Episode 10: What the Foot...Plantar Fasciitis Part 2

DM Us! We love chatting with our audience, please feel free to do so on Instagram and say what's up!

• Joe Gambino
• Joe LaVacca

Want to work with us? Apply here!

Watch on YouTube here.

Summary
In this episode, Joe Gambino and Joe LaVacca discuss various topics related to foot health, strength, and pain management. They cover the importance of assessing foot and ankle mobility, the significance of strength and endurance in the lower extremities, and the challenges of managing chronic pain. They also emphasize the need for individualized assessments and treatment plans, as well as the consideration of load management and progression in addressing foot and ankle issues.

Takeaways
Assessing foot and ankle mobility is crucial for understanding lower extremity function and addressing foot health issues.

Strength and endurance play a significant role in lower extremity health, and individualized assessments are essential for creating effective treatment plans.

Chronic pain management requires a multifaceted approach, considering factors beyond tissue-based issues and exploring options for pain relief and functional improvement.

Load management and progression are key components of addressing foot and ankle issues, and individualized treatment plans should be tailored to each person's unique needs and goals.

Transcript

Joe Gambino (00:01)
Welcome back into the Beyond Pain podcast. I am one of your co -hosts, Joe Gambino, and I'm here with your other co -host, Joe LaVacca looking stunning as always, very swag with the backwards hat.

Joe LaVacca (00:14)
Because I just worked out, I was trying to keep it real for anybody watching on YouTube. I didn't want to show up all, you know.

Joe Gambino (00:19)
I see you are looking a little swole just you know, I might only see the traps up but very nice

Joe LaVacca (00:25)
It's all you need to see, baby. It's all you need to see.

Joe Gambino (00:27)
Our IG handles please DM us you can DM us the word podcast and we'd be more than happy to open a conversation and talk about whatever you want My handle excuse me at Joe Gambino DPT LaVakas is at strength in motion underscore PT and you can always just generally reach out to us and check out the podcast dedicated to the show at Beyond Beyond pain podcast on Instagram

There is an application form and all the links in the show notes so you can go down there if you want to work with us. Fill out that application, reach out to us. Our links are there for Instagram. Make it nice and easy for you to reach out. And we're also on YouTube. You can watch the show there. cupsofjoe .pt. I think we're now up to seven subscribers, Joe. So we're moving on up in the world. And yes, yes. And most people are still consuming through Apple Podcasts after I was looking at them.

Joe LaVacca (01:16)
Boom, boom, double digits soon, I'm feeling it.

Joe Gambino (01:26)
the data, but please on that note, if you are listening and enjoying the show, please drop us a review. It doesn't matter where you do so. It'll be very, very beneficial to just continue to help the podcast get out in front of more listeners, especially if you're finding it beneficial to just kind of almost pass the baton. So to speak, Joe, as we were talking to help somebody out here in the future. And I want to start here, Joe, because there's a couple of changes from my perspective.

Joe LaVacca (01:45)
Here we go.

Joe Gambino (01:56)
on coffee and since somehow we do and I bring it up all the time. Somehow we have a coffee theme on this podcast. Well, maybe, I don't know if you have updates on how you take your coffee or how you're consuming your coffee. Why don't we just say, why don't you throw an update in life in general, something you've learned or something like that and then.

Joe LaVacca (01:58)
Yeah!

No.

Update on life, let's see. I'm out in Colorado. We're heading off to a wedding, not myself or Courtney's wedding, but one of her coworkers. So I'm looking forward to that. That's gonna be up in Steamboat Springs if you've ever been to Colorado. So I'm excited to get back up there. It's kind of beautiful, lots of good hikes, lots of nice open water areas and lakes. I guess the hot springs,

Joe Gambino (02:19)
in the next part.

Joe LaVacca (02:47)
I'm so, so interested about hot springs and how they actually exist and how they're like, just so freaking awesome, where you're just like in the middle of the wilderness and you're in like a hot tub, like just nature's hot tub. I think that's still like one of the coolest things to me. Let's see, what did I learn this week? I've been learning the whole, I mean, I read so much. I think, I got one. I'm reading this book, Super Communicators Now.

