#9 - Differential Diagnosis of Heel Pain with Dr. Dino Pappas, Part 1

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. In today's episode, we will be kicking off a brand new training with Dr. Dino Pappas titled From Pain to Performance: Differential Diagnosis of Heel Pain. This training was so full of great content and clinical pearls that That it extends over 3 episodes, so be sure to tune in for each one. 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 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 has worked with all types of patients from the average Joe or Jane to weekend warriors and amateur athletes, all the way to 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 today's episode, we dive into the movement assessment pyramid, discuss red and yellow flags, including what to do when you find them, And Dr. Pappas will discuss some of the emotional aspects of pain, how to promote exercise when patients are resistant, and dive into the nuts and bolts of testing the mechanics of plantar heel pain. As always, if you have questions as you're listening to today's training, you can submit them 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.

A little bit about me. I don't like talking about myself. I try to stay humble and be a pretty humble guy at its inception, but I've done quite a bit in sports medicine and sports performance enhancement. And really the big 2 things I want to mention from this slide is that my first start was strength training and conditioning. I was a strength training conditioning specialist, and that was my love and that was my passion. And I quickly realized that I could take some of those concepts and principles and loosely apply them into the athletic training setting as I became an athletic trainer, and later as a chiropractor. And now I'm a sports and rehab-based chiropractor. But I couldn't fit the sports performance exercises into the clinic, and I didn't know which clinic exercises would fit into the sports performance model. And over the course of about 18 years in healthcare, I've had a lot of successes and a lot of failures, and I've learned more from my failures than I ever have from my successes. And the important part I want to note is that those failures drive me today to be better, be better for myself, and be better, more importantly, for my patients who deserve that. So hopefully Hopefully I can impart some of what I've learned and some of my things that I failed on and come up with about 18 years in practice, a clinical model that makes sense, and hopefully be able to share some of that and answer your questions. So let's take it from there. Heel pain, do we have answers? And the answer is yes, we do. We're going to go over some history and exam protocols, some differentials, some management strategies, and the exam demo I'm going to reserve. I don't think I'm going to have enough time for that, but this is a transition into 4 courses that I'm writing content for, Pain to Performance, where we sift through the layers, taking a person from in-office pain out to sports performance enhancement. And I really think I can provide value in helping you navigate those steps. There are no financial disclosures or conflicts of interest. And frankly, I'm not that cool. So just ask my wife, right? I apologize in advance. I do a lot of dad jokes and a lot of bad jokes. So I know we have some international people here. Hopefully you'll laugh at me or with me or one or the other, but a lot of dad jokes and a lot of bad jokes coming your way. So I like to keep this light and funny. So this is a kind of a paradigm over about 18 years in healthcare. I've been on both ends. Again, the sports strength training and conditioning, the athletic training in-room, in the athletic training room working with athletes, and then as a sports chiropractor in rehab, now mostly in the outpatient setting where a patient comes in for a short treatment plan, then is discharged. So this is the paradigm I'm working towards building and working towards making that transition and hopefully being able to share more and more and more with you over the next several years. The bottom of the pyramid is the patient, is caring concern and empathy. The first, from the first phone call to your website, to your first contact with patients, they have to know at its core, at its inception, that you care. If they don't know, all bets are off. You've already lost that patient and possibly that outcome. So the bottom of the model is making sure that you care for your patients, and I can't emphasize that enough. That's why we are in healthcare. The second part of the model is to rule out red flags. Red flags are things that you need to get off the table quick. Those are your cancers, your strokes, your neurological or neurovascular conditions, or your major abdominal concerns. Or your autoimmune conditions. So we're going to go over a simple red flag rule out. We're going to understand yellow flags and learn how to classify dominant pain mechanisms, including to the PMCS. This cohesive and comprehensive model was recently brought to light by Annie O'Connor in her book, A World of Hurt. I believe that book was published in 2019, if I'm not mistaken, maybe 2018. And it really kind of struck a nerve to me that the last several years of my training that we really kind of Underemphasized and misunderstood how important the mind is, how important understanding what barriers are to soft tissue injuries and soft tissue