#10 - Differential Diagnosis of Heel Pain with Dr. Dino Pappas, Part 2

This episode is brought to you by China Gel. Please be sure to check out our online store at factor-store.com to try out the full line of China Gel products, and stay tuned for a special message from our sponsor. FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple. To bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest, with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. If you haven't listened to episode 9, I strongly suggest that you hit the pause button, go back and listen to episode 9 first, since this is the part 2 of a 3-part training series and Part 1 was in episode 9. So if you caught all that, definitely want to listen to episode 9 first, then hear episode 10, and then we will wrap up this training in our part 3, which will actually be in episode 11. So again, today's training was part of a massive training with Dr. Dino Pappas on pain to performance, differential diagnosis of heel pain, and it was chock-full of so much information that we split it into 3 different episodes. So a little bit about Dr. Pappas. Dr. Dino Pappas is a sports chiropractor, certified athletic trainer, certified strength and conditioning specialist, husband, father, chef, adventurer, and travel junkie. His passion is improving health and performance by using conservative-based treatments like manual therapy, manipulation, rehab exercises, advice, special testing, and lifestyle recommendations to help his patients achieve excellence. He has worked with all types of patients from the average Joe or Jane to weekend warriors, with amateur athletes, and Olympic and professional athletes as well. His main clinical interest is the Pain to Performance Model, where he lays out strategies that take you and your patients from zero to hero. In today's episode, Dr. Pappas continues his discussion of load management of the plantar fascia, heel strike patterns, The use of orthotics for structural pathology, and he will also discuss specific exercises for ischemic rehab that can address mechanical dysfunction. As always, if you have questions as you're listening to today's training, you can submit your questions in the Q&A link in our show notes. We will have our instructor back on for a future special Q&A episode so that we can cover all of your burning questions. Let's get started.

