August 27, 2023 • 25 mins
A patient with a diagnosis of Plantar Fasciitis will have different symptoms from the last one you saw with the same diagnosis and different from the next as well.
We need to think about foot biomechanics, nerves, the plantar aponeurosis and we need to know specifically where the patient is having pain.
https://richardhazel.podia.com
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(00:01):
Welcome to the Acupuncture Outsider podcast.
My name is Richard Hazel and in the time it takes for you to commute to or from work,
I hope to have shared something of interest about orthopedic acupuncture using motor points,
trigger points,
(00:23):
myofascial slings,
neuro functional acupuncture segmental treatments.
Anything that crosses my mind that seems to be of interest.
I hope you'll enjoy it.
Hello and welcome to another episode of the Acupuncture Outsider.
(00:45):
This is Richard Hazel and I want to talk about uh foot pain today.
Uh One of the members of the podia uh mentoring group had reached out about one of her patients who was having um planar foot pain really um not in the middle part of the planter FAA,
(01:09):
but on the medial and the lateral part of the heel.
And uh so we were talking about that and,
and discussing possible nerve entrapments.
Uh There is another episode about the plantar nerve entrapments.
And um and so I was,
I was recommending that she work on the muscles that could be possibly entrapping uh medial and lateral plantar nerve,
(01:37):
but also uh to use the motor points of the abductors,
the abductor lysis on the inner part because that attaches back at the calcaneus.
So,
medial heal pain caused by the tendon maybe a tendinopathy from the abductor lysis.
(01:57):
And then the lateral pain was close to the heel on the plantar surface on the lateral part of um yeah,
like lateral,
pretty much where the lateral band of the plantar apa neurosis would be attached.
So um and that apparently was successful the day after that treatment,
(02:20):
the patient had no pain.
Now,
I just saw a patient this week who was having sciatica.
I'm familiar with his sciatica,
uh sciatica flare ups every once in a while,
I'll see him maybe every two or three months.
Um It tends to get flared up if he has a long drive or something.
But um this time,
instead of just the sciatic radiation into the hamstring or the perons,
(02:44):
he was having lateral plantar uh foot pain,
which I would attribute to an irritation of the plantar nerve.
The really,
it's a tibial nerve being irritated,
causing plantar foot pain.
Um So I recommended that we treat the tibialis posterior,
(03:07):
the abductor lysis and then have him walk and see how he felt.
So he did and he,
he then felt uh some discomfort in the arch of the foot,
but not the lateral part of the foot.
So I treated his flexo digitorum longus,
had him walk again,
no pain.
So then he reaches out to me the day after treatment to say the that lateral foot pain is back because he mostly felt it in the mornings.
(03:38):
So I said,
you know what come in at the end of my day,
I'm not gonna charge you.
It's gonna take me 10 minutes.
I just want to release that,
that one lateral uh muscle.
That's the abductor,
digiti uh quinte or digiti mini me p however,
you wanna call it,
it's abductor digiti mini me of the foot and it is innervated by the lateral plantar nerve.
(04:04):
So what I think happened was the sciatic irritation of the tibial nerve and the lateral plantar nerve had also affected the muscle.
So he didn't get complete relief by taking pressure off the nerve.
I had to actually treat the muscle.
So um I did not hear back from him and I think no news is good news.
(04:26):
Um But I did treat that abductor uh Digiti mini me and I did a little bit more with the ti posterior and the abductor lysis because if you're,
if I'm gonna do one needle,
I might as well do four.
So I um so I treated that,
hopefully he'll feel better.
I think so.
Um but I wanted to talk about those lateral heel pain and medial heel pain symptoms because um the uh the term planter fasciitis gets thrown around.
(04:58):
It's a very big blanket term that,
you know,
um I think often does not apply to what people are dealing with.
Um I don't think that either one of those pains are actually plantar fascia related.
Um I think they're more um either nerve entrapments or muscular overuse injuries.
(05:25):
Um But the planner apa neurosis is uh has a,
has three different branches.
There's the middle one,
which is the wide one that goes to all five toes and is the one that we normally,
I think,
think of as the planner FASA.
But there are two other branches,
there's a medial and there's a lateral branch.
(05:47):
The medial one apparently is quite thin.
Um but the lateral one is pretty stabilizing.
So they all can um eventually cause that um attachment of the planter fas at the front of the calcaneus to get irritated.
