Episode 9: Plantar Fasciitis

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• Joe Gambino
• Joe LaVacca

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Summary

In this episode of the Beyond Pain podcast, Joe Gambino and Joe LaVacca discuss plantar fasciitis and foot and ankle injuries. 

They explore the demographics of those most susceptible to plantar fasciitis, including middle-aged individuals who are both sedentary and active. 

They also discuss the difference between fasciitis and fasciosis and the importance of understanding differential diagnoses. The hosts emphasize the need to set realistic expectations for recovery, as some individuals may take longer to respond to treatment. 

They also discuss the importance of respecting pain and modifying activity levels as needed. 

From a movement perspective, they highlight the importance of assessing big toe extension, midfoot adaptability, dorsiflexion, tibial rotation, and hip extension. They also discuss the role of nutrition and exercise in managing plantar fasciitis.

Takeaways

Plantar fasciitis is common among middle-aged individuals who are both sedentary and active.

Differential diagnoses, such as stress fractures and fat pad irritation, should be considered when assessing foot and ankle pain.

Recovery time can vary, with some individuals responding quickly and others taking several months to see improvements.

Pain guidelines should be respected, and activity levels should be modified as needed to manage symptoms.

Movement assessments should include tests for big toe extension, midfoot adaptability, dorsiflexion, tibial rotation, and hip extension.
Nutrition and exercise can play a role in managing plantar fasciitis and foot and ankle injuries.

Transcript

Joe Gambino (00:01)
Joey boy and everybody else welcome back to the Beyond Pain podcast. I am one of your lovely hosts, Joe Gambino and I'm here with your other lovely host, Joe LaVacca the two Joes. You can find me on Instagram at Joe Gambino DPT and joelavaca at strength and motion underscore PT. We love DMs, we love having conversations with you so please feel free to reach out to us.

I'm more than happy to have a conversation and there is an application form. So if you're interested in working with us, you can head right into the show notes and fill it out. And we, one of us will, we'll get back to you to chat. This is a also going to be on YouTube. So you can find this at cups of Joe underscore PT on YouTube. I don't have it in front of me. So hopefully I got that right. I'm 99 % sure I nailed that. And we are.

Joe LaVacca (00:52)
I think you did.

Joe Gambino (00:56)
Beyond pain podcast on Instagram as well. So feel free to follow along there as well and There it is for the intro Joe. Welcome back

Joe LaVacca (01:06)
Yeah, I think I hope people start watching these on YouTube because you know, I think our flair lately or your flair, especially, I mean, we were matching pink one time. Now, you know, you got the perfect shirt. I think that's never created. I am enough. You are more than enough, Joe. You know, I want you to always know that. Yeah, I think it's getting there. It's getting there. You for sure. The podcast is growing and.

Joe Gambino (01:14)
Who?

Thank you, thank you. This podcast is more than enough, right? Yeah.

Joe LaVacca (01:34)
you know, hopefully we'll continue to grow. But you know, for, for anyone who has the, you know, seen the Barbie movie, you know, that I am can offline or that the sweatshirt he's wearing at the end is still, I think one of my all time favorite scenes that still cracks me up to this day. So, and if you haven't seen the Barbie movie, go, go, go see it. It's, or, or I guess don't go see it now. Just go buy it and watch it over and over and over again.

Joe Gambino (01:46)
Yeah, it is. And this is, I mean...

Hehehehe.

I was pleasantly surprised with the movie. I wasn't really sure what to expect, but they did a good job. I enjoyed it, not gonna lie.

Joe LaVacca (02:05)
Yes. Yeah. So you were, were you that weekend? Did you go that weekend? Cause that was Barbenheimer weekend. That was when Barbie and Oppenheimer came out.

Joe Gambino (02:13)
I did not. I saw this well after the fact. Not well after the fact, but a few weeks after it was out. So I was not in with all the hype, but the hype did help get me to go see it, that's for sure.