One of the masters, and I use this example, and I have so much respect for Craig Liebensohn. I went to his seminar, and in his seminar, the topic of functional ankle dorsiflexion came up. So we all did a simple assessment. We did a kneeling ankle dorsiflexion assessment where basically we were in a kneeling position like you see in this picture right through here, and basically we rock forward to try to get the knee to touch the wall, and we try to see the point at which the heel rises. Right? It's a simple assessment of ankle dorsiflexion. And Craig wanted really quickly to separate out— there was maybe 80 people there, maybe 100 people there. So I'm going to round up and just say a nice simple number, say 100 people there. And Craig was like, I'm going to find in about the next 5 to 10 minutes those who truly have a mobility problem, those that have a stability problem, and those that need further in-depth assessment. So 3 things, I believe, is what he was looking for. And here's what he did. He had all of us for about 5 or 10 minutes. Go through core stability training. Now, if you've never taken a Craig Liebensohn course, be prepared for 2 things. A lot of knowledge dropped in you in a little time so that your head spins, which is awesome, especially when you can take it home and start processing it a couple days later because Craig is on a different playing field. Craig is on a different playing field than all of us, which is awesome because I learned so much from him. But you also find out that your abdominal core area is going to be sore for days. Like, you belly laugh and you will hurt for days. All right, so basically I just do planks, side planks, bird dogs, dead bugs, wall bugs, I mean, 10 minutes of nonstop circuit, one exercise to the next, the next, the next. He had us repeat the ankle rocker exercise, the kneeling ankle rocker exercise. And what we found out was maybe 65, 70% of people saw functional improvement in dorsiflexion from just doing core stability. So right then and there, he got rid of 70 people, 70 out of 100 people. Like literally, you have a stability problem, you work stability. When you plateau with stability, come back to me, maybe we'll try some mobility. And I was like, man, that he literally assessed 70 people. Pretty good confidence right then and there. That was awesome to see. So then he took the last 30, he had them work mobility. All right, stability didn't get you better, let's work mobility. So he went through a bunch of ankle mobility exercises with the remaining 30, and maybe 20 of those 30 got better. All right, you have a mobility problem, you need to work your ankles, your ankles are stiff, mobilize, mobilize, mobilize. Awesome. So again, he separated out, and then there were 10 left. And then really quickly, in 10 to 15 minutes, he assessed 100 people. And I was amazed because I know in my office, I assess one patient, Half hour to an hour long. And I've assessed groups before using movement screens, and maybe I get 5, 6, 7, 8 where I feel like I get quality, but literally Craig got 100 people in a room assessed in 15 minutes, and it was impressive. So the point of this is Craig actually had strategies and strategies in place to differentiate, separate out, and sift through the layers and sift through the kinetic chain. Who has mobility? Who has stability? Who just needs a further in-depth assessment? Maybe you have a structural deformity in the ankle, and he was able to separate those out pretty quickly so he could focus his time on the 10 needed a little more in-depth assessment. It was amazing, so kudos to Craig. So altering tensile load. One of the concepts that's popularized is that of Tim Gabbett. Tim Gabbett is a researcher that looks at load management. Load management is how much force is applied to certain specific tissues. Do you want to rest or active rest the plantar fascia? That's a load management strategy of reducing force to the area. Do you want to give an orthotic? Yeah, absolutely. That can alter the force applied to the plantar fascia. Do you want to give a patient a rocker-bottom shoe? A rocker-bottom shoe would be like a Hoka shoe. It's got a thick sole on the bottom so that it propels you from heel strike to dorsiflexion really quickly, and when it propels you from this position really quickly, the shoe takes the tensile force away from the plantar fascia because it forces you to dorsiflex and it absorbs some of the shock that would normally go to the plantar fascia. That's a load-altering mechanism as well if you determine and classify that's what the patient needs. Also, switching a patient that runs on their toes or runs with a midfoot stance to a heel strike mechanism avoids tensile force to the plantar fascia as well. Those are all offloading mechanisms. Orthotics. I get questions a lot about orthotics. I used to actually do them quite a bit in our office. I used to do them quite a bit in our office. I have since farmed that out and shipped that out to some good pedorthists in the area. And the reason why I do it is because I can't be everything to everyone, and I realize where I'm good at and I should focus my attention to. But when I was doing it, I used to always get questions from the manufacturers and from students and other people as well. Custom or prefab? They both can affect loading of the plantar fascia. But I will say this, if you have a condition to the right, like you look at the right of the screen, you see that really tricked-out orthotic. That's probably the most tricked-out pair of orthotics I've ever prescribed in my entire life, because the patient had bilateral heel spurs, bilateral plantar fasciitis, bilateral metatarsalgia, and modifications needed made. If you have a patient that has severe deficits, if you have a patient that has structural issues, moderate to severe bowing of the tibia, that's tibial varum, moderate to severe bunions, anything that has a true structural pathology that functionally cannot overcome, you'd better be going with a custom device. All right, so orthotics load modifying is for the average folk. Is custom better than prefabricated? No, but the custom device wins when structure is an issue, when major structural pathology is an issue. All right, you better for sure also have criteria for recommending your orthotics. Some of those criteria could be cost, a trial of care. I've tried the over-the-counter and then they're not working as well. And the assessment. What is your orthotic assessment? Mine would be like I would watch a patient lunge, squat, balance, and step down without an orthotic, and then I would insert an orthotic and watch them lunge, squat, balance, and walk with the ortho and step down with the orthotic in. And I'm looking for changes in the kinetic chain that could alter the load strategy. How much load is applied to the plantar fascia? That was my criteria. I'd videotape the patient on their iPhone, play it. Here's your squat, lunge, and balance. Put the orthotic in, watch them squat, lunge, or balance, show them this is the change in mechanics that we're looking for. Theoretically, that means less force applied. Theoretically, less force applied to the plantar fascia. That was my criteria. Let's get to some simple exercise. I'm going to pop some videos up. If you don't see these videos load, please let me know. So we're going to go through a progression from a simple exercise for the plantar fascia to a more complicated exercise. So let's pop this guy up here.

Hey, this is Steven from Crux Chiro.

And if you guys don't—

We're going to do an exercise called the Vélez lean. Great for foot activation and great for stability through the feet. So I'm going to show you a little diagonal view here. What we're going to do for this is we're going to get all 4 points of the foot down— 1, 2, 3, and 4. Don't let any of those come up during the exercise. You're going to press those into the ground. The knees can unlock just a little bit, and you're going to start to externally rotate through the lower leg and foot. And so you can see my arch on the right side is starting to lift up there right now. From that position, you start to lean forward. You lean forward like Michael Jackson, like that, or like Superman about ready to take off. So sometimes we do this right in front of a wall so you can feel yourself getting closer to that wall. You should feel like your feet are starting to grip at this point and like you're about to lift those heels off the floor and fall forward. That's right when you start to feel it. Try your best to spread your toes during this exercise. Lean forward as far as you can right before you fall over there.

