#11 - Differential Diagnosis of Heel Pain with Dr. Dino Pappas, Part 3

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 thanks for listening. If you have not listened to episodes 9 and 10, I strongly suggest that you hit the pause button, go back and listen to episode 9 first, which is part Part 1 of this training, then move on to episode 10, which is part 2, before listening to today's episode, which is the final segment of this 3-part training with Dr. Dino Pappas titled From Pain to Performance: Differential Diagnosis of Heel Pain. Dr. Pappas is a sports chiropractor, certified athletic trainer, certified strength and conditioning specialist, father, husband, chef, adventurer, and travel junkie. His passion is improving health and human performance by using conservative-based treatments like manual therapy, manipulation, rehab exercises, advice, and special testing and lifestyle recommendations to help his patients achieve excellence. He's worked with all types of patients, from the average Joe and Jane to weekend warriors to amateur athletes, and even Olympic and professional athletes. 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 this presentation, over the past few weeks in this series, we've discussed all of the different ways that your patients might be experiencing or presenting with heel pain, both standing, walking, or in doing different types of sports and activities. Today, we're going to continue our discussion in the assessment and treatment of stress fractures, suggestions for cross-training while injured. We're going to discuss neuropathic conditions that can affect the foot and the questions that you should be asking to rule out plantar fasciitis. Dr. Pappas will also discuss posterior heel pain, nerve flossing, and neurodynamics for the lower extremities, and how to determine if heel pain is spinal or a sciatic referral. 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.

Stress fractures. I like to classify these guys. So we classify, now we subclassify. There's 3 types. You got stress reaction, stress fracture, and fracture. What's the difference here? With a stress reaction, the internal architecture of the bone can't keep up. You're putting too much force and too much load, and it can't just rebuild as fast here. You'll see some swelling inside the bone, and it's more local. It's more of a local patch than anything here. Again, history: end of days worse, long periods of standing or walking, end of runs worse. Again, more force to the heel, it can't catch up. So what's the treatment and therapy? Most of the times it's unloading that, limited weight-bearing, say no running for 4 to 6 weeks, or we're going to put you in an orthopedic soft shoe or a cushioned orthotic, or we're going to put you in a walking boot for a period of 4 to 6 weeks to get the area to catch up. A patient can cross-train. This is the perfect time— exercise bike, swimming pool, things of that nature. Especially in our runners, and our female runners are a little bit more at risk because hormonal changes do impact the bone's ability to reduce and receive load. What's the next step up? The next step up is a fracture. And what's stress fracture explanation? Internal architecture is in imminent harm of failing. If we don't do something, the bone will break down. It's just a matter of time. All right, so first phase, stress reaction to me. Second phase, stress fracture. Hey, you keep going along this path, man, nothing good's going to come of it. And this is the point we have to tell our athletes, you're in imminent harm here. Like, there is no, I think I'm going to rest 3 weeks from now when my training cycle is done. Let's do this now because you may not make it 3 weeks. You got a bigger problem in 3 weeks. Imaging, again, quite a bit of swelling. You may even start to see small microfractures as well inside the bone. Again, progressively worsening. It's a lot fewer steps trigger the pain. Hey, it used to be 100 steps. Now it's 10 steps, right? And that's an indicator that this is progressively worsening. Heel pain earlier in the run, standing and walking goes down. Again, middle of the runs are often painful or uncomfortable, and then typically they're a little bit higher. You know, it was an ache, it was a 4 out of 10, now it's about a 7 or an 8. It was just, it ramped up. I don't know why or how. Timeout. We need to stop the bleeding here, and that's reduce the force immediately. Typically, that's 6 to 8 weeks of limited weight-bearing to no weight-bearing. What's the final phase? The final phase is the bone is actually fractured. The architecture of the bone has failed. This is the one that's most evident on an x-ray. You won't catch a stress fracture or a stress reaction on an x-ray unless quite a bit of the internal architecture is disrupted, Plus, you are cueing yourself or cueing the radiologist to specifically look for it. And that's why outside of history, which is the first clue, an MRI is an invaluable tool. The hardest thing is sometimes it is very difficult to get that approved and authorized through an insurance company here in the United States. That's why your history has to be on point. Again, cue yourself in. These are the factors here. Imaging, again, a fracture line is present. You often will hear a pop or snap. This is can't stand or can't walk more than one step here. What's the treatment? Well, I would say you're pretty clear by referring to an orthopedist. Make sure You get somebody good that understands sports injuries if it's an athlete or just foot and ankle dynamics. You want to x-ray and then follow up with an x-ray to clear them, especially if they're going back to athletic activities. You want that documentation in the athletic world. And typically it's 8 weeks for fracture healing unless a patient has some metabolic conditions or old age or something that slows the healing process down, which is also why I think a follow-up x-ray is probably one of the best things that you can do. Let's just shoot a picture, kind of see where we're at 8 weeks later. That looks pretty good. Reintroduce loading it over the next—

8 weeks.

