[Webinar] Staying Active with Heel Pain

We're going to try not to talk about highly technical things, but once again, thank you for giving us this half hour. So first a little intro why we're each going to kind of tell a little story of a patient that we have and I find we both of us with physical therapy and and in Podiatry, treating people every single day with plantar fasciitis. And I want to give an example of a woman that I was seeing recently. She's a 35 year old female.

She came in and she had been dealing with heel pain for three years and she kept on hoping that it would go away. Initially started when she was trying to work out for exercise to shed a little bit of weight after having a couple of children and it never got a never went away. And so part of her reason for keeping active is, she was trying to lose weight. And when you have really bad healing, you can't do anything. It's debilitating.

So for me, when I was able to treat her, send her over to physical therapy. Therapy, do some different types of treatments. I think she had some shock wave therapy and things like that getting her into Orthotics, she could be active during her recovery. So that's kind of why I like to help people. And Joe you had a marathon patient right recently. Yes I have a marathon patient right now she's at the mid 14-mile running to distance. It's just I'm becoming having

foot pain. She's in physical therapy, were taking care of the foot pain, but we still going to keep her cardio up. So we're having our do things like swimming getting on the bike.

For that two hour mark and keeping that heart rate where it is, so she can keep her cardio while she's still training and still getting better so she can get back into the Running part of it. Yes, I think that's key is keeping people active so they can either lose weight or run their Marathon or you do not have to switch boards. But I do tell people once in a while, you know, if you have a for example, other things like a stress fracture.

That might be a good opportunity to kind of learn another sport like swimming or something else like that. If it's to debilitating So let's get right into it. The two types of heel pain that we're talking about I would say 90% maybe 95% are something called plantar fasciitis and achilles tendonitis. Now the reason we're talking about heel pain generically is because both of these, if you look this is the heel bone or the calcaneus both of these insert into the heel, the plantar.

Sure inserts into the bottom in the Achilles inserts into the back. So in my opinion, to pretty much the same thing and they're treated very, similarly y, you get one versus the other, maybe a flip of the coin, there might be some what we call biomechanics, or how your foot structure is or how tight you are, but a lot of people they come in with plantar fasciitis and then maybe later on. They'll develop achilles tendonitis and I think the big

culprit is the back. Back of the calf and no one ever complains of back of calf pain. And when I bring up, you know, working the back of the calf or working your core, or working your quads, or your glutes, or your other things more up, or more proximal, everyone wonders. Why? It's because the foot is just a symptom of what's Happening, higher up. And so that's why it's essential. If you really want to get rid of it and avoid injury, you have to work on everything else.

Hi Up. And you're all it is is how your body moves over your foot. So if your body is moving over abnormal, abnormally, that needs to be fixed specifically in your pelvis. That's a big area or hip range of motion. Another thing that people should know of some they actually have degeneration of the tendon. So you can see here this is a thickened tendon and it develops Scar Tissue. That's called a bulbous.

Looks like a bulb. A bulbous change in the Achilles. Now if you think about it, if you have a A piece of string and you tie a whole bunch of knots in it that string is going to reduce in length because it takes up space those knots and it's the same thing in the Achilles and the same thing of the fashion you're going to see later on when I talk about the ultrasound it gets thicker if it's thicker it inherently gets shorter when it gets shorter,

it's going to put more strain on those on those tissues. So in my opinion I think about 80 percent is due to tight. Tightness in the back of the calf that then leads to Achilles tendonitis, or plantar fasciitis, for some patients that can be caused by flat feet over pronation increasing your

activity. The big, the big story I get is people, they go to Disney and they don't have plantar fasciitis, and they come back with plantar fasciitis, basically, because they've been on their feet for six or eight hours a day and they're in flip-flops.