So this exercise is from a classmate of mine. Actually, I graduated chiropractic school with Steve Sherman, and I give him kudos for the video and his control from his lower foot is actually pretty, pretty dang good. The exercise basically of a lazy lean. Many of you may have seen the exercise. Why do I bring this such a simplistic exercise to the table? Because it's an initial early exercise that mimics the gait cycle. That's a low threshold type of exercise for many folks that can load the plantar fascia. As you lean forward, as Steve was leaning forward in that picture, he was driving tensile force from the heel towards the toes, which initiates the load to the plantar fascia there. So Steve was taking care of business there. Good control over the foot as he was purchasing. Toes were slightly gripping and spreading the ground. He was increasing the surface area underneath, again transferring more force throughout the plantar fascia. And that's a Valaise lean type of exercise. And I know most of us overlook it, but that has great clinical utility here. So I'm going to go into the next video here. The next exercise is going to be something called Toe Pro in a forward lean here. So this exercise here, one of the best books is Tom Michaud, Human Locomotion, Gait and Locomotion. Michaud wrote a book that's a comprehensive tool. If you're interested in getting better at lower extremity, any lower extremity, particularly the foot, Michaud's book is phenomenal. He created a device, and the device here dorsiflexes, pushes the toes back. And as the toes dorsiflex here, it adds, pretenses the plantar fascia a little bit more. So this is a Valaise type of lean as you rock forward with the toes elevated. The ToePro device that he created dorsiflexes the toes and spreads the toes to add one more layer of force. Now, that ToePro is a great, great tool, and it's amazing. Do you need a ToePro? No. Anything like rolling a towel up, using a pad, using a yoga mat and rolling it up to get the toes elevated dorsiflexed will pretense plantar fascia and allow you to strengthen that plantar fascia. If you determine that tensile force and you need to add tensile force, this is the next evolution of the Valaise lean with the toes elevated. And again, he's got the toes elevated, rocking forward into the lase position that pre-elevates or increases tensile force before the forward lunge. And in this exercise, the toes are elevated. He brings the body up to add again more tensile force through the plantar fascia. At the end of the motion, he pushes his toes down. The rate of controlling digital dorsiflexion is linked to plantar fasciitis. So digital dorsiflexion, when the toes raise like this, it tenses the arch. So the rate at which that is controlled can lead to loading of the plantar fascia. So that's why at the end of the motion, you'll see him push the toes down. So the toes start elevated, pretense the plantar fascia, controlling digital dorsiflexion on the way up, again, as a mechanism of reducing force through that. That's why he pushes the toes down. And the last exercise I'm going to show you for the plantar fascia is this guy here. And that last exercise is a little bit more difficult and a little bit more invasive. It's a little bit more difficult and it's a little bit more invasive because you are now utilizing one foot with the toe dorsiflexed and you're going all the way up and then controlling yourself all the way down here.

I've tried a lot of different rubs and, and different types of ointments and lotions before. I used to use other topicals and never had the success that I now have with China Gel. China Gel is my pain reliever of choice. We use it in the office because of its consistency, and the response that I get from the patients is what my goal is. I, I want to get people better. China Gel allows me as the practitioner to use instrument-assisted techniques, me as the practitioner to do ultrasound and do many different techniques that I've learned over the years in conjunction with China Gel to get the maximum benefit for a patient. It's the combination of my skills as a chiropractor and what China Gel has in it that allows the patient to get better faster and more effectively.