I don't know, maybe 4 to 6 weeks slowly, and then good to go. If at any point in time you tell a patient, problem comes back, come back into my office. So that's kind of how we play it here. So what are the weight-bearing progressions? Well, most invasive, taking off the most weight, to least invasive, we're working down through that process there. Crutches, right? Or I should say wheelchair first, but most of the time you can get away with the wheelchair. Crutches, take pressure off of one leg, and then you go into a walking boot, right? You're still putting some weight through it, but it's a little bit more controlled. Then this is an orthopedic surgical shoe, which you can can find pretty easily on like Amazon. That's the next phase for me out of the walking boot. Typically after that, I'll progressively load them. For some patients that are high-mileage runners or the go, go, go, and they want to get back to 30, 40 miles, and you have the conversation, it's not going well, I'll then recommend either a custom orthotic with a soft spot, again, cushion around the heel like a donut cup. I'll recommend putting 2, 3, 4 gelatinous donut cups in the heel of the shoe, again, to act like cushions so that when that heel hits the ground, the cushion absorbs the force. Then you can go with an over-the-counter orthotic or a custom shoe fit. Again, that's working our way backwards from most invasive, taking most of the weight off, to less invasive, putting more force through that area here. When you're dealing with fractures or stress fractures, especially in our female runners, you have to consider hormonal cascades, thyroid issues, diabetes, osteoporosis, osteopenia. Those all matter into our healing times, which is why a slow progression is warranted, and which is also why when you start to see this, you need to put the brakes on the athlete here quickly, especially if they're running the— like, I, I dealt with a lot of marathoners in Chicago. I lived in Chicago for years, and Chicago Marathon was huge. 40,000 people used to run it. And every summer we would get to about July, August, and people would come in and be like, oh, I've got this heel pain here and I need to run 20 miles in 3 weeks, and what do you think? And I'm like, I'd ask them all, all the questions, and I'm like, you're in the process of getting a stress reaction. If you don't have one, progressive stress fracture. And we need to modify your training here for the next 4 weeks. But Doc, how am I going to PR in this marathon? How am I going to run marathon. And my suggestion is you're not going to run this marathon with a stress reaction or a stress fracture. It's pretty, pretty cut and dry, right? Like, I, I won't approve you to do it, right? And if you do do it, you're going to put yourself in increased risk. And I've documented this in my notes. So we need to cut the bleeding now. And your goal of PRing on your race day is going down, but getting you to the start line and more importantly the finish line safely, that is the goal. And if that's the goal, I can help you. I need to reduce the force for about 4 to 6 weeks. We'll slowly ramp it up over 4 weeks and we'll take it to race day. And that was the plan. Some other things: huge spikes in training, acute spike in training, or prolonged chronic training, especially in our runners in general, are cues for stress fractures in the foot and ankle. And Tim Gabbett is the source for that. Again, great guy that produced some key information on load management there. You may also want to switch foot patterns if your calcaneal stress reaction or stress fracture— midfoot stance unloads it, forefoot strike pattern unloads it. Changing strike patterns though takes time, and you have to emphasize patience with the patient and repetition over and over and over again to get them to learn that. I estimate for many patients, if you start embark on that, it'll take 6 months to a year, and they have to practice that every single run and every single step of every single run, or else they won't learn the new running pattern. So just a little bit on that. It does work, it's effective, but that's a slow process if you do that here. It's also important, and I bring you this story up, I've had some patients shadow me before in the office, and when the patients shadowed me before in the office, I actually had a patient that came in that day that had a reaction that also had chronic plantar fasciopathy. Yeah, you can have both at the same time. You can have apples and oranges at the same time. So what do you do, right? The problem is like, all right, I want to treat the stress reaction. I'm just going to put them in a walking boot. Well, you need to get load and force through the plantar fascia. Well, we're just going to wait till the boot's off and then load the plantar fascia. Well, I got news for you. The patient's going to be even more prolonged suffering here. So the answer to the story is you protect the stress reaction with a walking boot and you have them take the walking boot out about 4 or 5 times during the course of a day and you have them do your plantar fascia loading exercises, the video clips that we saw, and you have them roll the plantar fascia with the lacrosse ball here, and you just have them do that about 4 times a day, right? So you're treating both and you're balancing the scales on/off. So really the important part to this is that dogs and cats can play together, apples and oranges can exist together, and sometimes you deal with both mechanisms and you need to have tools to be able to sift through the layers, with the examination being key to tell you what strategy to recommend to what patient at what time. One of the other mechanisms that we discussed here earlier on is neuropathic. That's peripheral neurogenic pain. And what conditions live in that box? The conditions are tarsal tunnel, posterior tibial nerve. It runs down the inside part of the leg. If you look where my mouse is on the screen, I'm going down this inside part