Summary

Plantar Fasciitis is the most common cause of heel pain in adults. Historically termed an inflammatory "itis", it is now understood as a degenerative "osis" (microtears and collagen degeneration) at the origin of the plantar fascia on the medial calcaneal tubercle. Characterized by "Start-up Pain" (severe pain with the first few steps in the morning), it is self-limiting but can last 12-18 months. Management is overwhelmingly conservative (stretching, orthotics, shockwave therapy); surgery is a last resort due to the risk of lateral column instability/arch collapse. [1,2]

Key Facts

• Pathology: Angiofibroblastic hyperplasia (Degeneration, not inflammation).
• Site: Medial Calcaneal Tubercle (Origin).
• Symptom: "Start-up pain" (Post-static dyskinesia).
• Risk Factors: Obesity (BMI >30), Tight Achilles (Equinus), Standing occupations.
• Natural History: Self-limiting (12-18 months). 90% resolve without surgery.
• Imaging: Diagnosis is clinical. X-ray often shows a "Heel Spur" (which is irrelevant - 50% of asymptomatic people have one).

Clinical Pearls

"It's Not the Spur": Patients obsess over the "Heel Spur" seen on X-ray. Explain that the spur is a Traction Osteophyte (bone growing into the ligament due to pull) or lying in FDB muscle, not the cause of pain. Removing the spur doesn't fix the pain.

"Stretch the Calf, Not Just the Foot": The plantar fascia is contiguous with the Achilles tendon (paratenon). A tight calf (Equinus) locks the midfoot and puts massive strain on the fascia. Stretching the Gastroc/Soleus is the cure.

"Beware the Steroid": Corticosteroid injections provide short term relief (4 weeks) but weaken the structure. Risk of Plantar Fascia Rupture and Fat Pad Atrophy (which causes intractable heel pain) is significant.

"Bilateral? Think Rheumatology": If a young male presents with bilateral heel pain, ask about back pain. It could be the first sign of Ankylosing Spondylitis (Enthesopathy).

Inspection

• Pes Planus: Flat foot (over-pronation stretches the fascia).
• Pes Cavus: High arch (rigid foot, poor shock absorption).
• Swelling: Usually absent. If present, think fracture or rupture.

Palpation (The Diagnostic Triad)

1. Medial Calcaneal Tubercle: Maximal tenderness at the medial aspect of the heel pad (start of the fascia).
2. Planter Aponeurosis: Tenderness along the central band.
3. Medial Malleolar Compression: To rule out Tarsal Tunnel.

Special Tests

• Windlass Test (Specificity 100%):
  • Technique: Passively dorsiflex the great toe while the patient stands (weight-bearing).
  • Positive: Reproduction of heel pain.
  • Mechanism: Tightens the fascia via the windlass effect.
• Silfverskiold Test (Equinus):
  • Role: Distinguishes Gastrocnemius tightness from Soleus tightness.
  • Technique: Check ankle dorsiflexion with knee extended (gastroc) vs knee flexed (soleus).
  • Relevance: If tight only in extension, a Gastrocnemius Release (PMGR) is effective.
• Tinel's Test: Tap over the Tarsal Tunnel (posterior tibial nerve). Positive = Tarsal Tunnel Syndrome.
• Calcaneal Squeeze Test: Compress the heel medially and laterally. Pain = Stress Fracture.

        HEEL PAIN (START UP)
                ↓
    CLINICAL DIAGNOSIS CONFIRMED
    (Medial tubercle tenderness)
                ↓
┌─────────────────────────────────┐
│     CONSERVATIVE (Phase 1)      │
│ - Stretching (Achilles + Fascia)│
│ - Activity Modification         │
│ - Analgesia / Ice               │
│ - OTC Orthotics (Heel cups)     │
└─────────────────────────────────┘
         (Try for 6 weeks)
                ↓
         STILL PAINFUL?
                ↓
┌─────────────────────────────────┐
│       ADVANCED (Phase 2)        │
│ - Night Splints (Strassburg)    │
│ - Physiotherapy (Eccentric)     │
│ - Custom Orthotics              │
└─────────────────────────────────┘
         (Try for 3-6 months)
                ↓
         STILL PAINFUL?
                ↓
┌─────────────────────────────────┐
│      INTERVENTION (Phase 3)     │
│ - Shockwave Therapy (ESWT)      │
│ - Steroid Injection (Caution)   │
└─────────────────────────────────┘
                ↓
         STILL PAINFUL >12m?
                ↓
┌─────────────────────────────────┐
│       SURGERY (Phase 4)         │
│ - Partial Plantar Fasciotomy    │
│ - Gastrocnemius Release         │
└─────────────────────────────────┘

1. Stretching (The Cure)

• Plant-Specific: Pulling toes back to stretch fascia.
• Calf-Specific: Wall push-ups.
• Frequency: 3-5 times per day. Crucial before first steps in morning.