And then the, yeah, and on cement and they're walking a whole bunch, or they're starting to Work out there trying to do a marathon or half-marathon and then they get it and it never calms down if you get help right away, it can calm down and it can you can get help. What I was talking about in terms of the Imaging, you can either do an ultrasound or an

x-ray. We always get x-rays first to see if there's any bones for, but it's not as important in my opinion, if you have a Spur, not a Spur shows that you have traction on either the faccia or on the Achilles. So basically this is an example of the right plantar fascia. This is the heel in, this is the fashion, this little fibrous thing. If you pull hard enough on this bone, it's going to create a Spur out here, that's called Wolff's law, your body, it responds to pulling over a

period of time. So the goal is to reduce that polling or that traction but what happens with the faccia, if it's been there for a while, you can see this thickness, the distance between the two A's and then the distance right here between the two ways, this it looks darker looks black and it's thicker. That's chronic.

Your fashio says it gets thick and over time if you're looking at an ultrasound in a patient that just has plantar fasciitis, it's going to look the same thickness in the same color. If it's been there for a couple of months, it's going to get why it's going to get black and it's going to get thicker. And that means there's chronic effusion or swelling inside of that tissue. And you may need a different type of treatment to get rid of that.

The longer it is, I usually use three months, if you've had it for three months, you're going to probably need some of the more advanced treatments, if it's less than three months. You know, you came in sooner but most people don't come in right away. This is a lengthwise evaluation of an Achilles. You can see this little black line. So it's looking right down the Achilles and this has a little bit of a tear right in that area

and then it's thicker. Once again this thickness is kind of like scar tissue in that doesn't allow it to be as flexible and that needs treatment and you know, get kill. He's is a hard area because you can't really do a cortisone injection to that because it could cause a rupture. And so that's those are kind of the Yeah, they aspects of the energy so just going to talk a little bit about stretching here. So stretching is key and that's what we kind of promote.

When the patient comes in will ask them what they're stretching program is. And they're probably have nothing at all. They just know, I just go running. I just go exercise and I don't have time for stretching so most of the patients that are here from physical therapy because they don't stretch.

So we'll go over a nice routine of good stretching will make sure that they know the stretching, they have the stretching of the pictures word, so they can work on their own stretching along with that, we do the foam rolling. Make sure their pelvis is aligned, make sure all the joints are working, so that the whole leg is working for the foot and the foot is working for the legs. So, Joe talked a little bit about your habits. Let's say someone has Achilles or plantar fascia.

How many minutes do they need to dedicate to stretching or here's an example of a foam rolling? How much time are they gonna have to? We usually film about two minutes per muscle area. So they're going to get on their Catholic and go back and forth and get to work it out for a good, two minutes different angles so they can take their foot. They're going to Is the foot angle back and forth like their Comic-Con was like running in and out. Try to hit the different fibers

of each of those muscles. How many times a day it's up to them. At least once or twice. But if you know they're exercising, run, we want to do before and after would just to keep everything nice and loose and shouldn't hurt. Is it okay to hurt? It's Gonna Hurt, it's just that determining. What kind of heard it is a bad hurt that we have to hold off? If it's a good working her that's still okay?

And after we can ice and stem or whatever they want to do to kind of calm down, And then how about those those those the the people run pushing against the wall, the runners stretch here, letting your heels go. Down the E Centric, contracture, explain that a little bit, those types of stresses of nice. Good, lengthen and stretch. I usually tell them not to stretch to the point where it's painful.

It shouldn't be too painful, but should get a good comfortable stretch out of it. Yeah, I think a lot of times you go to see a doctor and they'll just recommend stretching Primary Care. You go to your primary care. They're going to recommend a shoe insert, maybe a new shoe and then stretching and time. Andres icing and fed doesn't get better. Then the probably send you to physical therapy or to see a podiatrist, I think foam rolling

is in deep tissue, work is key. And then if so, I basically foam rolling, is that two to three minutes on each muscle group. Maybe I say ten minutes in the morning, ten minutes at night, that's what eyes. And then during the day you can do your stretches like if you're at work or if you're at a stair or something else like that. But you have to become part of your routine. Now, even when they recovered, do they have to continue doing this?

Yeah, they'll keep them out of the doctor's office and other PC. Keep working. Keep stretching keep foam rolling. Yeah I think a lot of people all the time and you can speak better to that but everything gets kind of tight and then people start working out. I go to Disney or something like that. And they Wonder well how come I developed heel pain or something like that for sure? Yeah. Okay, talk about this here,

what's this? All right, so another way we can adapt the tissue or a kind of break up that strategy called fiberglassing. So, we have tools and see the tools up here. Use the tools that people love to hate because they hate it when we do it, but they love it after it, because they feel so much better. So, basically, we are digging into the muscle.