Joe Gambino (02:54)
Hahaha.

Joe LaVacca (03:17)
And I really liked this idea of speaking to people using the same language. And usually when you're breaking down in communication, it's just because you're speaking different languages. So in one of the first few chapters of the book, Charles Duhigg, who's one of my favorite authors, talked about knowing when people need to be heard, hugged, or helped. And when they need to be heard,

They just are sort of seeking connection or maybe relationship, you know, trying to find their identity. When they need to be helped, they're trying to figure out a problem and they need your expertise on that problem. And when they need to be hugged, might just be emotional ideas or concepts. And if you're not equipped to handle those, then don't just keep your mouth shut and keep listening or as Joe put it, pass the baton to someone else. So I've really just even been taking that into,

conversations with clients this week, right? And trying to figure out do they need to be hugged, helped or heard. And I feel like it's been a nice blend, but even just me pausing on that has made my sessions go a little bit easier. But I don't have any update on coffee. So I'm really excited to hear what's happening for you and what this big transition is. I'm almost worried because then I'm going to have to do something like big and meaningful.

Joe Gambino (04:39)
I wouldn't say it's a huge transition, but I have, you know, I've always been a cappuccino guy or an ice coffee guy. And I don't know what made me decide to do an ice latte, but I've actually been quite enjoying them. So now I'm, I'm leaning in that, but more importantly, after hearing Tyler and Stella talk about these espresso machines in their homes, I ended up, I ended up getting one, but.

Joe LaVacca (05:04)
no, you didn't.

Joe Gambino (05:07)
I don't, I don't know how or, I mean, it is, I felt, you know, like Stella was like, look, he was a gifted one, right? Like that's, that would be, that would be fantastic. Yes. but I found one on, well, Jen sent me a message, like a Facebook marketplace one. And it's literally like the person had it for like three months and decided to sell it. And it's like, it's sold it for 600 bucks. And I was like, no, I didn't really want to get one at this point, but I was like, I have to kind of get.

Joe LaVacca (05:07)
Wow.

Yes, very nice one at that.

Joe Gambino (05:37)
get it at this point because it's so cheap. So now it's sitting in our kitchen and I am dying to get to use it. I need to go get some espresso beans now and I need to finish cleaning it out. So that was exciting. That was a very exciting find.

Joe LaVacca (05:39)
percent.

I'm excited for you that that might have even accelerated. That might have accelerated my trip out to North Carolina where we got to do a couple of live. I got a couple of live sessions going, but I the best espresso martinis, which I don't know if you're you in general espresso martini lovers. All require fresh espresso and that is to me the secret ingredient. I don't care what vodka you're using.

Joe Gambino (05:56)
Yeah, I was just gonna say, get over here.

Joe LaVacca (06:16)
I don't care what Kahlua or like how much Kahlua you put in. I don't care if you use Bailey's or not, whatever. But the secret is fresh espresso. And because I have not taken the leap, I don't make great espresso martinis for myself or others, but it is what it is. So now I'm excited to come to North Carolina, not only have fresh espresso in the morning with the Gambino family, but to also then partake.

Joe Gambino (06:26)
There you go.

So now you're gonna come down, you're gonna make us espresso martinis. You and I will enjoy them, Jen will unfortunately not be able to enjoy them at this point.

Joe LaVacca (06:46)
Yeah.

Yeah. that's right. That's right. I keep forgetting.

Joe Gambino (06:57)
Yes, you know, but you know, after baby two's here, then, then we'll be able to show, be able to enjoy one. Maybe, you know, you teach me your secret and then I'll make them for her unless you come down again. But you got to come down in the summer while it's nice. All right, my friend. I was going to say something else. I was going to talk about a book, but I want to, I want to get, you know, we're already, seven minutes since this podcast. I'll bring it up next time. I'm actually reading a finance book.

Joe LaVacca (07:06)
There we go. All right, perfect. Done, donezo.