2. Extracorporeal Shockwave Therapy (ESWT)

• Mechanism: High energy sound waves induce micro-trauma, stimulating neovascularisation and healing response.
• Evidence: High level evidence (NICE recommended).
• Protocol: 3 sessions, weekly.

3. Night Splints

• Concept: Keep the foot in dorsiflexion (90 degrees) overnight. Prevents the fascia healing in a shortened position.
• Issues: Compliance (hard to sleep in).

4. Surgical Release

• Partial Plantar Fasciotomy: Cutting the medial 1/3 or 1/2 of the fascia.
• Proximal Medial Gastrocnemius Release (PMGR): Releasing the tight calf muscle behind the knee. Less invasive, preserves the arch function.
• Risks: Lateral Column Pain (caused by disrupting the windlass mechanism and arch collapse).

Baxter's Nerve Release

1. Identify: The nerve runs deep to the Abductor Hallucis muscle.
2. Compressor: The deep fascia of the Abductor Hallucis (the knot of Henry region).
3. Release: Divide this fascia to free the nerve.
4. Caution: Avoid the medial plantar artery.

Low-Dye Taping Technique (The Anti-Pronation Tape)

One of the most useful skills in the clinic.

1. Anchor: Place a strip of Zinc Oxide tape around the metatarsal heads (distal anchor).
2. Stirrups: Start at the massive toe (1st met), run down the medial border, around the heel, and up the lateral border to the 5th met. Pull the heel into inversion (neutral) as you stick it.
3. Repeat: Do 2-3 stirrups to create a strong "wall" against pronation.
4. Transverse Strips: Fill in the sole with horizontal strips (medial to lateral) to lift the arch ("C" strips).
5. Lock off: Apply a final anchor over the top of the foot.
6. Indication: If this relieves pain immediately, orthotics will likely work.

Corticosteroid Injection Technique

The Caution: Do not inject into the fascia (risk of rupture/necrosis). Inject peritendinous (around it). Approaches:

1. Medial Approach (Preferred):
   • Entry: Medial side of the heel, parallel to the floor, just superior to the palpable plantar fascia band.
   • Target: Deep to the fascia origin.
   • Pain: Less painful than plantar approach.
2. Plantar Approach:
   • Entry: Directly through the heel pad.
   • Target: Into the calcaneal spur region.
   • Pain: Very painful (thick skin).

Open Partial Plantar Fasciotomy

1. Incision: Medial approach (2-3cm).
2. Exposure: Identify the medial band and central band.
3. Cut: Release the medial 1/3 to 1/2 of the fascia.
4. Spare: The lateral band (preserves some lateral column stability).
5. Dangers: Cutting too much > Arch collapse (Flat foot) > Lateral Column Pain.

Landmark Trials: The Big 5

1. The High-Load Revolution: Rathleff et al. (2014)

• Citation: High-load strength training improves outcome in patients with plantar fasciitis. Scand J Med Sci Sports. [PMID: 25145361]
• The Question: Is specific high-load strength training (HLST) superior to standard stretching?
• Protocol:
  • Group A: Standard plantar-specific stretching (DiGiovanni protocol).
  • Group B: HLST (Single leg heel raises on a towel, backpack weight).
• Results: At 3 months, the HLST group had significantly lower Foot Function Index (FFI) scores (Better function) and less pain.
• Key Takeaway: The plantar fascia responds to load like a tendon (Mechanotransduction). "Strengthen, don't just stretch."

2. The Shockwave Standard: Gerdesmeyer et al. (2008)

• Citation: Radial extracorporeal shock wave therapy is safe and effective.... Am J Sports Med. [PMID: 18832341]
• The Question: Does Radial ESWT work?
• Design: Multicenter RCT (n=250). Placebo controlled.
• Protocol: 3 sessions of 2000 impulses.
• Results: 61% reduction in heel pain in the ESWT group vs 42% in placebo.
• Key Takeaway: Radial ESWT is a Level 1 Evidence treatment for recalcitrant fasciitis.

3. The Stretching Specificity: DiGiovanni et al. (2003)

• Citation: Tissue-specific plantar fascia-stretching exercise enhances outcomes.... J Bone Joint Surg Am. [PMID: 12851352]
• The Question: Is "Calf Stretching" (Gastroc) enough?
• Protocol: Standard Achilles stretching vs "Plantar Specific" stretching (pulling toes back by hand).
• Results: The isolated plantar fascia stretch group had better outcomes at 8 weeks.
• Key Takeaway: You must engage the Windlass mechanism to stretch the fascia effectively.