of the lower leg here, right inside this area, right inside the medial malleolus. This runs adjacent to the posterior tibial tendon. From the posterior tibial nerve splits several branches, including this medial calcaneal nerve. And stimulation of this can create burning in the inside part, calcaneal tubercle here. This calcaneal tubercle here, when you squeeze it, can be painful. And when that occurs here, you have to ask and differentiate out, is it burning, tingling, numbness? Is it sharp pain, right? Because this can mimic plantar fasciitis and plantar fasciopathy right here, this condition here, right? Aggravation of the posterior tibial nerve or aggravation of the medial calcaneal neuritis. Also on the bottom of the foot, running here to the lateral toes, the nerve to the abductor digiti quinti are the lateral plantar nerve and the inferior calcaneal nerve. Some people will reference this condition, Baxter's neuritis, as the lateral plantar nerve. Some textbooks I've actually seen reference it as the inferior calcaneal nerve. I just want to make you aware of pain on the bottom of the heel, lateral heel, that radiates towards the toes. Oh, it's plantar fasciitis. Probably not. It's probably Baxter's neuritis. For any nerve, key things in the history lead you down that pathway, and asking the right questions is important. You're looking for numbness, tingling, burning, and pins and needles indicating that you're dealing with a nerve-related component. If those go up, your ears raise, your flag raise. Hmm, I may be dealing with a neurogenic condition. A neurogenic condition will respond to mechanical therapy, the MDT principles. Do I need to go in with the lens of a neurodynamic assessment? That's why they're in the same portion of that pyramid that I first showed you. Nerves are extremely sensitive. They're sensitive to several things. They're sensitive to pH changes. They're sensitive to blood flow changes. They're sensitive to swelling. Inflammation, oxygen, carbon dioxide levels, stretch, and compression here. Because nerves are so sensitive, they're likely to be triggered and likely to be triggered by different mechanisms. And understanding those mechanisms are critical to treating a nerve-related condition. Is a nerve actually tight? And if it's tight, it means it's adhered, it's locked down, and it needs to be mobilized back and forth and back and forth. And here's my analogy here. I'm clasping my hands in front of the camera, and as you mobilize it progressively, it produces pain. No worries. Produce pain, no worse. Produce pain, no worse. Progressively, it starts to lengthen like this. Okay? These are commonly like surgical adhesions. Like if a patient has a low back surgery and they clip the nerve root, you get an adherent nerve root. That nerve root locks down as a result of scar tissue or dural adhesion. Those need to be mobilized. Those are the ones, the tight ones where, hey, guess what? I need to progressively produce pain, no worse, to stretch the nerve root over several weeks to months to actually mobilize that nerve root so that it's no longer sensitized anymore. The trap ones fly Those are big movements, like flossing teeth back and forth here, right? When you floss teeth back and forth here, you're tensing, putting tension through one side, relaxing from the other, and then you're just switching it back and forth. I'm going to show you an exercise video that mimics, shows this to the posterior tibial nerve slider. My fault. Let's play this guy for you.

Hello everyone, this is Paul from Ortho eBalance. All of my tarsal tunnel syndrome patients is nerve flossing. Okay, so the way I like to do this is start off passively with the patient on their back. I take the knee and I kind of hold on to it between my body and my elbow, and I keep it flexed at around 90 degrees. I abduct the hip a little bit and have it flexed a little, and then what I do is I take the big toe and grab the bottom of the foot. So what I'm doing is I'm extending Extending the knee, I'm pronating the foot a little bit, and I'm extending the big toe at the same time, getting this nice stretch over here. I might get up into a little more knee extension and then let off, and then pronate, dorsiflex, evert, extend the big toe, and relax. I might try to Try to extend the knee a little bit more and then do another stretch and try to floss that a little bit, all right, to try to get that neural mobility. One of the things you need to know about nerve flossing is you should never really aggressively pull hard and try to stretch it more. Nerve pain can be very, very uncomfortable. The whole idea here is to develop better neural mobility. of the nerve amongst the soft tissues better, and sometimes just taking that tension off of the nerve can help improve situations like tarsal tunnel, which we would do similarly with carpal tunnel. So that is how we do a posterior tibial nerve flossing exercise with people with tarsal tunnel. If you have any questions, get in touch with me at Paul— I've tried a lot of different rubs 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. It allows 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 that basically nerve sliding exercise was an exercise that mobilizes that posterior tibial nerve through that tight tunnel. He's right. You don't want to aggressively mobilize a nerve. You just want to take it into the resistance a little bit and back off. Now, why would you want neuromobility? And that's for a trapped and an entrapped nerve that needs a little bit of encouragement to slide and glide through that tight tunnel. In the case of the tarsal tunnel on the medial malleolus, there is soft tissues there that can basically lock that area down. So just a little bit of gradual motion, taking it into the resistance over time, desensitizes the nerve root, right? And when nerve is desensitized, it's a cascade. More blood flow occurs, exchanges more nutrients, local chemistry changes, oxygen and carbon dioxide levels flip, and