Joe LaVacca (02:27)
Totally. I, I went with my dad and my brother -in -law to see Oppenheimer that weekend and my sister, my mom, Avery, my niece went to go see Barbie and they came out with these glowing smiles on their face. Like they couldn't be happier. And I came out shaking and I was like, I think we just had very different experiences. so once I saw Barbie, I kind of like kind of re -centered myself and I saw it with court and.

Joe Gambino (02:34)
Hmm.

Ha ha ha!

Hahaha.

Joe LaVacca (02:56)
And Addison and we all dressed in pink and it was a really nice family experience. So, yeah, but very different, very different experiences. So.

Joe Gambino (03:01)
Nice.

Sure, I've not I've yet to see Oppenheimer we've been planning on watching this is I'm one of the streaming channels now ever since I Think every time they're like the Emmys or the Oscars goes through they just take all of them and just stick them on like Netflix or something like that So so we try to get through them all but I think it's a relatively long movie and I think that was the hurdle why we haven't seen it yet Yeah, so

Joe LaVacca (03:17)
Yeah, exactly.

I think it's like three and a half hours, not as long as our podcast episodes. So I think right now you can probably squeeze in all. I think this is going to be episode nine and still have plenty of time to, you know, enjoy yourself, be halfway through the movie. So what are we talking about today, brother?

Joe Gambino (03:35)
Yeah.

Hahaha!

Today we're talking about plantar fasciitis and the foot and the ankle and all the fun stuff that goes around that. And I know that this is, you know, I mean, you have taught a foot and ankle class with court, top down, bottoms up, bottoms up, top down.

Joe LaVacca (03:49)
Mmm.

Yeah, it started out as top down bottom up. I would say I was more along for the ride and Courtney occasionally let me speak more than we were co teaching it. But that's okay. I mean, you know, obviously with Courtney specializing in the foot and ankle more people including myself were interested in hearing her takes on a lot of what was happening as far as even plantar fasciitis and ankle sprains and things like that. So so luckily,

I've been able to be in the same room with court while she talked a lot about this stuff. So I'll share some of my own experience as well as the things that I've learned from court here. And hopefully we can leave with some good keys and takeaways for both people who are struggling with this. And I would say struggling, having worked with many people with it, and as well as clinicians struggling. And I do say struggling trying to treat it, having treated many people with it as well.

Joe Gambino (04:55)
Wonderful and I'm gonna let you you know with that with you be in the guru of the room, you know, maybe not to courts level but you know by Association and listening to her and seeping all of her knowledge in right? Well, we'll put you as the guru of this group here so and Well, let's start here just kind of like maybe like a general overview of who is more susceptible to getting plantar fasciitis and if you have any stats on other

foot and ankle injuries, maybe something that's high up there as well. And then we can just kind of draw from there.

Joe LaVacca (05:30)
Yeah, absolutely. So it's very common and it's sort of along the same line of like, just if you have a spine, you're susceptible to low back pain. And if you have feet, you're probably going to be susceptible to plantar fasciitis at one point or another. So from the data that I have up to four to 7 % of the population gets plantar fasciitis.

Typically though, they seem to be a little bit more middle -aged. So we're maybe in the 40 to 60 category. And here's the funny thing that I found interesting was it kind of was a mix of sedentary people and active people. And when I think about, you know, plantar fasciitis, I always sort of assume people were doing too much after to, you know, little of a period of time, they ramped up activity, things like that. And that's sort of what overloaded the tissue, but...

Joe Gambino (06:21)
Mm -hmm.

Joe LaVacca (06:24)
It doesn't seem to be that way, at least from a lot of the data that I've read or been exposed to. Women do seem to get it more than men. And I think with the kind of growing literature, maybe around waste circumference and obesity being tied into a lot of things, there does seem to be this BMI factor. So with your experiences thus far, does that seem to be where your clients have been? Like kind of...

Little bit mixed matched all over but mostly middle -aged some sedentary some active

Joe Gambino (06:57)
Yeah, I would say probably on average, like that 35 to, you know, maybe 40 is a start, but like 35 to 50 is kind of where I see it happen quite often. Interesting. And I mean, this is just kind of where my brain is going. And it's, you know, I'm looking at like, okay, hey, you know, oftentimes, right. It's that it's when you increase volume of activity, right? We see overuse things happen. So plantar fasciitis pops up.