4. The Pathological Truth: Lemont et al. (2003)

• Citation: Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. [PMID: 12756315]
• The Findings: Histological analysis of 50 surgical specimens.
• Results:
  • Myxoid degeneration.
  • Collagen fragmentation.
  • NO inflammatory cells.
• Key Takeaway: The term "Fasciitis" is wrong. Anti-inflammatories are illogical for long-term care.

5. The Biomechanical Engine: Hicks (1954)

• Citation: The mechanics of the foot. II. The plantar aponeurosis.... J Anat. [PMID: 13129168]
• The Discovery: Described the "Windlass Mechanism".
• Concept: Dorsiflexion of the hallux winds the fascia around the metatarsal head, shortening the distance between heel and toe, raising the arch.
• Clinical Relevance: Any treatment that blocks hallux dorsiflexion (stiff shoe, tight tendon) destroys this mechanism.

Clinical Guidelines

• NICE (UK): Recommends ESWT for cases > 6 months.
• American College of Foot and Ankle Surgeons (ACFAS):
  • Tier 1: Stretching, Taping, OTC Orthotics.
  • Tier 2: Night Splints, Injections, Prescription Orthotics.
  • Tier 3: ESWT, Surgery.

The "Drop" Debate

• Heel-to-Toe Drop: The difference in height between the heel and forefoot.
• High Drop (>10mm):
  • Pros: Offloads the calf/Achilles (Equinus).
  • Cons: Increases heel strike impact.
  • Verdict: Preferred for PF (takes tension off the windlass + gastroc).
• Zero Drop (0mm - Altra/Vibram):
  • Pros: Natural mechanics.
  • Cons: Maximum stretch on Achilles/Fascia.
  • Verdict: Avoid in acute phase.

The "Stack" (Cushioning)

• Maximalist (Hoka/Asics):
  • Pros: Shock absorption. Often has a "Rocker Sole".
  • Cons: Instability if too soft.
  • Verdict: Excellent IF it has a rocker.
• Minimalist (Vivobarefoot):
  • Verdict: Dangerous for acute PF. The fascia takes 100% of the load.

Key Features to Prescribe

1. Stiff Shank: You should NOT be able to fold the shoe in half.
2. Rocker Bottom: Included curvature to roll through the step (imitates windlass).
3. Heel Counter: Stiff cup to hold the calcaneus vertical (prevent eversion).

Setup & Portals

• Position: Supine, leg elevated. Tourniquet on thigh (250mmHg).
• Marking:
  • Draw the medial border of the plantar fascia.
  • Reference line from posterior calcaneus to 3rd webspace.
• Portals:
  • Medial Portal: 1cm anterior to the medial calcaneal tubercle.
  • Lateral Portal: Mirror image (for the camera).

The Procedure

1. Incision: Vertical stab incision medial portal.
2. Trocar: Blunt trocar passed deep to the extensive plantar fascia but superficial to the muscle (Quadratus Plantae).
3. Cannula: Slotted cannula inserted.
4. Visualization: 30-degree scope introduced laterally. Identify the white, fibrous bands of the fascia.
5. The Release:
   • Retrograde knife (hook).
   • Cut the Medial band (thin) and the Central band (thick).
   • STOP at the lateral band (preserve Lateral Column stability).
6. Confirmation: Visualize muscle belly of FDB rising up (sign of release).

Pearls & Pitfalls

• Don't cut the fake: Superficial fascia looks like plantar fascia. Make sure you are deep enough.
• Don't cut the nerve: The First Branch of Lateral Plantar Nerve (Baxter's) is just deep to your cannula. Don't plunge.
• Don't cut it all: Total release = Flat foot + Cuboid pain.

"Why won't it go away?"

Because you are still aggravating it. Every step is a micro-injury. It's like picking a scab. You need to reduce the "Load" (standing/running) to match the "Capacity" of the tissue.

"Can I run?"

• Acute Pain: No. Swap to cycling or swimming (low impact).
• Recovering: Yes, but follow the "10% Rule" (increase distance by max 10% per week). If pain > 3/10 the next morning, you did too much.

"What shoes should I wear?"

• Avoid: Flat shoes (Converses, Flip-flops).
• Wear: Shoes with a slight heel (running shoes) or a "Rocker Sole" (Hoka, MBT). The rocker does the work for your foot/windlass mechanism.

1. The Plantar Aponeurosis: "More than a ligament"

It is not a static chord; it is a dynamic energy storage system.

• Origin: The medial calcaneal tubercle.
• Insertion: The base of the proximal phalanges (via the plantar plates).
• Structure:
  • Central Band: The thickest and strongest. This is the part involved in "Fasciitis". It supports the longitudinal arch.
  • Lateral Band: Covers the Abductor Digiti Minimi. Often spared in surgery to prevent Lateral Column instability.
  • Medial Band: Thin investing fascia over the Abductor Hallucis.
• Function:
  • Static: Maintains arch height (Truss mechanism).
  • Dynamic: Stores elastic energy during stance phase and releases it at toe-off (Windlass mechanism).

