Ep 348 – Exploring Plantar Foot Pain with Whitney Lowe

A set of hands rubbing the plantar area of a foot.

There are several potential causes of plantar foot pain, including the most common, plantar fasciitis. In this episode of The ABMP Podcast, Kristin and Darren are joined by Whitney Lowe to discuss common causes of foot pain (including Morton’s Neuroma), muscle-tendon pathology, and some treatment options for each one.

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Author Bio: 

Whitney has been in the profession for more than 35 years. He is the author of the profession’s first accessible assessment text, Orthopedic Assessment in Massage Therapy. He is a contributing author on several other texts, as well as hundreds of published articles. He developed the groundbreaking orthopedic massage online certificate program, applying innovative educational methods and technology for the first time in the profession. He is a member of the editorial advisory board of the Journal of Bodywork & Movement Therapies and writes the Clinical Explorations column for Massage & Bodywork

Hosts:

Darren Buford is senior director of communications and editor-in-chief for ABMP. He is editor of Massage & Bodywork magazine and has worked for ABMP for 22 years, and been involved in journalism at the association, trade, and consumer levels for 24 years. He has served as board member and president of the Western Publishing Association, as well as board member for Association Media & Publishing. Contact him at editor@abmp.com.

Kristin Coverly, LMT is a massage therapist, educator, and the director of professional education at ABMP. She loves creating continuing education courses, events, and resources to support massage therapists and bodyworkers as they enhance their lives and practices. Contact her at ce@abmp.com.

Related Content

ABMP CE course "Plantar Foot Pain" with Whitney Lowe and Til Luchau

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Full Transcript: 

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0:00:39.0 Darren Buford: I am Darren Buford. 

 

0:00:48.1 Kristin Coverly: And I'm Kristin Coverly. 

 

0:00:49.3 DB: And welcome to the ABMP podcast, a podcast where we speak with the massage and bodywork profession. Our guest today is Whitney Lowe. Whitney is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His text and programs have been used by professionals in schools for almost 30 years. Learn more at academyofclinicalmassage.com. Whitney also co-hosts the ABMP-sponsored Thinking Practitioner podcast available on all podcast platforms. And Whitney is a continuing education provider with courses found in the ABMP education center, including a course on plantar foot pain, and he is a longtime author and columnist for Massage and Bodywork Magazine. His work exploring Plantar Foot Pain Parts One and Two are the basis of our discussion today and can be found in the January/February, 2023 and March/April, 2023 issues. 

 

0:01:41.3 DB: Hello Whitney and hello Kristin. 

 

0:01:42.9 Whitney Lowe: Hi everybody. Great to see you both. 

 

0:01:44.7 KC: Whitney, it's wonderful to have you back on the ABMP podcast and we're excited to be talking with you today about this topic because plantar foot pain is such a common problem that our clients experience and come to us to help with. So we really need to know more about that. So listeners, here's how we're gonna structure our conversation with Whitney today. We're gonna talk about three of the common causes of foot pain, plantar fasciitis, nerve entrapment, specifically Morton's neuroma and muscle tendon pathology, and a treatment option for each of those three conditions. In his articles, Whitney shares nine different techniques for foot pain and identifies which techniques are beneficial for each of the conditions. So here on the pod, because we don't have time for all of that, unfortunately, we're gonna talk about each of the conditions and one technique for each. So Whitney, let's get started. Let's start with plantar fasciitis. What are some of the common causes of plantar fasciitis and what's happening physically in the body to cause the pain?  

 

0:02:43.0 WL: Well, that's kind of like an open question right now because we used to think we had a good idea of what was happening to it. If you think about the name of this condition, fasciitis, it would indicate that there is an inflammatory process going on in the plantar fascia. And that's been sort of like the common idea for quite some time. But several years ago, we began looking at a lot of these connective tissue disorders that were associated with chronic overuse problems and finding there might be less inflammatory activity going on in many of those instances than we thought. And a lot of times the inflammatory activity is not in the plantar fascia, in this example, by itself. And so sometimes you might... More frequently hear people even talk about plantar fasciosis, which essentially means pathology of the plantar fascia. 

