Overview of Plantar Fasciitis and Plantar Heel Pain

Plantar heel pain affects 10-15% of the population with an estimation of 2 million Americans visiting a physician due to heel pain affecting their quality of life. The popular term in regard to heel pain is plantar fasciitis, though the ‘itis’ in the term refers to an inflammatory condition which is not always the case.  The average duration of plantar heel pain is greater than 6 months in length, leading to a progression through the acute inflammatory stage to eventual chronic heel pain which would change the diagnosis to plantar fibromatosis or plantar fasciosis. These are terms you may see on a podiatrists prescription, however they all refer to plantar (sole of the foot) heel pain.

The plantar fascia is a fibrous structure attaching on the inside portion of your heel bone, the calcaneus, and extending to the base of each of your five toes. This creates a stabilizing ‘floor’ to the base of your foot as the tissue of the plantar fascia tensions in response to the force of your weight on the floor.  This is shown below, the plantar fascia is represented as the horizontal ‘truss’ to the foot in response to the floor’s force.  The force is dependent many factors; foot mechanics and foot position, speed of gait, running vs. walking, weight of the individual, prolonged standing, foot and ankle stiffness, and repetitive activities in weight bearing.

The force developed on the plantar fascia causes repetitive stress and strain it’s insertion on the inside portion or medial portion of the calcaneus.  Over time this stress and strain can lead to onset of bone formation at the heel often referred to as ‘bone spurs.’  Overall plantar heel pain develops from a poor relationship between the stress on the plantar fascia and its ability to handle the intensity, duration, or frequency of the stress we place on it every day. Continue reading

Explaining Vertigo and the Vestibular System

Vestibular disorders are quite prevalent in the population and are one of the biggest reasons that someone goes to the ER.   The vestibular system is located in the inner ear and is responsible for balance and knowing where the body is in space.  If the vestibular system is not fully intact then quite often patients will complain of dizziness and possibly room spinning.   Patients may also complain of difficulty balancing while walking or going up stairs and can have symptoms of nausea.

One of the most frequent causes of dizziness is called BPPV, or benign paroxysmal positional vertigo.  In the vestibular system in the inner ear there is a small organ called the utricle.  There are normally crystals located inside the utricle.  The problem is when the calcium crystals travel out of the utricle and fall into one of the semi-circular canals.  These canals sense movement and rotation such as when you turn your head, or lay down.  When the crystals travel into the canal they give the body the sense that it is spinning or moving.   Sometimes this recovers on its own, however frequently a physical therapist or physician can provide a treatment which helps moves the crystals back where they should be in the utricle.

   Continue reading

Temporomandibular Joint Dysfunction – An Intro to Jaw Pain

Temporomandicular joint dysfunction (TMD) is a condition involving facial pain involving one or both sides of the jaw.  TMD can also be associated with neck pain, ear pain, and headaches.  It is an all encompassing term for jaw or facial pain including specific jaw joint pain or pain due to overload of the muscles surrounding the joint. Jaw pain is a unique situation in physical therapy as it is often difficult to think of our jaw as we would any other joint in the body.  The jaw is often overlooked as a cause of pain in the facial and cranial regions with patients often experiencing pain over a prolonged period of time.  TMD can be linked to a tricky recovery as the diagnosis is general and lacks a true treatment pathway without an in depth exam uncovering functional impairments that lead to pain.

From a physical therapy standpoint a patient arriving with a previously established diagnosis of TMD will be evaluated in regard to their jaw as well as the cervical spine.  This is due to a close relationship in cervical spine posture and jaw function.  A quick example of this can be completed by altering your own posture. Try to sit up extremely tall, (in perfect posture!) and click your teeth together softly. Now slump forward and push your chin out forward, click the teeth together again.  Your teeth may have approximated in a different position based on your changing your, this is a direct example of how our posture can affect our jaw function.