2. The Calcaneal Fat Pad: "The Shock Absorber"

An engineering marvel often overlooked.

• Structure: Composed of specialized adipose tissue enclosed in U-shaped fibro-elastic septae. These septae prevent the fat from spreading out under load.
• Hydrostatic Pressure: When you step, the fat is compressed but contained, creating a high-pressure shock absorber.
• Pathology:
  • Atrophy: In elderly or post-steroid injection. The septae break down, the fat leaks out, and the calcaneus strikes the ground directly.
  • Bruising: "Stone Bruise". Bleeding into the closed chambers causes intense pressure pain.

3. The Nerve Entrapment Sites ("The Double Crush")

Heel pain is not always the fascia.

• The First Branch of Lateral Plantar Nerve (Baxter's Nerve):
  • Course: Runs deep to the Abductor Hallucis and superficial to the Quadratus Plantae.
  • • entrapment*: Compressed between the deep fascia of the Abductor Hallucis and the medial calcaneus tuberosity.
  • Sign: Burning pain, no morning start-up pain, maximal tenderness deep to the muscle.
• The Medial Calcaneal Nerve:
  • Course: Branches off the Tibial nerve before the tarsal tunnel.
  • Sign: Sensory loss on the heel pad.

4. The Venous Plexus: "The Foot Pump"

• Location: Deep in the plantar vault (Lejars’s plexus).
• Function: Every step (weight bearing) empties this plexus, pumping blood back to the heart.
• Relevance: Inactivity (standing still) leads to venous stasis and congestion, which can mimic fasciitis throbbing pain.

5. The Achilles-Plantar System ("The Continuity")

• Concept: There is a continuous myofascial web from the calf to the toe.
• Anatomy: The paratenon of the Achilles tendon is continuous with the plantar fascia in young people. As we age, they separate.
• Clinical: Tight Gastrocnemius -> Pulls on Calcaneus -> Rotates Calcaneus -> Increased tension on Plantar Fascia.
• Treatment Implication: You CANNOT fix the fascia without fixing the calf (Gastroc release or stretching).

6. The Windlass Mechanism (Detailed Physics)

Described by Hicks in 1954.

1. Phase 1: Heel strike. The fascia tenses to absorb shock.
2. Phase 2: Mid-stance. The foot pronates (flattens) to adapt to the ground. The fascia stretches (stores energy).
3. Phase 3: Toe-off. The toes dorsiflex. This pulls the fascia around the "pulley" of the metatarsal heads.
4. Result: The distance between heel and toe shortens. The arch rises. The foot becomes a rigid lever for propulsion.
5. Failure: If the toe cannot dorsiflex (Hallux Rigidus) or the fascia is cut (Surgery), the arch collapses and power is lost.

The History

• In 1900, "Gonorrheal Heel" was the diagnosis for spurs.
• In 1950, spurs were thought to dig into the flesh.
• Today, we know they are Traction Osteophytes.

The Anatomy of the Spur

• Location: The spur grows at the origin of the Flexor Digitorum Brevis muscle, which sits deep to the plantar fascia.
• Mechanism: Wolf's Law. Bone grows where tension is applied. Long-term tension on the Flexor Digitorum Brevis pulls the periosteum, creating bone growth.
• The Verdict: The spur is a marker of history (long term pathology) but is rarely the source of pain. Removing it is "treating the X-ray, not the patient".

Q1: Explain the Windlass Mechanism. A: When the hallux is dorsiflexed, the plantar aponeurosis (which originates on the calcaneus and inserts on the phalanx) wraps around the metatarsal head. This shortens the distance between the heel and toes, raising the medial longitudinal arch and locking the midfoot bones into a rigid lever for propulsion.

Q2: What is the Silfverskiold Test? A: It differentiates Gastrocnemius tightness from Soleus tightness. If ankle dorsiflexion is restricted with the knee extended (Gastroc under tension) but normal with the knee flexed (Gastroc relaxed), the tightness is in the Gastrocnemius. If restricted in both, it is the Soleus (or joint capsule).

Q3: Why is "Plantar Fasciitis" a misnomer? A: "Itis" implies inflammation. Histology (Lemont 2003) shows myxoid degeneration, collagen fragmentation, and angiofibroblastic hyperplasia with NO inflammatory cells. It is a "Fasciosis" or "Fasciopathy" (Degenerative).

Q4: Principles of the Rathleff Protocol? A: High-load strength training to stimulate mechanotransduction (collagen synthesis). Uses the Windlass mechanism (towel under toes) to load the fascia specifically. 3s Up, 2s Hold, 3s Down. Every other day.