healing is. At one point, it was all the biological, the pathoanatomical. Now it's switched more to psychosocial variables. And to be quite frank, it's more of a balance between both. And you have to understand what those yellow flags are. You also have to understand pathoanatomy. You also have to understand the impact that you have on words and what you say and what you do to a patient can impact their outcome. So we're going to go into that a little bit. We're going to talk about some standard orthopedic If you have a patient that has an ACL tear and you're going through this paradigm, caring concern and empathy, making sure they don't have a red flag, you're understanding the yellow flags, and you find that they've torn their ACL and they're a 20-year-old wrestler, they've won a national championship in wrestling, and they have to defend a title their senior year, guess what? You've got 2 choices, and both choices are surgery and rehab and a redshirt, or trying to patch it through the season and realizing that surgery is on the horizon. So there are times to understand and recognize the importance of pathoanatomy here. And we'll go into that in more detail. We'll go into some of those exams to recognize that. My 5th rung on this totem pole is the McKenzie Method. I utilize that as a screening process. Is this something that would react to mechanical therapy, load, position, posture, static hold times, repeated motion, end range loading? I also, on that rung of the ladder, use neurodynamic assessments and neurodynamic treatments. I feel like there's so much interrelationship between the concept of neurodynamics and the McKenzie Method— sets, reps, hold times, static positions, unloading it, offloading it— that they should be somewhat synonymous in terms of the concepts and the principles of how to apply load and force. I think the next rung on the ladder is movement assessments. I think movement assessments give us a good idea once the pain is gone, once we put the fires out, of figuring out topics and concepts like motor control. Sometimes it's relevant if you're looking at a female volleyball player that lands wrong coming down from a jump in a valgus position. Yeah, that mechanical control or that motor control is important. Sometimes it's not very relevant to what a patient actually sees or what their goals are. That's why it's a little bit higher up on the ladder. The last couple rungs of the pyramid are getting out of that pain into that performance, that FMS, using a movement screen as a general guide to how to structure safe training, a general preparedness, physical preparedness screens like the ability to run a mile or run a 100-meter dash or ability to do some push-ups, and then your sport-specific training. And this is the paradigm I'd like to work on and like to have a dialogue and conversation with you folks for the next several years. People often ask me, where in this paradigm do neurodevelopment and DNS principles fit? They're levels 4 through 9. They help me fill in the Wherever the gaps may be lacking, they help me take a child or an infant from birth all the way to development. What's normal development? What's abnormal development? Why an exercise in a certain position is more likely to get reactive neuromuscular, why whereas another exercise is more likely not to get that neuromuscular activation, and how that can benefit in a rehab program. So this is the paradigm that ultimately I like to get to. So let's talk about some mechanical versus non-mechanical differentials. We're going to focus on the stuff on the left, but it's important to know how to sift through the stuff on the. Right-hand side of the screen, the autoimmune, the metabolics, the infections, the tumors, and any central mechanisms that are at play. Ruling out red flags, that's the first step after caring, concern, and empathy. You want to ask key questions in the history. Is pain constant versus intermittent? Constant pain is typically chemical-based. Chemical-based basically means that no position, posture, hands-on therapy, manipulation can touch that because it's inflammatory-based. And the only treatments that work are inflammation-based treatments and therapies, namely your medications, oral steroids, your nonsteroidal anti-inflammatories as well. So that's a really important question to ask for the history. Severe night pain unrelated to position. If they're on their back, have them flip to their stomach. If they haven't flipped their stomach, flip to their side. And if they can't find a sleeping position, not one bit, your flag goes up that, hey, this may be something that's a red flag condition. Unexplained weight loss, where most people will define it as about 5%, sometimes 10% weight loss within a 3 to 6 month period. Again, our flag goes up with the key question, are you intending to lose weight. And if a patient is not intending to lose weight, you got a problem. Fevers and chills. I've been asking that question a lot recently, especially with COVID We've been taking patients' temperatures in the office. Fevers, chills, body aches, breathing problems, history of recent travel. Those are the questions that I routinely have been asking my patients here. Contact with sick or COVID patients, right? So that's a red flag in this day and age. Recent surgery, major trauma, loss of bowel or bladder control, or a major change in bowel or bladder habits. Both questions I think are important because sometimes a patient may be