Orthobiologics: Rethinking Plantar Fasciitis as a Neurovascular Condition | Convos in Regen Ep 25

Discover how orthobiologics is reshaping the understanding of chronic plantar fasciitis and persistent heel pain by challenging the traditional degenerative model and introducing a neurovascular framework that may transform how physicians approach diagnosis and treatment.
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Disclaimer: This educational discussion is intended primarily for physicians and healthcare professionals. However, patients interested in modern regenerative medicine and orthobiologic approaches are also welcome to learn from the conversation.

In this episode of Conversations In Regenerative Medicine, hosted by Dr. Ariana Demers, the Queen of Business Orthobiologic, with guest Dr. Benjamin Sibley, the discussion explores a paradigm shift in musculoskeletal care—rethinking plantar fasciitis not as a simple degenerative condition, but as a potentially neurovascular-driven pathology. The conversation dives into clinical reasoning, including how this model impacts diagnosis of plantar fasciitis, patient selection, imaging interpretation, and treatment planning.

Key topics include Baxter’s nerve involvement, ultrasound diagnostic strategies, calcaneal edema findings on MRI, and evolving treatment options such as platelet rich plasma therapy, neuroprolotherapy, hydrodissection techniques, and when regenerative medicine may outperform traditional corticosteroid approaches.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

SPEAKER_02 0:00

While cortisone is really effective in the early stages at reducing inflammatory responses and pain, PRP tends to be medium-long-term superiority. What we're actually doing with the cortisone is we're suppressing that angiogenic response that the tissue is looking at to use to try and heal that area. And so what we're doing in the short term is we're winning the symptom battle, but we're destroying the biological wall. So what it is, this isn't a collagen problem anymore. I would look at treating plant fasciitis as an organ. Once I started taking that approach, results changed.

SPEAKER_00 0:44

Welcome everyone to Conversations in Regenerative Medicine, where we are exploring frontiers of PRP, BMC, and MFAT. And this is a really exciting time for me. Joining me is one of the pioneers of regenerative medicine and controversial topics where we're gonna be looking at cutting-edge insights that are shaping the future of interventional orthopedics. So we are going to welcome our friend, my friend and colleague, Dr. Benjamin Sibley. He is a podiatry, he's founder and CEO of Your Pediatrice Brisbane in Queensland, Australia. He has 30 plus years of experience in podiatry and six years in the regenerative MSK podiatry land. He's done over 5,000 plantar fasciitis patients treated and injections hip to foot. They have an expanded scope in Australia. So he's done a lot of things. He is a member of our Interventional Orthobiologics Foundation, American Society for Regenerative Medicine and Fellowship Training and Regenerative Medicine, Stem Cell and Anti-Aging Medicine. So, Dr. Sibley, welcome, welcome, welcome. So, for all of you who don't know me, I'm Dr. Ariana Demers. I'm a board certified fellowship training in sports and medicine orthopedic surgeon and regenerative medicine expert. I do a lot of training and education in both ultrasound as well as orthobiologics and business. I have successfully moved my practice in rural Northern California away from insurance-based practice, and I focus on cash-based, injection-based procedures. The thing I'm really passionate about is helping doctors to incorporate orthobiologics into their practices seamlessly. So I just want to go through this. This is going to be like a fireside chat. We're going to be chatting and hanging out with our friend Dr. Benjamin Zibley, who we do this a lot. We do a lot of chatting and it's super fun. But we're going to be hearing from internation renowned experts in regenerative medicine and exploring controversial topics. I can't wait. There's some spice today. And hopefully, we'll also gain some actual insights for your practice that you can implement immediately. And then my favorite part is the live QA sessions where we can get your burning questions answered by the expert. So I believe that orthobiologic treatments will be first-line treatment in musculoskeletal care in the next five years. It's a bold statement, but that is what I believe. And the train is leaving the station. So if you are not actively offering these treatments to your patients, you gotta get on the train. The problem sometimes is successful integration of these ortho biologics is hard. You know, we know ortho biologics is the best treatment for our patients, but sometimes we struggle a little bit on how to be successful. Maybe you've tried some things, maybe you know, say, I don't know the science, the science behind it, I don't know all the techniques. Maybe you don't know every in and out about cash business or marketing or sales. And maybe you just had that thought, like, man, I'm just not good at business. I don't know what I'm doing when it comes to business. But it is not our fault. We did not learn this in school. And so if you're struggling with how to be successful, how to seamlessly integrate orthobiologics and capitalize on this four billion dollar orthobiologics in the market out here, you're in the right place. Now, why is this so hard, right? Uh, I'd love to know in the chat what you eyes are struggling with from an orthobiologics and integration standpoint. Just pop that in the chat if you will, so we can address these things during our Q and A. So the question is, you know, how to win? While we are gonna be talking about the science today, we do also need to consider how we talk about this with our patients. So we all win. And clearly we need a system. Uh, and we aren't gonna go over all of this today, but we are gonna get you a little bit further on this journey to be wildly successful in your orthobiological practice. So we're gonna get started, uh, and this is basically our fireside chat. So, Dr. Defensively, let's get down to business. Man, we have questions for you. So, my first question is you've treated 5,000 patients with plantar fasciitis. That's a lot of plantar fasciitis, my friend. And you're making a claim that I think most physicians would push back on is that plantar fasciitis is fundamentally a neurovascular condition, not a degenerative one. So please walk me through that evidence that brought you to this conclusion and what's actually happening, uh, and what the maybe the how the standard model has gotten it wrong for so long.