 

0:03:28.0 WL: And sometimes there's a more of a collagen breakdown, breakdown of the collagen matrix in that plantar fascia that's leading to the problem. But there can also be, especially in plantar fasciitis, a lot of problems with the attachment side where that plantar fascia attaches onto the front side of the anterior base of the calcaneus. And when a connective tissue like a tendon or ligament attaches into a bone, it's a little deceiving when we think about this from what we learned in our anatomy study and anatomy books because it looks like the tendon or the ligament just attaches directly into the bone and that's it. But it goes through a very thin membrane around the bone called the periosteum. 

 

0:04:07.0 WL: And the periosteum is one of the most pain sensitive tissues in the body. So when you have constant pulling on that periosteum, as you do in plantar fasciitis, that's what causes a lot of the irritation and the extreme pain that people feel. So it's pain out of proportion to the level of tissue damage or irritation that's actually happening, but it's quite painful because that periosteum is so richly innervated and that's... Like kind of what's happening in most of those cases is some degree of tissue degeneration in there in the plantar fascia and some degree of periosteal pulling and irritation. And that periosteal pulling may also eventually lead to bone spurs developing on the front side of the calcaneus and that can become another problem as well. 

 

0:04:46.4 KC: And I'm curious, Whitney, what are some of the lifestyle factors that might contribute to someone developing this condition?  

 

0:04:53.8 WL: So we almost always have to look at foot mechanics as being a factor here. And sometimes this can happen from people with an excessively high arch, or the opposite, a completely flattened, or a loss to dropped arch of the foot. And we're talking here about the longitudinal arch that runs long ways down the foot from the toes back toward the heel. And the plantar fascia acts like a spring on the underside of that arch to sort of help shock absorbency of the foot and deal with alterations and ground surfaces and things, especially when we are doing a lot more things barefoot and has a lot of function of maintaining that propulsion of the body and pushing us forward. 

 

0:05:32.5 WL: So, the condition usually develops from improper foot mechanics and sometimes that's wearing, let's say like construction workers wearing steel shanked boots that just have a rigid under surface and don't have spring to them or it's the retail worker who's standing on her feet all day in a department store in high heeled shoes even. And so we've messed with foot mechanics in all kinds of ways with the shoes and the occupations and the things that we do. Or maybe it's a runner. A person who's doing recreational running and they're running on hard surfaces with poor footwear. That's just kinda like they're... The cushioning of their shoe. Their running shoes kind of collapsed a little bit and it's usually some type of repetitive loading on those structures that leads to the gradual dysfunction of the plantar fascia. 

 

0:06:18.4 DB: And Whitney, I know that you mentioned also as well, sometimes it can be a rapid weight gain that found in pregnancy too, right?  

 

0:06:24.6 WL: Yeah. Yeah. So that... Again, we have to... When we talk about foot mechanics or lower extremity mechanics, we have to think about all these things in the body that are playing a part in weightbearing, because that can change and shift. And here's another thing you think about, what you mentioned Darren with pregnancy, is that in pregnancy, especially in the later stages of pregnancy when the weight gain is greater, there's also greater concentration of relaxing in the tissues, which is the hormone that allows the ligaments to expand for childbirth. And that makes that individual less able to rely on a lot of the ligamentous structures of the foot to maintain that stability. So greater stresses are placed on some of those other tissues to take up the slack and play a part in that. And then, once you have a little bit of the loss of that stability of the foot, you can start having greater degrees of overpronation and other types of foot mechanic problems that then lead to as well. So it becomes this vicious cycle spinning out of control sometimes. 

 

0:07:19.8 KC: Okay, Whitney so, as a practitioner, if I have a client presenting with plantar fasciitis, what is one technique that you suggest we try to work with them?  

 

0:07:31.9 WL: So this gets into some interesting places when we talk about what we can do with them, because I am a big advocate, of course, of what we do with massage. But one of the things that I emphasize a great deal with these things is, a lot of what's gonna make the biggest difference is what happens outside the treatment room. And this becomes a really valuable and important point for clinicians and practitioners to remember, is that you really have two primary roles. You have the role as the clinician, doing work with them in the treatment room, and then you have the role as the educator. And every practitioner is an educator. You're gonna educate your clients because a lot of this has to do with what you're gonna encourage them to do and to not do outside of the treatment room. So, we can do a lot of work just on the tissues on the bottom surface of the foot just to try to help relax mainly the intrinsic muscles of the foot. 