Joe Gambino (07:21)
And we'll talk about it a little bit maybe next time because that is actually interesting. He actually brings up a whole lot of fitness and correlations, which I think is interesting. And I do feel like there are carryovers between the two worlds, right? As far as like making decisions and sticking to a plan and even the idea of like compound interest in how we make tissue adaptations, right? I see these parallels here. So maybe we'll talk a little about that a little bit next time.

Joe LaVacca (07:22)
Nice.

Joe Gambino (07:49)
But today we're talking, we're kind of building off our last conversation on plantar fasciitis and just kind of talking more about building a strong, resilient foot. So I'll let you kind of start off here and let's just talk everything in generalities. I mean, we obviously know that you can't give somebody advice if you don't assess them. You don't know what's kind of going on because you can try something, right? And there's almost a 50 -50 chance, right? So it can help them where it's going to make them worse or maybe we call it 33%, because then...

Also something could just not happen right now, a change has happened, has no benefit. So just in general, when you're thinking your thought process on how you look at the foot, the ankle, and maybe even the whole chain, how it all relates, what kind of general concepts do you kind of fall into or look for when you're assessing somebody?

Joe LaVacca (08:41)
Yeah, I think I'm not sure how much I dove into this in the previous podcast episode. But I think for me, it really all comes down to initially starting the process with can people make shapes? I want to see your foot be able to make an arch. I want to see it be able to flatten. I want to see your toe be able to extend and flex. I think both motions are important because it's a joint. And we know that healthy joints are maintained by

maintaining full range of motion. So to me, the big toe and the little toes, that means flexion and extension, not just extension, right? I wouldn't just move my knee or my elbow or one joint in one particular direction and to sort of quote unquote, keep it healthy. So I don't think that the toes fall into that premise either. Then, you know, kind of then moving up the chain, I'll probably just keep it fairly simple into the big toe shapes and the little toe shapes. Can that foot...

make an arch and kind of collapse from that arch position or for pronation supination. And then I'm going to probably just head on up towards the tibia and just sort of see what shapes the tibia is making. So can that tibia actually come over into dorsiflexion? Can it do so separate from the foot? So I do want to be able to see the foot still make shapes while the tibia is moving. I don't want them to do, like, necessarily be stuck all together.

And then I'd probably say the only other one that I'll look at is like that tibial rotation, which to me is kind of correlated. I mean, not maybe causative, but correlated definitely to the amount of pronation and supination people have at the foot. So when I'm seeing a loss of one of those motions and typically internal rotation or when the lower leg goes in, that's going to be coupled with the foot, you know, flattening. And when the external rotation of the tibia, the lower leg kind of rolling out, that's going to be more associated with our supination or locking of the foot.

So I do kind of just like to just generally assess those things. When it comes to the whole chain, I think that's where it gets a little bit more, in my opinion, speculative, where we're trying to jump around and make all these different connections. And I think I referenced this before, but I think it was Diego Hidalgo and, my God, Stuart Oliver.

I have to go double check now. I'll double check that when you're chatting. But they had a great article that came out a few months ago called Anatomical Possibilism, and where a lot of our professions are kind of creating these false narratives just because, quote unquote, fascia connects everything in the body, and you can make all these highway systems and things like that. And yeah, I think it could be a fun way to treat, but I think for me,

I always want to look at fundamentals first. And that's probably a big U -turn from clinical practice where I started trying to get good at the fundamentals, then I ran away from them. And then I ran so far away, you know, I'm thinking about like people's scapular position with their plantar fasciitis just because, hey, look, you know, your posture's off. And then realizing that after a few years, coming back to the basics was always going to serve me the best anyway. So...

I would say that's kind of like my simple assessment on top of ruling out maybe some of those ideas of like stress fracture, you know, bony injury, fat head injury. And I think we covered that in the last episode. So I'd say that's really the simplest part of it. But I mean, what about you? Where are you going with that? Will you go up the chain with your virtual sessions? Will you look at like a lot of these full body movements?