SPEAKER_02 6:09

Okay, thanks, Ariana. Welcome everyone. Look, the what we're talking about here, I'm going to be talking about is a chronic plant fasciotis, is what we tend to see in our regenerative, well, what I tend to see in my regenerative clinics. So these are people who have danced around, been going from practitioner to practitioner, trialing different standard classical medical treatments to get their plantofascia to settle itself down. So the standard model of plantofasciitis is a mechanical degenerative condition, repetitive stress, loads at the calconeal enthesis, microtears, they accumulate and look at healing, and then what happens is they tend to accumulate faster than they heal. And so we end up with this degenerative tissue or this itis that implies that there's some inflammation going on. And so the logical treatment, and this is really logical in terms of what we've been taught, what I've been taught as well, is reduce the load, reduce inflammation, and get the tissue, get that tissue healing. But what's really interesting is in the in the literature is biopsy of plantar fascia from people undergoing fascial release from surgery, you find fibroblastic hypertrophy, absence of inflammatory cells, disorganized collagen, and a chaotic vascular hyperplasia with zones of avascularity around the enthesis. So those histopathological findings, like mucoid, fribenoid collagen degeneration, and there's lots of angiofibrotic hyperplasia that's actually going on. And a lot of the colleagues who push back say, Yeah, yeah, we know, you know, it's not inflammatory, but it's still degenerative collagen failure. So it's like a fasciosis, not fasciitis. So what's really what I have found interesting in the research that I've been doing is the chaotic vascular hyperplasia. Now, this is where the vessels are really poorly disorganized, but they're growing into that medial heel area, the enthesis in around that region, and growing into tissue planes that are normally and relatively avascular. So that new vessel growth that produces like a pathological pattern, particularly in plantar fasciitis and all of the enthesopathies that we're studying. So we get sensory nerve fibers that come with that with that with that growth as well. So what we find is you end up with a neurovascular invasion into the tissue. So you've got new vessels, new nerves, neuropeptide release flooding into the area, not as a result of inflammation coming from the outside, but as a product of the new nerve fibers that actually grow there as part of the healing process. So this mechanism, the degenerative model doesn't explain. So if it was just simple collagen failure, we'd expect the treatments to be directed at restoring collagen architecture and to be working more reliably and durably in that chronic plantar fasciitis stage. In some of the research with light treatment using focused shockwave in terms of treating chronic plantar fasciitis, the proposed mechanisms with that is destruction of sensory unmyelinated nerve fibers and stimulation of neovascularization and collagen synthesis in degenerative tissues. So it's not actually patching collagen, it's not reducing the inflammation, but it's targeting that neurovascular apparatus. And that's what makes the focus shock wave work quite well, and that's what the literature is actually saying as well. And that same logic applies to the ortho biologics and the PRP, and typically why PRP injections outperform cortisone in six weeks and greater. So while cortisone is really effective in the early stages at reducing inflammatory responses and pain, PRP tends to be medium-long-term superiority in terms that it's looking at restoring that vascular biology, which really, really matters. Some of the other things we've that I've found in the journey of research and doing the research on this area is the evidence of cortisone-induced damage, you know, the potential for complications, including fascia rupture and fat pad problems. And what we're actually doing with the cortisone is we're suppressing that angiogenic response that the tissue is looking at to use to try and heal that area and heal that chronic tissue injury. And so what we're doing in the short term is we're winning the symptom battle, but we're destroying the biological wall, we're destroying the biological environment that's going to allow the tissue to effectively heal. And so, with the chronic failing of the anthesis to grow new vessels, to remodel the collagen, what we're doing is we're suppressing that neurovascular repair mechanism, which is essentially so important and important in regenerative medicine and also orthobiologics as well.

SPEAKER_00 11:06

You have uh really gone on a deep dive with this. And I think your depth of knowledge is about the plantar fascia, about what you see from the biopsies. It's really interesting, and it really gets me thinking about you know, how do you get more organized collagen? And you know, and is this offloading actually maybe problematic, right? Because we know when we want to get linear organized collagen, what do we do? We stress it, right? And so I yeah, I think like everything we've learned, like, oh, offload it, inject cortisone with it, like it seems like maybe none of it was right. Is that yeah? Am I am I off base here?