But people who are sedentary is kind of interesting, but I wonder if it's still a similar phenomenon, right? Because like it's under loaded tissue and then you still have to go through your day to day. So I wonder if like, I mean, in general, right? Plantar fasciitis would, I would assume it right to be some sort of like overuse in general. So even though they're not active, there's probably some of that, a little bit of that still going on. Where are your thoughts on that?

Joe LaVacca (07:49)
yeah, I mean, I think we could probably, when it comes to tissue that's living and adaptive, it's like, you can kind of make sense of it both ways. Like, well, we can see how weight could be a factor. We can see how overuse could be a factor, but then at the same time, it's like, well, people don't usually just gain weight very quickly. It happens gradually over periods of time. So wouldn't that be enough for the tissue to sort of adapt to those loads? And then, I mean, the same thing, I mean, maybe unless you were really hitting it hard, more so than you normally would. And.

Joe Gambino (08:05)
Mm -hmm.

Joe LaVacca (08:19)
and just going after and going after and going after it, which I mean, I know we talk about that a lot. I haven't seen too many clients come in to see me and be like, yeah, you know what? I really haven't moved off my couch in 15 years and then I decided to run a marathon on Saturday. Like, you know, so I know we joke about it, but I don't know if I've ever really seen someone like that. I'm sure they exist, but I just don't know if it's as common as we maybe give it credit for. Most people are on like some like very graded couch to 5K program. That's the most common thing I think I see when, when.

Joe Gambino (08:47)
Mm -hmm.

Joe LaVacca (08:48)
When runners come in with pain or people come in with pain, they go online, Hey, it's a couch to 5k. It was, I was on day 20, day 30, whatever. And then I started noticing some heel pain, but I think, you know, some other things within what Courtney would talk about or what clinicians have talked about, is there a nomenclature difference between fasciitis and fasciosis? And we can probably make that argument or distinction all over the body.

Right. Because fascia is this dense white connective tissue. I sort of liken it a lot to tendon and ligament, right. In terms of like the same collagen, you know, fibrous makeup. So is it when people are initially maybe feeling some pain for a couple of days, like it's that's the fasciitis, right. And then they ignore it. They don't really change their activity. They don't, you know, seek a healthcare provider, but because it went away, right. Why would I, and is that enough?

of an inflammatory cascade then with continued loading to maybe wear down the tissue itself. So it's hard to know like where to intervene here, but then once people have been suffering with it for a long time, and this is going to bring me to my next point. Some of the data I've read is that it goes on from like at least one month to 60 months in some of these case studies and things that I've read.

And it seems to be like there's a cutoff maybe around that six or seven month period where if you're having pain for that long, maybe now you're trending towards a little bit more of a worse prognosis. So how do you kind of prepare people for that? Or do you see the symptoms lasting that long for your clients that you work with?

Joe Gambino (10:33)
I have definitely seen...

this last and linger around for seven months, a year, a little bit longer than that. And usually in the beginning, and what I've at least, and this is definitely not research driven, and this is just kind of like what I've seen, is that people who are going to recover probably in those earlier months, they're going to have changes that happen very quickly on in our rehab process. So like in session one, we're gonna see like, the pain comes down, the mobility improves.

things seem like they're going to trend very well. And the people who take seven plus months, a year plus to kind of recover, they are like the, this almost like stubborn responders in a sense where you do all the things from a mobility perspective, you do all the things that you would have done with somebody else and it takes much longer for changes to start to settle and even just like a serious reduction in pain for that person. So that's probably where I kind of see, you know, like.