 

0:08:18.5 WL: There isn't a lot physiologically that we will change or do that will alter the structure of the plantar fascia itself. So a lot of this is just overall pain management, improvement of proprioception, nice, good broad contact, gliding things with the backside of fist or the palm or more specifically with the thumbs, fingertips, or pressure tools, all that kind of stuff can really give that client a specific sensation of having that area worked. And that enhances a lot of proprioceptive awareness in that area. And then you can say, "Now, let's really focus on what you're gonna be doing outside of here," which might mean cutting down your mileage if you're a runner, and wearing some other types of shoe inserts if you're doing some other things like that. And shoe inserts are sometimes helpful, but sometimes they're harmful. So, you gotta... Sometimes this is just a trial and error thing with people finding out what's gonna be the most supportive thing for them because some people might have a really high arch and you put additional support inside their shoe and it's too high and it really makes the plantar fascia go into too much of a curve and really loads it and puts pressure on other tissues on the under surface of the foot. So, a lot of this turns into being a trial and error process with them. 

 

0:09:27.7 KC: And Whitney, plantar fasciitis can take a long time before the client might feel pain free. 

 

0:09:32.7 WL: Oh yeah. It's a lot. And that's mainly because you can't just get off your feet [chuckle] and just not do anything. You gotta walk around and you gotta continue to load it while it's healing. So it can become a really problematic thing. And especially you see this a lot in the athletic population when somebody gets that and then they start to feel a little better and they get a little over eager to get back to their activity levels and they do too much and then they push it too far. Now you're back to you really lost ground. 

 

0:09:58.2 DB: In a worst case scenario, would surgery ever be an option? If you are not able to manually or through rest, allow a healing process to occur?  

 

0:10:07.8 WL: Surgery may be a potential option somewhere down the road. And the question always becomes what are they actually going to do in that surgical procedure? Because I'm not a big fan of a lot of those procedures being done simply because they'll go in and cut things that don't really need to be cut, because that's what you do in surgery. And there's other types of ways to address this. Now there are all other treatments that are probably gonna be done before surgery like When you've got a bone spurs that seem to be aggravating the problem you can do pulse shock wave therapy that can help break up those bone spurs. And so those are less invasive procedures that are not... They're outside the scope of what we would do with massage, but there are more... Other things that you can do short of surgery that a lot of people might wanna try as well. 

 

0:10:53.6 DB: Is that frustrating when you're trying to help the client heal through therapeutic methods and yet they want to get back [laughter] out again? How do you verbally balance that? I mean, the only thing I can bring is my own personal experience and I had a lot of elbow pain but I told the practitioner [laughter] and the physical therapist that I'm not gonna quit playing golf. So it was more like a relationship had to develop and there was a little bit of give and take on both sides, kind of what are your opinions on that?  

 

0:11:25.7 WL: I'll chime in. Kristin, love to hear what you say about this too, but it's a bargaining game, like you said. And I usually try to approach this by saying to them, "Okay, look, I'm gonna tell you here are the 10 things that would be absolutely ideal for the best healing process that you can have. Tell me how many of these things you can or are willing to do." And then we'll talk about what the strategy is for getting through that. 

 

0:11:49.8 KC: Exactly right, Whitney, and you were right on when you said it's a combination of things we can do in the treatment room. So I've had clients with plantar fasciitis, and yes I can work on that plantar foot all day, but if we're not also doing that education piece, it's really gonna take a lot longer for any change to happen. And not only are we educating, but then relying on the client to do the stretches, to change their behavior. So, it is a multifaceted process and the reason I asked about it taking a long time is because in my experience, working with my clients, plantar fasciitis is a long term condition that we're working with because it does rely on all those factors and you can't stop using that foot, having it be load bearing. So, yes, it is a very complicated multifaceted condition, all of the foot pain that we're gonna talk about today, all the conditions we're talking about, but absolutely relies on that client to do their part too. 

 

0:12:42.1 WL: And so is a teamwork process. And again, I can't emphasize this point enough because I don't think this really gets emphasized a lot in our training programs. The really crucial and important role that we play as educators, we talk a lot about educators being the people who are open front of the classroom, but everybody needs to realize that you are an educator every time you walk into that treatment room because your clients are expecting you to help them learn things and give them information about things that are going on with them as well. 

