Plantar Fasciitis

_Plantar Fasciopathy / Plantar Heel Pain_

Summary

Degenerative overload of the plantar aponeurosis at its calcaneal origin, associated with reduced ankle dorsiflexion and calf tightness. Offload the enthesis, restore dorsiflexion, progressively load.

Pathology. Plantar fasciopathy is a degenerative overload condition of the plantar aponeurosis at its calcaneal origin, driven by excessive tensile/compressive load, reduced ankle dorsiflexion and calf tightness. It is not primarily inflammatory. Treatment offloads the enthesis, restores dorsiflexion and progressively loads the fascia and calf.

Clinical presentation (signs & symptoms)

Sharp/stabbing plantar-medial heel pain; worst with first steps in the morning and after rest; eases with early movement then worsens with prolonged load; localised tenderness at medial calcaneal tubercle; usually no swelling.

Assessment (Examination & Assessment)

Subjective

Plantar-medial heel pain, worst with first steps in the morning / after rest ("first-step pain"); worse after prolonged standing or increased load. Footwear, training load, calf tightness history. Pain scale.

Objective

Palpation of the medial calcaneal tubercle (localised tenderness — key finding); Windlass test (passive great-toe/MTP dorsiflexion reproduces pain); calf flexibility (gastroc & soleus); foot posture (pes planus/cavus); single-leg heel raise; ankle dorsiflexion ROM.

Differentiate from

Fat pad syndrome, calcaneal stress fracture, tarsal tunnel / Baxter's nerve entrapment (neural).

Key special tests

| Test | What a positive result indicates | |---|---| | Palpation of the medial calcaneal tubercle | localises the enthesis (primary finding) | | Windlass test | great-toe dorsiflexion tensions the fascia and reproduces pain | | Ankle dorsiflexion ROM / calf length | identifies contributing tightness | | Single-leg heel raise | calf function and load tolerance |

Red flags & when to refer

• Calcaneal stress fracture (worsening rest/night pain, positive squeeze test)
• Tarsal tunnel or Baxter's nerve entrapment (neural symptoms, tingling)
• Inflammatory arthropathy if bilateral/atypical or systemic features

Contraindications & precautions

• Dry needling: avoid the posterior tibial neurovascular bundle (medial ankle); consent, hygiene, anticoagulant caution.
• Ultrasound: avoid over growth plates (children), malignancy, DVT, altered sensation.
• General: rule out calcaneal stress fracture (worsening rest/night pain) and nerve entrapment — refer if suspected.

Treatment protocol

Session structure & time scales

• Pre-assessment + prep (10 min): tests, palpation, Windlass.
• Soft tissue — plantar fascia, gastrocnemius, soleus, intrinsics (12–15 min).
• Joint mobilisations — talocrural/subtalar to restore dorsiflexion (5 min).
• Dry needling — calf / intrinsic trigger points (8 min).
• Electrotherapy — therapeutic US (8 min).
• Low-dye taping + loading demo (5–8 min).
• Reassessment + home programme (5 min).

Modalities & rationale

| Modality / technique | Rationale (why it is used for this pathology) | |---|---| | Soft tissue (plantar fascia + calf) | reduces tension along the calf–fascia chain, offloading the enthesis. | | Talocrural/subtalar mobilisations | restore dorsiflexion so gait doesn't overload the fascia (Banks, 2013). | | Dry needling (gastroc/soleus/intrinsics) | relieves trigger points contributing to load (Sharkey, 2017). | | Therapeutic ultrasound | may support the repair environment (parameter-dependent; Watson, 2008). | | Low-dye taping | temporary arch support / offloading for symptom relief. | | Loading education | progressive plantar-fascia-specific and calf loading as the active driver. |

Loading & exercise progression

Progressive plantar-fascia-specific and calf loading (high-load heel raise with toe extended on a step/towel) → return to running. Footwear/orthotic support; night-splint option.

Home care / self-management

Calf & plantar-fascia stretching, plantar-fascia-specific progressive loading (heel raise with toe on step/towel), footwear/orthotic advice, night-splint option, load management.

Outcome measures & re-assessment

• Pain scale (NPRS 0–10) pre and post; note first-step pain over sessions.
• Repeat Windlass test and medial-tubercle palpation.
• Reassess ankle dorsiflexion ROM.
• Function: single-leg heel raise tolerance.

Anatomy reference

| Structure | Origin | Insertion | Action | |---|---|---|---| | Plantar fascia (aponeurosis) | medial calcaneal tuberosity | bases of proximal phalanges (digital slips) | supports medial arch (windlass) | | Gastrocnemius | medial & lateral femoral condyles | calcaneus via Achilles | plantarflexion + knee flexion | | Soleus | soleal line/posterior tibia & fibular head | calcaneus via Achilles | plantarflexion | | Abductor hallucis | medial calcaneal tuberosity | base of proximal phalanx of hallux | abducts/flexes great toe; arch support | | Tibialis posterior | interosseous membrane/posterior tibia & fibula | navicular & medial cuneiform | plantarflexion + inversion; arch support |

Clinical reasoning (Q&A for the system)

_These question–answer pairs encode the expected clinical reasoning for this condition. Use them to justify decisions and to check generated plans._

Q: How does plantar fasciopathy typically present? A: Sharp plantar-medial heel pain, worst with the first steps in the morning or after rest, worse after prolonged standing/load; localised tenderness at the medial calcaneal tubercle.

Q: Which two tests would you prioritise, and why? A: Palpation of the medial calcaneal tubercle (localises the enthesis) and the Windlass test (great-toe dorsiflexion tensions the fascia and reproduces pain); also check ankle dorsiflexion and calf length.

Q: Why treat the calf for what the client feels as a heel problem? A: Reduced ankle dorsiflexion and gastroc/soleus tightness increase tensile load on the plantar fascia through the calf–fascia chain, so releasing and loading the calf offloads the enthesis.

Q: Give the origin and insertion of the plantar fascia. A: O: medial calcaneal tuberosity; I: bases of the proximal phalanges via digital slips; it supports the medial arch via the windlass mechanism.

Q: What red flag/differential would you rule out, and how? A: Calcaneal stress fracture (worsening rest/night pain, squeeze test) and tarsal tunnel/Baxter's nerve entrapment (neural symptoms) — refer if suspected.

References

• Banks, K. (2013) _Maitland's Peripheral Manipulation Management._ Elsevier.
• Banks, K. (2013) _Maitland's Vertebral Manipulation Management._ Elsevier.
• Sharkey, J. (2017) _The Concise Book of Dry Needling._ Lotus Publishing.
• Watson, T. (2008) _Electrotherapy: Evidence Based Practice._ Elsevier.
• Clarkson, H. M. (2013) _Musculoskeletal Assessment._ 3rd edn. Lippincott.
• TODO: add a condition-specific loading-protocol reference (from module notes), Harvard format.