So again, as the great toe goes on up, it pretenses the plantar fascia. You raise your body up again, adding tensile force. You slowly work eccentrically on the way down, and that's a really good progression of loading the plantar fascia, especially in those degenerative tensile based conditions here. So what about the opposite mechanism? Didn't I mention an ischemic mechanism? I mean, I just talked about tensile for a whole bunch of time. Ischemic mechanism shortening— this is your true adhesion. This is tissue that needs lengthening, that needs mobilization. And if you're a chiropractor and a manual therapist, have at it. This is the one you aggressively want to strip out. This is where you use your graston tools. This is where your ART— this is where your fascial distortion model manual therapy comes in and is effective to modulate pain Bring more blood flow, start the inflammation or healing process all over again. And don't forget to load these guys at home, frequent mobilization. And you see in the picture, the person has their thumb in the arch, they're dorsiflexing their toes, they're stretching and stripping out the plantar fascia. And you want to do this multiple times over the course of a day. Load it, load it, load it. 30 reps daily, hold 10 seconds, self-massage. That's coming from Michaud's book here. This is also the one you want a lacrosse ball or have them walk and have them move. All right, and also, if you notice any kinetic chain things, this is the one where you want to say practice, practice, practice. The more motion, the better it is. Motion is lotion. So what are some rehab cues? This is Texas here. I'm in Austin, Texas. I know some people are coming in from all over the world. This is barbecue nirvana. I mean, we do it bigger, we do it better, we do it more expensive. This is it. I know Jessica's husband is a big barbecue guy. Every time I look at his Facebook feed, it makes my mouth water and my bank account a lot more poor. because it makes me want to go out and buy expensive barbecue all the time, and Todd does this at home. So real kids eat well at their household, it looks like. But the ischemic rehab cues— low and slow like good barbecue— basically, when you're having a patient load something and it's painful, whether it's a tendinopathy or plantar fasciopathy, or you're giving them cues to overcome ischemic rehab, here I use some funny sayings to get patients to remember it. We were all taught once upon a long time ago, never give a patient an exercise that creates pain. Well, the tables have turned and the tides have shifted. We do want to load patients into a painful zone when it is relevant, and when it is relevant is largely predicated on getting the right assessment and diagnosis, which is why we also have that pain-to-performance paradigm, right? That pain-to-performance paradigm, again, caring concern and empathy, red flags, yellow flags, orthopedic assessment, MDT. MDT tells me this is tendinopathy, fasciopathy, or It lets me know that there's something ischemic going on that requires more load and more force and more repetition. So I use 1, 2, 3, 4, and no more. Your pain on a 10-point scale, up to about 4, no more. Stay right there. If I'm 5, I'm good with it. You're staying alive. 5 and trending up, all right, back it down just a little bit. 5 and trending down, keep loading it, keep loading it. You're doing the right thing. Your body is adapting. 6, 7, 8, I don't want my patients to train with pain. Their self-rated scale, 6, 7, 8. I use 6, 7, 8, and I hate Pull it back just a couple notches, or I need to modify the exercise, or I missed the diagnosis because it should not load like this. Nine and ten. If your pain is being reproduced and it's a nine and ten, never again. We don't want to train anybody that high for fear that we are working either a bad psychological mechanism and grooving a bad pattern in the brain, or grooving something bad in the tissues or the brain or the spinal cord. So nine and ten, never again. I don't recommend training at that level. One, two, three, four, maybe five. Everything else, back it down. Produce no worse. Good training for tendinopathy, good training for ischemic mechanisms. Produce pain but no worse afterwards. You can also use cues. Annie O'Connor uses this: find the pain, find the thing that causes you pain, and then do it. You also can get some cues like motion is lotion, motion is lotion, move it, move it, right? And then there's a traffic light guide which I'll go over next. I really recommend that you implement, you implement this in your offices as well. So what is the traffic light guide? And this is coming from A World of Hurt. And basically what they find is a red light is tissue harm and tissue injury. A red light means there's a major change after the exercise of greater than 50% loss of motion, loss