 

0:13:10.0 KC: Let's take a short break to hear a word from our sponsors. 

 

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0:14:32.0 KC: Let's get back to our conversation. 

 

0:14:34.8 DB: All right, Whitney, let's transition to nerve entrapment. What are some causes of nerve entrapment and specifically Morton's neuroma?  

 

0:14:42.4 WL: Yeah, so this is a big one that I think gets underappreciated and undervalued a lot. There are actually a number of potential areas of nerve entrapment in the foot that can cause plantar foot pain, Morton's neuroma being one of them. And again, just for a quick sort of overview, Morton's neuroma is a pinching of the digital plantar nerves in between the heads of the metatarsals. So near the toes of your feet is where this occurs, most commonly between the third and fourth metatarsals. Now, it can occur between others as well, it just happens to be the space is smallest between those and because the way the anatomy of the branches of the nerves go through there, that tends to be the space that's most common. But there's a number of places short of that you can have entrapment of those very same nerves more proximally. On the base of the foot, you can have entrapments in the tarsal tunnel, which is on the medial side of the ankle. 

 

0:15:35.7 WL: It doesn't get... A lot of tarsal tunnel problems don't get a lot of attention and they really should because for example, what we just talked about with treatment of plantar fasciitis when we talked about doing maybe deep stripping or maybe even some friction treatments like that on the bottom surface of the foot, you could have nerve entrapments on the bottom surface of your foot that are giving similar pain and a person might say, "Oh, I've got plantar fasciitis," because they have plantar foot pain. And you go in and friction or do deep work on a nerve entrapment, you're going to make that worse. So that's why recognizing the nature of these different problems and some of the unique characteristics and signs and symptoms of them is so important so that you can guide your treatment appropriately. 

 

0:16:14.1 KC: And I will chime in as someone with Morton's neuroma, bilaterally more prominently on my left side. Yeah, absolutely. It doesn't get talked about a lot. It causes regular pain and you have to be careful with your treatment options, absolutely. 

 

0:16:29.1 WL: And I'm curious, Kristin, with your Morton's neuroma, was this a chronic onset, a gradual onset, or how did it occur?  

 

0:16:36.5 KC: It was a pretty quick onset. It was at the time where I was wearing high-heeled shoes with a narrow toe box. And I remember very specifically, I went to an event in a new pair of shoes and I could almost not walk by the end of that evening. I could not get those shoes off enough. It was dramatic pain radiating from the ball of the foot into the toes and I didn't know what was happening at that time. It was long before I was a massage therapist and yeah, very dramatic. And so now I just have to be really careful. Wide toe box shoes, take care of myself, self-care, but very quick onset and then has been periodic since. 

 

0:17:14.2 WL: And the reason I ask that is that I want to make a point here about, again, making a plug for why I think both assessment and understanding the nature of some of these problems and being able to think critically about them or be the thinking practitioner. How about that? Put in a plug for the podcast. [laughter] Why I think it's so valuable to be thinking critically about these, because what you described is the sort of standard that we hear about most commonly for Morton's neuroma. Chronic onset related to footwear frequently, narrow toe box shoes and especially high heels that jam the foot down into that shoe, squeeze the metatarsal heads together and pinch the nerve. I have a Morton's neuroma on my left foot. Didn't come from wearing high-heeled shoes, not necessarily from narrow toe box shoes. It was actually the result of a martial arts accident where I was hit on the side of my foot with a stick and broke my fifth metatarsal. And ever since that point, when I wear those narrow toe box shoes, it squeezes that nerve and gives me Morton's neuroma symptoms. So it was an acute onset Morton's neuroma, which is really much less common. But again, to think about the mechanisms of that and recognize those signs and symptoms, then the solutions are very similar. Get out of the narrow shoes, do the things of metatarsal spreading and all that kind of stuff. That's really helpful there. 

 

0:18:31.9 DB: All right, Whitney, what are some treatment suggestions for Morton's neuroma?  