SPEAKER_02 11:59

Look, I think early stages, it has a place. So the the mechanical degenerative theory has a model, has a place in the early stages of what I call acute plantar fasciitis. So that's your acute management, maybe say from day one through to say week three, maybe week four. But long term, in terms of the chronic chronic plantar fasciitis, we need to have a a new new look at how we're going to treat this and look at producing better results for our patients longer term. It was interesting, in a there was a study done of 106 patients with chronic plantofasciitis, and what they found there was neuropathic pain was detected in 63.2% of patients using what's called a pain detect scale. And a centralized sensitization was detected in 85.8% using a central sensitization inventory scale. And that was compared to 7% neuropathic pain and 44% central sensitization in the musculoskeletal pain control. That was an article by Kara Killick in 2025 about the frequency of central sensitization and nocyplastic pain in patients with planar fasciitis. So what that actually tells us, like 86% of patients with chronic planar fasciitis, patients coming to us have this central sensitization. Two-thirds nearly have neuropathic pain. So what it is, this isn't a collagen problem anymore. You know, the tissue, for some of these people, the tissue may have healed on imaging and the fascia may have reduced in thickness, but pain's still being generated and is amplified by a nervous system that's continually running an OC septic loop. And this may go on for months or years for people. And so, you know, in terms of management, you know, we typically go, okay, let's inject some cortisone, you know, maybe come back in four or six weeks, we'll reinject it again. So that's just suppressing the peripheral repair process, and we keep watching the pain come back and injecting it again, which doesn't make sense, you know, and that's a frustrating thing that I found with the plantar fasciitis. So, and then my other question is why when we use regenerative treatments that directly targets the vascular biology outperform anti-inflammatory and cortisone beyond the six-week mark? You know, it's very well documented in the literature. And you know, my other question is why do 86% of chronic cases show this central sensitization and two-thirds have got neuropathic symptoms? So it's and why does the histology show us that there's this chaotic vascular hyperplasia that's going on and an angiofibroblastic invasion rather than a simple kind of like collagen repair where you'd sort of expect scarring and and things to be forming. So the degenerative model isn't wrong. What it does, it starts the process, but what we need to look with our chronic plantar fasciitis is maybe we need to have a little bit of a different look longer term. You know, the neurovascular repair mechanism runs at a chaotically tight pace, but it's bringing in sensitized nerve fibers hot into high zones of mechanical stress, those fibers are releasing the peptides, which is driving further vascular dysregulation. So we need to look at managing that in a better way.

SPEAKER_00 15:23

Well, so you know, if planar fasciitis uh is a neurovascular and not degenerative, I feel like that changes everything about patient selection, treatment planning, expected outcomes. Like so, walk me through this diagnostic workup. How how do you kind of work these patients up? It seems like number one, you kind of delineate acute versus chronic. How else do you kind of do your diagnostic workup?

SPEAKER_02 15:52

Well, this is I'm implementing a relatively new new process within my clinic in terms of a different format in terms of how we classify. The problem, one of the biggest problems is in my literature research at the moment, is that there are very few protocols, classification protocols available for practitioners that help them to delineate the different stages of plantar fasciitis acute through to chronic, and then look at okay, well, what's the best treatment in terms of implementing at those particular stages? So there's not a very good classification system or protocol system available out there. In my research at the moment, I think I've come across four. So it makes it really, really challenging for practitioners. What I find is history and physical, so some of the key questions like we need to ask as practitioners is and looking through the neurovascular lens, is which biological process is driving patients' pain at that moment? So, and this answer actually changes everything. So we want a neurovascular-informed history when we're doing that screening, we're looking for two things at once. Is there peripheral nerve involvement and is there central sensitization going on? Because these are often frequently common and presenting, but often frequently missed as well. And so, you know, some of the questions you'll ask is is it burning pain, electric shooting rather than aching type pain? Does it worsen throughout the day rather than easing after the first few minutes of weight bearing and walking? And that's classical fascial pain and a fascial mechanical pattern that we see. Does it wake them at night? Is it present at rest? Is there any tingling, numbness into the toes? These features will actually start to push us towards a neurogenic and sensitize phenotypes immediately. So you do your conventional exam, three maneuvers that I use is palpate medial tubercle, the windlass mechanism, so you flex the big toe with the ankle at 90 degrees and palpate along the plantar fascia to see if there's tenderness and soreness, and then I'll do a simple heel squeeze test. The first one that you can actually look at doing is the Tanel sign at the tarsal tunnel. So what we're doing is we're palpating the posterior tibial nerve, and I typically like to palpate it as it's entering the tunnel itself, not at the tunnel, and then what we're looking for is distal radiation either into the arch of the foot or into the heel of the foot, and that's is an indicator that there's issues with the post-tib nerve. I do a little extension test on that. I'll palpate proximally back up the leg, looking for tenels or what we call valet sign. So valet sign is when you palpate the nerve, you get a radiating sensation of the nerve or even a proximal radiation of pain going back up into the leg. There's another test that's diagnostic for tarsal tunnel syndrome. You want to test that. It's called the triple compression stress test. So you pull the ankle back to 90 degrees, you evert the foot and then palpate into the tarsal tunnel. And that has 100% specificity for tarsal tunnel syndrome. Then I'm looking at Star's nerve. So Baxter's nerve typically is in the regional location. If you have a look at the medial malleolus and drop down onto the calcaneus before you hit the medial tubercle, that's typically where Baxter's nerve is, and you're compressing and palpating there, and what you're looking for is inferior pain going into the heel. Also, sometimes you can get pain that goes over to the lateral side of the foot. So sometimes I've palpated the Baxter's nerve, no local sensation, no inferior heel sensation, but a lateral, a lateral foot, lateral heel pain sensation that they'll experience as well. So that's indicative that there's Baxter's nerve entrapment that's going on there as well. There's the abductor digidi minimi assessment test, and so what we're looking at is on the lateral side of the foot, is we're looking at the abductor digidi minimi muscle belly, and we're looking at the wastage of that. So often there'll be wastage, and there'll be an inability of the person to be able to separate that fifth toe and fourth toe if there's a dysfunction in that in that muscle as well. So some of the other quick things that I look for is I'll map a neurological map of the nerves of the medial foot. So I'll map the medial calconeal nerve. There's an inferior calconeal nerve that sometimes branches off and runs to the posterior heel that can be involved. Post-hib, the medial lateral branch, and then the baxis branch. So I'll palpate those and mark those and create a map of where those particular problems are. And then finally, what I look at is the gastroxilius complex, particularly at the musculoskeletal junction, can develop issues in terms of trigger points. And so with those trigger points, they can cause referred pain into the heel as well. So I'll palpate those areas, looking for potential trigger points that's actually referring pain back into those regions. From an imaging perspective, in clinic, got to have the ultrasound. So I'll use a power Doppler as well. So I'll power Doppler in around the medial heel and the inferior heel. So we're looking for neovascularization tissue in around that area, and so that again helps supports the neurovascular aspect of plant fasciitis presenting itself as well. What else do we look at doing? You look at MRI. So MRI, we look at utilizing.

