciitis and runners. And

767
00:45:57,440 --> 00:46:00,960
Speaker 1: again this is outside of something like rich plasma, where

768
00:46:01,000 --> 00:46:04,960
Speaker 1: there may be a specific timeframe before starting back into activity,

769
00:46:05,560 --> 00:46:09,600
Speaker 1: but for individuals after shockwave treatment, we oftentimes will talk

770
00:46:09,640 --> 00:46:12,680
Speaker 1: about the green zone being any activity you can do

771
00:46:13,040 --> 00:46:17,120
Speaker 1: with zero to two out of ten pain is desirable.

772
00:46:18,040 --> 00:46:22,560
Speaker 1: Acceptable is the yellow zone, So that's any activity that

773
00:46:22,600 --> 00:46:25,799
Speaker 1: causes pain between two to five out of ten, and

774
00:46:25,840 --> 00:46:29,120
Speaker 1: that's both during as well as after the activity. We

775
00:46:29,200 --> 00:46:32,360
Speaker 1: call that the yellow zone. So yellow means it's okay

776
00:46:32,400 --> 00:46:34,640
Speaker 1: to have that amount of pain, but we need to

777
00:46:34,680 --> 00:46:36,839
Speaker 1: be cautious, and we need to make sure that that

778
00:46:36,920 --> 00:46:40,400
Speaker 1: pain comes back down to baseline before we return to

779
00:46:40,480 --> 00:46:44,319
Speaker 1: doing that activity. Any activity that exceeds five out of

780
00:46:44,360 --> 00:46:46,840
Speaker 1: ten we refer to as a red zone, which really

781
00:46:46,880 --> 00:46:51,000
Speaker 1: means stop. If we're pushing our body into pain that

782
00:46:51,080 --> 00:46:54,800
Speaker 1: exceeds five out of ten, the concern is this tissue

783
00:46:54,880 --> 00:46:58,839
Speaker 1: is getting overloaded and that's just going to cause more

784
00:46:58,960 --> 00:47:02,600
Speaker 1: damage that the body needs time to repair. So it's

785
00:47:02,719 --> 00:47:05,879
Speaker 1: just going to keep the body in this chronically irritated

786
00:47:05,920 --> 00:47:08,520
Speaker 1: state where the body will not ultimately heal and get

787
00:47:08,600 --> 00:47:11,160
Speaker 1: that desirable long term goal of pain relief.

788
00:47:11,480 --> 00:47:11,760
Speaker 3: Again.

789
00:47:11,800 --> 00:47:13,200
Speaker 2: I know when I was in the prime of my

790
00:47:13,280 --> 00:47:17,960
Speaker 2: planter fasciitis diagnosis and really working back to slowly up

791
00:47:18,000 --> 00:47:20,640
Speaker 2: my mileage as I was training for a marathon, the

792
00:47:20,719 --> 00:47:24,399
Speaker 2: goal was always to do it a only adding ten

793
00:47:24,440 --> 00:47:27,239
Speaker 2: percent each week, so no more than an additional of

794
00:47:27,360 --> 00:47:31,840
Speaker 2: ten percent total mileage week over week, and then to

795
00:47:31,920 --> 00:47:37,200
Speaker 2: increase the volume without changing or increasing the pain. Right, So,

796
00:47:37,680 --> 00:47:40,040
Speaker 2: as long as we were in as you described that

797
00:47:40,200 --> 00:47:43,680
Speaker 2: yellow zone or below, it was a safe place to be.

798
00:47:43,840 --> 00:47:47,040
Speaker 2: So I think that breakdown is actually truly truly helpful

799
00:47:47,040 --> 00:47:49,640
Speaker 2: in a really great way to visualize what someone may

800
00:47:49,640 --> 00:47:50,400
Speaker 2: be going through.