 

0:18:34.0 WL: So the biggest one is, and this is again, it's not always a massage solution, but change your shoes. Because a lot of times, if you can just get out of the narrow toe box shoes and get into something that's a little broader, sometimes you can get a little padded dome that goes underneath the metatarsals inside your shoe that will spread them out a little bit and get pressure off that nerve. But from a manual therapy perspective in the treatment room, we can also do some things that just feel good and really help it where you just sort of grab the distal end of the metatarsals and spread them apart and kind of mobilize those individual metatarsals with your fingers and hands and get them moving and sort of separating from each other and really working those short intrinsic muscles of the foot that don't get addressed very frequently. Those kinds of things can all aid to keeping pressure off the nerves. But the biggest factor is going to be to stop the mechanical loading that's putting pressure and squeezing the metatarsal heads together. So off with the high heeled shoes and the cowboy boots and the other things like that that squeeze the foot. 

 

0:19:36.7 KC: Okay, Whitney, let's transition now to talking about muscle tendon pathology and how the extrinsic and intrinsic muscles of the foot can really cause pain as well. 

 

0:19:46.4 WL: Yeah. So this is one where I say it's really important to go back to our anatomy resources and books and look at where things go because we forget sometimes about some of the other things that might be happening there. For example, we talked a few moments ago about plantar fasciitis and how common it is for anybody with plantar foot pain to just be either told or assume they have plantar fasciitis because they've heard about it. That's what happens when your foot hurts on the bottom surface of it. But look at the pathway of the tibialis posterior muscle. It curves around, it comes from the backside of the leg, curves around the medial side of the ankle, and then fans out and attaches to almost every foot bone in the base of your foot. And again, we talked about irritation of those tendon attachments into the periosteum excessive pulling from that tibialis posterior can irritate periosteal attachments or other ligamentous and fascial connections in there. And those are some of the big muscles that we think about, but then there's a lot of the short ones that we never really hear about much quadratus plantae and some of the other intrinsic foot muscles. And when we say intrinsic versus extrinsic, let me just clarify, intrinsic muscles are those that have both ends of their attachment within the foot complex itself. 

 

0:20:58.0 WL: So something like the quadratus plantae or the the lumbricals or any of those kinds of muscles that have attachment sites within the foot itself would be intrinsic muscles. The tibialis posterior, flexor and hallucis longus, digitorum longus, those would all be extrinsic muscles that have one end of their attachment up in the leg and the other part going down into the foot. 

 

0:21:18.7 KC: And talk to us about some of your treatment suggestions for working with a client that might be presenting with a pathology muscle tendon. 

 

0:21:25.0 WL: Well, let's look at a couple. There's a couple things to think about here with plantar foot pain. We said that we might have some attachment problems with the attachment sites in there, but you may also have things going on near the plantar side of the foot with a lot of these tendons from those extrinsic muscles, which come down from the leg and then make a sharp right angle turn before going down into the foot and then they're covered with tendon sheaths as they make those right angle turns and there's oftentimes irritation or inflammation and inflammatory reactions between the tendon and the surrounding synovial sheath. So those oftentimes benefit from deep friction treatments around the medial side of the ankle where those problems are occurring or also some of the friction treatments that help stimulate fibroblast activity to help encourage better tissue remodeling and tissue repair for anything that's torn possibly down on the bottom surface of the foot and you can have tearing of some of these kinds of muscles when you think about the violent forces that your foot is subjected to because, I mean, even just in something normal that we do like recreational running, your foot takes about three to four times of body weight on each foot strike when you land. 

 

0:22:34.0 WL: And so one of the things you have to remember is that your foot can take quite a pounding here. So for example, when you're just doing something like recreational running, you can have roughly three to four times your body weight on each foot strike when you land. And so you take an average 150 pound person and then that's somewhere between 450 to 600 pounds of impact load on each foot strike. So just think about that for a moment. And then those muscles, let's say that person is doing that kind of running and let's say maybe their plantar fascia is kind of weak and they have a little bit of a fallen arch, the tibialis posterior is taking on a lot of that role of shock absorbency to prevent overpronation of the foot that the plantar fascia and some of the other connective tissues would have been doing. So a lot of the muscles and tendons in the foot, both intrinsic and extrinsic muscles, really have to take on a lot of that chronic overload issue. So when we're working with foot problems, it's crucially important we not only do a lot of our techniques and special focus on those foot muscles, but take that all the way up into the lower extremity certainly into the lower leg region, but all the way on up through the lower extremity kinetic chain as well. 