Q5: What are the risks of Steroid Injection? A: Plantar Fascia Rupture (acute flattening of arch) and Fat Pad Atrophy (causes severe pain on heel strike).

Q6: Differentiate Plantar Fasciitis from Tarsal Tunnel Syndrome. A:

• PF: Start-up pain, Medial tubercle tenderness, Windlass positive.
• TTS: Burning/Tingling, Radiates to sole, Tinel's positive, Worse with activity/standing (not just start-up).

Q7: What is Baxter's Nerve? A: The First Branch of the Lateral Plantar Nerve (Inferior Calcaneal Nerve). Compressed by the deep fascia of the Abductor Hallucis. Causes heel pain that mimics PF but often without start-up pain and may have paresthesia.

Q8: Surgical options for Recalcitrant PF? A:

1. Partial Plantar Fasciotomy: Release medial 1/3. Risk of Lateral Column Pain.
2. PMGR (Gastrocnemius Release): If Equinus is the cause. Low risk.
3. Radiofrequency Microtenotomy (Topaz).

Q9: What is the "Lateral Column Liability"? A: Pain on the lateral side of the foot (Calcaneocuboid joint) following plantar fascia release. Caused by arch collapse and shifting of load to the lateral column.

Q10: X-Ray findings in PF? A: Often normal. 50% have a "Heel Spur" (Traction osteophyte). This is usually incidental. The spur is in the Flexor Digitorum Brevis origin, not the fascia.

**## 14. Clinical Cases (Scenario Based Learning)

Case 1: The Weekend Warrior (Classic PF)

Presentation: A 45-year-old male accountant who started training for a marathon. Pain started 4 weeks ago. Severe start-up pain in the morning ("Walking on glass"). Improves after 10 minutes. Examination: BMI 28. Pes Planus. Tender Medial Tubercle. Windlass Positive. Diagnosis: Acute-on-chronic Plantar Fasciitis. Management:

• Phase 1: Reduce running volume by 50% (Load management).
• Taping: Low-Dye tape for immediate relief.
• Protocol: Start Rathleff High-Load training every other day.
• Shoes: Switch to Hoka One One (Rocker sole). Outcome: Resolved in 12 weeks.

Case 2: The Standing Nurse (Chronic)

Presentation: A 52-year-old ICU nurse. Standing 12 hours/day. Pain for 18 months. Failed "stretching" and "ibuprofen". Examination: BMI 34. Tight Calves (Silfverskiold positive for Gastroc). Limited ankle dorsiflexion. Diagnosis: Chronic Plantar Fasciosis driven by Equinus and Obesity. Management:

• Mechanism: The tight gastroc is the driver.
• Action: Night Splint (Strassburg sock) to treat the equinus.
• Intervention: Radial ESWT (Shockwave). 3 sessions.
• Work: Gel heel cups in work shoes. Outcome: Pain free at 6 months.

Case 3: The Young Male (Systemic)

Presentation: A 24-year-old male. Bilateral heel pain for 6 months. Also complains of morning stiffness in his lower back. Red Flag: Bilateral heel pain in a young male is a hallmark of Enthesopathy. Action: Refer to Rheumatology. HLA-B27 test. MRI Sacroiliac joints. Diagnosis: Ankylosing Spondylitis. Lesson: Do not treat bilateral heel pain as simple mechanical fasciitis without ruling out inflammatory causes.

Case 4: The "Pop" (Rupture)

Presentation: A 38-year-old female. Had a steroid injection 2 weeks ago for heel pain. While chasing a bus, she felt a loud "Pop" and sudden sharp pain, followed by relief of the heel pain but new arch pain. Examination: Massive bruising in the sole. Flattening of the medial arch (Pes Planus). Medial tubercle is non-tender (tension released). Diagnosis: Acute Plantar Fascia Rupture. Management: CAM Boot for 4-6 weeks (Non-weight bearing initially). Sequelae: She developed significant Lateral Column Pain 6 months later due to arch collapse.

Case 5: The Burning Heel (Nerve)

Presentation: A 60-year-old female. "Heel pain" for 2 years. Describes it as "Burning" and "Shooting". Worse at night and after standing all day. Not much start-up pain. Examination: Tender over the Abductor Hallucis muscle belly (distal to the tubercle). Tinel's sign radiates across the heel. Diagnosis: Baxter's Nerve Entrapment (First Branch Lateral Plantar Nerve). Action: MRI showed fatty atrophy of Abductor Digiti Minimi. Treatment: Surgical Release of Baxter's Nerve.