Joe Gambino (12:28)
Well, in general, when I work with somebody, because I'm not married to being in insurance, right, in their work environment, I look at everything holistically regardless. So I'm coming in with foot issues and we're moving into strength training plus all the stuff that they need to kind of bring themselves out of pain. I look at everything, look at general patterns and see how things go, right? Because, you know.

But if we are working on foot and ankle issues, and most people also have other areas that bother them at the same time. And then if we're also talking about getting back into exercise, we want to make sure that everything's kind of moving well, right? I don't want to be caught by surprise, so to speak, as we're kind of like, I've thrown overhead pressing here. But then we find out that they're missing shoulder flexion and they have shoulder issues, right? I don't want stuff like that to pop up. So I do look at everything holistically, but if I'm kind of diving deep into an area, I mean, I completely agree with you, right? It's like, how well can, you know, do they have, you know,

foot intrinsic muscle strength, right? We're sort of talking about being able to pronate and supinate and move the toes, you know, with full range of motion, being able to abduct the toe. I think that's kind of like a big one that many people overlook, right? We're just talking about flexion and extension, right? But the ability to kind of get that big toe to come out is another one. Dorsiflexion, plantar flexion. I mean, I think everyone overlooks plantar flexion mobility in general, but like, does the foot actually have the ability to move in all the directions that we want?

We do it for every other body part in the shoulder, except for the foot and except for the spine, I feel like those are like the two exceptions for most people. Like they're not actual joints that have actual muscles attached to them. Like, so they should be treated differently. So yeah, I agree. You know, I'll look around, I'll look at tibial rotation. I think that that's an important component because I mean, the tibia and the foot, they are highly blended together, right? You can't have one without the other in a sense for that, for the ankle joint to work.

Joe LaVacca (13:57)
Yeah, that's a good point.

Joe Gambino (14:20)
So I think you nailed it there. And then I think the other thing is just making sure that everything's kind of strong around the like, can you actually do heel raises without compensation and through full range of motion? Can you do a bunch of them? Right. And like, what does, I mean, I do look at gait, but I don't necessarily find it overly valuable. I feel like people's gaits kind of correct themselves when they, when you just improve range of motion in general and movement quality that I feel like harping on.

those kind of movement patterns just kind of almost facilitate a little bit more of like something's always wrong when you step how many times throughout the day you're constantly walking. So little things like that. So I wouldn't say we're very different on the front. And then it's just like, how do you start to load that and make sure that you have as much active control as possible. And I would say those in general terms is kind of what I look at as well.

Joe LaVacca (15:11)
Yeah, I want to come back to a few things you said, but I do want to correct myself on something I said before. So that article about anatomical possible -ism by Diego Hidalgo and Oliver Thompson. Oliver Thompson. And Oliver Thompson is also a great follow on social media. And if you guys haven't heard his podcast, the Words Matter podcast, it's definitely worth a listen to. He hasn't posted something in a long time, but I've been politely messaging him to bring it back. So hopefully we'll see him there. But I do want to...

come back to this idea that you mentioned with strength. And I think the big thing that clients will come in with all body parts, regardless if it's their back and their foot and their this, but they have this desire or goal to get stronger. And I've been very intrigued by some of the ongoing conversations around strength as it pertains to the shoulder. And I've even seen a couple of things recently as it pertains to even knee osteoarthritis.

And what these kind of studies or conversations are pointing us to is that strength is a very small factor in kind of mediating a lot of these outcomes with pain to the extent where it was maybe less than like 5%. So people will come in and they want to get stronger at any body part. And, you know, I know I'm referencing some shoulder and knee, but then whenever I hear those trends start to emerge,

my thought becomes, why would that be different at any other body part? Because it is so hard to really, I think, assess strength in a given clinic. It's really hard to do it virtually. So I know I'm always trying to come up with clever ways or ideas to measure capacity. And you brought up the heel raise test. So when you're doing the heel raise test with people, do you have a specific number in mind, Mr. Gambino?

where you like to see people go.