embarrassed to that they've lost it. They went, not controlled it. So maybe they'll say words like, it was a little bit of a dribble, or it was a little bit awkward, which again prompts the follow-up. Progressive neurodeficits and saddle anesthesia, being numb in the groin on both sides. Saddle anesthesia is a red flag. Some other things you should want to know, if they have a family history of autoimmune disease. Autoimmune diseases come in clusters. Thyroid conditions come in clusters. Family history are triggers for that. Any metabolic disease, diabetes, Cushing's disorder, things like that impact your ability to treat them from a mechanical standpoint. Sexually transmitted diseases, Abdominal infections. And then the, the lover's heel: conjunctivitis, urethritis, and heel pain. And that's from our national boards if you're a chiropractor: can't see, can't pee, and can't dance with me. All right, so those are red flags when you're looking at heel pain. Some other questions: better or worse. If there are things that you can do to make the patient better, then odds are that is not a red flag. Age 55 or older, that's a relative. Sometimes 55-year-olds are more at risk for certain types of conditions, but that's not an absolute. And then just checking their vitals. vitals are important to getting an overall sense of a person's just general well-being. Understanding yellow flags, and this is one of the things that recently was put to light by Annie O'Connor, again from the Rehab Institute of Chicago, in her landmark work, I believe was in 2019, A World of Hurt. She really talked about and kind of honed in on these yellow flags. What are psychosocial obstacles, things that are around you, your environment, your peer group, your network around you, your work environment, how these things can really impact your recovery from an injury or impact or even use this to project who can be disabled from a soft tissue or other orthopedic injury. And she uses the Yellow Flag Risk Form, which will pop up on the next screen. Yellow Flag Risk Form helps us by domain. You can break it down by domain and find out where a patient is scoring very high. Are they fear avoidance? Are they avoiding a behavior that could trigger the inability and more fear and more fear, more pain and more perceived threat without actual threat? Does the patient have enough self-efficacy and willingness? Can they cope? Do they have the mental capacity to rise above their condition? They're not their condition. Can they rise above that? Depression, anxiety, and emotional disturbance are other domains that can be seen on that. When we score this, there are 13 questions. They're scored on a 10-point scale. If you score less than a 50 on that, yellow flag. And I really recommend you guys implement this in your practice if you're not already, because it lets you know really quickly, are you dealing with something that's more than a physical issue? That's what you wanna know. Less than 50, low risk. You treat mechanically. You implement your strategies: manual therapy, manipulation, soft tissue work, rehabilitation advice, posture mechanics. You start to score that 51 to 64 category. Timeout, timeout, timeout. Maybe that patient has moderate risk, right? That moderate risk is I'm going to figure out what type of pain they have and then assess and treat mechanically, fully well knowing I could morph. into more of a psychological-based treatment, all right? And then greater than 65, you absolutely wanna classify the dominant pain mechanism and address that appropriately. The Yellow Flag forms looks like this. The questions are on the right and domains are colored in different colors. You've got blue, you've got purple, you've got red. You get a question that asks about sleep. Sleep is important. Matthew Walker wrote a book. In Matthew Walker's book, he's a sleep neuroscientist. He looks at sleep for physiological healing, sleep for overall health and wellbeing. And Getting good quality sleep is critical, critical for your tasks. And if your patients aren't sleeping, of course they're going to be in more pain. Of course they're going to be more depressed. That's a key question to have on the yellow flag form. Now, if a patient starts to score and they start to score towards the domain that they're centrally sensitized, a nervous system that is spun up, wound up, it indicates maybe that fear avoidance is one of the important players in this. And they're afraid of activities. Try to do your best to disarm that. Hurt does not equal harm. You are grooving something. And over time, your body, your muscles, tendons, ligaments, joints, Your brain and your spinal cord says, I can do this. It's like working out. The first couple times you work out, it does not feel good, but you keep doing it, doing it, and doing it. And over time, you get the benefit— bigger, faster, stronger, harder to kill, right? That's the benefit of exercise. Same thing, central sensitization. Sometimes fear does not equal harm, and we have to train that. And if you don't have the tools, try to find somebody like a cognitive behavioral therapist that has specific training that can try to help you.

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. ChinaGel 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 ChinaGel to get the maximum benefit for a patient. It's the combination of my skills as a chiropractor and And what China Gel has in it that allows the patient to get better, faster, and more effectively.