Case 6: The Failed Surgery

Presentation: A 55-year-old obese male. Had a "Open Plantar Fascia Release" 1 year ago. Original heel pain is gone, but now has severe pain on the outside (lateral) border of the foot. Diagnosis: Lateral Column Overload Syndrome. Mechanism: The surgeon cut >50% of the fascia. The Windlass mechanism failed. The arch collapsed. Load shifted to the Calcaneocuboid joint (lateral column). Management: Custom rigid orthotic with lateral wedge. Difficult to treat. Lesson: Caution with surgery.

Case 7: The Soldier (Stress Fracture)

Presentation: A 19-year-old recruit. 3 weeks into basic training. Diffuse heel pain. Worse with impact. Examination: Medial-Lateral Squeeze Test is positive. Diagnosis: Calcaneal Stress Fracture. Action: MRI confirms marrow edema. Management: Non-weight bearing (Crutches/Boot) for 6 weeks. Vitamin D check.

Phase 1: Weeks 0-2 (Protection)

• Weight Bearing: Full weight bearing in a CAM boot or Sneakers with heel lift.
• Wound: Keep dry. Sutures out at 14 days.
• Exercise: Ankle pumps. Quads setting.

Phase 2: Weeks 2-6 (Mobilisation)

• Weight Bearing: Wean off heel lift. Normal shoes.
• Exercise:
  • Active ankle dorsiflexion.
  • Double leg heel raises.
  • Stationary bike (low resistance).
• Restrictions: No running. No heavy impact.

Phase 3: Weeks 6-12 (Strengthening)

• Exercise:
  • Single leg heel raises (eccentric).
  • Proprioception (wobble board).
  • Elliptical trainer.
• Return to Sport: Jogging at 10 weeks if pain free.

Phase 4: Months 3-6 (Return to Function)

• Exercise:
  • Plyometrics (jumping).
  • Sprinting.
• Full Sport: Usually by 4-5 months.

Myth 1: "It caused by a Heel Spur."

Truth: The spur is a red herring. It is a traction osteophyte at the origin of the Flexor Digitorum Brevis, NOT the Plantar Fascia. 50% of the population has one. Removing it does not cure the pain.

Myth 2: "I need to rest it completely."

Truth: Complete rest (crutches/boot) causes collagen catabolism and atrophy. The fascia needs load to align the fibers. "Relative Rest" (avoiding impact) is better than "Absolute Rest".

Myth 3: "It is inflammation (Fasciitis)."

Truth: It is "Fasciosis" (Degeneration). There are no neutrophils. Taking Ibuprofen for 6 months will destroy your stomach and do nothing for the fascia.

Myth 4: "I need softer shoes."

Truth: Soft, squishy shoes (Memory Foam) can worsen it by increasing the instability of the foot. You need a stiff sole (Rocker Bottom) to do the work for the foot.

Myth 5: "Cortisone will fix it."

Truth: It is a powerful painkiller for 4 weeks. After that, the pain returns, often worse. It stops the biological healing process and weakens the collagen.

Ultrasound Protocol

• Probe: High frequency linear array (12-18 MHz).
• Position: Patient prone, feet hanging off edge. Dorsiflex toes to tighten fascia.
• Measurements: Measure thickness at the insertion (calcaneus).
  • Normal: < 3.0mm
  • Fasciitis: > 4.0mm (often 6-8mm)
• Doppler: Turn on Power Doppler. Hyperemia indicates an "Acute-on-Chronic" phase.

MRI Findings

• Sequence: Sagittal STIR (Fat Suppression) is the money sequence.
• Signs:
  • High signal intensity within the proximal 2cm of the fascia.
  • Perifascial Edema: Fluid in the fat pad (halo sign).
  • Marrow Edema: High signal in the calcaneus (Reactive osteitis).
  • Rupture: Complete disruption with retraction of fibers and hematoma.

The 12-Week Roadmap (The "Heavy Load" Protocol)

This protocol is based on the Rathleff study (2014) and is the Gold Standard for chronic fasciosis.

Phase 1: Weeks 1-2 (The Unloading Phase)

• Goal: Reduce pain to < 3/10 (NRS) to allow healing to begin.
• Rules:
  • No barefoot walking (not even for a midnight toilet run).
  • Taping (Low-Dye) applied 24/7 (change every 3 days).
  • "Relative Rest": Stop running/jumping. Cycling/Swimming is allowed.
• Exercise 1: Isometric Holds
  • Why: Isometrics induce analgesia (pain relief) without mechanical damage.
  • How: Stand on a step. Rise up on toes. Hold for 45 seconds. Rest 2 mins. Repeat x 5.
  • Load: Bodyweight only (double leg -> single leg as able).
• Exercise 2: The "Frozen Bottle" Roll
  • How: Roll arch over a frozen water bottle for 10 mins.
  • Why: Analgesia + Massage.