(06:08):
The way I think we should look at it though is that the planter fascia is there basically to make sure that your foot doesn't collapse,
make sure that your foot doesn't get broken backwards.
It's a they're stabiliz,
it's a stabilizer that also is giving us very important proprioceptive input.
(06:28):
So it's meant to be receptive and stabilizing for the arch and the just the bottom of the foot in general,
very strong stabilizer because I think the muscles alone could not stabilize the amount of weight that we put on a foot,
especially for things like running.
(06:48):
So I think the planter facia can get irritated when the muscles have uh basically gotten weak from overuse injury and tension.
And then the planter fascia does start to get irritated and have um micro tears and inflammation and pain.
(07:09):
What I think many people get is more like a um sci opathy,
you know,
like a tendinopathy of the plantar fascia of the apa neurosis where there's pain,
it from uh tension on the FASA.
(07:34):
But that we,
that we can address fairly quickly by addressing the muscular tension that is causing weakness of the muscles causing the apa neurosis to be the primary stabilizer.
So,
for instance,
um well,
let's talk about the main one,
the middle,
strong apa neurosis which attaches in the front of the calcaneus,
(07:59):
it goes all the way out and branches underneath all the meta tails,
there's like a different branch for each toe.
So why would that cause heel pain?
So you know what it is attached on the front of the calcaneus?
I I think most people feel the heel pain though under the heel in the pad of the foot.
(08:24):
So based on experimentation,
basically,
when,
when it was baffling to me,
you can read all you want about planter fa plantar fasciitis.
It's not usually very helpful from an acupuncture perspective.
So what I found that was very successful was to work on primarily the soleus and the gastric neus muscles and eventually some of the other plantar flexors,
(08:53):
but really sometimes just soleus and gastric NAUS would get me to zero pain for uh heel pain,
uh plantar fasciitis patients,
especially runners.
And what I think is happening is that the uh achilles tendon which goes down under the calculus in the back and the planter FASA which or the apa neurosis,
(09:22):
which is attached kind of medial uh and sort of an interior in the calcaneus are fighting each other um on toe off during,
during walking or running.
And I think it puts pressure on that fat pad um under the heel.
(09:44):
So they're,
they're being pulled in both directions and causing terrible heel pain.
And then I think as you warm up the calves,
there's less pulling from the back and then there's less pain.
Now,
I think that's why that would give people significant relief when that was not successful.
(10:04):
I would have to look further into um the stabilizers of the arch like the tibialis,
posterior flexor digitorum longus,
um flexor digitorum brevis,
uh flexor Haasis,
longus and brevis abductor lysis and the abductor digiti mini meat.
(10:28):
Those are things that I learned kind of uh by just by reading because there are,
there were no acupuncturists putting this information out when I was trying to struggle with it and figure it out.
So I kind of had to really,
you know,
read a lot about running runner's gate,
um how the foot um pron and then soups and stabilization of the arch,
(10:52):
the winless mechanism and kind of piece it together myself for an acupuncture treatment.
And what I found was that the most successful treatment for heel pain and even instep pain was to treat the plantar flexors.
(11:13):
So then you're getting tibialis posterior,
getting the um flexor digital longest you may do,
you may get into the flexor hays longest.
And you know,
if you know the winless test for planter fasciitis,
it's the dors selection of the big toe which will pull on the planter fascia where it attaches and if there's pain there,
then you're positive for planter fasciitis.
(11:36):
Um But functionally,
you know,
the,
the how the lysis longus is really important for toe off.
Um As a,
you know,
walker or a runner,
it becomes a big problem for someone who has like a stuck big toe,
a rigid uh lysis rigid where they really can't do a flex because then they then their gate shortens and they use more hip flexor and can cause all sorts of other problems.
(12:03):
So,
um so I really had to kind of piece that together,
but I,
I realized those plantar flexors were really a big winner for uh foot pain,
heel pain,
instep pain.
And then I kind of had to think through the anatomy for the medial heal pain,
the lateral heel pain.
(12:24):
Um it did not uh instantly occur to me that the abductor hays went all the way back to the calcaneus.
Um But when,
when I reviewed it in,
you know,
in images,
II,
I thought,
oh,
I wonder if that's the medial heal pain.
So I started treating it that way.
Just because of where it attaches.