801
00:47:50,680 --> 00:47:52,960
Speaker 1: One other piece of that that I think is important

802
00:47:53,040 --> 00:47:55,680
Speaker 1: is to understand how long does it take for soft

803
00:47:55,680 --> 00:48:00,239
Speaker 1: tissue to heal. So oftentimes, you know, when I was

804
00:48:00,280 --> 00:48:02,120
Speaker 1: growing up, when you were growing up, we were told

805
00:48:02,160 --> 00:48:06,160
Speaker 1: everything was itis. Right, it's inflammatory, a couple weeks, you

806
00:48:06,160 --> 00:48:08,600
Speaker 1: should be able to knock it out. But the way

807
00:48:08,640 --> 00:48:13,320
Speaker 1: we're understanding soft tissue healing is we're actually there's actually

808
00:48:13,400 --> 00:48:16,520
Speaker 1: belief that it may take six to twelve months for

809
00:48:16,600 --> 00:48:20,319
Speaker 1: the body to fully repair a soft tissue injury. So

810
00:48:20,840 --> 00:48:23,680
Speaker 1: as we talked about before, and I feel as almost

811
00:48:23,680 --> 00:48:26,160
Speaker 1: insulting to my patients to tell them they need to

812
00:48:26,200 --> 00:48:30,320
Speaker 1: be patient, there is something to be said for recognizing

813
00:48:30,480 --> 00:48:33,120
Speaker 1: how long it takes for the body to fully repair

814
00:48:33,239 --> 00:48:37,560
Speaker 1: a soft tissue area of injury. That can take six

815
00:48:37,640 --> 00:48:41,200
Speaker 1: months or longer. So if someone is still having pain

816
00:48:41,320 --> 00:48:46,280
Speaker 1: but they're following those guidelines of the green yellow red zone,

817
00:48:46,000 --> 00:48:49,239
Speaker 1: if they stay the course, my hope is they'll get

818
00:48:49,280 --> 00:48:51,319
Speaker 1: to a point in which they're not having pain.

819
00:48:51,520 --> 00:48:53,640
Speaker 2: Now, before I let you go, I do want to

820
00:48:53,640 --> 00:48:57,320
Speaker 2: touch on what could be some advice for home remedies

821
00:48:57,360 --> 00:49:00,400
Speaker 2: when it comes to dealing with planter fascy itis. Obviously,

822
00:49:00,400 --> 00:49:04,319
Speaker 2: getting in to see an expert is highly important for

823
00:49:04,400 --> 00:49:06,279
Speaker 2: everyone to get back to a quality of life that

824
00:49:06,280 --> 00:49:09,680
Speaker 2: feels much more enjoyable. But when it comes to ice,

825
00:49:09,760 --> 00:49:12,479
Speaker 2: I know you touched about anti inflammatories. What else should

826
00:49:12,520 --> 00:49:14,759
Speaker 2: someone know who's dealing with this on their own at home.

827
00:49:15,920 --> 00:49:20,279
Speaker 1: Yeah, so I think icing is fine. Stretching is a

828
00:49:20,280 --> 00:49:23,320
Speaker 1: little controversial. You know. While I described a night splend

829
00:49:23,360 --> 00:49:26,960
Speaker 1: as a way to keep your feet from being in

830
00:49:27,000 --> 00:49:30,400
Speaker 1: a passive, you know, slack state where you're going to

831
00:49:30,480 --> 00:49:33,719
Speaker 1: have a lot of pain when you take steps, stretching

832
00:49:33,760 --> 00:49:36,640
Speaker 1: itself in some cases will cause the tissue to be

833
00:49:37,239 --> 00:49:41,080
Speaker 1: chronically irritated. So I'm not as big of a proponent

834
00:49:41,120 --> 00:49:43,520
Speaker 1: for stretching as I used to be. Once someone explained

835
00:49:43,520 --> 00:49:46,400
Speaker 1: the you know, the idea that that tissue might have

836
00:49:46,480 --> 00:49:49,279
Speaker 1: some frame, And the analogy I use now is if

837
00:49:49,320 --> 00:49:52,440
Speaker 1: you pull on a rope that's already frayed, it's not

838
00:49:52,480 --> 00:49:55,160
Speaker 1: necessarily going to make the rope hole again. It's probably

839
00:49:55,200 --> 00:49:59,240
Speaker 1: going to cause more damage. There are exercises the short

840
00:49:59,239 --> 00:50:05,680
Speaker 1: foot exercise or toe spread exercises, which sometimes people will

841
00:50:05,800 --> 00:50:08,799
Speaker 1: use toet spacers on top of it, using wider toe

842
00:50:08,840 --> 00:50:12,680
Speaker 1: box shoes can also be helpful because if there's a