We're breaking up while the fibers and we're stretching it out, so we'll do it at different angles at different points, it will do it action, but movement, sometimes just so we can break up those five or so we can get The muscle working better. It's what technologically, what is it doing to the tissue? Is it lengthening? It? Is it helping it to repair? Or what is it?

Doing all the mom. So basically we're breaking up the scar tissue, increasing the blood flow, and we'll do it at different points of the joint angles so that we can hit different areas of the muscles. Yeah, and so what Joe's talking about on that ultrasound when I showed you that it was thicker, I guess you could call that scar tissue or a thickened tissue and then he takes this any, any rubs it on that area.

What I find is that when you do treatment such as this or shock wave, it can actually thin down over time, that swelling goes down from within that tissue and it can thin it down to more of a normal level. But just like, scarring, anywhere else. For example, if you have a surgery or if you have a cut it's going to be initially,

swollen thick and scarred. And then over about six months to a year it's going to remodel and it's going to get That thinner little line, you're always going to have a scar but the whole goal is that it's not as swollen and part of the problem is we never stopped in a. We are always busy, I find especially kids. You know, we don't see this as much in kids but like we're going from one sport to another sport.

Were either sitting down or very active and no one gives anything a chance to kind of rest and recover. So it's an issue. How important our shoes Joe She was our key. So we have pronate and supinate has in neutral feet and most Runners. Even there if they've been doing multiple marathons, really don't know about their feet. You'll find a particular sneaker and they'll just go with it and more likely are in pain. But once we see them will evaluate their foot to see if

which, what type they are. And there's different shoes that fit for different kinds of fees, especially for runners on the top, right? You'll see the new balance, you see the yellow band in there and that's a guys, it's a pronated.

So it's an anti pronate. So it's a bar It's somewhat like let your foot came in as much and that will cause the pronation pain cause deep and right up to the hip pain for these Runners. The one on the bottom is more of a neutral, you can see where it's just basically nice, good Soul, nice cushion, soft as someone that has it more neutral foot and needs that needs to be able to select just like through when they're going through the running process and that's after

afterwards when you feel nice. And so again it's a nice good sandal like that. It just makes you feel good. Yeah, I keep it real simple. One asked me. Hey Doc, am I gonna have to wear ugly shoes? The rest of my life. I say. It's for now. It's not forever, okay?

And I say when you're at home, if you don't want to wear shoes, I like either a new foe or there's a Hoka sandal something with a really good arch support when you're when you're at home or it's a better alternative to a flip-flop. Now, you can tell something's good when you give it to your mom. So when my mom came and visited me, she had bunion surgery and I put her in these things and she

absolutely love them. It could be from the cushion, could be from the arch, but there's a lot of things. These shoes are great. Now, specifically, I want to talk a little bit about a little to get a little technical here, a lot of shoes. You can see here, it's thicker at the heel than it is at the toe. And it has this little curvature thing here. So, this is kind of like a little rocker in the front of

the foot. And this is a probably, a five to seven millimeter drop what that Ins is the height here, down to there is about five millimeters. This works well with someone, with Achilles tendonitis and finer fasciitis, because if you have a group called a zero drop shoe or it's exactly the same height that's going to put more pressure on the back of the Achilles now.

Even though I do recommend a lot of shoes that are zero drop, I find that when you're recovering from one of these conditions, you tend to do better with the shoe with a little bit of a heel in it. Is that what you find as well for sure? Yeah. Some of my achilles patients I'll ask them.

Have they changed their shoes and then someone will go from the zero drop two and another sneaker or Nike sticking with a higher heel bed and that's what's probably given the issues are going to a higher arch for actually lower. Look down and see where you're at, in terms of shoes. Can they go to? Like I said O, My People sneak around Mama, we have a script will write down the script, it will validate the foot. They look at the script.