again, pain goes down. So you're modulating pain through mechanical motion of a nerve through a tunnel, and that's what that gentleman was showing in that video right through there. This guy is the master. If you're looking to learn about neurodynamics, Michael Shaklock teaches excellent clinical neurodynamics courses. If you're in the United States, he is touring around the United States with increased frequency. I've seen him, or posters or flyers for his work here in the United States, and I highly recommend that you take a course. To date, I've read all the neurodynamics textbooks that are around. I've not taken a course, just my schedule has not flipped. I do not sufficiently match up with Michael Shacklocks, but I do use the principles day in and day out with patients to assess and classify as well. He's got a couple different studies, and I posted the links right then and there, where in several situations patients with plantar fasciitis have come to his office, and through examination he's actually found that many of these cases were not plantar fasciitis. So one of the Studies is 23 subjects with plantar fasciitis symptoms by clinical exam and diagnostic ultrasound. So they actually looked at the plantar fascia and found degenerative changes on ultrasound. Six, 23 or 23 percent actually had nerve conduction abnormalities of abnormal latency and abnormal amplitude to get a concurrent diagnosis of medial calcaneal neuropathy. So if you start to hear the words numbness, tingling, burning, you start to hear some signs that don't sound like the typical plantar fasciitis. Your tensile mechanism. Your ischemic degenerative mechanism, or your tensile degenerative mechanism, and you start to hear numbness, tingling, burning, and you perform your exam, keep your ears open that peripheral neurogenic is a mechanism of heel pain. All right, that's kind of the point. He's got 2 good articles that support that viewpoint on his Neurodynamic website. What about posterior heel pain? I feel like we've left that alone for a little bit. Let's get to that right now. So Achilles tendinopathy is the number one thing that we see back there, and I'm seeing that more and more and more because as more patients come out of the woodwork and start aggressively exercising like they were in February before this COVID crisis happened, right? They're ramping up way too quickly and giving themselves tendinopathy. There's a couple mechanisms here. There's the tendinitis, nociceptive inflammatory. There's nociceptive ischemic contractile, which means that the tendon can't chronically handle load and force. There's nociceptive ischemic, or your adhesion is just too tight and needs to be stretched or mobilized over and over and over again. Location also matters with Achilles tendinopathy. The insertion ones, to be honest with you, are a son of a gun. Why are they a son of a gun? They're a son of a gun because bad blood flow occurs at the lowest part. That's the attachment into the heel. There's bad blood flow down there. That's the worst blood flow to the tendon, that part of the tendon, to be honest with you. This means that they're not no healing areas, they're slow healing areas, and that needs to be conferred to the patient. I'm expecting to make progress. Your progress will be slow. Look for progress somewhere between 6 to 12 months. The initial benefits you may feel in 4 to 6 months. If we're not getting benefits in 4 to 6 months, then I will send you elsewhere to figure out If we miss something or this is just a slow-healing tendinopathy, to take the other stuff off the table, right? What other stuff could be on the table? Metabolic, thyroid conditions, autoimmune conditions, all can slow down your capacity of the tendon to rebound from a loading program, a home exercise, a home loading program. Peritendinitis, which is the sheath, the mid-belly of the tendon, that can be, again, nociceptive inflammatory-based pain. And then the non-insertional tendinosis or tendinopathy, Ischemic contractile or ischemic adhesion can be the mechanism of pain there, and that's greater than 4 centimeters away from the heel is where you often find these things here. Some impressive feats, right? Vince Carter, recently retired from the NBA. Man, that guy could load it and unload it. He could spring like a coil, and that's actually the Achilles tendon. Their job, their job is to coil and uncoil the fibers as they come down. They attach in the posterior heel, come down and rotate. They rotate approximately like this, and as they spiral and rotate. They go through a coiling phase, which allows us to store kinetic energy to explode. Vince Carter was amongst the best in-game dunkers and the best at exploding and dunking. And here he is dunking over a gentleman from France. Well, that guy's famous now, but for the wrong reasons, right? The guy at the bottom, the guy at the bottom is David Goggins. He's an ultra endurance athlete, former Navy SEAL. Thank you for his service. He's a public speaker now, and he's got an interesting story. But that interesting story has driven him to some impressive feats of endurance. And here he's doing one of the hardest races known to man called the Badwater 100. They literally run through one of the hottest places on earth. That's the desert in California, and that's Death Valley. That's where it starts, and they run all the way out to Mount Whitney, California. That's the mountain that's 14,400 and something feet in elevation, and they literally run through the desert, 120-degree conditions, one of the hardest races on mankind. And the Achilles likewise has to coil and uncoil, not to the same degree as Vince Carter, but it has to chronically do this over hundreds of miles of training and 100-mile miles plus during the race. So the Achilles is actually an engineering marvel, which is why I bring it to your attention. Why is the Achilles unique? Because it was a survival mechanism. Our ancient ancestors had to move about the terrain for thousands of