 

0:23:43.8 DB: And from the client perspective, I just think how valuable it is for all the weekend warriors out there to take it slowly. 

 

0:23:51.0 WL: Well, we all do that like I remember this time when I, this friend of mine, I've never really been a runner, I've never been a really good recreational runner. And so this friend of mine talked me into doing one of these, I don't know, 10K races or something for some charity event because I was gonna get a free T-shirt or something like that. So that was the incentive. And this is back in Atlanta. It's very hilly. We were running hard asphalt and I was, I don't know, maybe two kilometers, three kilometers into the race. And I started just getting this screaming iliotibial band friction pain on both sides of my knees. But it was kind of like, "Hey, this is cool. I know what this is. And I know why it's occurring. And I know how I can adjust those kinds of things." But everybody has their different motivations to keep pushing through and doing things. 

 

0:24:32.1 DB: All right, Whitney, as we bring this podcast to a close, what are your takeaways for our listeners today?  

 

0:24:37.5 WL: Well, the big takeaways that I would say is that first of all, so many people out there have lower extremity, but in particular foot pain problems that we can really do some great things for. And I would say that I do think what we're doing, our approach is a combination of the manual hands-on things that we do in the clinic with them, as well as good education about some things... Learn some things about foot biomechanics and the loading of those tissues, because it really helps you understand what might have been damaged, overloaded or taken a bit more than they really should have been taking on and find ways to really work together with your client as much as possible to find good solutions for doing those kinds of things. And here's the other thing. We didn't really get into this a whole lot, but the feet are so absolutely richly innervated. I mean, if you were just to talk to somebody about like, "Hey, would you like me to rub your feet?" Most people would say, "Yeah, that would feel great," because it feels great. And we cannot under emphasize the value and importance that that has in settling down a lot of excessive nervous system irritability in dealing with any kind of pain complaint. Just rubbing their feet and making them feel better, it's really therapeutically helpful. So even if you're not absolutely sure what the nature of that problem is, by rubbing somebody's feet and helping them feel better, you're doing good things for them. 

 

0:26:02.5 DB: I want to thank our guest today, Whitney Lowe. For more information about Whitney, visit academyofclinicalmassage.com and read parts one and two of this column we discussed today by visiting massageandbodyworkdigital.com. Thanks Whitney and thanks Kristin. 

 

0:26:16.3 WL: Thank you both. 

 

0:26:17.7 KC: Whitney, thank you so much for this incredible conversation today. Fantastic. 

 

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0:26:28.7 S1: Members are loving ABMP2 Five Minute Muscles and ABMP Pocket Pathology, two quick reference web apps included with ABMP membership. ABMP Five Minute Muscles delivers muscle specific palpation and technique videos plus origins, insertions, and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology, created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the featured benefits section of your member homepage. Not a member? Learn about these exciting member benefits at abmp.com/more.

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Minnesota Introduces Licensing Bills for Massage and Asian Bodywork Therapies

Serve the best interest of your profession and the public while ensuring ongoing competence and high standards of practice. How? Support licensing efforts in Minnesota! Write a letter to your elected officials, sharing why licensure is an important and necessary step to advance the massage therapy industry.

ABMP Advocates to Protect the Autonomy of the Arizona Massage Board

ABMP submitted written commentary to the Arizona legislature regarding House BIll 2169, which would merge the Arizona State Board of Massage Therapy with the Arizona Barbering and Cosmetology Board. We are opposed to this legislation and invite you to read our comments and write to your elected officials.

Blog

ABMP CE Summit: Headaches

 Headaches.

Join us online Tuesday, April 30, 2024, for the ABMP CE Summit: Headaches, which take learners on a journey from understanding headaches to working with clients with headache pain using multiple modalities and techniques.

New CE Course: Stretching the Hip

Dr. Joe Muscolino displays a massage therapy technique.

The new ABMP CE course, “Stretching the Hip,” is available in the ABMP Education Center to view and earn 1.5 CE hours.

Benefits

Podcast: Gainful Employment (and the 100% Rule)

Les Sweeney, president and CEO of ABMP, and Lance Hostetter, ABMP director of government relations, explain the 100% rule, the flaws within the rule, and the Interstate Massage Compact.

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