Summary

Plantar Fasciitis is the most common cause of heel pain, affecting 10% of the population. Despite the suffix "-itis", the pathology is degenerative fasciosis (microtears, collagen necrosis, and angiofibroblastic hyperplasia) rather than acute inflammation. The hallmark symptom is "First Step Pain" (Post-static dyskinesia)—searing pain upon rising from bed. Management is 90% conservative, focusing on correcting biomechanics (Tight Calves / Windlass Mechanism) and load management. High-Load Strength Training (Rathleff Protocol) and Extracorporeal Shockwave Therapy (ESWT) are the current gold standards. Corticosteroid injections should be used with extreme caution due to the risk of fascial rupture and fat pad atrophy. [1,2,3]

Key Facts

• Misnomer: It is a "Fasciosis" or "Fasciopathy", not an "Itis". NSAIDs have limited long-term benefit.
• The "Heel Spur": A spur is present in 50% of patients but also 20% of asymptomatic controls. It is a traction reaction (Wolff's Law), not the source of pain. Do not excise the spur.
• Windlass Mechanism: Dorsiflexing the toes tightens the fascia, raising the arch (Hicks 1954). This is why calf tightness (Equinus) overloads the fascia.

Clinical Pearls

"First Step Pain": The most sensitive question in the history. "Does it feel like walking on glass when you get out of bed?" -> Yes = Plantar Fasciitis.

"The Bilateral Young Male": If a man <40 presents with bilateral heel pain, you must screen for Ankylosing Spondylitis (HLA-B27). Enthesitis (heel pain) is often the first sign of inflammatory spinal disease.

"Beware the Steroid": Injecting the fascia provides glorious relief for 3 weeks, but increases the risk of rupture by 10%. A ruptured fascia leads to arch collapse and chronic lateral foot pain.

                  HEEL PAIN
                      ↓
           IS IT PLANTAR FASCIOSIS?
       (First Step Pain + Medial Tenderness)
                      ↓
             TIER 1: CONSERVATIVE
      (Stretching + Night Splint + Shoes)
               (90% Success)
                      ↓
              TIER 2: RECALCITRANT
             (Shockwave / High Load)
                      ↓
              TIER 3: INVASIVE
            (Partial Release Surgery)
                 (Last Resort)

1. Stretching Protocol (The Basics)

• Fascia Stretch: Pull toes back with hand. Do 10 times before getting out of bed.
• Calf Stretch: Gastrocnemius/Soleus stretches against a wall. 3x30 seconds daily.

2. High-Load Strength Training (Rathleff Protocol)

• Concept: Fascia is collagen. It needs load to remodel (like a tendon).
• Technique: Single leg heel raises with a towel rolled under the toes (to engage the Windlass). Use a backpack for weight.
• Dose: Every second day. High weight, slow tempo (3s up, 3s down). 3 sets of 12 -> 4 sets of 10 -> 5 sets of 8.
• Evidence: Superior to stretching at 3 months (Rathleff 2014).

3. Mechanical Aids

• Night Splints: Keep the foot at 90° overnight. Prevents the fascia healing in a shortened position (stops the morning tear).
• Orthotics: Corrects over-pronation.
• Gel Heel Cups: Cushioning.

Extracorporeal Shockwave Therapy (ESWT)

• Mechanism: High energy sound waves cause micro-trauma, stimulating a healing response (VEGF release, neovascularization) and numbing nerves.
• Efficacy: FDA approved. Level 1 evidence for chronic (>6 months) pain. Success rate ~70%.
• Protocol: 3-5 sessions, weekly. Painful but effective.

Injections?

• Steroid: Short term relief only. Risk of rupture and fat pad atrophy. Avoid.
• PRP (Platelet Rich Plasma): Emerging evidence. Safer than steroids. Promotes healing.

Plantar Fascia Release

• Indication: Failure of 12 months comprehensive non-op care (<5% of patients).
• Technique: Endoscopic or Open. Cutting the medial 1/3 to 1/2 of the fascia.
• Risk: Lateral Column Pain. By releasing the medial tie-bar, the arch collapses, overloading the lateral column (Cuboid/4th/5th Metatarsals). This new pain can be worse than the original.

Gastrocnemius Recession (Strayer Procedure)

• Indication: Isolated gastrocnemius tightness.
• Technique: Lengthening the calf muscle to offload the fascia. Treats the cause, not the symptoms.

Rathleff et al (Scand J Med Sci Sport 2015)

• RCT: Stretching vs High-Load Strength Training.
• Result: High-Load group had significantly better Foot Function Index (FFI) scores at 3 months.
• Conclusion: Treat it like a tendinopathy. Load it.

Gollwitzer et al (JBJS 2015)

• Double-blind RCT on ESWT.
• Result: Radical Extracorporeal Shockwave Therapy significantly reduced visual analog scale (VAS) pain scores compared to placebo in chronic cases.

The "Heel Spur" Myth

• Anatomical studies show the spur is located in the origin of Flexor Digitorum Brevis, deep to the fascia. It is a bystander.

Why does it hurt in the morning?

When you sleep, your foot points down and relaxes. The micro-tears in the fascia try to heal in this shortened position. When you stand up and flatten your arch, you rip that new healing tissue apart. It's like tearing a scab off a wound every single morning.

Will it go away?

Yes, but it is slow. It takes 6-18 months to run its course. 90% of people get better without surgery.

Should I rest it?

Actively resting (stopping running) helps, but "complete rest" (crutches) is bad. The tissue needs load to stay strong.

Can I get the injection?

I advise against it. It numbs the pain for a month, but it weakens the structure. If the fascia snaps, your arch collapses, and you get a flat foot for life.

Q1: What is the Windlass Mechanism? A: Extension of the toes creates tension in the plantar fascia, which pulls the calcaneus distally, raising the medial longitudinal arch and creating a rigid lever for push-off.

Q2: Differentiate Plantar Fasciitis from Baxter's Nerve Entrapment. A: Fasciitis has "Start-up pain" and improves with activity. Baxter's Nerve (First branch of lateral plantar nerve) entrapment causes burning/radiating pain that worsens with activity and may have night pain.

Q3: Why is Gastrocnemius Recession used for Plantar Fasciitis? A: Tightness of the gastrocnemius (Equinus) limits dorsiflexion. The foot compensates by pronating, which puts excessive strain on the plantar fascia. Lengthening the calf restores mechanics and offloads the fascia.

(End of Topic)