years to be hunters, gatherers, and foragers, right? Which meant what? They needed a physiological adaptation. One of that physiological adaptations was the coiling property and the uncoiling property of the Achilles tendon. So some mechanisms: nociceptive inflammatory, again insertional or paratendinitis. The message that you want to understand is calm it down, then it back up. And how do you calm it down and build it back up? Ice, load management, rest or active rest. Do not, do not aggressively stretch an insertional tendonitis or a flared-up paratendonitis. It will backfire, right? I made that mistake so many times in my career where I aggressively stretched this and all it did was piss off the patients, stimulated more nociception, more inflammation as that was stimulated, ramped up their pain, less tolerance to activity, less confidence in therapy and rehab. So I don't even bother stretching The insertional ones, not for a very long time, if ever. I more so will have them do self-myofascial release. I'll do some manual therapy, unload it for a period of time. When the time is right, reload it. And manual therapy does have a role in pain control and modulation. I know that question's been asked on our chat screen. What about orthotics for insertional and paratendinitis? The insertional and paratendinitis orthotics, they can help normalize calf activity of the gastroc and soleus and force transmission to the Achilles. So there is a Supinated foot, typically a valgus wedge. That helps control where the foot is touching that ground. And if you have a pronated foot, a varus post can be of service in, again, unloading portions of the Achilles. There's been much ado about heel lifts. Should we recommend them? Should we not recommend them? Am I putting a patient at further risk of Achilles strain if I put a wedge underneath the foot and I tilt the foot forward in this position? And the answer to the question is, short-term, it appears to be OK. Long-term, there's an increased chance of calf injury, injury to the tib anterior, and strain on the Achilles. But when you plantarflex the foot, Here, you're reducing some of the stretch, tensile force, and that's why aggressive dorsiflexion, that aggressive tensile force when the foot rocks back, stretches that insertion point like right here on the heel. And that's why like a temporary heel lift where you plantarflex the foot temporarily reduces that stretch right at the insertion. What about loading programs here? There are different loading programs, and the big point with these loading programs is to progress from low and slow, progress from low and slow. So from a little force to a lot of force here, slowly reintroduce load and force with a multi-phased approach. In a controlled loading manner, non-weight-bearing open chain to modified closed chain exercises, from isometrics to isotonic, isotonic concentrics, isotonic eccentrics, using body weight, closed chain, right? Isometrics, concentrics, eccentrics, then to a dynamic position. That graph on the right kind of shows a nice stepwise progression to load the Achilles tendon. There are a couple specific protocols, 4 of them in particular. Each one has a pro and a con, and which one do you prescribe? You prescribe the one that works best for your patient depending on the following factors: time, Some of these protocols require 120 to 160 repetitions a day, right? That requires a pretty good commitment by a patient. But if you can reduce the repetitions and still get the same effect, isn't that also advantageous? The answer is yes. So how much time do you have? What equipment do you have? And what equipment does a patient have? That matters in the loading protocol. What activities or sports do they want to participate in? Listen, it's going to take a little longer because in athletes, we've got a higher level of function to plyometrically load and stretch and unstretch that tendon in a short amount of Do you have patient buy-in? Asking a patient to do something that's painful requires buy-in. You need their trust. You need to gain their trust. You need to earn their trust. That's also why caring, concern, and empathy is the bottom part of that pyramid that I showed you. Will pain or perceived harm be an obstacle? You need to address that pretty quickly if you get that situation that, hey, hurt does not equal harm, and over time your body will adapt. So there's the Alfredson's protocol, and I won't get into all the specifics, but this is a lot of repetition and progressively adding weight, and it's as pain allows. So You exercise to pain and you don't want the pain to be excessive. And this was a protocol that's probably about 10 or 15 years old at this point in time. Silbernagel came up with a protocol that sets and reps varied. It went up and down and you went through a progression of isometrics to concentrics, eccentrics, plyometrics, and then return to sport. He recommended daily loading that lasted a period of 12 weeks to 6 months starting with body weight. Basically what you would tell a patient is increase it, make it harder based on your tolerance. You progressively check them throughout this progress. That also was effective just like Alpert. There was a protocol that was Kongsgaard et al., which was heavy, heavyweight, slow resistance. So low reps, heavy weighted reps, slow repetitions. And guess what? That worked as well. There was also a low rep volume protocol. Guess what? That worked as well. So moral of the story is consider when you're picking a protocol for the patient what the situation is and which, which I'm going to recommend. Typically I'm moderate, middle of the road. If I have an athlete I need to get a little bit more aggressive on, I'll use heavy and slow because they like to be challenged with speed and control and they like to be challenged with weight. I typically don't use the true Alfredson's protocol because the Alfredson's protocol is a lot of reps and requires a lot of work by the patient. I typically like to make