They look at the sneakers, they'll choose they'll give them three or four options and that's how we usually do it. Yeah, the real key is you want to go to a place that We're going to watch you walk and they'll be able to get something that's appropriate for you. You know. I can't emphasize when you're when you're starting to deal with heel pain. If you're if you're just in the beginning it's about its shoes as key. And you may say oh I have tons of shoes.

I particularly don't like some of these cuter shoes, the Skechers, the Nikes, the things like that, they have really kept up with the technology, whereas the New Balance, the Saucony, the A6 and things like that. They have a better shoot. Now, for those patients doing to come in and say, you know, you know, Joe, I tried I'd 10 shoes in my heel, still doesn't feel better. What do you tell them? That's when I you should promote doctor Pelt, 04 Orthotics.

And, you know, we'll take them, see how the taping feeling if that feels. Well, go see, dr. Kelso for Orthotics, and we're from there. Yeah, Joe that's the key is like if you've tried 20 pairs of shoes and the shoes of hurts, and it only hurts on your right foot because your right foot as pain pressure to the problem isn't the shoe don't go buying more shoes and don't you can spend like thousands of dollars on Amazon trying to buy every

single thing don't do that. Save a lot of time and a lot of money by seeing someone. So, how about activity, modifications, if your want to stay active? Sure. So, if the running or the walking part hurts, this other ways of doing it. So, you're walking or running on the cement or Tire, you can get you onto a treadmill or you can go to a track. That's a lot softer. That'll help out a little bit.

You can do some cycling cycle, will keep you going but I won't put a lot for stir that through your foot. Strengthen your core is always key and then for some people if they're running, if they're doing a marathon and they can't really put a lot of weight, we'll get him, the pool and we'll do some In the pool that will burn them out real quick. We'll give them the all the exercise but it won't put all that force on that foot and there's a special pred know that

they make right. The that was a cup of G-Force if you're for yeah and you're pretty much sit in a saddle and then it you can take off 50% of the way, 30 percent of the weight. And you can still get that cardio that you like that's a good option if you're having a

lot of pain. Now, how about if someone let's say Joe someone has pain when they get up in the morning but when they do their stretches and things like that, everything goes Away. Can they be as active or how do you determine how active you can be? Yeah, they can be a source is the pains gone. Let them do what they're workout. It is and it's all by space on the pain. If the pain increases that we have to slow down a little bit.

Yeah, I always say if you're limping and if you're changing your gate, or if you're going to injure yourself because of because you're a cheap accommodating, how you're going to injure yourself, you're gonna have to go see Joe, you're going to throw your hip off. You're going to throw something else off because you're changing your gate. If it's that level you're going to have Switch your activity temporarily until you get calm until you calm down.

So I'm going to talk a little bit about some of the initial treatments. I'm not going to go into detail about all of those like hundreds of treatment, but a few things, if you're trying to deal with this, something that you may not have heard of is something called a contrast bath, and everyone knows about like taking the bottle of water and rolling on the bottom of the foot or a bottle on the back of the calf

of ice water. But a contrast bath, if you've never tried it, you take a bucket of ice water in a bucket of hot water. You know, you don't want to burn yourself and You five minutes in the ice water, five minutes in the hot water, and then 5 and Ice. You always start and end in the ice water and what that does is it, basically restarts reboots the computer. So it's going to cause the ice is going to cause

vasoconstriction. Meaning it's going to shrink down the the hot water is going to vasodilate, it's going to swell and then it's going to shrink down again, it's kind of shocking the area to help increase the blood flow, all of its blood flow getting to that area. So if you want to think about it, if you want your body to heal itself, you have to have adequate blood flow and there are things that can restrict the blood flow. Okay. And that's what we're going to

talk about anti-inflammatories. I don't do more than two weeks of an anti-inflammatory. It can be used temporarily. If you like okay I II once in a while you do a prednisone, not too much. I'm not too much of an anti-inflammatory person. I think you should work on the treatments of getting rid of the pain. I want to talk a little bit about offloading.

Now, the reason I want to talk about this is because if you want to stay active, you're going to have to take the tension off the faccia or off the Achilles and there are different levels of pain reduction. I'm going to start with the kind of the most severe so if your pain level is 8 9 or a 10, what we call an on that visual analog scale. Basically you look at the

frowning face and a happy face. And if you're if you're basically a limping around, you're going to probably need to be in a walking boot for a short period of time or if you have a tear or something else like that. Now the key I you see so many people they come in with the boot but then they complain of hip pain or back pain or something else like that. That's why I just want to take a moment to talk about this thing. This is called an even up.