Affective pain. This is pain from past traumas, mostly psychological traumas, although it could be physical traumas. These are your PTSD. Think about our veterans that have fought in foreign wars that have PTSD, post-traumatic stress disorder, or a child that was abused, or a child that was neglected, or Any of those major life traumas that you experience. Sometimes the physical presentation of pain can be driven by a psychological issue. And if you find on this yellow flag form they're scoring high in those domains, best thing to do is not treat them. Look them in the eye and say, I need to get you to the right spot today for what you're presenting with. That's not to say you ignore the physical pain, but they need to be altered. Their course needs to be shifted towards the right direction here. And the last thing is motor autonomic or cortical These are your reflex sympathetic dystrophies, your pseudoadrophies of the world, where the mechanism of pain winds up the autonomic nervous system and pushes you into fight or flight. Touching the area could be extremely painful. The area may be discolored. This is autonomic pain. And unfortunately, hands-on therapy manipulation may not be the best strategies for that. Maybe we need to start reprogramming the autonomic and central nervous system from the ground floor. But like training, like training, like building muscles, tendons, ligaments, and joints, Building robustness, building strength, building stamina. Over time, this process can be effective. Conservative treatments can be effective if given enough time and routed appropriately. Pain mechanisms, and that's what the book covers. It separates it into peripheral on the left side and central on the right side. And peripheral on the left side here, there's 3 mechanisms: nociceptive inflammatory— this is your itises of the world— nociceptive ischemic, Hey, bad blood flow, bad nutrition to the area has led to tissue degeneration that needs remodeling, and that requires us to promote exercise. Even if the exercise may be painful, we need to promote it. And then peripheral neurogenic, this is actually coming from a peripheral nerve. So we got peripheral, and that's about 60% of what comes into an MSK practice. Again, Annie O'Connor, World of Hurt, that's the reference tool. Central mechanisms, central sensitization, the nervous system is spun up. Affective pain, that's again your traumas, psychological traumas induced. And that nociceptive plastic motor autonomic system is wound up. Again, your reflex sympathetic dystrophies, pseudocatrophies of the world. So why am I bringing this up to you? Like, this is a talk about heel pain, right? Like, why am I bringing this concept of pain classification up to you? Because this is the famous scene from Indiana Jones, and I believe it's the first Indiana Jones movie, Raiders of the Lost Ark, where our guy is flipping the knife and spinning the knife on up, and Indiana Jones He's got the bullwhip and he looks on out and he takes out the gun and he shoots the guy and he puts the guy down. The reason why I bring this up is you don't want to bring a knife to a gunfight. You don't want to prescribe a physical treatment or a physical course when you're dealing with a psychological problem. You don't want to prescribe the wrong treatment or classify incorrectly and then have to go backwards and waste patients' time, money, energy, and their hope in some cases. So bring a gun, right, to a knife fight. You'll win every time. Classify a dominant pain mechanism if it needs to be classified. Get the patient to the right provider, start the healing process both physically, psychologically, and emotionally. Again, learn how to classify the pain mechanism. And that's why understanding yellow flags and classifying the mechanism is the 3rd rung on our ladder after caring, concern, and empathy, red flags, and then yellow flag rollout. So the only guy ever to win a knife fight is Chuck Norris. He brought a knife to a gunfight and he won, right? Chuck Norris memes I really love, so you'll see a couple references to that as well. Hopefully you're chuckling at home. Michael Jordan, right? The King. Crying Michael Jordan, right? Cheer up, MJ. It's not that bad. Yeah, this requires some work. Yes, this requires us to study a little harder, to understand our patients, to admit our failures and learn from them. I have. I failed so many times in my career with certain patients, and those drive me, drive me hopefully to be successful and more successful every day so I get it wrong less and get it right more. So crying MJ, you got to be a doctor. You can't just be this chiropractor that racks and cracks everybody. You can't just be this manual therapist that does Manual therapy, grade 3 mobilizations, grade 4 mobilizations, Maitlands, Mulligans. You got to understand there's more to it than muscles, tendons, ligaments, and joints. Yep, it takes a little work, MJ. But MJ's happy here, right? He figured it out. He figured out that there is a method to the madness. So the great news is that we can help most mechanical heel pain. I feel like if we can classify and make sure we get the mechanical on our treatment tables, that we can be successful. I will say this: Anthony Davis is rocking the unibrow, and that's been out of style for a long time. So Anthony Davis, shame on you, right? Trying to bring it back, and you're not having any support these days here. But this guy, I don't think we can do anything for. This guy's got way too much going on. He's got exophthalmos, eyes bulging out. He's probably got Hashimoto's, a thyroid condition. He's got cachexia. He walks around, crawls around, and asks for something called precious all the time. So he's got affective pain. This guy we don't want on our treatment table. We probably can't help him. And maybe nobody can help him in general. So let's focus now that we've talked about the first 3 rungs of the