TMD, and jaw pain by association, can be caused by differing sources of pain including the jaw itself (intra-articular pain) and the surrounding musculature and joints (extra-articular pain).  These sources of pain alert the nervous system to potential damage leading to stimulus to the portion of the brain that is responsible facial sensation. This often leads to confusion in the brain as to what the source of the pain is, and can lead to generalized facial pain, sharp jaw pain, ear pain, headache, any or all of the above.  A short explanation of the various causes:


  1. Disc derangement: the temporomandibular joint is composed of a stable joint surface and a movable joint surface, between the two is a small disc that buffers and aides motion of the jaw.  If the disc does not move properly it can be a hindrance to movement and be the cause of clicking and popping in the jaw.  If the disc holds, holds, hoooolds..then moves quickly into its proper position this can cause an audible pop.  If the disc holds, holds, hoooolds and does not slide there is no click or pop, but the jaw will move significantly less. This are called reducing and non reducing disc conditions. 
  2. Inflammation: The actual jaw joint tissue or tissue associated with the previously mentioned disc become inflamed and can be pain generating sources.
  3. Degeneration: jaw joint surface degeneration or degeneration of the disc tissue lead to a more grinding presentation rather than clicking and can contribute to dysfunction.
  4. Joint hypermobility or hypomobility: In hypermobility the jaw joint moves in excess and with less stability leading to uncontrolled movement that is in need of stabilization and coordination.  In hypomobility (capsular restriction) the jaw joint is stiff leading to less mobility on one or both sides of the jaw, manual therapy and jaw exercises can improve mobility. 


  1. Postural dysfunction: Changes in standing and seated postures can result in interruption of proper jaw function. Think back to our teeth clicking example.
  2. Muscular Imbalance: imbalance between the opening muscles of the jaw and the masticating muscles of the jaw result in improper function of the jaw joint itself.


Treatment of TMD by a physical therapist is supported by medical research showing gains in ability to open the jaw and mouth and reduction in pain associated with TMD. Manual therapy provided by a physical therapist can provide the proper treatment path to improve your quality of life by allowing you to return to pain free daily function. This can be a wide range of activities when talking about a unique joint such as the TMJ. Improved quality of life may be as simple as being able to yawn without pain, open your mouth wide enough to enjoy your favorite sandwich, or be able to sleep in your favorite position.

Evaluation, education, and proper one on one treatment are important in any rehabilitation and with TMD the analysis offered with one on one treatment becomes even more important. Facial pain can be caused by any number of conditions that are in need of further investigation and care outside of the physical therapy clinic.

At Rose Physical Therapy we strive to offer one on one analysis that will provide the best treatment available, and this analysis begins by determining how appropriate PT is for each individual and whether or not further referral is needed. We will be an advocate for each patient that needs further care from a specializing dentist, neurologist, or is in need of referral to their primary care physician following our in depth evaluation.

Jaw pain is common, though it is not a normal occurrence. You should be able to enjoy a quality of life that is not interrupted by jaw and facial pain.  Visit our website for further education or to contact our office with any questions!




Calixtre, L. B., Moreira, R. F. C., Franchini, G. H., Alburquerque‐Sendín, F., & Oliveira, A. B. (2015). Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. Journal of oral rehabilitation, 42(11), 847-861.

Balasubramanium, R; Delcanho, R, Temporomandibular disorders and related headache; Headache, Orofacial Pain and Bruxism, Diagnosis and multidisciplinary approaches to management, Chapt 7, pg 76-77, Churchill Livingston Elsevier, 2009.

Dworkin, S. F. (1992). Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord, 6, 301-355.

Discs Can Bulge and Herniate – They Can Also Heal!

Intervertebral discs are composed of an outer layer called the annulus fibrosis and an inner layer, the nucleus pulposus.  The annulus is a more fibrous substance that encircles the nucleus, a more jelly like substance. The nucleus should be contained by the annulus, though with excessive or repetitive pressure and strain the nucleus can deform the annulus or exit the annulus.  

There are several terms that describe these happenings in the cervical, thoracic, and lumbar spine. During your research involving the spine and back and neck pain, terms such as ‘protrusion,’ ‘bulge,’ ‘herniation,’ and ‘extrusion’ arise.  These are the scientific terms that are used to describe the nature of disc changes, some that may cause back pain, and some that are not pain generating changes.  Here is a quick explanation of terms you may be introduced to on the internet, or in your MRI report, or through your physician or physical therapist.


Disc Bulge: Tissue of the annulus, the outer layer of the disc, projects outward beyond the border of a comparable disc (usually the adjacent disc).  Think of what happens when you sit on a couch in the same place every day, the couch cushion begins to change its shape in response.