(12:47):
And then that was successful.
And same thing happened with the abductor digiti uh MMI or quinte or whatever you wanna call it.
Um And then I would read that that actually could lead to plant or fasciitis and heel pain because of its attachment.
Um And then interestingly as you look at the plantar nerves,
(13:08):
you start to see that the abductor lysis is innervated by the medial plantar nerve.
And then the abductor digiti mini me is is innervated by the lateral plantar nerve.
Exactly the pattern that you would get foot pain from uh plantar nerve entrapments.
(13:28):
So it starts to make sense that you have uh this sensory and motor nerve that can irritate the muscle.
So you may have nerve entrapment,
but the nerve entrapment may be kind of like a double crushed situation where you now have uh the muscles getting tight,
causing pain because of the nerve irritation from further up the chain.
(13:54):
Um from the uh tibials posterior usually can be the quadratus plante,
but usually it's abductor hays.
And then that may be tight because the person had sciatica or some sort of low back issue,
some sort of L five issue that would cause plantar flexors to get tight,
(14:14):
that would cause a tibial nerve entrapment that would cause foot muscles to get tight,
that would cause planter fascia to be irritated because the tight muscles are no longer stabilizing the arch,
the way they're supposed to.
So you can see how the chain goes.
Um And you know,
one of the things that,
(14:35):
that isn't always um something to be on the lookout for the,
the patient always almost always comes in with a diagnosis.
You know,
they come in saying I have planter fasciitis and if we didn't take that and then set it aside and say,
(14:57):
let's just see what you and your doctor are calling planter fasciitis.
And then you realize that what they were calling plantar fasciitis was medial heal,
pain and pain in the arch along the medial border of the arch.
(15:17):
In the abductor lysis,
sometimes it's as simple as that.
They've got medial heel pain and they've got pain in the arch because the big toe is trying to stabilize the arch because the tib posterior is not doing a good job and they are overrating when they walk.
(15:39):
So they need arch support and they need tibialis posterior to be released and they need the abductor Haasis to be released.
And possibly the flexor hali brevis,
possibly flexor Hali Longus.
But you get where I'm going there.
The,
the,
the big toe is always going to try to stabilize the arch when the tibialis posterior has gotten tight and weak and the,
(16:05):
and the foot is overrating when they walk.
Um And you notice,
I say over pronating because a lot of times people talk about dysfunction and they just say pronating,
you're pronating.
Well,
good for you.
If you're pronating,
you should be pronating when you walk.
It's part of the gate cycle right after your heel strike.
(16:25):
You should the foot pron dates before it supinate.
The pronation is normal.
It's a good thing.
It unlocks the arch and then as you go into toe off,
it should lock the arch because the win loss mechanism and then you supinate.
So you want pron super eight pron super eight,
that's normal.
Over pronation is not good.
(16:47):
It's,
it is probably considered normal because so many people over primate because they're,
they have poor art support.
They wear terrible shoes.
Um They're,
you know,
they wear shoes that do not support their arch at all.
And if you're overweight and you don't wear art support,
you're gonna be in trouble because it's just too much,
(17:10):
too much weight on the arch of the foot.
You're,
you're basically creating a flat foot and then you're gonna have strain on the planter fas because it's the last resort.
Your body has your,
your muscles have given out.
They're too tight to support you.
Now,
the planter fascia where I should say the planter Auro is doing most of the stabilization and that's not a good place to be.
(17:36):
Let your plan a neurosis be proprioception and stabilization.
Um But it really,
it should be the muscles of the foot that are stabilizing.
And if,
if all those muscles gotten too tight,
then it's time for you to get an acupuncture treatment and get that stuff reset.
(17:57):
So it will be strong.
And of course,
um in the process of working on someone with this kind of foot pain,
we have to think about the uh the antagonist.
Um just because I mentioned all of those planter flex of plantar flexors does not mean I don't need to work on the Dorsa flexors.
Those are also gonna be totally jacked.
(18:19):
Um They're gonna be tight,
you're gonna have tight Perons because you're,
you're overrating.
Um You're gonna have tight tibialis,
anterior and extensive Dior longus.
Um All of those muscles get a lot of work uh regardless.
So,
(18:40):
you know,
if you're having plantar flexor injury,
your,
your Dorsa flexors are probably out of whack too.