it as easy and take away the barriers as much as possible. I mentioned non-insertional Achilles tendinopathy and non-insertional tendinosis. Again, mechanism, ischemic contractile. Load it for the non-insertion progressive strengthening and check for asymmetric dorsiflexion. Anytime if you have Achilles tendinopathy on the side of pain, one side dorsiflexes way more than the other side, that's actually a sign that there's actually tearing. The tendon is no longer intact. The tendon is no longer intact because it's got micro ruptures and micro tears in it, and that's one of those ones we want to time out. We want to slow the force to that, so loading will be slower and less aggressive. We don't want to aggressively stretch In fact, for a period of time, we may actually want to put them in a boot or a brace so that they limit the amount of dorsiflexion through the ankle joint so that they can reduce that force that is causing that microtear and microtrauma as well. And then the tendinosis, the degenerative ones, the ischemic degenerative, load it, progressive lengthening. Hey man, I need to stretch this to kingdom come so it produces pain, no worse. Let's do repetitions, 1 set, 10 to 15 reps, 6 to 8 times. Times a day or more if you can tolerate it. So what about manual therapy, right? I've gotten a couple questions on manual therapy. Yeah, if you've got Achilles tendinopathy, go ahead and do manual therapy. Again, pain modulation, fibroblast proliferation to stimulate repair after acute injury is recommended. And this again will jumpstart the inflammatory process. It's important, critical, and I think we're starting to figure this out, that you can't heal without inflammation. For years and years and years, doctors, chiropractors, physical therapists have been recommending anti-inflammatory medications. In the short term, that's okay, but Extended courses of anti-inflammatory, especially oral nonsteroidal anti-inflammatories, do slow down the healing process. When they do slow down the healing process over and over and over again, that leads to decreased bone stimulation if it's a bone injury, decreased soft tissue healing like ligaments, tendons, fascia, and muscle as well. So moral of the story is that again, deep tissue massage, great. We want inflammation as part of the healing process. Sometimes deep tissue massage induces that inflammation process and assists with healing as well here. Some general other information, and I have a comment on there, near 75 slides. Yeah, that's correct. This is a masterclass, right? So my goal is to give you some information about the subject and hopefully lead you thirsty for more, and there is definitely more. This is the baseline for a 4-part course that my colleague and I are writing content for, and hopefully you'll be interested at some point in time. And unfortunately, if you haven't already, sit back, grab a beer or a glass of wine, and enjoy the last 10 to 15 slides because we're almost there. And thank you again. Thank you for staying with us as well. So one of my favorite comedians, Fluffy, right? Oh, hell no, I'm out. There's not been really good studies about injections inside the Achilles tendon. There have not been very good information about studies of injection inside the Achilles tendon because they don't pass internal review boards. Why don't they pass internal review boards? Because they could lead to tendon rupture. And putting a patient in imminent harm, never a good idea. So we have to look to the animal models. The animal models suggest that when you inject inside an animal's Achilles tendon, death of collagen— collagen does not respond and look good and handle force— there's decreased tensile strength, and there's increased risk of tearing rupture, right? Which is never a good thing. And that's why Fluffy, one of my favorite comedians, says, oh hell no, I'm out. What about injections around the tendon sheath? Sheath. There's less robust research even there. It's not as common of a procedure as well. Typically, it does not appear— again, keyword appear— to be as deleterious as the intratendinous, but I heavily recommend and limit my patients' recommendations from getting injections in and around the Achilles tendon, period. And if they do, I tell them, one, put the brakes on, and you better be willing to modify your activities and do your homework as well, because it's not supposed to be a standalone get out and run 100-mile or run 26.2-mile afterward type of treatment. Some other reasons for posterior heel pain would be S1 radiculopathy or sciatica, and this is a nociceptive inflammatory mechanism. Again, you're screaming for chemical versus mechanical pain. You want to check for directional preference. I'll get into that. That's part of the MDT principles. You want to evaluate for centralization. I've had patients, maybe 10 or 12 over the years, complain about burning in the Achilles. Achilles. We've done the traditional treatments, they've been in the traditional therapy, everything looks right, but they're still in pain. I had them do a whole bunch of press-ups, end-range exhaustion. Hey, I need you to load this over and over and over again. Your back may hurt, but I want to know what happens to your Achilles. All of a sudden they're bouncing around and walking around and moving around. Hey, you know what, it's burning less. I haven't come back in about 2 to 3 days and just have them do that. And miraculously, a handful of patients have been significantly better. So these were S1 radiculopathies in disguise. as Achilles tendinopathies. And if you have a directional preference, work it early and work it often if that's what you find here. So what is directional preference and centralization? Directional preference is a movement of any joint— it could be the spine, it could be the knee, it could be the hip, it could be the ankle— that basically does 3 things. And the most obvious one is it takes pain. So if you're having heel pain in this particular situation