of strength, and loss of function. You may also find that pain spikes during the activity. Pain went up to a high level during the activity, or pain persists after the activity by 3 numbers above baseline for 4 days to several weeks. If you get into that red light situation, you gotta reassess. Probably there are better options out there for your patients. This is when the patient is required to notify the therapy team, or if you are the therapist, you notify the other team members and you stop activity. The patient's then instructed to seek medical advice regarding that injury. Traffic guide, yellow light. Again, coming from a world of hurt, too much, too fast. You're doing the right thing, it's just the volume and repetition thing is too much for the patient. We want to harm check here. No changes in range of motion, no change in strength, no change in function, no better, no worse. is what occurs. Pain spikes, it went up during the activity but it went back down fairly soon. Or pain persisted after the activity by 3 numbers of baseline for 2 hours if you're 4 to 8 weeks post-injury, 24 hours if you're 8 to 16 weeks post-injury, or excuse me, 48 hours if you're 16 weeks post-injury. The action plan for this is stay the course, continue with normal activities, avoid any new activities, positive words and positive thoughts. Those do matter. And then wear a flare-up plan with ice, rest, ice, meds, or anything that you need modality-wise. Yellow pain is safe pain, no harm. So what's a green light, right? We went through the traffic light here. The green light is condition tolerance. Hey, it's favorable to loading. It's favorable to situation. It means that either pain was better during or better afterwards. So that's one of the mechanisms. MDT, mechanical diagnosis and therapy, also uses a traffic light guide. And this is more so what we utilize in our office because it's a little bit more simple and easier to consider. There's less layers. This is easier to explain to a patient. The best way of implementing this in your office is to sit down with your rehab team, namely your recovery specialists, your athletic trainers, your chiropractic technicians, your physical therapy assistants, and talk about how best to implement this. I recommend putting poster boards in your office, especially in your rehab rooms and in your therapy rooms. And then as part of your education after the first session, when you start to get a feel for the patient, at the end of it, hey, I'm going to prescribe some rehab exercises But we need to have a common language about should I continue this exercise, what should it feel like, and when do I stop? And that's when you show them the poster in the corner about the traffic light. Most of us have the green, yellow, red. I think if you're in New Zealand and Australia, you may have amber light, but the concept is so common to so many folks. In MDT, the red light is pain worse during, but it stays worse after. Pain peripheralized, it spread. So if I had pain in my neck, it spread down into my arm. That's a stop. We don't want pain to spread. That's a bad thing. Diminished baseline strength, sensation, range of motion, tolerance How has the tolerance to activity changed? Yellow light in the MDT paradigm is pain worse during, but it goes back to baseline afterwards. It went from a 3 over 10 to a 6 over 10 during the exercise, but 40 minutes later, I'm back to a 3 out of 10. My pain's no different. Continue to load it, load it, please load it. You're changing patterns in the brain, spinal cord, and the tissues when you load it. There's no change in location. There's no peripheralization there. That's a yellow light. And there's no change in baseline. It's no better and no worse. And then your green light exercises. Right? Pain, you have pain during or no pain during, but it's better afterward. Like you did that and then an hour later, man, I feel good. Please continue. In fact, do more of that, right? You've got centralization, pain moving from the arm back towards the neck. That's another green light. Okay, continue to do it. We don't want the pain down in the extremity. We want the pain back in the spine. And then your baselines are better. So the questions that I get with this is, how do you implement this in your office? Sit down with your therapy team. And when you sit down with your therapy team, have a pretty good conversation, create some poster boards, and then start How do you differentiate plantar fasciopathy versus impact? Plantar fasciopathy versus impact. Impact is we're talking about the heel hitting the ground, and underneath that heel, things like stress reactions, calcaneal fat pad atrophy, or a bone spur can develop as regard to this impact mechanisms. Well, they're a little bit different. With plantar fasciopathy, the mechanisms are nociceptive, inflammatory.