Joe Gambino (17:09)
I do, and I know that there are definitely limitations with it, but, you know, I use the age old, you know, 20 single leg heel raises with, you know, without, being, without seeing compensation. And really what I look for, right. Is like, do they have the ability to actually, you know, especially on those first few, right. Can they get forward range of motion through, through plantar flexion? Cause it's, I see often, people who really struggle with foot and ankle issues that they can't like, you know, their heel raises like a quarter.

of the range of motion that you would expect, right? Or half the range of motion that you would expect. So like, how can you start to drive some of those normal things? And I like to see some sort of endurance that tends to happen with that, whether or not how much that actually correlates to some of these higher level tasks. But then when I'm looking at like return to activity, right? I just tend to use the activities as the barometers for success, right? So like, if we're talking about running or we're talking about like walking the golf course, right? Like,

Joe LaVacca (17:41)
Yeah.

Joe Gambino (18:06)
Well, what happens if we start to do that in these small doses, right? Does pain pop up? Do we start to see issues? What is your cadence like? So now we can get more specific towards the tasks at hand. And I think that's really how you bridge some of these things like these like BS rules we make around movement in the clinic and how do we get you out of the clinic and into the real life stuff. And if that makes sense.

Joe LaVacca (18:28)
Yeah, for sure. I think, you know, I'm always interested in in what does a norm mean? Right? Like when we say like the classic 20 heel raise test or, you know, a return to sport test and, you know, looking at the data across the board, this return to sport is, I think it's still a big question mark, because you just mentioned like, you know, walking could be your sport. But what if I'm a runner? What if I play basketball? What if I play soccer? What if I do lacrosse and I have heel pain? Like all of those different

ideas, movements, sporting events that people are in are going to require different demands. And when you or I and think other clinicians are kind of scaling back and it's like, well, we can do a hop test, we can do a T test, we can do the six meter jump test, we could do this test, we can do that test. It's like, well, that looked at a range of athletes across the board in multiple sports. So really would that cross over for us? And I think that's where it gets really, really hard. The thing I wanted to see if you had.

heard was that there was an updated normative value for a standing heel raise test in healthy adults. And they looked at people all the way from 20 to 80 years old. And being that you and I, Joe, are in our 30s, what do you think the average norm for heel raise for males in their 30s were? And with this new updated literature as of 2017?

this was.

Joe Gambino (20:00)
This is my answer is very anecdotal, but I'm going to go with. Like 12.

Joe LaVacca (20:04)
You

man. Okay. So, so high, like low numbers were around 12. So you got it. High numbers were up to 50. So an average for about 33, 33 single leg heel raises for males in their 30s was new normative data. Yeah, I mean, you know, I don't know if I could do that right now.

Joe Gambino (20:18)
50, that's impressive.

That's impressive.

I've never seen anybody, I mean, I've seen people pass the 20 tests like pretty well, you know, like if they kept going, right, like maybe in the thirties, but 50, I mean, I've never actually tested people to see like, just go infinitely to see how many you can do. Cause I just know, I mean, like out of all the people that I've worked with, I mean, there's not a lot of people who get to 20. So I'm a little surprised that the numbers are that high. That's why I went so low with 12 because that just seems to be a lot of people.

Joe LaVacca (20:57)
Yeah, no, I -

Joe Gambino (20:59)
And maybe it's just because we see injured people, right? Like, hey, we see injured people, right? So that affects our perception of the whole population, right? Being able to do certain things.

Joe LaVacca (21:03)
Correct.

Correct, correct. And I think pain changes everything, right? But now even, I'll give you some notes, is what we talked about in the previous episode was people with this heel pain are gonna probably be around 40 to 60. All right, so if you're in your 40s and you're a male, average heel raise tests be about 28. If you're female, 24, 25. If you're 50, 23, 24 for male, 21, 22 for female.