Um The low leg is one of those situations where you really have to consider treating agonist and antagonists on almost all issues because of the way the foot works,
(19:01):
the way the low leg works,
it's all engaged.
Even if it's not,
even if you're doing something like the heel strike with some Dorff selection.
The plantar flexors are,
are working too.
Everything has to decelerated for you to have normal gate.
So you have,
you have muscles that are doing primary function and the other muscles,
(19:25):
their antagonists are doing some sort of deceleration activity.
Um or,
you know,
even you have to go into Dorff selection before your heel strikes that you don't trip and then even even while you're doing toe off your,
your Dorsa,
flexor muscles are still engaged in order to control the speed of everything.
(19:48):
So everything is engaged in a low leg.
It's not like when we talk about doing bicep curls and the triceps are relaxing.
Uh uh It's not like that.
So,
um so you always have to think about the antagonist,
but I just,
I just wanted to put it out there that there are um a lot of uh there are a lot of ways to get foot pain that someone is going to diagnose as plantar fasciitis.
(20:17):
And it really matters when you get them in your office to palpate you need.
You should palpate the to be posterior tendon to see if that,
if there's a tale tunnel uh situation with nerve entrapment,
you should palpate the abductor hays,
the flexor hays brevis,
(20:38):
you should palpate the instep,
you should palpate the attachment of the planter fas to the winless mechanism.
See,
see if there's pain there.
Um palpate the the lateral and medial part of the heel.
Um You got to get a sense of what that patient has been told is plantar fasciitis in order to help them because the planner a neurosis is a big thing and there's three branches of it.
(21:10):
And yes,
it might be in distress,
but maybe if you fix the muscles,
it won't be in distress,
then you don't have to worry about the planner a neurosis.
Um in many cases.
That's,
that's what's going on.
The app neurosis is like the last ditch effort to keep your foot from completely collapsing.
Um And you just need to get the strength back in those uh,
(21:32):
toe muscle,
the toe flexors and the art support to take pressure off of the apa neurosis so that it has a chance to not have pain anymore.
But for the heel pain that someone gets right underneath the heel,
try working with the sous and the gas trucks.
(21:55):
That's like that's a winner many,
many,
many times.
And then if it's not getting better from that,
then,
then you could,
you know,
think more about the intrinsic muscles of the foot or some of the stabilizers of the ankle or the arch and go from there.
But um you know,
(22:17):
treating the actual plantar or the plantar aosis,
especially the middle one is not usually the winner because even if you're reducing inflammation in the apa neurosis,
if you really haven't fixed the structural muscles that are supposed to be stabilizing the foot,
(22:39):
preventing over pronation,
et cetera,
the the stress is back on the apa neurosis as soon as they're walking out of your office.
So you really,
you really,
the apa neurosis is more your symptomatic indication that something is not stabilizing and it's gonna be muscles.
(23:01):
Um So I guess um I guess I said what I wanted to say,
I hope that was of some interest to some of you um really just a matter of think,
you know,
ask the right questions.
Find out where the pain really is.
Think about the anatomy,
think about the nerves that innervate those different segments.
(23:24):
The medial plantar nerve,
the lateral plantar nerve,
think about the fascia and the three branches of the apa neurosis.
Think about how the foot actually lands on the floor.
Um Ask them,
you know,
what is their activity of choice?
Are they a runner?
Is,
are they just,
(23:45):
um,
um,
maybe wearing terrible shoes?
You know,
there's,
there's no shame in having art support in your shoes,
you know.
Um,
it's not,
you haven't given up,
you know,
sometimes you need that extra art support at least temporarily to get to where you don't have pain and inflammation.
(24:10):
You know,
there's no shame in having to wear art support.
Um,
and then the other thing I would say is,
you know,
find a good topical anti-inflammatory in the States.
We use a lot of CBD um,
in some countries.
I know you need a,
a prescription.
But,
um,
but if you can get a good hemp CBD product,
(24:32):
um in the interim while work,
you know,
working through the process that can be very,
very helpful too.
It's,
you know,
even if you're correcting the muscle imbalances,
if there's,
there is some irritation of the apa neurosis,
then that topical anti inflammatory is helping calm that down just so they get faster relief.
(24:54):
Um,
I find that's very effective for achilles tendinitis.
Uh,
I don't want to go into too much on achilles.