SPEAKER_00 21:22

Uh-oh. We got a little glitch here. That's what happens when we have international, right? It goes all the way around. Just one second. Okay, we good.

SPEAKER_02 21:30

Okay. We good? Okay. Okay, we're split. We dropped out for a minute. We had a little break.

SPEAKER_00 21:38

Little little brain break. Oh my gosh.

SPEAKER_02 21:43

Okay, so we'll be here.

SPEAKER_00 21:45

Do you get MRIs for everybody?

SPEAKER_02 21:48

I will get MRIs if I'm suspecting Baxter's neuropathy. And so if I'm suspecting issues with the Baxter's nerve, I'll get MRI. For those who are not aware, I'm Looking at getting involved in writing some articles and doing some research into plantar fasciitis. So what we're doing is is I'm starting to MRI all my patients at the moment. So it's yeah, so we're collecting a good a good series of cases in regards to that. But if there's Baxter's neuropathy, then what I do is I look at if I suspect that we do the MRI as well.

SPEAKER_00 22:22

Gotcha, gotcha. Man, you like I have lots more questions. That is that is a lot of like when I'm when I'm I've I feel so like inadequate, but when I'm looking at plantar fasciitis, I'm like, hmm, I don't map the nerve. I do look at Baxter sometimes, but man, that that really nice kind of overview of a very comprehensive approach to looking at plantar fasciitis and not as like a oh my heel hurts. Oh, does it hurt here? Yep, you probably have a plantar fasciitis. Here's some orthotics, right? That's such a more comprehensive approach and such a thoughtful approach. I really it's really great. So, you know, clearly cortisone is still the most commonly used intervention, right? For plantar fasciitis. If this neurovascular model is correct, and then cortisone is maybe harmful in many cases, then you know, do we then make that jump to say, okay, the current world standard is not just suboptimal, but maybe harmful? So what are the strongest arguments against cortisone as that first line treatment for plantar fasciitis? And and do we need to really put more thought into saying, hey, listen, this is harmful. Not only is it okay, well, it probably won't work long term, but is it actually causing harm? And what what's that the what are those risks?

SPEAKER_02 24:05

Yeah, look, I think because the topic of our discussion here is with chronic cases, before I jump into like the arguments, is I do believe cortisome does have a place in the acute setting. So where there's a true inflammatory phase that's actually going on, and we want to knock that initial inflammatory phase on its head. So something like your first maybe week to maybe six weeks, I do believe it does have a place for a single ultrasound guided injection into that area. But the challenge is, is it's used as a default intervention for chronic recurrent and treatment-resistant plantar fasciitis, and it's often done repeatedly, and I think that's where the issue and the big issues come along. So, first argument is the evidence base for cortisone has never supported its use for chronic use. What's happened? We've just chosen to read it that way.

SPEAKER_00 25:05

We were reading it wrong, or maybe you know, we just didn't realize that was there was other treatments like orthobiologics, right? Or you know, maybe maybe maybe we didn't know that yet. So yeah, there's definitely a gap in in training and education regarding that. So I think it is unfortunate.