So if you ever get a boot or if you ever see someone that has a boot in there, limping around you have you can use an even up or you can use your shoe with a little bit of a heel so you can just Mine on Amazon is called even up. So that's the worst amount of pain, the next, the next kind of the if you're if you're only in moderate pain, there are two options. What is called an air cast in? The other one is called a velocity brace and I want to

explain both of these. The purpose of these are to be used temporarily, okay? Just like the boot. You're not using these forever, the are past. It has a bladder of are in the bottom and a bladder of are in the Back of the Achilles. So as you're walking, it's pushing the air back and forth with a little tube and it's massaging the back of the Achilles to increase blood flow.

And it's as you push here, it's taking pressure off the heel so it can be used both for plantar fasciitis, and achilles tendonitis, this isn't my first go to that. These are for people that have quite a bit of pain and you do this, I would say for two to four weeks, For patients that that need more stability to avoid pronation. This is called a velocity brace. It's kind of like an afo. An afo is an ankle, so it involves the ankle and a foot

and it's an orthotic. So it has a little orthotic piece in the bottom, and it also has an ankle brace. So this won't allow people to invert or E vert. It won't allow that pronation to happen and it puts less strain. So specifically patients. Have posterior tibial, tendonitis or tendinitis on this tender on the inside or a lot of flattening, they're going to work. Well in this, another reason that this works well is because

it works in one unit. And what I say is my expectation is about 30% of the pressure is going to go into the lower leg. So it's going to attenuate or take the pressure off the back of the Achilles and off the faccia, input it into the lower leg. It's a lot easier to get used to this. That it is a big bulky boot. These are both. 'The only used I would say two to four weeks when you're in the recovery period, I don't use it

for a long, long time. Once people are feeling better than I'm going to transition them to an orthotic. In the way I use Orthotics is I use it to correct posture? Okay. Go ahead. So our thoughts are different types.

You can try an over-the-counter insert and there are different ones once again, if you're going to get an insert, please don't hope dr. Scholl's isn't listening but don't get a doctor, Scholl's. They're overpriced, and they're not doing anything where I would recommend is going to sneak around mama. And what you're going to find is you're going to find an over-the-counter insert.

There's like a spend Co something that's more rigid because when it's rigid, it's actually doing something patients, can start with an over-the-counter one. But the main key, and I want to explain this for everyone is, when you have an orthotic, they did some research and they found that with the faccia, the higher, the orthotic Contours, as to the foot, the better, it takes the strain and stress off the fashion and what you'll find is a normal.

Insert is going to be a big gap between there in that Gap. Still allows pronation and it doesn't take as much strain off. That's the reason we do a custom one because it basically sits right with the arch and it that takes more of the strain off and you just can't do that with an over-the-counter because you don't have an over-the-counter foot and no one does. But for a lot of patients in over the counters, a good way to

start. And if that's not enough, then we'll move some Into a custom orthotic. And that's, and that's, and they're made to be used, maybe not the rest of your life. Everyone asked me to have to warm the rest of my life. Probably not. You're going to wear them until you feel better. And then for certain types of activities that could aggravate your plantar fascial, anything else you want to say about

these? How about a patient that has the Orthotics. But there's still having pain and if I tape them, they feel better. Yeah. I think taping is great and I don't tape you guys tape. I think what taping does is it holds everything in proper Ian, I a lot of a lot of doctors what they do is if they have a custom orthotic already, then that custom orthotic isn't contouring enough so you may need something

that's even higher. Yeah in the big problem for us going to high is that it's not going to be comfortable. But doing a higher one is going to feel even better. That's why that taping feels good that extra support but you can't take for the rest of your life. No. Do you still have to kind of get that, get that area down. You may need a higher contouring or thought because there are a lot they are there. A lot of places around the they say it's a custom orthotic.