But,
um,
but,
you know,
um,
there's,
that can be very helpful too as far as getting moved forward,
um,
and out of pain relatively quickly.
Ok.
So that's it for this week and,
(25:16):
uh,
take care,
talk to you soon.
Welcome to the Acupuncture Outsider podcast.
My name is Richard Hazel and in the time it takes for you to commute to or from work,
I hope to have shared something of interest about orthopedic acupuncture using motor points,
trigger points,
(00:23):
myofascial slings,
neuro functional acupuncture segmental treatments.
Anything that crosses my mind that seems to be of interest.
I hope you'll enjoy it.
Hello and welcome to another episode of the Acupuncture Outsider.
(00:45):
This is Richard Hazel and I want to talk about uh foot pain today.
Uh One of the members of the podia uh mentoring group had reached out about one of her patients who was having um planar foot pain really um not in the middle part of the planter FAA,
(01:09):
but on the medial and the lateral part of the heel.
And uh so we were talking about that and,
and discussing possible nerve entrapments.
Uh There is another episode about the plantar nerve entrapments.
And um and so I was,
I was recommending that she work on the muscles that could be possibly entrapping uh medial and lateral plantar nerve,
(01:37):
but also uh to use the motor points of the abductors,
the abductor lysis on the inner part because that attaches back at the calcaneus.
So,
medial heal pain caused by the tendon maybe a tendinopathy from the abductor lysis.
(01:57):
And then the lateral pain was close to the heel on the plantar surface on the lateral part of um yeah,
like lateral,
pretty much where the lateral band of the plantar apa neurosis would be attached.
So um and that apparently was successful the day after that treatment,
(02:20):
the patient had no pain.
Now,
I just saw a patient this week who was having sciatica.
I'm familiar with his sciatica,
uh sciatica flare ups every once in a while,
I'll see him maybe every two or three months.
Um It tends to get flared up if he has a long drive or something.
But um this time,
instead of just the sciatic radiation into the hamstring or the perons,
(02:44):
he was having lateral plantar uh foot pain,
which I would attribute to an irritation of the plantar nerve.
The really,
it's a tibial nerve being irritated,
causing plantar foot pain.
Um So I recommended that we treat the tibialis posterior,
(03:07):
the abductor lysis and then have him walk and see how he felt.
So he did and he,
he then felt uh some discomfort in the arch of the foot,
but not the lateral part of the foot.
So I treated his flexo digitorum longus,
had him walk again,
no pain.
So then he reaches out to me the day after treatment to say the that lateral foot pain is back because he mostly felt it in the mornings.
(03:38):
So I said,
you know what come in at the end of my day,
I'm not gonna charge you.
It's gonna take me 10 minutes.
I just want to release that,
that one lateral uh muscle.
That's the abductor,
digiti uh quinte or digiti mini me p however,
you wanna call it,
it's abductor digiti mini me of the foot and it is innervated by the lateral plantar nerve.
(04:04):
So what I think happened was the sciatic irritation of the tibial nerve and the lateral plantar nerve had also affected the muscle.
So he didn't get complete relief by taking pressure off the nerve.
I had to actually treat the muscle.
So um I did not hear back from him and I think no news is good news.
(04:26):
Um But I did treat that abductor uh Digiti mini me and I did a little bit more with the ti posterior and the abductor lysis because if you're,
if I'm gonna do one needle,
I might as well do four.
So I um so I treated that,
hopefully he'll feel better.
I think so.
Um but I wanted to talk about those lateral heel pain and medial heel pain symptoms because um the uh the term planter fasciitis gets thrown around.
(04:58):
It's a very big blanket term that,
you know,
um I think often does not apply to what people are dealing with.
Um I don't think that either one of those pains are actually plantar fascia related.
Um I think they're more um either nerve entrapments or muscular overuse injuries.
(05:25):
Um But the planner apa neurosis is uh has a,
has three different branches.
There's the middle one,
which is the wide one that goes to all five toes and is the one that we normally,
I think,
think of as the planner FASA.
But there are two other branches,
there's a medial and there's a lateral branch.
(05:47):
The medial one apparently is quite thin.
Um but the lateral one is pretty stabilizing.
So they all can um eventually cause that um attachment of the planter fas at the front of the calcaneus to get irritated.
(06:08):
The way I think we should look at it though is that the planter fascia is there basically to make sure that your foot doesn't collapse,
make sure that your foot doesn't get broken backwards.