SPEAKER_02 25:28

Yeah, it's huge, it's huge. So with uh I did a systematic literature review, and this has been pretty ambiguous, so and it has been for years. So a meta-analysis of 47 studies, randomized controlled trials with 2989 participants found that cortisone was effective in reducing pain in the short term, but with no significant findings for the medium and long term. Well, the other interesting thing is after three months, cortisone is just not neutral, it's act actually actively outporn by cheaper, simpler biologically opposite interventions, particularly like PRP. So the thing with cortisone, what it does it suppresses, remember that no susceptive environment temporarily, and that is the real effect in terms of what it delivers in terms of short pain relief. But what it also does, it stops and inhibits the angiogenesis process, and that's what we need from an orthobody from a biological perspective moving forward for people with the chronic case, and so it has really potent anti-angiogenic effects, and so that reduces BEGF production and also inhibits endothelial cell migration as well, and that all affects how we get revascularization of that tissue and healing of that tissue in that particular area. So, argument three the structural damage is real and documented and under-reported. So one of the arguments is that reporting of adverse reactions to cortisone is possibly underreported. So the most common things we see is fat pad atrophy, plantar fascia rupture, and lateral plantar nerve injury. And so the rupture occurs in, if you have a look at the literature, anywhere from one and a half to 2.4% of the population. Now, going on the United States, planet fasciitis accounts for over a million physician visits per year in the United States. So there's a pretty high number of people walking around with adverse reactions as a result of cortisone.

SPEAKER_00 27:43

Dun dun dun.

SPEAKER_01 27:45

Dun dun dun.

SPEAKER_00 27:47

So yeah, I mean, we were talking offline that as we go forward, you know, as we start to more critically look at our use of cortisone and more critically understand that not only is it not neutral, but is it damaging of the tissue. I know in the orthopedic literature, there was a there's some pretty you know damaging studies showing that intraarticular injections of cortisone in hip arthritis accelerated that hip arthritis significantly. And so that was really the the the tip of the iceberg in condemning intraarticular use of cortisone for hip arthritis. Do you think that that's going to, as as we start to go forward, do you think that there's enough evidence currently to start to push and say, hey, not only is it not neutral, but it is a it is damaging in a majority of the patients. Do we have enough data to show that right now?

SPEAKER_02 28:48

I don't think we have enough data, so we need a lot more more data. But the more and more studies that are coming out, and the more studies that will would support the neurovascular response in terms of chronic plantar fasciitis, I think, I think, yes, in terms of the chronic cases, most definitely. I think it still has a place in acute cases. The only time I use cortisone in people with plantar fasciitis, if they have a what I call an interstitial bursitis that sometimes comes along with the plantar fasciitis. And that's the only time that I'll use a cortisone for plantar fasciitis is to treat that bursa.

SPEAKER_01 29:22

Gotcha.

SPEAKER_02 29:23

Everything else, it yeah, everything else is ortho biologic that that I look at utilizing.

SPEAKER_00 29:28

Gotcha, gotcha. So, you know, if a physician is seeing a patient with recurrent or treatment-resistant plantar fasciitis, what are the red flags to maybe suggest maybe an autoimmune driver rather than a mechanical or degenerative? And and then how does that change? You know, based on the systemic inflammation, how does that change your treatment plan?

SPEAKER_02 29:54

Yeah, that change it changes it really from my perspective, really aggressively. I've because we offer a concierge service, and it depends what you I think it depends on what you're trying to deliver in your practice. So my focus is delivering a really high-level concierge service with really high-level results for people. So if we have red flags for autoimmune disease, I actually don't treat them with ortho biologics. And that's just a personal preference in terms of the variability of responses that we get, I get with those those specific patients. And that's just a decision we've made not within our business. So the red flags for autoimmune or systemic drivers, so the thing is in like your mechanical fasciosis, anthesis fails because of initially load vascular deregulation, and then there's neurovascular remodeling, so it's what I call a bottom-up process. In inflammatory enthesopathy, the enthesis fails because immune cells are targeting it, and it tends to concentrate at high stress attachment sites in the body. So, you know, the Achilles, plant fascia, you know, elbows, wrist, shoulder as well. So those there's a really close link between enthocitis and cyanobitis in swelling of the peripheral joints, suggesting that the enthocytis incites an inflammatory response that's really closely related to synovial tissue in people with autoimmune disease. So some of the red flags are sort of it's they're sort of like a cluster of folks. So typical mechanical plantar fasciitis, so it's worse with first steps in the morning but improves as you're going along, but tends to recur with really, really prolonged standing or end-of-day pain. So what tends to happen in people with the autoimmune stuff is they'll get again pain first thing in the morning, but what happens is that pain tends not to dissipate, it tends to reduce a little bit, but tends to stay for most of the day. Then morning stiffers will typically last longer than say 45 to 60 minutes, and often these people will have pain with rest. So your typical feature of mechanical fasciosis is that once they get off their feet, pain goes away. But if they've got some autoimmune problem going on, then what you'll find is that they'll rest, but they'll still have residual pain that's presenting and going on that actually doesn't go away. These people will typically have night pain that wakes them from sleep, and that's typically the second half of the night, and often it's bilateral. Some of the other indicators are other joint pain, generalized aches and pains that are going on. I see a lot of women that have thyroid issues, so thyroid disorders with musculoskeletal problems, so they've got a myriad of other conditions that are going on and other problems that are going on. And then the other common thing is the is the sausage digits. So typically these folk they'll get like a uh non-specific swelling of maybe one finger, maybe two fingers that are going on. And really, typically, you'll see this with people with psoriasis, huhvitis, people have had like a preceding infection, so always screen for that. So uridogenital, gastrointestinal intestinal infections, and that typically that that heel pain will start anywhere from say two to six weeks after that bout of infection that they've had, things like inflammatory bowel disease. So the other thing is to my concern is I'm often seeing people at the end of their treatment. So they've been to every man, what I call every man and his dog, they come in, and often they're coming in with, so they've said, I've had three or four cortisone injections for this, it's not going away. They'll turn up with a bag full of orthotics and bag full of shoes saying to me, Oh, I think I need some new orthotics. These these are just all little things that are are really are really highlighted. And like for all of us, first line blood, ZSR, CRP, HLAB27, anti-nuclear antibodies, uric acid, all appropriate or appropriate tests that we should be doing. And just imaging, I like to use the Doppler hyperumria at the seeing if there's any hyperumria at the enthesis. So if they come in with that history and then they're showing that on the Doppler as well, okay, that's sort of a really, really big red flag. So you're building building like a schema of of checkboxes to say, yep, we believe that this is autoimmune.

