foot pain

The Fallacy of Plantar Fasciitis

Bare Physical Therapy bunion, Cortizone Injections, foot pain, Manual Physical Therapy, metatarsalgia, Orthotics, plantar fasciitis, Podiatrist , , , , , , , , , , , ,

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Plantar fasciitis is such a problem that you can hardly conduct an image search for plantar fascia without returning mostly images of the plantar fascia with a big angry red splotch on the plantar fascia near the heel.

I recently watched a video on Facebook posted by one of my Physical Therapy peers on the topic of plantar fasciitis. I privately messaged him to let him know that I thought his presentation had missed some key points and his reply cited the Clinical Practice Guidelines for plantar fasciitis. There are some issues with that response from my standpoint:
1. The Clinical Practice Guidelines for plantar fasciitis are fairly useless in regards to “what to do” to treat plantar fasciitis and of some limited value in “what not to do”. They very accurately reflect current available research which is of little clinical value in this instance.
2. I’m concerned that my profession is so entranced by Evidence Based Practice (EBP) that they have stopped seeking information or guidance outside of what research has generated, and as a result their patients often suffer through suboptimal care and (pun intended) limp down the clinical plank of failed conservative care, injection and ill-advised surgery. I know this not what the developers of EBP-theory intended, but I’ve seen it just about daily on social media.
3. The research available on this topic is doing very little to help clinicians truly heal their patients of their foot pain. I would dearly love to pitch research ideas for anyone who has faculty connections.
Now off the Soap Box and on to clinical guidance…
– Plantar fasciitis is a misnomer, most of these patients don’t use their plantar fascia at all. A more appropriate term would be “Mechanical Heel Pain”. Typically, the origin of Mechanical Heel Pain is a poor initial contact in stance phase in which the contact is too medial in magnitude and/or duration. The medial aspect of the midtarsal joint, subtalar joint and calcaneus are very neural dense and do not tolerate this increased pressure well and eventually leads to heel/foot pain.

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– Unfortunately, a bad initial contact (as described above), has consequences throughout the foot and lower extremity that further perpetuate an inefficient gait cycle. Here are some examples: hallux abductovalgus (painful bunion), metatarsalgia, achilles tendinitis, medial knee pain (pes anserine, plica, etc), lateral hip pain (trochanteric bursitis, piriformis syndrome, etc) and SI dysfunction.
– The good news is that when you treat the cause (improve foot mechanics) and treat the tissue (manual therapy), the patients’ symptoms resolve very quickly…1-4 visits.
If you are a clinician reading this blog and you didn’t delete it from your feed after reading #2 above,  you have practiced long enough to be frustrated at heel and foot pain patients’ poor prognoses. Please consider attending a lower extremity biomechanical course, it will completely change your practice. I teach a 2 day course called Thinking on Your Feet. Of course, I’m biased and think mine is best, but there are some other good courses out there. Give one of them a chance and it will elevate your practice above the limitations of the current Clinical Practice Guidelines.
If you are a patient reading this blog, you may have had “mainstream” care for your foot pain which probably included: activity modification, exercises (strengthening/stretching), modalities (heat, ice, ultrasound), massage, shoe inserts, dry needling, injections or surgery. You have probably been nodding your head the whole time, because you know your foot pain isn’t completely (or any) better. Find a clinician with biomechanical training in this topic or contact me directly for advice at Tony@BarePT.com or find out more about my unique practice and skill set at Barephysicaltherapy.com

LTC Tony Bare (ret) DPT, ATC, OCS

Laramie, WY

How to Avoid Foot Surgery

Bare Physical Therapy foot pain, knee pain, Manual Physical Therapy, metatarsalgia, Orthotics, plantar fasciitis, Podiatrist , , , , , , , , , , , , , , , ,

 

 

  Elective foot surgery is expensive, debilitating, time consuming, frequently unnecessary, and patients are often worse pain following surgery. Matter of fact, if you find anyone happy with an elective foot surgery you might also want to go ahead and buy yourself a lottery ticket…the odds are about the same. I always say, “there is NOTHING surgery can’t make worse”.   That is especially true in elective foot procedures.

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Has your surgeon told you that you need surgery for the following?

  •  Neuroma
  •  Bunion
  •  Hammertoe
  • Plantar fasciitis
  • or maybe because you had advanced degenerative Osteoarthritis?

Trust me, the surgery will not address the cause of any of the above pathology.  If you fuse, remove, dissect, or realign something in the foot without addressing the cause, you are just kicking the can down the road until you need surgery #2, #3, etc.