Disc Protrusion: Movement of the nucleus of the disc causing a more pronounced bulge in the disc that extends past the border of the nearby vertebrae. This creates a dome like shape.  Think of the same couch cushion example, the sides of the couch cushion begin to ‘protrude’ in response to the pressure on the top of the cushion.

Disc Extrusion: Movement of the nucleus of the disc further from the central containment of the annulus creating more of a bubble shape outside of the annulus, though the disc maintains it continuity. You’re starting to lose some of the cushion’s filling, but the cotton filling is still intact.

Disc Sequestration: This the characterization of a disc extrusion that loses its continuity with the disc. This is some of the cushion’s filling falling out of the cushion.


Let’s look a little deeper into the couch cushion analogy and how that relates to daily function of the spine.  We all have a favorite spot we like to sit in right?  The special spot on the couch where everything is at your fingertips while your favorite movie plays.  Over time that spot in the couch becomes noticeable as the cushion’s filling begins to shift away from the spot that is used more often.  This same process happens in the intervertebral discs of the spine. We all have a daily routine that involves repetition and prolonged positioning and it just so happens that most of these activities involve bending forward. Bending to sit, sitting for a prolonged period at work, driving in the same bent position, bending to put on pants, socks, and shoes, among others.  These repetitious and prolonged activities cause the inner substance of the disc to push toward the back portion of the discs borders, leading to the above mentioned structural changes.

Now think about how it feels when you ‘miss’ the favorite spot in the couch and sit just off target. The stimulus from the couch feels a little odd and a little different until you can settle back into the favorite spot. This also happens in the spine when we introduce a new stimulus to our day, however the stimulus is often perceived as pain. This leads to a common presentation of low back pain which if left untreated can lead to a more severe low back pain and involve pain in the leg, often times termed ‘sciatica.’  

However if we introduce that stimulus in a safe manner and with enough repetition to compete with our daily tasks we can return the structure of the disc to a more normal presentation and alleviate low back pain. If we introduce this new stimulus in a safe manner we can reorganize the couch cushion’s filling.

At Rose Physical Therapy part of our evaluative procedures attempt to identify the patterns in daily activity that cause changes in the intervertebral disc structure and use functional examination procedures to reach the solution that will lead to a return in the proper structure of the disc, or better yet reach pain free activities of daily living regardless of the structure of the disc!

Dr. Nicholas Smith


Contact us today to establish a visit to discuss your pain and create a plan to alleviate the pain and improve your quality of life!


Your Postoperative Care

Whether choosing to undergo a surgical procedure to better your quality of life or experiencing an unexpected trauma in need of surgical intervention it is imperative that your postoperative care be tailored to your specific needs.  Each individual case is in need of a foundation in evidence based medicine and proper tissue healing timeline based protocols as well as an experienced therapist that can analyze specific patient needs. At Rose Physical Therapy our staff clinicians are experienced and trained in evidence based postoperative care.

A patient beginning their postoperative care should be examined for red flag symptoms in regard to deep vein thrombosis (DVT), or blood clot, and infection of the involved joint or body part.  The Well’s Score, developed from a clinical checklist, leads a clinician to a “likely” or “unlikely” clinical probability in regard to DVT and physical therapists are well trained at identifying signs and patient symptoms of infection.

Physical therapists are educated in a tissue healing timeline that provides a centerpiece for an evidence based, safe treatment procedure in the initial phases of healing.  Soft tissue healing ranges from 6-8 weeks to provide a safe structure to an area that was surgically repaired.  During this healing phase physical therapists provide care that limits soft tissue and joint loading to provide a safe healing environment.  During this time it is essential that a physical therapist remain safe and continue to observe a patient’s subjective reports for signs that healing is delayed or ahead of time. This is where individual analysis is important and one on one care can provide the proper setting for clinical conversation and planning between physical therapist and client.

When soft tissue healing timelines have passed and the physical therapist has observed and measured changes indicating proper healing individuality to a treatment plan again takes the forefront.  Rehabilitation includes increasing a patient’s quality of life, functional abilities, vocational abilities, and generating patient driven goals.  Physical therapists that can provide one on one care and individualized care planning can drive their care toward each patients needs rather than completing a solely protocol based rehabilitation.