Phase 2: Weeks 3-8 (The Loading Phase - "Rathleff")

• Goal: Stimulate collagen synthesis via mechanotransduction.
• The Protocol: High-load strength training.
• Setup: Stand on a step. Place a rolled-up towel under the toes (to dorsiflex the MPJ and engage the Windlass).
• Technique:
  • Concentric (Up): 3 seconds.
  • Isometric (Hold): 2 seconds at the top.
  • Eccentric (Down): 3 seconds (slowly).
• Progression:
  • Weeks 3-4: 3 sets of 12 reps (Bodyweight).
  • Weeks 5-6: 4 sets of 10 reps (Add a backpack with books).
  • Weeks 7-8: 5 sets of 8 reps (Technical failure weight).
• The Pain Rule: Pain during exercise is allowed (up to 4/10). However, if morning pain is worse the next day, reduce the load.

Phase 3: Weeks 9-12 (Function & Plyometrics)

• Goal: Restore energy storage capacity of the fascia (spring function).
• Exercise 3: Pogo Hops
  • How: Bouncing on toes (knees straight/soft). 3 sets of 20 seconds.
  • Progression: Double leg -> Alternating -> Single leg.
• Exercise 4: A-Skips
  • How: Running drill (high knee, rapid foot strike).
• Exercise 5: Soleus Press
  • How: Seated calf raise with heavy weight on knees.
  • Why: Targets Soleus (the main stabilizer).

Adjunct Therapies (The "Good to have")

1. Intrinsic Foot Strengthening ("Short Foot")
   • Concept: Dominate the arch muscles (Abductor Hallucis) to support the fascia.
   • How: Sit with foot flat. Try to shorten the foot by pulling the ball of the foot towards the heel without curling toes. Hold 10s.
2. Towel Scrunches
   • How: Scrunch a towel with toes.
   • Value: Low. Targets long flexors, not intrinsic arch stabilizers.
3. Marble Pickup
   • How: Pick up marbles with toes.
   • Value: Good for dexterity.

Taping Techniques (Detailed)

1. Low-Dye Taping (Anti-Pronation)

• Indication: Acute pain, flat foot.
• Steps:
  1. Anchor: 5cm Zinc Oxide tape around met heads.
  2. Stirrup 1: 5th Met head -> Around Heel -> 1st Met head. Apply tension to Invert the heel.
  3. Stirrup 2 & 3: Repeat, overlapping by 50%.
  4. C-Strips: Transverse strips from lateral to medial under the arch. Pull UP the arch.
  5. Closing Anchor: Lock everything down.

2. Kinesiology Tape (K-Tape)

• Indication: Sub-acute pain, sensory feedback.
• Steps:
  1. Fan Strip: Cut tape into 4 "fingers". Anchor at heel, fan out to toes.
  2. Arch Lift: One strip across the arch with 75% tension.
• Note: Less mechanical support than Zinc Oxide, but better tolerated.

The "First Step" Protocol

The most critical moment of your day is the first step out of bed. Do NOT just walk. Follow this routine:

1. Sit: Wake up and swing legs over the edge.
2. Self-Massage: Use your thumb to dig into the arch for 60 seconds to mobilize fluid.
3. The Windlass Stretch: Pull your big toe back towards your shin firmly. Hold for 30s. Release. Repeat x 3.
4. Alphabet: Draw the alphabet (A-Z) with your ankle to mobilize the joint.
5. Shoes On: Have your supportive shoes (Hoka/Birkenstock) right next to the bed. Put them on BEFORE standing up.

Frequently Asked Questions (FAQ)

Q: Can I walk for exercise? A: Yes, but pain is your guide. "Pain-Free Distance". If you can walk 2km pain-free, do that. Do not push through pain.

Q: Should I be barefoot at home? A: NO. This is the #1 mistake. Hard floors (tile/wood) are the enemy. Wear supportive house shoes or Oofos recovery sandals at all times inside.

Q: Is heat or ice better? A: Ice is a naturally analgesic (pain killer). Heat brings blood flow. Use ICE after activity (roll on frozen bottle). Use HEAT before activity (warm foot bath) to loosen stiffness.

Q: Why do my hips/knees hurt now? A: You are limping (Antalgic Gait). You are walking on the outside of your foot to avoid the heel. This changes the mechanics of your knee and hip. Treating the heel will fix the knee.

Q: Will it rupture? A: Rarely. But if you have had steroid injections, the risk is higher. If you feel a sudden "POP" and bruise, seek medical attention.

Q: What about PRP (Platelet Rich Plasma)? A: It is expensive (£500+). The evidence is mixed (50/50). It is safer than steroids but not a guaranteed cure. Save your money for Shockwave therapy first.