If you're 60, that's maybe where the 20 test is a little bit more reliable across the board, because the numbers there are pretty similar for both male and female around 18, 19. So it seems like the males have a slight advantage in some of this output up until about maybe that 60th decade of life. And then we kind of all flatten out together, which I think is another really important thing to consider because muscle mass for men as we age is...

really important to consider, just like bone mass, I think in females as they age is something really important to consider. But I think this goes back to this idea that if you're over the age of 50, especially, we should be strength training, we should be loading, we should be trying to build as much lean muscle mass going into those later decades of life, because even in healthy people, we're seeing that tail off naturally. So if you're already in pain and heading into that 50th, 60th, 70th decade with a lot less capacity,

That's maybe why people are struggling a lot too, but just a thought.

Joe Gambino (22:37)
That is interesting. They definitely exceed. And that's why I think that having normative data, not necessarily normative data, but rules around what we should look for, especially what I really care about most. Do I really care if someone can do 20 versus 30? He always is, I don't know. But what I really like to see is that things are symmetrical side by side. So if someone can do 20 on the right, can they also do 20 on the left or whatever the number is? And the single A confidence is the distance.

close together, right? Where we're seeing there's really not that much of a huge disparity, because if there are, right, like, does it make sense to really get into like, should I have somebody go out and really go for a run and prep for a marathon, right? If they're single -leg hop test is so far off. Probably not, right? Like you probably want to work on some of these little more common things, right, that we can do in the clinic. And then once we hit some benchmarks, say, okay, now it makes more sense to go this route. What are you thinking on that?

Joe LaVacca (23:38)
Well, I mean, I think again, it's like this idea of like the all the normative stuff, right? So if I'm evaluating people, and they're in pain, even if they're getting 2020 and their hop is symmetrical, I'm still going to probably want to work on that because maybe the numbers I'm holding them accountable to still aren't enough for the sport that they need to get back to. Right. And I think that's where that individualization is really so important.

And maybe why I've been thinking about that even a little bit more is I did take a dynamometer course. I don't know if I told you about that a few weeks ago. And what I found really interesting with this force output testing was that your torque to body weight ratio is a really important thing. So when we're doing, you know, a handheld test on a table or I'm looking at someone do 20 heel raises or 30 raises or whatever. Okay, great. I mean, is that testing?

strength? Is that more testing endurance? Is that testing, you know, just tolerance to the activity before pain comes on? So I think it becomes harder to qualify a lot of the tests that we do, because I can quantify anything. But what, you know, I learned at the course, which was great, and I can always, you know, send a link for, you know, more information on that was,

just the ability to calculate torque and bring that into the clinic over the last few weeks, right? When I'm strength testing people, just to give them a good clear, like thumbs up, thumbs down, when I put them on the torque testing, it's so different from the numbers or the conversations we were gonna have. And it's just started to kind of streamlining the conversation of, hey, look, I know you wanna get stronger, but here's the two or three things I'd focus on. Let's hammer these out for like six or eight weeks.

and then come back and retest this stuff. And even then the point they made was, look, the normative data is all over the place. I don't really know what normative data is, but I like what you're saying is, well, what's acceptable asymmetry and what's unacceptable asymmetry? So when you're looking for those differences side to side, be it a hop test, a heel raise test, do you have a certain cutoff in your mind?

Joe Gambino (26:06)
I don't know. And maybe I think ACL protocols are probably the most systematic of all the protocols out there. So maybe there's stuff that you can kind of glean from that. But I kind of mean, like if I was going to create like a percentage, I mean, I would like them ideally to be like 90, 95 percent.

there, right? Like a pretty, pretty close. I don't need them to be perfect. And that doesn't necessarily mean that we wouldn't be doing other things like returning, like doing the activities that they enjoy more. I'm kind of working back there. If they're at like 85%, it just depends really on like their presentation, how they can, you know, how much pain they have, what they can tolerate. I think there's a lot of factors that play into it and you can't just base it off these percentages and these tests. It's impossible. And there's two things.