Ice, you know, like when you see those trends like that then the education can be changed for the person in front of you where someone's responding immediately Very easy to tell them. Hey, this is this is great way Like if you're seeing changes like this in the first few sessions, you know The prognosis is going to be much easier and then if you're having somebody who's taking a few months to really start to get the ball rolling for things that start to feel better

then you can have those conversations with them and say like, hey, this is the expectations. We're not really seeing the mobility changes that happen. There's something kind of going on here that's making you a slower responder. So we need to expect that this is going to take months to happen. And I think once you set those expectations, maybe there's some, they have a certain way they feel about it when they hear it, but those expectations definitely help with the outcomes, I think, because they know what to expect and they know it's gonna be a little bit more up and down. It's going to take them a little longer to get there. So that's kind of my.

feeling on it because it's definitely, I haven't read any research specifically about that.

Joe LaVacca (12:28)
Yeah. Well, I think that, you know, comparing what you just said to some of the points that we've made when teaching or have read about that, what seems to put more people at risk aside from maybe BMI or waist circumference, which might arise maybe more of these questions of metabolic sort of issues or metabolic inflammation, sort of like contributing to pain, but it is the catastrophization. So it is reporting these like.

constantly higher pain levels. It is probably more avoiding things that hurt. It is resting it. It is just relying on ice or tape or maybe more passive things. So for your point of, hey, well, if we do an intervention, it doesn't matter what, it could be isometrics, it could be manual therapy, it could be some loading strategies. And then for people to sort of see, okay, well, I can shift my state here a little bit.

Maybe that's what helps decrease catastrophization. Whereas when people maybe come and see us for this condition and probably all conditions, and Joe does something or I'm trying to do something or X, Y, or Z. And now I didn't have the relief I was hoping for. And then maybe that trickles down into the thought of, well, this must be worse than I thought. Right. And maybe that opens up that line of questioning or perception for the client to be, well, now I probably should, I should go back to the.

Maybe I need to go to another doctor. Maybe I need to explore cortisone and things like that. So I think that that's kind of valid from what you've been gathering and your clinical experience. But then one other thing too, when we have those people who respond and don't respond, I think it kind of can put us into maybe a bucket of differential diagnosis, right? Right, you're right.

Joe Gambino (14:17)
I was just going to bring that up.

Joe LaVacca (14:20)
So I mean, from the biggest thing I think I'd run a rule out as a clinician would be any sort of like fracture to the heel, right? Or some sort of like stress fracture to the foot. And that's where I think maybe your mechanism comes in. Do they have a fall? You know, all right, were they one of those people who said, hey, on Friday, I feel like I haven't done a lot. So Saturday, I'm going to go run a marathon. You know, maybe that's the case. But typically what I would say to people and, you know,

Joe Gambino (14:29)
Mm -hmm.

Mm -hmm.

Joe LaVacca (14:47)
wonder what you were thinking to a differential diagnosis stuff is if there's a fat pad irritation, because I think everyone just points at the heel or points at something in their body and they just label the most commonly referenced structure like, Hey, that's what hurts. So it has to be this. But if you have, you have a big old beautiful fat pad down there at the bottom of your heel and that fat pads pretty highly innervated. And if you're continuing to walk and you're loading it and that's getting worse, well, maybe that's where I'm thinking this is a fat pad issue, not a.

Joe Gambino (14:54)
Mm -hmm.

Joe LaVacca (15:17)
fascia issue because for fascia and tendon, typically the more you load it, the better it is, right? And then that's where that first step in the morning pain comes in. You haven't been doing anything. And then I kind of get moving around a little bit and then it feels better. And then I sit and then I get up again and then it hurts again. So has that been like a pretty classic presentation for you? I mean, that's always what people talk about the most, right? The morning pain and then this like back and forth between the day.

Joe Gambino (15:26)
Mm -hmm.

Yeah, exactly. And that's what I was going to bring up is that I think anytime somebody has pain on the bottom of their foot, it doesn't matter if they see a doctor or not, the diagnosis is plantar fasciitis, right? It's like, this is just what it is, right? Like any, any pain on the bottom of the foot is this, right? And I think you nailed, you nailed it with, you know, like the, the fat pad irritation is one of the other more common things that I've seen where,

Joe LaVacca (16:00)
Yep.

Joe Gambino (16:14)
Again, right, it's like, you know, those things don't really respond as well to load, right? So like there's a little bit of a differentiation there. And on your point with like the stress fractures, I've actually seen like very odd cases of stress fractures where there's like no real mechanism that would have really tied to it, but they actually came up on X on imaging. So if things are stubborn in a sense, it's.