ladder: caring concern and empathy, the red flags, the yellow flags. Let's get into the mechanical stuff that we can treat: plantar heel pain. So plantar heel pain, what before we get there real quick, a sub point: What do orthopedic tests actually test? What do they actually work on? Are they anatomy based? Are they biomechanical noise receptive mechanisms? And what we're finding out from all these orthopedic tests, from all these doctors that like to have their name on orthopedic tests, is they really test mechanisms. More than true anatomy most of the time. Now, you're going to get like a Lachemann's test in the knee where you're testing the ACL, but you're also testing other structures as well. So they're testing mechanisms more importantly than they're actually testing tissue structure. For example, in recent weeks there was a study that was published that looked at the orthopedic tests for rotator cuff tears and shoulder injury and shoulder pathology, and they found out they weren't so good at isolating the pathology, but they can test mechanisms, how force is applied to specific tissues, and is it a trigger in a pain. And the value of those tests, they became important as a track or a gauge or a measure of progress. Not that this tissue is wrong, but this mechanism is overloaded, creating some pain and discomfort, nociceptive pain and discomfort. Therefore, we can retest it 2, 3, 4 visits later and see if there's a change in that test here. So some key mechanisms for the plantar fascia are tensile and contractile. How does the plantar fascia give force? And receive force? How does it transmit force? The plantar fascia is actually interesting in that it has the ability subtly of producing small minute contraction, which is interesting because fascia typically doesn't have that. So it has a tensile mechanism and is more like a tendon in some way, shape, or form than it is traditional thick rigid fascia. Impact, axial force, loading through the heel. When I walk, in many cases my heel hits the ground. Impact forces can produce pain, namely stress fractures, fat pad atrophy, and heel spurs. And then neurological pain. Is the nerve trapped or is it tight? And that's important for conditions like your tarsal tunnel, your medial calcaneal neuritis, or your Baxter neuritis. Again, we're moving now into the categorization of the orthopedic testing clusters, your MDT, and then your neurodynamic assessments here. Why do I bring this up? Because without a way of classifying mechanisms of pain, how do you got there— impact, tensile, neurodynamic— you're basically throwing a dart at a dartboard with your eyes blindfolded. You may hit the board, but there is a greater chance that you'll miss the board, miss the board completely. So it's one of the things I want you to try to understand with this heel pain talk is understanding mechanisms by how you got there. So let's get into plantar fascia a little bit. Raise your hand if you've ever had a frustrating, non-responsive plantar fascia case, right? Both my hands are up if you can see me in the screen. Both my hands are up in the screen because we've all been there and done that. We've all thrown treatments at the plantar fascia or looked at the internet and asked for help And seeing we're trying ice, electric stim, dry needling, Graston, fascial distortion model, all these cute exercises. But what we now know is that we should probably understand, yeah, I see a couple of yups on the screen. I've had those cases of plantar fasciitis that, man, it really just, I felt bad for the patient because I wasn't doing the patient a service. So I really took a step back and analyzed how did the patient get here? Not what they have, that's easy. How did they get here is really the difficult part for us. So plantar fascia, force transmission. The foot does not elongate well, so stretching it routinely over and over and over again typically, typically, typically is not the best solution here, right? That works with the intrinsic muscles of the foot to deflect the arch during early stance and raise the arch during late stance. Why is that important? Because what we're finding is control, not the amount of pronation or the amount of supination, the control over pronation and the control over supination is critical to how a structure is loaded or more importantly unloaded in the right circumstances. Also, I had a doctor that told every patient, oh, you got a low arch, you're going to get plantar fasciitis. Well, I got news for you. Supinated feet, cavovarus feet, flexible valgus feet, both of them get plantar fasciitis but for entirely different purposes and different reasons. Some mechanisms we want to consider: is this inflammatory? There are some inflammatory cases of plantar fasciitis. I know that there's studies that say that they have found no white blood cells, so no signs of inflammation on tissue biopsies, of plantar fascia cases. And I say to myself, hmm, what is the sample side that's often taken? A lot of times the patient with acute 1, 2, 3, 4, 5 days a week of plantar fasciopathy is not coming to your office unless they've torn or ruptured the plantar fascia. Those cases are probably 5, 6, 7, 8, 10 weeks in the making. Oh, I've had this problem for 2 months. They come into your office. Those are the ones more likely where you won't find white blood cells, you won't find signs inflammation. You actually will find degenerative changes or your tendinosis or fasciosis rather than more of your fasciitis. And you have to treat those a little bit differently, right? Like you can't throw a Graston at an acute inflammatory condition, right? Because what's Graston do? It tries to recreate the inflammatory process. Well, that's not going to go so well because that turns up the nociceptive mechanism. And when that nociceptive mechanism gets turned up, it could produce more pain. But the degenerative case that it's ischemic, that