One specifically what you said I love like right we can quantify anything but we can't but can we actually like Qualified and put actual meaning behind it. Those are two very very different things. So I really like that The other thing that I wanted that I think is important to just mention here in general is just because someone can do something doesn't mean that There will be an absence of pain. I don't like I mean when we look at all those bodies of research right where it's like

Joe LaVacca (27:20)
Correct, sure.

Joe Gambino (27:23)
There's nothing underlying. You can get MRIs, x -rays, all this stuff is clear, but you still have pain, right? Like why is that the case? Someone can have perfect mobility. Someone can have perfect strength and someone can still have pain, right? Like, so we can't just like go into the heel raise test. Like I'm just going to go back to it because we were talking about it. If someone was able to do 20 reps and maybe they had pain during it or maybe they did have pain during it. It doesn't mean that they're not going to have pain on a daily basis for whatever reason, right? I think that pain goes beyond.

logic in a sense, right? So how then do we help that population of people where movement looks good, strength looks good, and what can we do to start to calm down the system and then figure out how we can kind of load them again to create an environment that's going to at least make things more comfortable for them. Because now if we're really talking about like chronic pain where movement looks good, well, I think we're having a whole different conversation. I think that's kind of, I don't know, did we really, we've talked about it before. I don't know if that, what episode or not.

But how we start to kind of like figure out how we chronic pain like calming down the system and creating like It's a definitely a different plan. You can't really you can't really base that around these generalities at that point. So I Kind of wanted to talk there. You can give me your thoughts and then I think that will be we can take it home from there so to speak

Joe LaVacca (28:41)
Yeah, well, I think, you know, you're the limb symmetry index, right? I think, you know, probably I picked up on through FMS, SFMA, things like that. You know, because return to sport testing when when we came out of school, right, I think was like, as long as you're within 80 % of the other limb, your range of motion is full, there's no joint diffusion or swelling. You can start going back. But that I mean, that 80 % number was I think,

hurting a lot of people because it was just too much of a gap in terms of capacity. Now, so I think for me, I'll lead to the 10 % rule, I think for most people. I don't believe that you need to be perfectly symmetrical or I don't even know if that's actually an attainable goal. And when I always bring this up for the lower extremity, people are always really worried about the one glute and the...

the one toe that doesn't do something and the quad that's a little bit weaker. And then I just ask them to pause and say, okay, well, are you thinking about all those things with your upper body? Right? What hand are you dominant in? Right or left? It doesn't matter. Let's say you're dominant with your right hand, like I think what 80 or 80 plus percent of us are. I write with my right hand. I can't write with my left hand. That is an asymmetry. I'm not going home and chasing that asymmetry, learning how to write with my left hand. I can throw with my right.

Joe Gambino (30:01)
Hehehehe

Joe LaVacca (30:05)
barely, I can't throw with my left at all. So why am I not going home then and trying to become, you know, ambidextrous and clean up all these, you know, top asymmetries that just seemingly, it is what it is. And then I'm going to be sort of like really focused or compulsive about them in the lower body. So I think that 10 % cut off for me is a good starting point for people. Like, hey, let's, let's make sure you're at least within this range. If I'm with an athlete,

I'm gonna probably hold them more accountable to that 5%. And that's where I think context matters and being a little bit more nitpicky with people who have specific goals rather than, hey, I wanna be a little bit more pain -free, hey, I wanna be able to enjoy walks, a hike, time with my family and things like that. So I definitely agree with that sort of synopsis there. But I think it just goes back to the idea that, yeah, we have lots of...

you know, data and different ideas. But I think for me, what I probably tell most people with plantar fascia issues, and maybe what I've been telling just most people in general, is I think your best treatment is going to be load management and progression. Right? And, you know, to know we're talking about the treatment stuff right now. But, you know, and if that doesn't work, you know, like, yeah, heel cups are okay, like having some soft cushion on the heel for a little bit of time.

If again, that helps you walk and that helps you move, that's awesome. Okay. You know, injections get a little bit tricky from the data I've seen. A single cortisone injection doesn't seem to be too dangerous. Maybe you can try it if your quality of life is really, really down. But I think the load management idea and the education that, you know, this is going to take a while with a lot of plantar fascia or white connective tissue injuries.