It's a they're stabiliz,
it's a stabilizer that also is giving us very important proprioceptive input.
(06:28):
So it's meant to be receptive and stabilizing for the arch and the just the bottom of the foot in general,
very strong stabilizer because I think the muscles alone could not stabilize the amount of weight that we put on a foot,
especially for things like running.
(06:48):
So I think the planter facia can get irritated when the muscles have uh basically gotten weak from overuse injury and tension.
And then the planter fascia does start to get irritated and have um micro tears and inflammation and pain.
(07:09):
What I think many people get is more like a um sci opathy,
you know,
like a tendinopathy of the plantar fascia of the apa neurosis where there's pain,
it from uh tension on the FASA.
(07:34):
But that we,
that we can address fairly quickly by addressing the muscular tension that is causing weakness of the muscles causing the apa neurosis to be the primary stabilizer.
So,
for instance,
um well,
let's talk about the main one,
the middle,
strong apa neurosis which attaches in the front of the calcaneus,
(07:59):
it goes all the way out and branches underneath all the meta tails,
there's like a different branch for each toe.
So why would that cause heel pain?
So you know what it is attached on the front of the calcaneus?
I I think most people feel the heel pain though under the heel in the pad of the foot.
(08:24):
So based on experimentation,
basically,
when,
when it was baffling to me,
you can read all you want about planter fa plantar fasciitis.
It's not usually very helpful from an acupuncture perspective.
So what I found that was very successful was to work on primarily the soleus and the gastric neus muscles and eventually some of the other plantar flexors,
(08:53):
but really sometimes just soleus and gastric NAUS would get me to zero pain for uh heel pain,
uh plantar fasciitis patients,
especially runners.
And what I think is happening is that the uh achilles tendon which goes down under the calculus in the back and the planter FASA which or the apa neurosis,
(09:22):
which is attached kind of medial uh and sort of an interior in the calcaneus are fighting each other um on toe off during,
during walking or running.
And I think it puts pressure on that fat pad um under the heel.
(09:44):
So they're,
they're being pulled in both directions and causing terrible heel pain.
And then I think as you warm up the calves,
there's less pulling from the back and then there's less pain.
Now,
I think that's why that would give people significant relief when that was not successful.
(10:04):
I would have to look further into um the stabilizers of the arch like the tibialis,
posterior flexor digitorum longus,
um flexor digitorum brevis,
uh flexor Haasis,
longus and brevis abductor lysis and the abductor digiti mini meat.
(10:28):
Those are things that I learned kind of uh by just by reading because there are,
there were no acupuncturists putting this information out when I was trying to struggle with it and figure it out.
So I kind of had to really,
you know,
read a lot about running runner's gate,
um how the foot um pron and then soups and stabilization of the arch,
(10:52):
the winless mechanism and kind of piece it together myself for an acupuncture treatment.
And what I found was that the most successful treatment for heel pain and even instep pain was to treat the plantar flexors.
(11:13):
So then you're getting tibialis posterior,
getting the um flexor digital longest you may do,
you may get into the flexor hays longest.
And you know,
if you know the winless test for planter fasciitis,
it's the dors selection of the big toe which will pull on the planter fascia where it attaches and if there's pain there,
then you're positive for planter fasciitis.
(11:36):
Um But functionally,
you know,
the,
the how the lysis longus is really important for toe off.
Um As a,
you know,
walker or a runner,
it becomes a big problem for someone who has like a stuck big toe,
a rigid uh lysis rigid where they really can't do a flex because then they then their gate shortens and they use more hip flexor and can cause all sorts of other problems.
(12:03):
So,
um so I really had to kind of piece that together,
but I,
I realized those plantar flexors were really a big winner for uh foot pain,
heel pain,
instep pain.
And then I kind of had to think through the anatomy for the medial heal pain,
the lateral heel pain.
(12:24):
Um it did not uh instantly occur to me that the abductor hays went all the way back to the calcaneus.
Um But when,
when I reviewed it in,
you know,
in images,
II,
I thought,
oh,
I wonder if that's the medial heal pain.
So I started treating it that way.
Just because of where it attaches.
(12:47):
And then that was successful.
And same thing happened with the abductor digiti uh MMI or quinte or whatever you wanna call it.
Um And then I would read that that actually could lead to plant or fasciitis and heel pain because of its attachment.