And like they are, you know, they were, it was a runner, right? So there was repetitive strain that happened, but there was nothing abnormal that happened there. It just might be worthy if something is kind of lingering around, like to just go get, just rule it out. You know, if things aren't making sense from a clinical perspective. And then that last one you have in here is nerve. And I think that's another one that kind of pops up because you can get referral pain down to the foot in different ways. And those things, and you know,

I think the most common place that we see that is like at the elbow, right? Where there's so many different nerve pathways that can get irritated that can cause elbow pain. And then it's the same thing, right? It's like, it's on the outside of my elbow. So that's like lateral apocondylitis and it's on the inside, right? So it has to be medial. And it's kind of the same thing in and around the foot that I found is where, you you can have areas where nerves get entrapped and cause referral pain. And now all of a you think it's plantar fasciitis. And if you just do the things that are going to mobilize those tissues, you're just not going to see the effects. So.

Joe LaVacca (17:11)
Yeah.

Joe Gambino (17:37)
I think being able to have someone that can help you differentiate between those structures will become important because I'm not as very like heavy on like the diagnosis really makes a difference in how we're coming about like the rehab program. But little things like this, right? Would make a huge difference because if you missed a fat pad versus a plantar fasciitis and you catch those symptoms, well, then you can be doing things that would help, you know, that would have helped plantar fasciitis, but would make a fat pad irritation worse, right? And then now you don't know what to do. So I can, I can see those pathways there.

Joe LaVacca (18:09)
Yeah, and I think that's where I think, you know, for people going through this process or trying to treat this process, the notion, I think, again, across social media, physical therapy, the new age of like, no, we load and we push and, you we don't tell you not to stop anything and, you know, rah rah. Sometimes you just got to fucking stop, right? You got to unload stuff and.

You have to be able to identify when that is that stress fracture, right? Like you said, you've had some weird cases. And if you're thinking of, this is a plant or fascia issue, but it is that stress fracture. It is a fat pad. Well, then yeah, you're going to piss off a lot more people than you're going to end up helping. And this is where like, yeah, rest is okay. And I, and I think that you made that point, even learning the experiences about your back, right? When we talked to you, back in episode five.

And you know, you, what you said stuck out to me. It's like, Hey, when I have a flare, I used to roll it and poke it and things like that. And that's what I was sharing in my episode, but you realize that that wasn't good for me. I just had to give it a day. You know, I had to rest for two, three days. I had to modify my weight training experience. I had to go on more, you know, whatever it was walks or call your buddies and say, Hey, I can't go golfing this weekend, but I can go mini golfing. Right. Like we can still do that together.

Right. And then those are sort of like some modifications, but I think that that's really important. do you see that too? I mean, that's the message or the feeling I get from social media is that we were kind of falling into this gap of always push people, always load people, never rest. And, you know, gotten away from the whole idea of, I think maybe because we're just worried about inactivity and sedentary behavior that maybe we swung this pendulum a little bit too far.

Joe Gambino (19:53)
Mm -hmm.

That's exactly the word I was going to use. It's, it's a industry overreaction to new information that comes out. Right. Cause we learned that rest isn't the best medicine. Right. But that's taken out to this extreme other, you know, the complete other side of things. And I think there's also like with the PT industry being an underloading.

process in the past where people have lost faith in the PT system because it's like clamshells and work on the table, right? Like now we're all overcompensating for that. And it's like, okay, well now we just need to load, we need to load, we need to load. And I mean, I fall into that pattern, you know? I mean, I much prefer to load and I try not to take away activity from somebody because usually it's meaningful to that person. And I let that initial...

few weeks of working with someone make the decisions for me. So I mean, I don't know how many times on this podcast we've talked about pain guidelines, but those things dictate everything. If someone asked me, can I do this? I'm like, yes, you can go do it and tell me how it feels. And then we make a decision from there. And you just need to respect pain. And I actually had somebody I was working with remotely shoulder issue, not a foot issue, but I think to this point it will, it correlates here, right?