SPEAKER_00 34:17

Gotcha, gotcha. For the for the physician who is currently still treating plantar fasciitis with cortisone and wants to transition to a more regenerative approach, what does that shift look like practically? So, what do they need to learn? What do they need to stop doing? Maybe what is the minimum viable protocol to get started on this shift towards a regenerative medicine style treatment for plantar fasciitis?

SPEAKER_02 34:44

I think the essential thing is ultrasound. If you're looking at getting into regenerative, you have to have ultrasound. That's I think that's a game changer, and it just improves your results out of sight. So, my first thing would be invest in ultrasound, ultrasound training. If you want to sort of like quick step on things, look at go to a course on perineural injection therapy, prolate therapy, PRP training as well. So that's really, really cost effective in the States. Like you can get some really good PRP training, it's really, really cost-effective, quick. You can go go away and do, say, a weekend course with lots of organizations in the US that provide that. So I'd look at doing that, and then get a few cases up and going, and then invest in some of the machines that electrotherapy machines that actually assist with your regen. I use laser a lot, so we particularly in acute stages of plantar fasciitis when maybe the first two weeks is I'll just laser it if there's just pure inflammation in that area, and three weeks, two to three weeks of laser treatment, real really quick frequency, I can get acute plantar fasciitis to settle really, really nicely. A laser is great because it's non-invasive, it's easy here in Australia. I can get my assistants to do it so I don't have to be in the room using a laser to actually get that. It's really a big mind shift shift in terms of treating plantar fasciitis. So it's having a look at, you know, we've got the classical medical cortisone model inject orthotic shoes, physical therapy. So it's really a mindset change into okay, what's actually going on from a neurovascular perspective and what stage are they at in regards to that journey? Some of the things that I would stop, I'd stop doing blind cortisone injections into the planopascia origin, stop repeated cortisone injections for chronic or recurrent plano fasciitis, and stop using cortisone as a default. You know, we tend to use tend to use it as a default treatment to get that to settle itself down. So yeah, that that would be my recommendation in terms of your steps and and steps and progression. In two months, you can have all of that, all of those tools ready to go.

SPEAKER_00 36:59

Nice, nice. So after 5,000 cases, what do you think is the most single surprising thing that you've learned about plantar fasciitis that you didn't expect when you started, clearly, if you had a couple of years under your belt, just like two. And you know, what do you think still most physicians treating plantar fasciitis still don't know?

SPEAKER_02 37:26

I would look at treating plantar fasciitis as an organ. And so once I took on that concept, so the plantar fascia is this complex organ with multiple tissues that needs a systemized biological approach in terms of treatment. Once I started taking that approach, results changed in terms of getting the plantar fascia to heal itself and getting people back out back out into life. So that would be the single thing that I would say that really changed how I look at this.

SPEAKER_00 38:00

Amazing. Oh my goodness. So here's my question: what is the next step? Well, clearly we've talked about this. Uh, you know, Dr. Ben Sidley, thank you so much for sharing a really, I think, unique approach, a thought, a process change to plantar fasciitis or fasciosis, or you know, the the organ of the plantar fascia. But you know, you also do need to take that knowledge, and we have to be able to attract those right patients, right? So these acute plantar fascia patients maybe are not the patients that we are looking to serve or looking to serve those those patients who are really at their rope's end. And then we also want to be able to have this system, create a cash-based business, have converting consultations that really walk the patient through, and then clearly this putting it all together for success. And that is our practice launch system. And so you this is how we take all this knowledge and pick the right patients, the ones that need your help. If you're thinking that you are ready to integrate orthodiologics into your practice, make sure you scan this QR code. And what this will do is help you make the decision for what the next step is going to be. Now, once we get that, we'll just make sure you just scan that QR code. I'll flip back to that. Now, if you want the fast track, I have a really exciting option. We have a three-day immersive event to create your predictable cash pay offering for your practice. This is June 5th through the 7th, and this is an immersive event. This is a working group session to build your plan. And this is not a passive event, it is not calm and sit and listen. This is a plan that we are building alongside with you with guidance in real time. So by the time you're done with the weekend, you have a predictable cash pay practice. So we are going to limit that to 40 positions. So please, this is not a massive event. This is a small, intimate event, personalized event to be able to get that predictable cash pay option up and running with, and and you'll leave with a 90-day plan. So I am gonna go ahead and just have you scan that QR code. I'll drop the link in the chat if that's something that you're interested in. Uh go ahead and we'll go from there. All right. So what I'm gonna do now is we're gonna go over to the QA. So thank you so much. Man, your QA has been doing all crazy. The conversation is going nuts. So we got a lot of questions to hit before you get going. So there is a question on how do you define and identify Baxter's neuropathy? And and is there a role for platelet lysate or is PRP just as good?