Copy and paste this for your patients:

Good Morning! Before you stand up:

1. Sit on the edge of the bed.
2. Cross your painful leg over your other knee.
3. Grab your toes and pull them back towards your shin until you feel a stretch in the arch.
4. Massage the arch with your thumb for 1 minute.
5. Do 10 ankle circles.
6. Put your shoes on BEFORE you take your first step.

The "Missed Diagnoses"

Litigation in heel pain arises not from the fasciitis itself, but from what was missed.

1. Calcaneal Stress Fracture:
   • Scenario: Continued advice to "stretch" a fracture.
   • Defense: Document a negative "Squeeze Test". If pain persists >6 weeks despite rest, order MRI.
2. Spondyloarthropathy:
   • Scenario: Treating bilateral heel pain in a 25-year-old male for 2 years without asking about back pain.
   • Defense: Document "Bilateral check" and "Morning stiffness in spine".
3. Rupture post-Injection:
   • Scenario: Patient ruptures fascia 2 weeks after steroid injection.
   • Defense: Informed Consent. You MUST document: "Warned of risk of rupture, fat pad atrophy, and skin depigmentation."

The "Cauda Equina" Mimic

• Rare but devastating.
• S1 radiculopathy can present as heel pain (S1 dermatome).
• Red Flag: Bilateral heel pain + Urinary/Bowel dysfunction + Saddle anesthesia.
• Action: Document PR exam/Bladder scan if any suspicion.

1900-1950: The "Gonorrheal" Era

• Heel pain was widely attributed to Gonorrhea.
• Radical excision of "spurs" was common.
• Lesson: We treat the dogma of our time.

1950-1980: The "Inflammatory" Era

• Cortisone became king.
• The term "Fasciitis" was coined.
• Treatment focused on extinguishing inflammation (Ice, NSAIDs, Steroids).

1990-2000: The "Biomechanical" Era

• Hicks' Windlass Mechanism gained traction.
• Orthotics became the gold standard.
• "Control Pronation" was the mantra.

2003-Present: The "Degenerative" Era (Fasciosis)

• Lemont's paper changed everything.
• Shift from anti-inflammatory to Pro-Healing (Shockwave, Heavy Load).
• "Fasciitis" is now widely accepted as a misnomer.

Orthobiologics

• Platelet Rich Plasma (PRP):
  • Concept: Inject growth factors.
  • Evidence: Conflicting. Better than steroids long term, but no better than saline in some RCTs.
• Amniotic Tissue:
  • Concept: Stem cell scaffolding.
  • Status: Experimental.

Minimally Invasive Surgery

• Tenex (Ultrasonic Debridement):
  • Concept: Like cataract surgery for the heel. Phacoemulsification of the bad tissue.
  • Status: Promising. Less invasive than open release.
• Topaz (Radiofrequency Microtenotomy):
  • Concept: Poke holes with a wand to stimulate bleeding/healing.
  • Status: Good for recalcitrant cases.

• Prevalence: 10% of the population will get it.
• Cost: $284 Million annually in the US alone.
• Work Loss: Leading cause of foot-related disability in nurses and teachers.

Collagen Peptides

• Theory: The plantar fascia is Type I Collagen. Supplementing with hydrolyzed collagen + Vitamin C increases collagen synthesis.
• Evidence: Shaw et al. (2017) showed Vitamin C-enriched gelatin improves collagen synthesis.
• Protocol: 15g Gelatin + 500mg Vitamin C taken 45 mins before loading exercise (Rathleff training). The blood peak coincides with the mechanical stimulus.

Omega-3 Fatty Acids

• Theory: Anti-inflammatory.
• Evidence: Modest. Helpful for generalized enthesopathy but not specific to fasciosis (which is non-inflammatory).

Vitamin D

• Theory: Low Vitamin D is linked to chronic pain syndromes.
• Evidence: Correction of deficiency (<30 nmol/L) correlates with improved pain scores in chronic musculoskeletal conditions.

The "Glycated Fascia"

• Pathology: Advanced Glycation End-products (AGEs) cross-link the collagen fibers.
• Result: The fascia becomes thicker, stiffer, and more brittle.
• Ultrasound: Diabetics often have a baseline fascia thickness of >4mm without pain.
• Risk: Stiff fascia = Poor shock absorption = Increased risk of ulceration on the metatarsal heads.

The Charcot Mimic

• Red Flag: A diabetic patient with a swollen, hot foot and "heel pain".
• Diagnosis: Charcot Neuroarthropathy until proven otherwise.
• Action: MRI and Total Contact Cast. Do NOT inject steroids (infection risk).

• Runners: 10% lifetime prevalence.
• Sedentary: Higher risk in obese, sedentary females (BMI > 30 is the strongest predictor).
• Age: Peak incidence 40-60 years. Rare in children (Seen in Severs Disease).

(End of Topic)