You know pressing motions are the things that irritate him. We've been working on shoulder mobility all that stuff has been getting better but he's been noticing pain kind of creeping up a little bit and We went on a call. We went through all the different movements. We were kind of testing things. He was painful was not painful and Really what he was doing is because he had the ability to move into the ranges. It was just blow through pain

It's like, well, you know, the pain guideline says it's a two, right? So I can kind of crank through it when we're working internal rotation. And, you know, I can keep going through pushups and, you know, like whatever, as long as they're kind of falling in this, but we're seeing pain increase, right? So I'm like, okay, let's dive into this. So our conversation was around, let's respect the pain. We can still do these movements because when we tested it, but respected the pain boundary, his pain levels actually came down and it freed up motion in like these painful ranges that we had.

Joe LaVacca (21:44)
Yeah.

Joe Gambino (22:09)
So now we're like, okay, well, we're not gonna stop doing the things that we're doing. We're just going to respect these pain boundaries a little bit more. And I think just that little change there is going to be the difference that's gonna make it where like pain was getting a little bit worse over our first month together to things starting to get better over the next, this next month. And we have tests. So like now we know like extension and reaching across his body are the most painful movements. If you do X, Y or Z and those movements shorten up on you.

No bueno, right? Like go back to the exercise we know make you feel good. Let's open it up. Let's create like a positive environment and get you back on track. If you do something in a freeze up more space, then those are the things we want to do more of for right now. And this way we can just bring down that pain response so we can actually train these positions and load it and do the things that we want to do to build up that shoulder. So that's how I think we need to view the activities, right? Like we want to keep them in, but we'd still need to respect pain. We need to respect the boundaries of your body. And if you're not seeing,

the pain level trend in the right directions, you need to make the changes and you can't just say do it because you like it, because it's not the best thing for that person and they're not going to be able to enjoy the things that they want. Like he wants to be able to do pushups at will and bench and do all those things, but he can't do it. And I'm gonna do pushups off like pins, right? Like elevated pushups. And he's like, yeah, there are a piece like a four, it's not that fun, but we're trying to load that pattern to some degree. So, you know, that's what we're dealing with. So in order for me to get him back there, we have to strip it back.

Right, so he can get out of pain so then we can bring these things back in for him so we can actually enjoy him. So you have to have that balance.

Joe LaVacca (23:42)
All right. All right. And I know we talk about pain guidelines a lot, but I think the important message for clinicians and patients that I, that I hope they always hear is that you don't need to rewrite your system for every new thing that comes across your pathway, right? Have your framework, have your fundamentals and let those things guide you across the board. And I think you'll be a lot more successful, when it comes to rehab, if you approach it like that.

Right? Like have your system, go through your system, go through your thought process, write it out. And then that doesn't matter if you're really kind of then chasing a foot pain or shoulder pain or back pain, as long as you know how to classify it, rule out the serious things. Right. And maybe that's another good takeaway from your point and what we were saying before. Hey, if you never thought about the idea of a stress fracture or fat pad, well, go on chat GPT. How do I rule out stress fractures in the heel? Right. Like.

This is the, we have such amazing tools now as clinicians and chat TV team. I give you two or three tests. Cool. Take it. Right. How do I rule out some fat pet issues with clients or maybe it's worse, just pain with worse loading. Hmm. That doesn't seem like facial tissue. Right. So just having like a couple of quick checks and measures within your system, I think will help you. And I think the other thing too, within your story with your client is, you know, something that really checks a lot of my biases with this stuff is what's the lived experiences of these people.

Are we really helping them set expectations? And I like what Tyler said when we interviewed Tyler, Hey, this process is going to be painful as we work through it. You know, I'm being upfront about that. Like I do think you're going to come out better on the other side in eight weeks or 12 weeks or 16 weeks, if you're consistent and you follow the advice and we work together, but there that's not going to be a linear pain -free pathway where every day is going to build and compound. I think the other thing too, is important to understand beliefs.