here— burning, tingling, numbness, pins and needles— you think it's the Achilles You give them a movement of the spine, forward bending, backward bending, knees to chest. This is supine flexion, side bending to your side, or on your stomach pushing your body up press-ups. You start to see pain slowly move back towards the source, and if it moves back towards the source, indicates that it has spinal linkage. And that spinal linkage, you'll start to see in a predictable pattern in most cases pain moving progressively. And you see these pictures back towards the source where it's coming from back here on the low back. That's an indicator that you're dealing with. with a spine-based problem and not a distal or Achilles-based problem here. What is another peripheral neuropathy? Well, it could be a sciatic lesion, lesion of the sciatic nerve in the piriformis and the hamstrings, or something below that manifests with posterior heel pain. What's your test and what's your treatment? Well, the neural tension test, the slump test, and you're looking for is an increase in symptoms when you go down in this position. Just indicates basically putting stress or tension or pull through a nerve is your trigger, and maybe mechanisms to undo that are going to be sufficient for treatment of posterior heel pain rather than treating locally at the site of the heel. Tensioner— the patient needs, needs pull, needs force, needs stress to that. That's what this one is on the right-hand side of the screen, whereas the slider is a big mechanism. The head goes up, the leg comes up, the toes come back, so you're relaxing from the neck, you're applying tension from the torso And then you switch it, the leg comes down, right? So this leg bends back, this chin comes down to your chest, and you're alternating these movements back and forth and back and forth as a sliding mechanism that, again, can affect the Achilles as well. So these are really great tools, assessment tools, that lead right into a real simple treatment if you're suspecting sciatic entrapment leading to posterior heel pain. One of the studies of recent importance that came out in the last couple years was the EXPO study. And it stands for Extremity Pain of Spinal Source. And the design of this study was this: there was 322 subjects, and they put them through some of the MDT assessments. The MDT assessments are repeated motion-based testing, and they looked to see if the symptoms would leave the extremity. And this was the upper arm, this was the lower body as well. And what they found was pain in the extremity, about 182 of the 322 Their pain was truly extremity-driven, but repeated motion-based testing and moving the spine, moving the neck, moving the low back was able to show a benefit in about 140 of these patients. So that's about 42, maybe 43%. So if you're having a patient that you do not know if they're responding to your conservative care, timeout. Let me reassess the spine. Let me do through a bunch of repeated motions of the spine and let's see if this pain centralizes, my baselines improve, and my overall Overall, pain starts to get better. And if you do, you're more likely not dealing with a spinal condition here. Again, here's the study. Here's some of the data charts from the study. Again, extremity sourced versus spinal sourced in the hip. Spinal source of pain was 71% versus extremity 29%. 72% in the thigh and the leg and 27% versus the extremity. The further you get from the spine, like the knee, the ankle, the more likely it's extremity sourced rather than spinal sourced. But again, what's the important part? The important part that you'll see here is even in the ankle and the foot, and that's That's what we're talking about. Something like 29.2%, so somewhere right in this ballpark, so about 30%, may have actually had a spinal problem masquerading around as an extremity-based condition. So how do you determine it? Basically look for the words burning, tingling, numbness, pins and needles, current spinal pain, history of past major debilitating episode of spinal pain. Your exam, you're looking for any range of motion loss of the spine, any altered sensation possibly. There's specific testing clusters that can help you tease out whether it's more likely to be the spine or more likely to be the extremity. There's testing clusters called the cluster of Wainier for the neck, neck radiating into the arm that lets you know whether it's a neck problem and whether it lets you know whether it's a neck problem radiating into the arm or shoulder or it's a true neck problem. And then your repeated motion testing, that's one of the ways that you differentiate. So I'd like to thank you. That's it. I know it's a mouthful. I've been going for about an hour and 45 minutes. This was intended, and I'd like to thank Jessica and Factor and Southeast Sports Seminars to be a master class. So if you're confused yet, right, a lot of information, if your head's spinning or you want more, you're a glutton for punishment, right? We're working with one of my colleagues and collaborators, Dr. Peter Thomas, and you can find his link there, create a 4-part series called Pain to Performance. Our endgame here is live courses and recorded courses, hopefully on this platform as well. And our goal is to have these out within the next 1 to 2 years. And look for content from myself and Dr. Peter Thomas. If you have any questions, please feel free to screenshot that. I'm Dr. Dino Pappas. That's my business cell phone. That's my personal email address. Feel free to shoot those questions over to me. I'm active on YouTube. I'm active on Facebook, pretty active on Facebook and on Twitter. I do have a blog site, Pain to Performance, that I do update periodically when I need to go into a little bit more depth than a 3 to 4 or 5 minute YouTube video will show. Again, I wanna thank you all for sticking with me to the end. I appreciate any comments and questions, and I'd like to thank Factor and Jessica Jessica, one more time for the support here.

