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.

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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!