A lot of clients, when I think they have pain or a fasciitis or tendonitis, they immediately think I'm at risk for tearing this. And I just think that that's not the case. There's nothing that I've seen so far that leads me to believe that, okay, if you developed a plantar fasciitis, you're going to be at a higher risk of tearing the next day within the next week or throughout the course of rehab. So maybe that's why people are kind of hesitant to load because of the idea of worsening the issue, right?

But by not loading it, you're kind of making it worse because we're not getting that cellular turnover, the healing process, and so on and so forth. So I think we need to give that better education. And then when we think about these metabolic issues or the weight circumferential issues, BMI issues with maybe a growing number of diagnoses, but even with foot pain, if we're going to tell somebody to be active or lose weight, how?

You know, and this is where maybe, you know, working with a nutritionist is very helpful or a dietitian is very helpful. Maybe this is where, you know, we're looking at just maybe just giving general advice. Can you cut back on like two or 300 calories a day? Like where are you snacking? Can we fill that space with a glass of water? Can we fill that space with listening to music? Can we fill that space with reading a book? Like just distract yourself, right? And then lastly, if we are going to, you know, sort of.

help them understand what's happening. I think we kind of got to go beyond the foot just a little bit, right? And then how can you stay engaged in your environment? If you can't walk within your environment, how can you load yourself in a squad of deadlift or a sled or this and that if your foot hurts? So you can train upper body, right? There's no restrictions there. So can we put people on a row machine? Can we put people on a skier? Can that be their cardiovascular conditioning? Can they be on an arm bike? Right?

These are easy things and I love that there's a Planet Fitness for this, right? Or is it a 24 -7 fitness for this? Because those memberships are so cheap, right? Like 10 bucks, 20 bucks, whatever a month. And I'm like, hey, this is a perfect time. Go in there and use that horn bike, right? Walk in there for 10 bucks a month. You can get your cardiovascular work in. Just get your heart rate going. And then just kind of feel like you're still moving forward, right? So what do you think about that? I mean, is it...

Do you have a dietician, a nurse, a nutritionist on your team? I know a couple of coaches who do it. So I always will just kind of recommend clients reach out to those people, but how would we handle something like that? Or how have you handled something like that?

Joe Gambino (28:15)
Yeah, so I don't have anyone on my team specifically. My background does have a good amount of nutrition in it. So I do use some habit change stuff to help people get on the right track. But if it's something significant or really needed and it's not outside of my wheelhouse, I know, you know, fitness coaches that do highly specialized nutrition is just refer out for me. But I do want to say one thing based on what you were saying. You know, you talked a lot about like clinicians, like understanding like differential diagnosis and

you know, using CHADPT, but for people who aren't clinicians, I think the one big takeaway for them is don't be scared about pain because pain, it comes and goes like a little flare up here once in a while is not going to change things for you. But you need to realize that you like, you need to test movement to figure out where you have success and where you don't have success. So this way you can live in those places where you have success for movement. So you can still train to some degree, you can.

Interact with your environment. You can find some sort of meaning and movement And then you realize where those barriers are so now you can start to do the things that you can now and just work on the ability to Feel better, but I just want to mention that real quick and I want to shift gears here because we don't have a you know kind of like a you know already getting close to that 30 -minute mark So I want you know, we talk a lot on this podcast about like pain concepts, right? I mean we are chronic pain Podcast right, but I want to talk just a little bit about

you know, if we're looking at the body from a movement perspective here, because we can't just like ignore movement, right? And like how mobility is and things that we can see from a movement perspective. What are things that you look for when you're assessing somebody from a movement perspective? And what are some common themes that you've seen where like, you know, like these are the things that nine times out of 10, we're working on these specific qualities.

Joe LaVacca (29:48)
Sure.

Yeah, I think it's a great question. And I think for most people I see with this condition, it's happening when they're like walking or running. Right. so I want to start to look at their gate first or they're walking first from a sort of basic fundamental range of motion standpoint, my table tests or, you know, my sort of like pre dynamic tests to get like, before I bring them out into the clinic and watch them walk and do a couple of different things is going to be, I want to check their big toe extension. Right.