SPEAKER_02 41:23

So there's a role for platelet lysate specifically for nerve. So I'll look at utilizing lysate for nerve, but I also find D5 really, really effective, really, really easy as well. So it's yeah, I'm more of a proponent of that D5, but most definitely the platelet lysate. So identify uh Baxter's neuropathy, is so what we're looking at is clinically you're palpating around around the origin of the abductor hallucis, because Baxter's nerve passes through a fascial plane of the abductor hallucis. So you're palpating that in around that region. So you'll palpate if it produces symptoms that go into the heel, also into the lateral foot, then that's an indicator of Baxter's neuropathy. I'll also do a sensory testing around the medial heel and compare that to the opposite heel. And so there'll be altered sensory patterns in around that area, typically a loss of sensation in that region. Then you're looking at the abductor digidi minimum because what Baxter's nerve does, it sends a motor innervation to that muscle. And so what you're doing is you're doing a comparison of that muscle with the opposite foot, just looking for muscle bulk. Has there been some wastage? And then also you're looking at the clinical test. So can the patient separate that fifth toe from the fourth toe? That's activating adductor digidine minimized. So there's some clinical tests that you can actually do. If you suspect that there's Baxter's neuropathy, you can also utilize a diagnostic injection in and around the Baxter's nerve, and then what that can do is that can is really a good tool to differentiate if there's a true neuropathy that's going on there.

SPEAKER_00 43:04

Now there's some questions about how to best identify that Baxter's nerve on ultrasound. Do you have any good tips or tricks to be able to be like, aha, here we are? Because sometimes I'm like, uh, I'm pretty sure this is Baxter's nerve, but it doesn't have a label on it. So is there some tips that would be helpful for everybody to kind of get that? And then you're the when you're talking, you're talking about five percent dextras, and and what we classify that as is neuroparallotherapy, right? Yeah, awesome. Okay.

SPEAKER_02 43:36

Hang on a second, I'll grab my foot so we can demonstrate this.

SPEAKER_00 43:40

Okay, awesome, awesome, awesome.

SPEAKER_02 43:44

Okay, can we see the foot?

SPEAKER_00 43:46

We can see the foot.

SPEAKER_02 43:48

Okay, awesome. Okay, so what we're doing is so you've got your abductor abductor hallucis running down through here. Typically, what we'll do. Is with ultrasound you locate uh bone so bony landmark so medial malleolis. I'll do it in short axis to the posterior tibial nerve. So we're running short axis, running down, running down, and I'll locate the ultrasound probe in around this area. And what we're looking for is firstly, I'll look for there's a small uh blood vessel that branches off the tibial artery, and that follows and courses itself along the backsis nerve. So you're actually looking for that little little area, and it'll sit around about this region here, and then in terms of approach, injection approach, is I'll go long axis to the probe. So the probe's short access to the vessel, but the injection is long axis. So we come in from the posterior heel, and then probably at about a what are we looking at? At about 30 degrees, and then come come in.

SPEAKER_00 45:09

This is worth it all. Like I'm done. This is so great. It's because you know, I struggle with this. This is fantastic. So you're in in plain technique, short access to that vessel that's branching off the tibial artery. Awesome. Holy cow. Okay, well, that this is worth it just here. Thanks a lot.

SPEAKER_02 45:30

Yeah, so that's the approach, and and it takes practice this one. So it's it's and often I'll I'll just use the needle, I'll get the needle in, position the needle, and then sometimes I I always ask the patient, just tell me if you feel any sharp pain. And so slow approach, okay. We're there. We're you know, yes, I feel a sharp pain, yes, I've got pain, they're getting pain going into the heel, and then I just back off a little bit, and then I'll drop anywhere from say about five to ten mils.

SPEAKER_00 45:56

That was gonna be my next question. Yeah, so that's a lot.

SPEAKER_02 46:00

Yeah, it is a lot, and it will be quite tense in that area, and that can do two things. So, what that can do is if it's a true like neuropathy that's going on, the pain will settle, the pain will ease over time. But sometimes what happens is that they might have a really severe compression neuropathy, or if there's a lesion that's sitting inside of the inside of the nerve as it passes through the fascia, when you drop that high volume in there, and once the local local runs out or wears off a bit, is that they'll get intense pain. So that's a really good indicator that there may be a lesion that's sitting in that fascial plane as well.