I think is also very important for people to understand and that we just did an episode on that that came out that came out this week, right? About how long this process takes and if you're not prepared for that as a clinician if you're not prepared for that as a client Well, then yeah six or eight weeks later, you're gonna become more frustrated, right? And you're gonna be like, well, what the hell's going on? Why am I not getting better? And it's like well because it hasn't been six eight months or for some people hasn't been a year or more

going through this journey. So I think like in terms of treatments, again, we could probably talk another hour about all the things that we like to do. But if we're going to kind of keep it broad and pretty general today, and I know we got a tangent on strength there, which I thought was important. That would say those are probably like my big three pieces and then, you know, honing in on individualized assessments as we find them with the things that we were mentioning before.

Joe Gambino (32:57)
Yeah, I really like that. And just one little point on what you said. I think that the PT industry, the, you know, know, caros chiros all that, right? Like we've gotten, we've swung so far away from like the surgeries, the shots, the, you know, orthotics, right? Like these things that can potentially really help somebody and like, no, we have the answers, right? Because conservative care really can help. And I think,

that at some point, right, if things aren't changing, aren't progressing, someone's been really, really struggling that those conversations should be had with people. And I mean, that's a whole conversation for another episode. But I do think it's kind of a little bit of a important to highlight there that we shouldn't be shaming people for having conversations with their doctors at some point in time, right? We should be referring out and letting them get the imaging that may be needed to rule things out that we could be missing with our eyes, with our hands and our environment. So I think that's important as well.

Any last points here to add, Jerry Boyd?

Joe LaVacca (33:58)
No, I mean, I think you summed it up really well right there. And listening to you talk, I was reminded of a quote from Eric Mira, where if it's in your clinical skill set, right, and you can alleviate someone's pain, just do it. Just do it. If that's an orthotic, if that could potentially be an injection and they haven't had one before, if they're a single mother of three kids working two jobs,

and they cannot commit to a gym membership and a strength -based program, like please give people options, okay? Even if you don't love them, there are options. And to your point, even if the efficacy or effectiveness is, well, it's not much better than usual care or there's not really much difference, okay, but there were still people who got better from those treatments, right?

It wasn't just across the board where no one benefited from. So I think that that's a really valuable thing that you brought up to close it out and to keep that in mind because we're again, we're so the concept of pain being multifactorial and complex and you know, not only a tissue based thing, I think pushes us or a lot of clinicians away from just trying to help people feel better while we're trying to help them get better. So.

Don't hesitate to feel better. And if you're a client and you find something that makes you feel better, don't feel ashamed doing it. Do it more and then pair it with something that you want to try to get better at, be it walking or heel raising or holding an isometric or doing toe yoga, whatever it is that you and your kind of clinician come up to terms on. But I think that was a great closing point, Joe.

Joe Gambino (35:44)
Well, thank you. And then same to you. I think I think you, you know, there's some great points there as far as, you know, just the topic in general. I think PTs, we kind of play the hero card a lot. I like, I have to do all this stuff to help them. Right. And sometimes the best thing to help that person is just to refer them out. And that's why I think understanding their history, what's kind of going on and really getting to kind of like know how whatever's happening is really affecting their lives and just not just beyond like paint, right? Like.

How is it impacting your relationships, your function? How much time do you have to devote to all this stuff? Like all that stuff really matters when you're trying to come up with a plan for somebody. But again, this is a conversation that we can dive into probably for another seven hours from here.

Joe LaVacca (36:28)
Yeah, yeah, and hopefully next week we'll get Courtney Conley on and we'll round out some foot talk with her and her experiences. So it'll be a nice like a few weeks segment I think we got going on.

Joe Gambino (36:40)
Yeah, perfect man. Well, Joey, I love you. It was a great conversation today. Listeners, love you as well. And if you made it this far to the episode, extra love for you as well. And we'll see you next time.

Joe LaVacca (36:44)
I love you.

Take care, everyone.