But it's really not. They see how it's made for you. You step in a box or something else like that, the way we do it as perfect a 3D scanner and we make it specifically for you. So you have to go to a place. Yeah. Are they going to be more expensive? Yeah. But these over-the-counter ones the last maybe six months and you have to change it.

So and then I want to talk a little bit about questions about doing a cortisone injection and then there's a new type of therapy called Shockwave. So, the way I think about it is it, if you're in a lot of pain, if you're limping around, if you've had this and you just can't function in life. And so basically, if you're looking at an eight, nine or ten pain, You can't tolerate Shockwave, you can't tolerate Physical Therapy, you're going to be living around.

You can't do anything. So for patients, like that, if it's in the heel, I will do a cortisone injection, okay? If it's under eight, if it's seven or below and then if I do an ultrasound and I see that it's thicker, that's where I'll recommend the shock wave now, I don't do this.

Usually first line meaning. What I do first is I say, change your shoes, try the inserts, try the ice, You can try the anti-inflammatories if that doesn't work, then what I tend to do is I switch to the shock wave, and the physical therapy, okay? People start with the foam rolling and then if that doesn't work, then they go into the shock wave in the physical therapy. What? How this works? There are two types of shock waves. But you see, this little thing that looks like a bullet.

This bullet runs back and forth, and it hits this piece of metal in a create something called radial shockwaves, okay? There's two different devices we have One that's focused in one. That's radial, I'm just showing you the radio one, this is the one that we've had for a number of years. But what does it do? Basically areas that are chronically, injured like the fashion in the Achilles tendon, they get thick and they get scarred.

And if you know anything about Scar Tissue, it doesn't have the best blood flow. The flow is bad. And what what, you try to do with your breasts and technique, or there's another Physical Therapy modality called dry needling, and That, what that does is that tries to increase the blood flow to the area. So your own body heals it. Okay. And that's what this does. I whack the heck out of it and it increases the blood flow.

So during the course of treatment with shockwave, you can't do any anti-inflammatories Motrin ibuprofen. You can do Tylenol, two days before and two days after, and we do between three and six sessions in what that does is that increases the blood flow to the area. And it's Matt, it's almost like magic and it takes away the pain. There are some other Advanced

ones. Well like platelet-rich plasma or amnio injections, we might do those if there's a tear or something else we specifically see on the ultrasound but this is our go-to for treating. I used to do ton of cortisone, but what I found with cortisone, I had a patient today. I did a cortisone, he had a four weeks ago and he was feeling a little bit better for about two to three weeks. And then all of a sudden, all the pain came back. The reason for that is cortisone, only lasts about

four. Four to six weeks depending on what type you put in. We do a combination of a short-acting and a Long acting and then what I find is, what it wears off. If you don't change the tissue or the structure with the foam rolling and the physical therapy in the offloading, it can come back, not for everyone but it can come back. But what this does is it actually heals the tissue. What's been your experience?

With this drone we're seeing a lot more patients, those truck where they usually like it. They'll come in will do the stretching and the check out the pelvis, getting all the joints working, and we're just work with their pain level and getting them better. Yeah, I think it's A real practice changer, especially in the Achilles on the back and the Achilles you can't do cortisone because it could cause a rupture. So we really didn't have any

options besides doing a surgery. If there's a big bump back there or something else. Now with patients that are not coming from a podiatrist that have heel pain. What I'll do is I'll show them the book by Don Pelt. Oh and open up the page which Shockwave so they can read about shock wave that I'll do you give them the card so they can called on and see if they can do the shockwaves for them. Yeah. I I can't, I can't it's really

been a practice changer. There's been an only a few things subbing in this remote on over 10 years now. But this has been a practice changer and it's something that's it tended to start. I'll tell you a little history of it. Shockwave, it started in Germany and it was used to break up kidney stones. So what they did is they put people in big things of water and they still use it to this day and they shoot these sound waves with his huge shock wave machine and it broke up the

kidney stones. But what they found is that people with chronic back I mean, because a lot of times back pain is caused by the tightness in the muscles, their back pain went away and they're like, hmmm. I wonder why their back pain went away when were treating their kidneys and then the machines got smaller and smaller, and instead of putting people in water, now we put ultrasound gel on it and what we're finding and it's not just

using the foot. It's used pretty much everywhere in your body for area of chronic inflammation to help it naturally reduce it and I think the reason they do it more in Germany, is it might because I think it's covered by Insurance there and they're more natural than we are here. We're Like running the surgery there. They do everything they can to avoid surgery because they have public health and it takes forever to get a surgery. So that's why they have some of those other options.