SPEAKER_00 46:40

Gotcha, gotcha. Yeah. There was a question about you know, doing hydrodissection of the the posterior tip nerve, you know, would a local anesthesia or just hydrodissection, would that be effective to relieve the symptoms, but it probably wouldn't treat it. Is that correct?

SPEAKER_02 47:05

Well, it again it depends on what's driving the pain here. And that's the thing. Is it like an acute inflammatory and angiogenic where there's lots of inflammation in around that area? Is that driving the the pain and it's actual mechanical type pain? Is the pain being driven by like neurogenic? So is it neurogenic pain? Typically, what I find with the neurogenic pain, as soon as you do the nerve work, pain starts to settle immediately. So we I had a guy who had complex, what I call complex plantar fasciitis. So he had multiple plantar fascia tears, he had fibromas in the proximal portion of his plantar fascia, he had Baxter's nerve and posterior tibial nerve neuritis that was causing the pain. So he had multiple tissue issues that were generating pain. So we PRP'd the tear, we PPP'd the fibromas and fenestrated the fibromas using a D5 solution, so we separated those out. And then we also did a little bit of nerve work on the Baxter's nerve, and we got him some laser. So at four weeks he was still getting quite a bit of pain, and we isolated that to the Baxter's nerve. We did another hydro dissection at four weeks, and then we did a two-week review, and at two weeks his pain had reduced by about 80%.

SPEAKER_00 48:28

So that's pretty impressive. That's really amazing. Now there's a one question here, and I was asking, I was thinking the same thing. What are you doing for pain relief for all of these patients to be able to tolerate the injection and such?

SPEAKER_02 48:43

Yeah, I'm really kind. So I'll block the post-tib nerve in two locations. So I'll block about probably about three centimeters proximal from the medial malleolis, and then I'll also block at the tarsal tunnel, and that gives me almost immediate foot coverage. So the whole foot's numb, and then what I'll do is I'll just do a planter wheel on the bottom where we go in for the injection. My injection technique, a lot of the technique comes immediately, but I actually like to come from a distal proximal approach on the planter aspect of the foot. So I'll have the patient lying down on their belly, I'll have my nurse holding the foot like this, and then I'll come in plane to the planar fascia and inject. And for me personally, just for how I do it, I find I can get better approach into the emphasis at all different locations. Whereas if I'm taking a medial approach, I can get the medial well, I can get the middle aspect well, but I can't get the lateral aspect if they're getting lateral aspect issues as well. So I like to get good coverage, I like to get really, really good coverage across here, but you do need assistance for that.

SPEAKER_00 49:55

And then one final question: the there's a question if you get calconeal edema on the MRI that's present with the plantar fasciosis, do you immobilize? Do you change your approach? So maybe talk a little bit about that.

SPEAKER_02 50:10

Okay, so there's two approaches that I'll do. I will immobilize, so I'll do the procedure. I'll immobilize for two weeks, then we'll do a pain review in terms of how things are tracking, and then what I do is a progressive unloading out of the moon boot, and so I'll progressively unload over a four-week period. So it might be okay, today you're just going to go barefoot for half an hour, and you're in the moon boot for the rest of the day. Following day, okay, you're out of the moon boot for an hour, you're in it for the rest of the day. So we do a progressive unloading, so to speak, out of the moon boot. I have done one case study where had wasn't responding to any treatment, and what we did is we did a I did an interosseous injection of PRP into the bony edema.

SPEAKER_00 51:06

And that resolved.

SPEAKER_02 51:08

Yeah, using an eight-ing gauge.

SPEAKER_00 51:10

Yeah.

SPEAKER_02 51:10

So yeah, and they responded really, really well from that. Sometimes it just needs that bony edema just needs decompression. Sometimes decompression is enough to stimulate healing and and get the pain to settle down and get that lesion to settle itself down as well.

SPEAKER_00 51:25

Yeah, yeah. There's that's also controversial, you know, with the bony edema. Do you need that decompression, the vascular decompression? So my goodness, Ben, thank you so much. How do people get a hold of you if they have further questions? Oh, great question.

SPEAKER_02 51:47

Yeah, they can get on the website. I'll just put my email. Like if anyone wants to shoot me questions, I'll probably be delayed because we're in a different time zone.

SPEAKER_00 51:57

Yep, yep. This is halfway across the world and down around the the other way.

SPEAKER_01 52:01

Okay.

SPEAKER_00 52:02

Well, thank you so much for joining me. Really appreciate it. So I put the the link for the practice launchpad live event, that immersive event we're doing in June. So if anyone's looking to really launch their orthobiologic practice, if you're not sure if you're ready or not, please take this quiz. And then this has been so, so phenomenal. And if nothing else, now we all know how to do a hydro dissection on boxer nerve under ultrasound guidance. So phenomenal job, as always. So amazing. Thanks for watching. Everyone else, thanks so much for joining us and hanging in there. And we'll see you in two weeks for a really exciting talk about culture expanded stem cells. So we'll see. I know. Woo! We're gonna see you then, and we'll see you in two weeks for the next adventure on conversations in regenerative medicine. Have a great night, you all, and we see you next time. Thanks again, Dr. Sibley.

SPEAKER_02 53:05

Thank you.