843
00:50:12,760 --> 00:50:16,520
Speaker 1: component of having a bunion or HeLEX falgus, having a

844
00:50:16,560 --> 00:50:18,880
Speaker 1: little bit more space and the shoe will allow for

845
00:50:18,960 --> 00:50:21,920
Speaker 1: the toast to not be as constrained and then helps

846
00:50:21,960 --> 00:50:25,400
Speaker 1: to and then doing that in combination with strengthening the

847
00:50:25,400 --> 00:50:28,359
Speaker 1: feet might actually help to restore something we're referring to

848
00:50:28,400 --> 00:50:31,480
Speaker 1: as the foot core, so the muscles to make up

849
00:50:31,520 --> 00:50:32,759
Speaker 1: the foot and ankle complex.

850
00:50:33,320 --> 00:50:35,440
Speaker 2: You know, it's funny we talk about leg day and

851
00:50:35,719 --> 00:50:38,400
Speaker 2: upper body day and working on our core, but we

852
00:50:38,800 --> 00:50:42,360
Speaker 2: rarely ever think about the importance of strengthening our foot,

853
00:50:42,440 --> 00:50:45,000
Speaker 2: this thing that we rely on so much, day in

854
00:50:45,400 --> 00:50:48,960
Speaker 2: and day out, so much really really great advice in here,

855
00:50:49,320 --> 00:50:53,320
Speaker 2: truly a really in depth explainer on plant fasci itis.

856
00:50:53,320 --> 00:50:56,440
Speaker 2: So I appreciate you, doctor ten forty for taking the

857
00:50:56,520 --> 00:50:58,880
Speaker 2: time to go through this with me. Anything else that

858
00:50:58,960 --> 00:51:02,400
Speaker 2: you want to offer the hurdlers before I let you

859
00:51:02,440 --> 00:51:04,520
Speaker 2: go today, No, I.

860
00:51:04,920 --> 00:51:09,359
Speaker 1: Think this is this has been been a great opportunity

861
00:51:09,400 --> 00:51:11,880
Speaker 1: to share what I know on the on the planner fascia.

862
00:51:12,160 --> 00:51:16,080
Speaker 1: And and again I hope for those listening who suffer

863
00:51:16,120 --> 00:51:18,799
Speaker 1: with this injury. You know, seeing myself seeing one of

864
00:51:18,800 --> 00:51:21,680
Speaker 1: my colleagues in mas General Brigham, or you know, seeing

865
00:51:21,680 --> 00:51:25,000
Speaker 1: a provider that that has an expertise in this if

866
00:51:25,080 --> 00:51:27,799
Speaker 1: if you're you're not in the Boston area and just

867
00:51:27,840 --> 00:51:31,600
Speaker 1: remaining hopeful that there can be a strategy to treat

868
00:51:31,640 --> 00:51:34,040
Speaker 1: this this injury and to get back to doing the

869
00:51:34,080 --> 00:51:35,640
Speaker 1: things you enjoy and love.

870
00:51:36,239 --> 00:51:36,839
Speaker 3: We love that.

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00:51:37,000 --> 00:51:39,480
Speaker 2: Well for those that are not in the area, or

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00:51:39,560 --> 00:51:41,839
Speaker 2: they may be but want to follow along with you,

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00:51:42,200 --> 00:51:43,279
Speaker 2: how do they keep up with you?

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00:51:43,360 --> 00:51:44,719
Speaker 3: Is there a way to hang out with you on

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00:51:44,760 --> 00:51:45,400
Speaker 3: social media?

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00:51:46,080 --> 00:51:50,719
Speaker 1: Sure? So on on x Adam ten forty MD is

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00:51:50,760 --> 00:51:54,439
Speaker 1: my is my X handle and feel free to reach out.

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00:51:54,600 --> 00:51:57,359
Speaker 1: I just want to help my fellow human beings.

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00:51:57,920 --> 00:52:00,160
Speaker 2: I love that I'm over at Emily a Badi an

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00:52:00,160 --> 00:52:03,080
Speaker 2: at Hurdle podcast Another Hurdle Conquered.

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00:52:03,560 --> 00:52:04,600
Speaker 3: Catch you guys next time.