Um And then interestingly as you look at the plantar nerves,
(13:08):
you start to see that the abductor lysis is innervated by the medial plantar nerve.
And then the abductor digiti mini me is is innervated by the lateral plantar nerve.
Exactly the pattern that you would get foot pain from uh plantar nerve entrapments.
(13:28):
So it starts to make sense that you have uh this sensory and motor nerve that can irritate the muscle.
So you may have nerve entrapment,
but the nerve entrapment may be kind of like a double crushed situation where you now have uh the muscles getting tight,
causing pain because of the nerve irritation from further up the chain.
(13:54):
Um from the uh tibials posterior usually can be the quadratus plante,
but usually it's abductor hays.
And then that may be tight because the person had sciatica or some sort of low back issue,
some sort of L five issue that would cause plantar flexors to get tight,
(14:14):
that would cause a tibial nerve entrapment that would cause foot muscles to get tight,
that would cause planter fascia to be irritated because the tight muscles are no longer stabilizing the arch,
the way they're supposed to.
So you can see how the chain goes.
Um And you know,
one of the things that,
(14:35):
that isn't always um something to be on the lookout for the,
the patient always almost always comes in with a diagnosis.
You know,
they come in saying I have planter fasciitis and if we didn't take that and then set it aside and say,
(14:57):
let's just see what you and your doctor are calling planter fasciitis.
And then you realize that what they were calling plantar fasciitis was medial heal,
pain and pain in the arch along the medial border of the arch.
(15:17):
In the abductor lysis,
sometimes it's as simple as that.
They've got medial heel pain and they've got pain in the arch because the big toe is trying to stabilize the arch because the tib posterior is not doing a good job and they are overrating when they walk.
(15:39):
So they need arch support and they need tibialis posterior to be released and they need the abductor Haasis to be released.
And possibly the flexor hali brevis,
possibly flexor Hali Longus.
But you get where I'm going there.
The,
the,
the big toe is always going to try to stabilize the arch when the tibialis posterior has gotten tight and weak and the,
(16:05):
and the foot is overrating when they walk.
Um And you notice,
I say over pronating because a lot of times people talk about dysfunction and they just say pronating,
you're pronating.
Well,
good for you.
If you're pronating,
you should be pronating when you walk.
It's part of the gate cycle right after your heel strike.
(16:25):
You should the foot pron dates before it supinate.
The pronation is normal.
It's a good thing.
It unlocks the arch and then as you go into toe off,
it should lock the arch because the win loss mechanism and then you supinate.
So you want pron super eight pron super eight,
that's normal.
Over pronation is not good.
(16:47):
It's,
it is probably considered normal because so many people over primate because they're,
they have poor art support.
They wear terrible shoes.
Um They're,
you know,
they wear shoes that do not support their arch at all.
And if you're overweight and you don't wear art support,
you're gonna be in trouble because it's just too much,
(17:10):
too much weight on the arch of the foot.
You're,
you're basically creating a flat foot and then you're gonna have strain on the planter fas because it's the last resort.
Your body has your,
your muscles have given out.
They're too tight to support you.
Now,
the planter fascia where I should say the planter Auro is doing most of the stabilization and that's not a good place to be.
(17:36):
Let your plan a neurosis be proprioception and stabilization.
Um But it really,
it should be the muscles of the foot that are stabilizing.
And if,
if all those muscles gotten too tight,
then it's time for you to get an acupuncture treatment and get that stuff reset.
(17:57):
So it will be strong.
And of course,
um in the process of working on someone with this kind of foot pain,
we have to think about the uh the antagonist.
Um just because I mentioned all of those planter flex of plantar flexors does not mean I don't need to work on the Dorsa flexors.
Those are also gonna be totally jacked.
(18:19):
Um They're gonna be tight,
you're gonna have tight Perons because you're,
you're overrating.
Um You're gonna have tight tibialis,
anterior and extensive Dior longus.
Um All of those muscles get a lot of work uh regardless.
So,
(18:40):
you know,
if you're having plantar flexor injury,
your,
your Dorsa flexors are probably out of whack too.
Um The low leg is one of those situations where you really have to consider treating agonist and antagonists on almost all issues because of the way the foot works,
(19:01):
the way the low leg works,
it's all engaged.
Even if it's not,
even if you're doing something like the heel strike with some Dorff selection.