A brief bio on me to provide credibility on this subject:  I became the Army’s expert in lower extremity biomechanics and foot/ankle treatment specialist in 2000 and was honored to hold that position until my retirement in 2013.  I’ve attended 120 hours of continuing education in biomechanics and have taught courses all over the country.  I have also successfully treated thousands of patients in my career, relieving their pain and in countless circumstances, avoided the above mentioned surgeries.

The BARE NECESSITIES Do’s and Don’ts of foot pain…

The Don’ts

  1. Don’t see a podiatrist. Podiatrists are foot surgeons and they have little knowledge or inclination toward conservative treatment options.
  2. Don’t let anyone inject your foot. Cortisone injections are somewhat effective in treating foot pain, BUT they do NOTHING to address the cause of foot pain. As a result, when the steroid wears off the foot pain often returns worse than before.
  3. Don’t let anyone sell you a hard plastic arch support. Your foot was designed to bend and flex during the stance phase of gait, and it can’t perform correctly with a hard piece of plastic wedged under the arch. These “custom” arch supports are also expensive and rarely covered by health insurance.
  4. Don’t let anyone convince you that you just need to “stretch” more. Typically the most common cause of foot pain is an underlying instability… instabilities get WORSE with stretching even though it can feel a bit better short term.

The Do’s

  1. Do try a change of shoe. Many times replacing a worn out, or poorly fit shoe will be enough to start the healing process. If possible get advice on footware from a reputable shoe dealership (none of the chains) or medical professional with significant foot/shoe experience or training. If you are on your feet a lot (work, home, sports), don’t skimp on your shoes. You don’t need to spend a fortune, but the shoe market is competitive and you do get what you pay for.
  2. Do try a full length off-the-shelf shoe insert that you can usually get in a running shoe store for $40-$70. This is a semi-rigid arch support and will still allow your foot to flex and bend as it’s intended to, but will still provide some support.
  3. Do find a good manual therapist (Massage or Physical Therapist) to break up the adhesions that are likely contributing to the pain in your foot. If your therapist tries pushing “exercise” as the cornerstone of treatment and does no or very little manual therapy, go find a different provider. This condition cannot be fixed with exercise, though exercise can be a component of recovery…the main emphasis should be on manual therapy (not dry needling) to both lower extremities.
  4. If all else fails…Do find a biomechanical specialist to construct a custom biomechanical corrective orthotic (shoe insert) to address the underlying cause of your foot pain. These professionals are few and far between. I noted above how I became a specialist in this field, and here is a link to my website. You will find information on the difference between arch supports and biomechanical orthotics as well as examples of what I would need to conduct an assessment on you (video and other) if you happen to not live close to Colorado Springs.

Lastly, if you happen to find this blog AFTER you already had a surgery (or 4)…there is still hope. Follow these same do’s and don’ts and you will be amazed at your recovery!!

By LTC Tony Bare (ret), DPT, OCS, ATC

The Calamity of the 1st MTP fusion…

Bare Physical Therapy Arch Support, bunion, foot pain, metatarsalgia, Podiatrist

 

MTP = MetaTarsoPhalangeal, the joint at the ball of your foot where your toe joins…also the joint where patients develop bunions.

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I’m not even sure where to start with this blog, my heart breaks every time I see a patient with a 1st MTP fusion…usually they are fused bilaterally. It is a biomechanical disaster that should essentially never happen.

Why do patients have this debilitating procedure?

  • They have 1st MTP joint pain.
  • They have radiographic evidence of 1st MTP degeneration (osteoarthritis).
  • Failed conservative management (arch supports, physical therapy, and medications).

Surgeons motivated to help the patient with their only real tool: surgery and NOT understanding the consequences of fusing this MOST critical joint in ambulation.

What leads to 1st MTP degeneration? Unless you are a ballerina, you have earned a degenerative 1st MTP through bad biomechanics and physics. The most common cause I see for 1st MTP pain and degeneration is a collapse of the Metatarsal or Transverse Arch which is also frequently a victim of further biomechanical issues.

Treatment of 1st MTP pain?

  1. Fix the biomechanics…this usually entails an Orthotic…NOT AN ARCH SUPPORT. (See my post on the difference between a biomechanical orthotic and a “custom” arch support)
  2. Get the 1st MTP joint moving.
    1. Treat the soft tissue on the medial (inside) and plantar (bottom) of the joint.
    2. Mobilize the joint (1st MTP extension in sagittal alignment).
    3. If the 1st MTP has been dysfunction for a long time, there is likely restriction of the plantar fascia and that will need to be treated too.
    4. This is NOT a problem that can be fixed with patient stretching exercises, however use of a “Prostretch” device can be a helpful addition to manual therapy intervention.
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  3. NEVER consider surgical fusion of this joint!!! 5 degrees of motion is a whole lot better than zero. It may make the 1st MTP joint feel better to be fused, but it doesn’t fix the problem that caused it to fail in the first place and it forces further compensations up the lower extremity chain of joints where the patient will likely begin to manifest other symptoms (hip/back most common).