Okay, wonderful. Thank you everyone for joining us today. We just have a few minutes left, but I did want to open the floor to questions. We did receive one here that says, in their experience, some athletes use wrong or weak-condition shoes and then they overtrain with less stretch within the shoe. Have you encountered that a lot, especially with your runners or athletes that Sometimes it's a shoe problem that can be a big factor.

Yeah, so the— yes, that does happen, and that's one of the things on your treatment team if you're getting into especially running-related injuries is to find a trusted shoe store in your area that they can accurately assess the patient's gait and recommend the right model. A little tangent and tidbit that I want to recommend here is that the shoe industry got smart approximately about 30 years ago, they tried to figure out a way to get into podiatry and a way to get into orthotic making, right? Because they realized that one shoe did not fit all, that one Nike, that one Adidas, that one New Balance did not work for everybody. So they started to put orthotics in shoes, and those orthotics and shoes are not custom recommendations, especially for your patients that have specific and certain conditions. So yes, wrong shoes can be an issue, and if I feel that there are, on my treatment team, I've got 2 good shoe stores in my area that I will send with a prescription pad with what I'm seeing. Take it to the shoe store, have them watch your gait analysis and get that right prescription shoe. So that is a possibility. And yes, the shoe companies try to get into podiatry and orthotic industry, and sometimes that's created more problems than what it's solved.

Wonderful. Next question here kind of goes back to what you were saying regarding the green light, yellow light, red light. When you have someone who is used to training hard and is used to going all the time, maybe even someone that works on their feet all of the time, how do you kind of coach them to take a step back and using those green light, yellow light guidelines, how do you help them when they have a job or they have training that requires them to use their feet or be on their feet a lot more than you would recommend typically?

Yeah, good question. If you're on your feet all the time, I'm thinking about some factory workers that literally work physical, physically demanding jobs, and, you know, they're working 8 to 12 hour shifts and they're in work boots on hard concrete surfaces, that's a little bit harder. You have to tilt the scale in their favor. So in that type of situation, I'm more likely to prescribe a device, an orthotic device, to kind of bridge that gap, especially if you're getting the of foot pain and all that. The other thing too is I recommend that they try to keep a diary or a journal, and the diary or journal does not have to be in the written format. It can be done on your smartphone, on your mobile phone, or your device. And basically, what are you feeling when you're feeling it? And, and what we want to do is track that data for about 2 weeks and start to see the patterns and start to educate the patient on, you are spiraling from a green light to a yellow light. Just pay attention and make some modifications or you're going from a yellow light to a red light at this point in time where you need to stop the activity because you're toast for 3, 4, 5 days. The journal is not so much for me as it is, is just to have the patient accountable and say, I can control this and I know when I'm gonna hit a green light, yellow light, red light because I now have the data in front of me. Sometimes we see the world with blinders on and the benefit of that journal is it exposes This a little bit more. Oh, I know that I was standing and walking for four miles, or you know what? I know that I did a lot of plyometrics, and after the plyometrics, my feet hurt, my knees hurt. But I know that four or five days later, I was okay. Well, maybe I can modify the amount of plyometrics to take it from a red light where you were toast for four, five, six days to I was only sore for two days, and it was just part of the natural training cycle. So that's what I think that question. is try to modify the terms around it a little bit better if you can, or really have them start to track if they're a motivated person, what their activities are over, over about a 2-week cycle, and look for trends in the data. Not so much for me, so it takes their blinders off.

Thank you so much, Dr. Pappas. We really appreciate you taking the time today. This has been incredibly informative and educational.

Thank you. Thank you for the opportunity. Thanks for everybody for sticking with us. I appreciate This and appreciate the forum. The intent was to do a masterclass and I was able to get it done. And kudos to you and Factor and everybody for sticking on. Thank you guys so much. And I appreciate a little bit of your time during these turbulent times as well. Thank you.

That's it for today's training. Be sure to tune in for episode 12, where we have our very first First special Q&A episode featuring the instructors from our first 2 trainings that were featured in episodes 1 through 4. Doctors Tom Teeter and Todd Riddle will be our special guests. In this special broadcast, we ask our instructors the questions submitted by you, our listeners, subscribers, and patrons. Guys, I have to tell you, this interview lasted well over an hour and was full of great clinical pearls and insights on the topics of rehab, fitness, and clinical practice. You won't want to miss it. Episode 12 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. Give us a 5-star rating to help us grow the show. Every little bit helps. Also, be sure to look out for our Patreon link in the show notes to access additional bonus 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. Also, remember to visit the show notes for a link to download the PDF of today's full presentation if you haven't done that yet from episodes 9 or 10. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor 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 big 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.