basically is lack blood flow, lack oxygen, maybe you want to introduce a microtrauma to the area. Maybe you want to interject manual therapy into that. Maybe you want to tell them to get moving as much as possible versus protect it a little bit in an inflammatoryitis to calm it down. So again, mechanism becomes important. One of the major mechanisms is tensile, tensile force. So when my foot hits the ground and I propel myself forward like this, the plantar fascia, especially the great toe that goes into dorsiflexion, Dorsiflexion here in this position triggers tensile force all the way throughout the plantar fascia. So that propulsion tensile mechanism like this where the foot is raising up again creates tensile force, and that's an important distinguishment to understand that. How do we test that? Windlass test. What's the windlass test? You put patient in a weight-bearing position, you have them rock forward a little bit, you dorsiflex the great toe. If that produces pain in the arch, that lets you know that a tensile mechanism is Other ways tensile force is transmitted, having toe walk in your office, right? We think about the toe walk as a neurological test, but it also is testing tensile ability of the plantar fascia. Can the patient tolerate tensile force? They also complain in their history of propulsion, mid-stance to toe-off, that is painful. Like heel strike, my heel hits the ground like this, I'm good, but the moment I get here to here, I start to feel it. Lets you know that a tensile mechanism is at play. Running uphill, because you're running on your toes more, It's typically a little bit more painful. How do you separate inflammatory tensile mechanism from degenerative tensile mechanism? Well, the inflammatory tensile mechanism is recent pain or spiking pain with or without a microtear or rupture. Hey man, this triggered and triggered really high, really quick, really fast, short amount of time span. Where the degenerative pain is basically months in the making with progressively decreased tolerance, right? That's how you separate out the time component And how intense, in many cases, the symptoms are. All right? This picture on the right is actually showing propulsion, and the propulsion mechanism with the great toe dorsiflexed, tensile force is driven all across right through here. This is the plantar fascia here, and then loading of that fascia produces pain. Again, overload mechanism, tensile force. And tensile force and the inflammatory component, you want to be able to separate your rapid responders, those who respond very rapidly to conservative treatment, And the big question with tensile mechanism is how much force, too much or too little? Too little, if you determine from the history and the exam there's too little force, load it. If you determined that there is too much force, you want to protect it. You want to alter the load and slowly reintroduce that back. So where in the cascade are they? Too much, load it. Excuse me, too much, protect it. Too little, load it. So plantar fascia, how do we alter tensile load and alter pain? Therefore. And one of the key things is manual therapy. Manual therapy does have the role. This is your manipulation. This is your soft tissue mobilization of the world. And what is the role? Pain modulation. You can modulate pain pretty good and pretty easily, and that's best efficacy. You're not really reducing adhesions. You're not really lengthening tissue. Really, you're using inputs, tactile inputs, into the person's peripheral and central nervous system to modulate the pain Pain response, pain response locally and centrally. And then when you're able to modulate pain from that mechanism, it opens up a window to load the tissue, to exercise it, to rehab it successfully. When you start to talk about how to alter tensile load and pain, rehab is critical, rehabbing the kinetic chain. And it's up to you to determine, and that's where movement screens and this paradigm of pain to performance, your movement screens, where are the movement flaws that we can address that We can add some exercises into the mix that can help alter how force is applied to that. Is it bottom-up? You want to change how the loading strategy from the foot up, or do you want to be able to change that from the top down? How do you assess the kinetic chain, right? Like, I use my McKenzie and my neurodynamic, and then I move into my components of the SFMA and movement screen, side-lying hip abduction, gait assessment, double-leg squat, single-leg balance, lunge. I'm also looking at core control from a couple different purposes. That's how I assess it. I just use these movement screens depending on the case. I've got my favorites for different types of conditions. And then what's your criteria for exercise prescription? You need to have a cohesive system in place for specific pinpoint exercises. And that's where the McKenzie and NDS funnel helps me funnel down what's the one or two things that would get them the most benefit. Let's focus on that. Pain is better and what happens? We transfer up one or two rungs up the ladder to look at more of a global perspective. of why the tissue is getting overloaded. Turn down the volume button, shut off the alarm system, put out the fires. When the fire is put out, then start looking for the reasons why.

That's it for part 1 of this 3-part series. Be sure to tune in for part 2 of this training in episode 10, where Dr. Pappas continues his breakdown of the mechanical assessment and differential diagnosis of plantar heel pain. You won't want to miss it. Episode 10 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 are constantly adding more benefits for our patrons, so get in early for maximum value. And don't forget to visit the show notes for a link to download the PDF of today's full 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 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.