So, the plantar fascia is a very important part of the foot.

Contractile. Nociceptive is ischemic, lack of blood flow that degenerated again via contractile mechanism. Or nociceptive ischemic tightened, shortened, and adhesion, right? So the mechanisms by which you get there are different. Notice that nociceptive is in all of those, and notice that we have a contractile component and then an adhesion ischemic component, whereas impact— impact drives the heel spurs, the stress fractures, and the fat pad atrophies. So, what treatments can we utilize for plantar fasciitis from a manual standpoint, and what should we do for an impact injury? The treatments are a little bit different. Like plantar fasciitis, your manual therapy, your manipulation, rehabbing it, right? Load management, altering the force through that. Again, orthotics, altering tensile force or modifying force through the kinetic chain. And then shoe modification, that's another way of changing load and force through the plantar fascia, and that's a big strategy with plantar fascia, changing load force through that area. But impact, We want to reduce force, like we want to reduce that impact force through the heel. So you can also recommend weight loss. That's a way of reducing impact through the heel. I know many of us are manual therapists, physical therapists, chiropractors, athletic trainers, but one of the things we have to have a hard conversation, especially in the United States, is that in some way, shape, or form, weight does play a role in orthopedic injuries and musculoskeletal conditions. We can't not address it. We need to be polite, need to show caring concern and empathy, But again, having a conversation in a polite manner that's for the patient. I'm telling you this from a position of concern. I want you to feel better. One of the things you can do to reduce force through the heel, Mrs. Jones, is just try your best to be as active as possible. Any weight loss that you can experience is reduced force to that tissue, that joint that's suffering some discomfort, okay? And just leave it at that. And that's a really good way of doing it. What about steroid injections, right? Like steroid injections for the bottom of the foot. I know that we've got podiatrists out there, orthopedists that are injection Happy injections can further degenerate the fat pad and plantar fascia. There's no doubt about that. Secondarily, you can also aggravate the lateral calcaneal nerve. Yeah, how about that? Numbness, tingling, burning, pins and needles—that wasn't there. That now is there post an injection. I've had a couple patients that had that. I bit my tongue and just said, "You know, something was funky with that." Check with the podiatrist that performed the injection. But my odds, my suspicion is that this numbness, burning, tingling, pins and needles will be there for months. It's just going to work itself out on its own. I would not get another injection and do anything more invasive. Matter of fact, for a period of time, we probably want to protect that area, put you in a walking boot for a couple weeks, and then bring you out slowly and reintroduce load to that area, but that will get better. Unfortunately, that person had a nerve-related injury from a plantar fascia injection that went wrong. There's some short-term benefits from injections of the plantar fascia, about 1 month, but long-term, and this is what we have to sell our patients on, you're in this for a long time. You have one body, right? That body has to last you for years, and the more that we are invasive and put invasive options in there sooner, especially without clinical rationale and clinical reason that supports it, the worse the prognosis is long-term. And if you could just wait just a little bit of time, the outcome is better and your chances of serious adverse reactions go down. And that's the conversation we need to have with patients because sometimes they're expecting this. And if they're expecting a quick, rapid result and they're much dismayed that it will occur weeks down the road, then they're not led astray. I think we led them astray with an unrealistic expectation Things like orthotics, exercise, rehab, other injections rather than cortisone injections like PRP, dry needling, and shockwave are way more effective in the long term than our steroid injections here. So let's get into impact, right? We've talked enough about plantar fascia and we beat that horse dead. Its impact mechanism is nociceptive and inflammatory. Again, stimulation of the bone. Bone has receptors. Those receptors in the bone get wound up, get spun up. Why? Too much force. Bone is a tissue. It's a living tissue. It can alter versus force and load and pressure and things like that. So, it can definitely get affected. What's the impact mechanism look like? All right. Worse with heel strike. Foot heel hits the ground, stimulation of the soft tissue, stimulation of the fat pad, stimulation of the bone. It is driving that pain. That impact on that ground is triggering that. Worse running downhill. You heel strike a lot more when you run downhill. So, if you hear these things, you're thinking, okay, One of the following: fat pad atrophy, you're thinking heel spur, or stress reaction there. Worse at the end of the day. The more weight that you put through your feet, the more the bone's going to get stimulated. So, typically, impact mechanisms for those 3 things, worse at the end of the day. Worse in the middle or at the end of the run. Again, progressive loading throughout the run, stimulating pain right there, right on that heel over and over and over again. And it's better with rest. Bone gets better with rest. It has a tendency to catch up, a tendency to remodel. Over time, it can, but in the cases of stress reaction, is breaking down faster than it is building up. These impact mechanisms are responsible for these diagnoses. Here's the heel spur. In a weird twist of fate, the heel spur is not actually bone overgrowth; it's soft tissue that morphs into bone. This is the attachment here of a couple key tendons that occur. So this bony overgrowth, bony attachment, actually occurs over the overlaying soft tissue, and the irritation that occurs is typically irritation to the soft tissues around. The heel. So they once would remove these bone spurs 20, 30 years ago, and the outcomes removing them were not any better than just leaving it alone. So podiatrists and orthopedists are less likely to remove these and more likely to recommend things like cushion around it. So cushion shoes, soft shoes, orthotics with cushion, or losing weight, weight loss. That's a way of reducing force to that. You look at the calcaneus up in this picture on the right, you see quite a bit of swelling in that calcaneus, right? Right through here, and that's an indicator of stress reaction of the calcaneus. And if you can focus on that triangle down here, this right here, this arrow and this little triangular patch that I'm overlaying here—that's a breakdown of the calcaneal fat pad. Again, impact driven. Impact, impact, impact is driving those guys right there. So heel spur again not formed by plantar fascia, but the abductor digiti minimi and flexor digitorum brevis. Again, obesity, weight loss, right? Obesity is linked to this condition. Weight loss is one of the solutions. These are hard conversations to. But I think there is value in having that for a patient's long-term and short-term health here. Again, obesity is the number one predictor of heel spur. And what does pain look like? Contact, heel strike, end of the day. You start thinking that impact mechanism and those 3 differentials shore up higher on the list here.

Alrighty guys, that is it for today's training. Be sure to tune in for episode 11, where we will conclude this 3-part series, where Dr. Pappas will discuss neuropathic and inflammatory causes for heel pain. We will look at what the research says regarding the most effective treatments for common heel pain diagnoses, as well as the tests you can use to determine if the pain is indicative of sciatica or radiculopathy. You won't want to miss it. Episode 11 drops in 2 weeks, or 1 for our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. Be sure to also look for our Patreon link in the show notes to access additional bonus content, early release episodes, and an ad-free listening experience. We're constantly adding more benefits for our patrons, so get in early for maximum value. Remember to also visit the show notes for a link to download the full PDF of today's presentation. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings, as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.