Their big toe extension is going to help them become a little bit more efficient through that gait cycle. It'll help that foot kind of rocker in and out of pronation and supination a bit more effectively. Then the next thing I want to look at is, is the mid foot adapting, right? So can that foot flatten and can the foot form a decent arch? Now there is no sort of, I think more predisposition again to the things I've seen or read where if you're flat footed,

you get more plantar fasciitis versus if you're supinated, you get more plantar fasciitis. So I think again, it kind of is down the middle. I would say maybe there's more of a tendency just based on where the structures are getting loaded for me to see more flat -footed people with plantar fasciitis. But then I think at the same time, if they're a little bit more supinated or rigid, maybe that's where they have more of an irritable like heel spur or bone spur, maybe causing some of their pain too. So.

I think there's a little context there, a little nuance, and maybe we can extend this out to like a part two or something to dive into those things a little bit more. And then as we kind of keep going up the chain, then it just becomes, all right, well, most, most people, I'm going to be honest, I think have 10 degrees of dorsiflexion that's necessary for the gait cycle. So I'm not seeing too many people like stuck without dorsiflexion. So I think maybe we're, again, that's another one of those clinical overreactions where we just have to get more dorsiflexion. And I'm like,

I'm not seeing too many people with a functional imitation in dorsiflexion. And then tibial internal -external rotation is important. And then I think hip extension is important. But then that hip extension piece typically would tie into toe extension. So if you're seeing probably a deficit in one, you're probably going to notice a deficit in the other. And then I'm going to start there. And then see if we can open up these spaces for joints to move or for people to have a little bit more variability. And then maybe I'll just have them go test and walk.

I think a lot of the movements that we try to observe like running and walking, there's just too many things happening too fast. And I know that you're virtual for the most part. So it's probably even less likely for you to get an accurate readout on someone unless they're sending you videos ahead of time on a walking deficit or a running deficit. Cause how would we be able to do that in the comfort of someone's own home or living room, right? So I find that just breaking it down fundamentally, working on those things first.

that may lead to a redistribution of forces that may lead to us changing some behavior a little bit more. And then that's going to go kind of test and retest for me. But is there some specific things that I may be missed that that you look for, especially again, being mostly virtual?

Joe Gambino (33:21)
Yeah, I don't really think you miss anything. I mean, it's, you know, I look at the foot and ankle, make sure that, you know, it does things that it needs to do from a mobility and a function standpoint. Look at the things around it. And then maybe the only thing that you miss is like, you know, figuring out where they currently are and what they can tolerate. And then how do you start to progressively load those things? Right. Cause everyone has a specific starting point. So maybe they can.

Maybe they have pain while walking, maybe they don't have pain while walking, maybe it requires more stress, maybe it's just when they've been sitting for long periods of time, right? So what can we start to do to figure out where their starting point is and start to build up tissue quality and capacity so that this way they can get the tissue healing that they need and kind of get out of pain and resume some of the things that they want. But otherwise, I think you did a good job. I don't think I would really look at anything specifically different than you would as far as those things go.

Joe LaVacca (34:13)
Cool. Well then why don't we have a part two dive into a little bit more of what you just said. Maybe some treatment considerations, ways we would maybe bring people more through like greater exposure and assessing capacity. What do think about that?

Joe Gambino (34:28)
Yeah, I love that. And then maybe we can even talk more on general just like how do we keep feeding ankle generally healthy? Even if you don't have any issues, so this way you can just you know, if you're a runner or whatever, you know, you'd like to walk the golf course like you want to have good healthy feet like these are the things you can work on to make sure they stay good. I love it. All right. Well, let's.

Joe LaVacca (34:47)
All right, sounds good. Let's do it. Part two coming at you.

Joe Gambino (34:51)
Let's take it home then, Joey boy. I appreciate everyone for listening. The next episode will be a little continuation of this conversation. And Joe, I love you. Listeners, I love you. And if you have made it this far in the podcast and are hearing these words, extra love for you.

Joe LaVacca (35:00)
I love you.