There were a few questions that people ask. So I'd like you, if you're listening here and you have any other questions, put it in the chat box right now and we're going to start answering the questions that were sent over previously and then we'll answer the other ones that people are putting it to us right now. So I'll ask you Joe, is it best to avoid impact exercises? Like aerobic exercises, while you're healing it all depends on your pain level.

If you're able to do the exercise without causing increased pain, then it's okay if you're doing the exercise and causing more pain, that means you the tissues being overwhelmed, you got to cut it down and that's where we can go to the cycling. You get the swimming, you got the elliptical. That's not pounding as much, but still give me an aerobic capacity.

Yeah, and I would say, try doing the shoes And the the offloading with, either an orthotic, or something else to see how it's doing, or even one of those braces like that are cast, that you mentioned to me, that perfect, you could probably stay being active with that. So how do you know what the balances between pain and exercise therapy for achilles tendonitis. I don't, if you have any ideas here, the pain. So it's there's good pain in

this bad pain. If you're in that bad pains Zone. Once again, you're over texting that tissue and it's not going to get better. So we going to cut it back here with otix global you're stretching. The scraping, comment down in the build from there. Perfect question, 3 plantar fasciitis versus achilles tendonitis treatment, any major differences any studies and this was a saint by one of the colleagues from physical therapy.

I usually treat them pretty similar in terms of PT treatments in terms of plantar, fasciitis. I think there are almost exactly the same. The only difference is, I think plantar fasciitis responds, much better to orthotic therapy than achilles tendonitis. Achilles tendonitis, there's no, not really Many studies about responding to to orthotic therapy. I find that Achilles tendinitis tends to respond a little bit better to heal lips. So putting a he lifts in there.

Taking the pull off temporarily, that works for Achilles tendinitis also treatments in terms of what I do. I don't do cortisone on Achilles, I can do it on plantar fasciitis, the Shockwave is all the same, all the other icing anti-inflammatories, PT is pretty much the same, anything else that you do different for both of you. I usually go after the hip if the hip has really poor range emotion when they're walking or running their always hitting in

that same spot on the heel. So I Really Work the hip get that range of motion better. So they have multiple angles when they're walking, they're moving to different spots. Perfect. So, Joe which shoes are better or worse for it. We can address that but yeah, there's so many shoes out there. Once we evaluate the foot, we figure out your opponent is super neutral. And we sent you over to the Seeker stuff, they'll get the shoe on for him and from there we can evaluate, which you can

works for best for you. Yeah, and Joe, does it ever go away? Does it ever go away? It should. But if you don't do your stretching, you don't do all your exercise. You don't do what you're supposed to do. It's going to creep back and basically just going to keep on doing it or you can come back to us and we can figure out again. Yeah, I so I guess there's two ways of thinking about this question. It might go away and then come back. If it's Coming back.

It tends to be something structural that you're going to need physical therapy for meaning. You may have a pelvic issue, you may have a stability issue, it might be a tightness issue. That's not addressed, maybe new orthotic issue, something else like that, but it should go away. So, long away coming back, it's usually because of that, I usually say, it's like an incident meaning, you went to Disney, you went on a long walk.

You're starting to train for something very commonly people at train or starting to be more active, trying to lose weight, the Cavs, get tight, not usually day one. Wanted to day three. But after a few weeks and they start to have foot pain, it's because the tightness normally and then the other for you if you're listening to this and you've had this for years and it's never gotten better. It's probably because you haven't had treatment or the

right kind of treatment. I find many patients. They come as a second opinion, they've like seen a doctor a number of times, but they just say, okay, I'll do 3 cortisone injections in an orthotic and if you can't get better, you can't get better. You know, you have to really advocate for yourself. There are some Advanced treatments, but I do have a certain Number of patients that just might need a surgical procedure or something more involved. I think I've done this maybe one

surgery in the last three years. There's not really surgery isn't the option, okay? Isn't the best option but there are other people that can help you. So you have to kind of advocate for yourself and try to get help. Yeah. And there are some other questions were going to address here before we finish up here for patients, who get custom orthotics. How long do they usually last? What do you tell them? So custom orthotics.