The plantar flexors are,
are working too.
Everything has to decelerated for you to have normal gate.
So you have,
you have muscles that are doing primary function and the other muscles,
(19:25):
their antagonists are doing some sort of deceleration activity.
Um or,
you know,
even you have to go into Dorff selection before your heel strikes that you don't trip and then even even while you're doing toe off your,
your Dorsa,
flexor muscles are still engaged in order to control the speed of everything.
(19:48):
So everything is engaged in a low leg.
It's not like when we talk about doing bicep curls and the triceps are relaxing.
Uh uh It's not like that.
So,
um so you always have to think about the antagonist,
but I just,
I just wanted to put it out there that there are um a lot of uh there are a lot of ways to get foot pain that someone is going to diagnose as plantar fasciitis.
(20:17):
And it really matters when you get them in your office to palpate you need.
You should palpate the to be posterior tendon to see if that,
if there's a tale tunnel uh situation with nerve entrapment,
you should palpate the abductor hays,
the flexor hays brevis,
(20:38):
you should palpate the instep,
you should palpate the attachment of the planter fas to the winless mechanism.
See,
see if there's pain there.
Um palpate the the lateral and medial part of the heel.
Um You got to get a sense of what that patient has been told is plantar fasciitis in order to help them because the planner a neurosis is a big thing and there's three branches of it.
(21:10):
And yes,
it might be in distress,
but maybe if you fix the muscles,
it won't be in distress,
then you don't have to worry about the planner a neurosis.
Um in many cases.
That's,
that's what's going on.
The app neurosis is like the last ditch effort to keep your foot from completely collapsing.
Um And you just need to get the strength back in those uh,
(21:32):
toe muscle,
the toe flexors and the art support to take pressure off of the apa neurosis so that it has a chance to not have pain anymore.
But for the heel pain that someone gets right underneath the heel,
try working with the sous and the gas trucks.
(21:55):
That's like that's a winner many,
many,
many times.
And then if it's not getting better from that,
then,
then you could,
you know,
think more about the intrinsic muscles of the foot or some of the stabilizers of the ankle or the arch and go from there.
But um you know,
(22:17):
treating the actual plantar or the plantar aosis,
especially the middle one is not usually the winner because even if you're reducing inflammation in the apa neurosis,
if you really haven't fixed the structural muscles that are supposed to be stabilizing the foot,
(22:39):
preventing over pronation,
et cetera,
the the stress is back on the apa neurosis as soon as they're walking out of your office.
So you really,
you really,
the apa neurosis is more your symptomatic indication that something is not stabilizing and it's gonna be muscles.
(23:01):
Um So I guess um I guess I said what I wanted to say,
I hope that was of some interest to some of you um really just a matter of think,
you know,
ask the right questions.
Find out where the pain really is.
Think about the anatomy,
think about the nerves that innervate those different segments.
(23:24):
The medial plantar nerve,
the lateral plantar nerve,
think about the fascia and the three branches of the apa neurosis.
Think about how the foot actually lands on the floor.
Um Ask them,
you know,
what is their activity of choice?
Are they a runner?
Is,
are they just,
(23:45):
um,
um,
maybe wearing terrible shoes?
You know,
there's,
there's no shame in having art support in your shoes,
you know.
Um,
it's not,
you haven't given up,
you know,
sometimes you need that extra art support at least temporarily to get to where you don't have pain and inflammation.
(24:10):
You know,
there's no shame in having to wear art support.
Um,
and then the other thing I would say is,
you know,
find a good topical anti-inflammatory in the States.
We use a lot of CBD um,
in some countries.
I know you need a,
a prescription.
But,
um,
but if you can get a good hemp CBD product,
(24:32):
um in the interim while work,
you know,
working through the process that can be very,
very helpful too.
It's,
you know,
even if you're correcting the muscle imbalances,
if there's,
there is some irritation of the apa neurosis,
then that topical anti inflammatory is helping calm that down just so they get faster relief.
(24:54):
Um,
I find that's very effective for achilles tendinitis.
Uh,
I don't want to go into too much on achilles.
But,
um,
but,
you know,
um,
there's,
that can be very helpful too as far as getting moved forward,
um,
and out of pain relatively quickly.
Ok.
So that's it for this week and,
(25:16):
uh,
take care,
talk to you soon.
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