Patient driven goals provide a unique endpoint to physical therapy care that often result in varying discharge dates from physical therapy. Our goal as physical therapists is to achieve outcomes that are valued by our clients which results in discharge from our care with unique and comprehensive home exercise programs.

The end result of postoperative care is always to achieve patient satisfaction with functional outcomes. At Rose Physical Therapy we strive to achieve these results with every client who enters the clinic.

Dr. Nicholas Smith

How Physical Therapy can help you achieve a pain free shoulder….

One of our most frequent inquiries from patients is whether physical therapy can help a stiff and painful shoulder. Patients often complain of pain due to sports injury, car accident, arthritis or adhesive capsulitis (“frozen shoulder”).
The shoulder is a ball and socket joint. The ball of the humerus or upper arm  rolls and glides in the socket of the scapula or shoulder blade when we move our arm. Limiting conditions such as arthritis, general stiffness or adhesive capsulitis (“frozen shoulder”) stop this roll and glide and shoulder motion becomes quite limited and painful. Quality of life is impacted as it becomes difficult to perform simply daily tasks.
Frozen Shoulder is a condition that occurs fairly commonly with 200,000 cases diagnosed per year in the United States. Patients suffering from frozen shoulder often work with a therapist over an extended period of time so that pain is minimized without the need for prescription pain medication and motion is restored without surgery. Targeted manual joint mobilization can restore the shoulder roll and glide and therefore, the pain free mobility of the shoulder.
For patients who have suffered from chronic arthritis in their shoulder, physical therapy works to improve joint mobility that has been lessened by damage and inflammation.
Our office can be reached at 716.204.8734.  Any questions can be emailed to admin@rosephysicaltherapy.com.

Celebrating the Holiday Season!

The holidays are a wonderful time for celebrating the community! We were so excited this year to be a designated collection site for Peyton’s Toy Drive For Children’s Hospital of Buffalo. We invited patients and their families to take part as we collected unwrapped toys at both our Williamsville and Lockport locations. We gathered on December 9th in Clarence to present all the toys collected and to meet young Peyton!

Toys will be distributed on site at the hospital in coming weeks.

Crossing Holiday Stress Headaches Off Your List….

The holiday season is filled with so many traditions and joys but with it comes hectic days, sleepless nights and busy weekend celebrations. Often people experience an increase in stress as they try to fit everything into this busy time of year. Tension headaches are a common reaction and become a real problem when they start interfering with doing the things you love. These type of stress headaches can result from several factors including holiday scheduling, fatigue, anxiety, poor posture as well as over stimulation from scents, music and crowded parties.

When patients come into Rose Physical Therapy we try to identify causes of their lingering tension headaches. Stress to your system can be effectively relieved by working with a therapist to lessen muscle tension in your neck, jaw, back and shoulders. Poor posture and rigidness puts pressure on your nerves and contributes to making a minor headache even worse. Eliminating poor habits and triggers will help reduce pain and lessen the need for medication. Therapists work with patients through manual therapy to increase strength in their neck and shoulders and improve their range of motion. Therapists also provide an individualized home exercise routine that is useful to maintaining overall strength, decreasing stress and improving flexibility.

Headaches do not have to be part of your holiday routine and eliminating this common occurrence  makes for a more festive, healthy season!


How I found my passion for Physical Therapy….


When I was in high school, I became very interested in the science of exercise and finding a way to improve my overall performance in soccer, football and wrestling.  After suffering an injury playing travel soccer, and having the pressure of an upcoming football season, I was diagnosed with a medial meniscus tear of my right knee. Faced with the option of surgery…. and knowing that would mean a missed football season… I explored the idea of therapy.  Through intense and targeted therapy,  I healed thoroughly and was able to continue forward with a successful season.

Senior year of high school, I was at Lake Shore Hospital in Silver Creek as a patient transport aide and onsite I was taking care of the PT facilities. It was there that I saw people improving their quality of life through movement and exercise. My contact with these patients was very rewarding and inspiring. The therapists there took me under their wing and advised me on how and where to find local Physical Therapy college programs.  Armed with my new found passion and their helpful advice,  I soon entered the PT program at Daemen College. Thirty five years later, I look back at that time as critical in pointing me toward this rewarding field.

Dr. Terry Rose