Once again, you have to have the sneaker and shoe to fit with it, if you have the wrong shoe with the Orthotics, that's not going to help as much. What we're talking three to five years, depending on how it was built, how was made? And you have to where you have to do. All your stress is all the stuff you do to keep it going. Yeah. Orthotics are kind of like glasses, right? I can't I don't wear my glasses when I'm doing the webinars, but I'm not wearing these.

I can't see far away but if I'm wearing them, I can see far away it. So it corrects for mechanical instability in the foot and it's the same thing with an orthotic in the way I kind of explained. It is if you're doing Out of walking, a lot of standing, you're probably going to feel better in them. Now, you may only need them for a period of time to heal that injury, though, once you're better, if you're an athlete, you can probably try to ditch

them. But if you have a really really collapsing foot, you're just going to feel better in them, some patients just feel better because they're so collapsed for them. There was some comments here about a book, I'll show you guys how you can get these books if you want. I have them as a download and then in the at the PTA Greendale, they have them

sitting there as well. So when patients are getting shopping, this is a question here, when patients are getting shock wave therapy in an attending Physical Therapy. Should they modify the exercise and all my opinion, if they're getting Shockwave? It's usually for, let's say, for the heel, I'll have them. That session work, more on the calf region, okay? Or working on the poor stability or something else like that because if it's way too painful.

But frankly, if you do Shockwave that day, Would just the next day, you should be better. Shockwave doesn't usually have much pain for a few days after it doesn't another thing about Shockwave, Shockwave is an instantaneous, like, cortisone injection of cortisone, you get the cortisone, you're better Shockwave to. It actually has to create new blood vessels, and blood flow to the area and that takes six to eight weeks. So, just for you.

So, you know, so from day one of shock wave to you actually start seeing the results is six weeks. And so if we do three sessions as you six weeks after that's when it started, And it works for like three or four months afterwards and it's not instantaneous. So that's where you have to control the load so people can kind of Be Active with that as well. Another question here, I wear slippers at home, I think that may be part of my problem. Can you be more specific on what I can wear?

What can they wear at home? So a good sandals of once again I said I'm down to see Grandma. They have always good sandals over there, they have good arch. Support a lot of cushioning them in the much better in the house. You come into the house, you take your shoes off, you're going to do sandals and you could pick out. Yeah I think there's a couple of Brands Spangled hasn't okay. One who follows have a good one. Hoka has a good one and you can just wear shoes though.

If you have a you get a second pair of shoes, I have a whole shoe and wear that at home, and I think you're going to be, you're going to be much better with that. So I think we answered all the questions. I put a little link here for the the replay and resources. So if you're watching this, we're going to post this. You can use your phone and kind of scan it and it'll go to a blog post. And then you can also go to the Greendale PT and contact them. They can give you a copy of this

video. If you want to listen to it afterwards. There's a couple of resources I make available on my blog after build a.com. It'll there's one thing on a heel and wanting to kill. He's the one that Joe was referring to. I'm just going to open it up right here. Look at that. Doesn't even open up. You have to have an Achilles with a capital A and it's a little course, I put together. So it basically has a book.

You can download a quick start guide, icing and contrast oofos, shoes recommendations and then basically down here it's kind of cool because I put your how do you treat achilles tendonitis, deep tissue, massage and loosening exercises actually recorded this at Greendale PT a number of years ago. Trigger point tools. What To do when you get up in the morning this is kind of fun. So it patients we talk about core belly, breathing, doing a stretching routine before you

get out of bed. This is to help that first step out of bed. Talk about Shockwave or E Pat and amnio injections and then things like that. So there's other resources. So I take a lot of pride in doing these things. It's been a lot of fun and I really appreciate all the help over at Greendale PT. So it's been great. I think we've answered all the questions. I don't really see any other questions here. If you guys have any more, you can post it. Otherwise we're going to stop this.