 

 

 

Custom Orthotics By Providing Video Gait Analysis

Bare Physical Therapy achilles tendonitis, Arch Support, bunion, foot pain, knee pain, metatarsalgia, Orthotics , , , , , , , , , , , , , , , , , , , , , , , , ,

I’ve had a lot of interest in my Bare Necessities  Custom Orthotics (arch supports or shoe inserts) from people across the country and I’ve had good success making them based off the information below. If you’ve read my post on the Fallacy of Arch Supports, you know that one of the components of my exam that makes the orthotic successful is the dynamic gait analysis, so if I’m provided the video footage I’ll have great insight into your biomechanics and if they need any help or correction.

The good news is that I’ll assess your videos FREE!! All I need is 10 second clips of you walking barefoot on the treadmill from behind and from each side.   Just do your best to walk on the treadmill at your comfortable walking pace.  Take video footage of the following angle/level  (including both sides/foot):

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I’ll need a tracing of your foot next to a ruler. See picture below (it doesn’t have a ruler but you’ll need a ruler next to your tracing).  The tracing will let me know what size of orthotic to make and I’ll have an idea what adaptations your biomechanics have forced your foot to make and that will be even more information helping to guide my orthotic prescription.

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IMG_2431The orthotics themselves are only an average cost of $85 plus $10 shipping and handling, so send me your videos and get on the road to pain free walking or running.

Now that we are relocating to Laramie, WY please refer your Colorado Springs friends to this post.

Please email me your video and foot tracing to tony@barept.com

LTC Tony Bare (ret), DPT, ATC, OCS
Physical Therapist
Laramie, WY

The Fallacy of Arch Supports

Bare Physical Therapy achilles tendonitis, Arch Support, bunion, Cortizone Injections, foot pain, knee pain, metatarsalgia, Orthotics, plantar fasciitis, Podiatrist, shin splints , , , , , , , , , , , , , , ,

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Have you been told you need foot surgery? Have you been failed by physical therapy? Orthotics (shoe inserts)? Podiatry (cortisone injections)? Have you been told surgery is your last option?

Please let me share three things I’ve learned as a 15 year military expert on foot mechanics, pain and dysfunction:

  • There is nothing a foot surgery can’t make worse
  • You can’t “unsurgery”
  • Foot surgery is like a potato chip….hard to stop at one

Step 1
Why did conventional physical therapy fail you?
You were treated with modalities (ultrasound, heat, electrical therapy), stretching, strengthening and balancing exercises…you may have received massage or myofascial release. You probably did get some relief but never complete and always temporary….why?
NONE of the above treatments addressed the cause of your pain….just the symptoms. Once your cause is addressed all of these treatments become amazingly effective!

Step 2
Next, you receive a cortisone injection. You may have felt great for hours, days or maybe months but gradually your symptoms returned and you were ready for your next injection and the next and the next. There are consequences to a single cortisone injection let alone multiple injections. Please do your research!

Lastly, this injection also fails to address the cause of your foot pain, the reason why your symptoms return eventually.

Step 3
Orthotics (shoe inserts)
these may be included as a part of physical therapy or podiatry treatments. Why have they failed you?

Failure 1: Your assessment

How detailed was your orthotic evaluation? Were your feet glanced at?
Maybe your health care provider watched you walk back and forth across a clinic floor. Maybe you just stepped in a foam box or had your foot casted.

My evaluation includes detailed assessment of your:

  • Current shoes and any inserts that either came in your shoes or were purchased separately
  • Static standing posture of your leg/ankle/foot. Static prone posture of your leg/ankle/foot
  • Dynamic (treadmill) barefoot multi directional gait analysis

 Failure 2: Your orthotic construction/development
The most common error? You’ve been fitted with an arch support. Your arch was NEVER designed to be a primary weight-bearing structure. An arch support does very little to correct the mechanics of your foot and that’s what has led to your foot pain, leg pain, knee pain or hip pain. To make matters worse the forced correction into your arch can be so uncomfortable that you won’t even wear them. On the rare occasion that your orthotic has a mechanical correction, it’s often based on a faulty or incomplete assessments. See Failure 1 above.
Lastly, your orthotic has been constructed of a rigid unforgiving plastic shell. This shell does not allow your foot to flex, adapt and function normally and can create another series of issues.

Step 4: Surgery
Don’t go here! Please let me see you first. My assessment is free . If I feel I can help you with orthotics, my average cost is only $85. Please read my testimonials on this website and Facebook.

LTC Tony Bare (ret), DPT, ATC, OCS
Physical Therapist
Laramie, WY