This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.

A basic version of this tutorial was first published in 2003 when I originally observed that many stubborn cases of plantar fasciitis could be cured by “power icing,” and I wanted to get that idea out into the world. The tutorial underwent a major upgrade in July of 2006, becoming what I still believe to be the best available single source of information on the subject. Numerous minor improvements have been made since then, and this record of changes was started on August 26, 2007. A particularly large number of improvements are in progress in the fall of 2012, in preparation for recording the audiobook version.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 49 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Minor update (Mar 29 '13, section #4.7) — Upgraded risk and safety information about Voltaren Gel. See section #4.7, Ibuprofen and friends: non-steroidal anti-inflammatory medications (NSAIDs), especially Voltaren® Gel.

Product upgrade (Feb 4 '13) — Audiobook version now available. See the announcement for more information.

Improved (Jan 11 '13, section #4.25) — Expanded and edited. Reflexology and acupuncture added. See section #4.25, Don’t bother with ….

improved (Jan 11 '13, section #4.24) — A little more and better advice. See section #4.24, Some tips on beating the morning pain.

Minor update (Dec 7 '12, section #2.4) — More detail in my personal story of truly structural foot problem. See section #2.4, So what if you are a flat-footed, tight-calved pronator?

Expanded (Nov 29 '12, section #4.13) — Added much more detailed self-help information for trigger points. See section #4.13, Trigger point massage for your feet, shins & calves.

Major upgrade (Nov 26 '12, section #4.13) — Rewritten, modernized, expanded. See section #4.13, Trigger point massage for your feet, shins & calves.

Minor update (Nov 24 '12, section #4.15) — Some customizing of “brain wrangling” for plantar fasciitis. See section #4.15, Brain wrangling: what to do about sensitization.

Science update (Nov 20 '12, section #4.20) — Weak but interesting new evidence on natural running and injury prevention. See section #4.20, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Rewritten (Nov 9 '12, section #4.14) — Bigger, better, more positive discussion of this option. See section #4.14, Friction massage the plantar fascia.

Major update (Oct 28 '12, section #4.22) — A “minor” science item really changed the tone of this section. The point is still the same — avoid heels — but now it’s a more interesting point. See section #4.22, Beware of high heels.

Science update (Oct 25 '12, section #2) — Unimportant but interesting science update about the forces required for arch muscles to activate for support. See section #2, Nature of the Beast: What is plantar fasciitis?

New section (Oct 17 '12, section #4.1) — New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. See section #4.1, So what’s the plan?

Rewritten (Oct 15 '12, section #4.8) — Completely revised to reflect new science and new understanding of the interaction of ice with “inflammation.” See section #4.8, Icing: more is better?

New science (Oct 12 '12, section #3.2) — Same content, more science support. See section #3.2, Ultrasonography and plantar fascia thickness.

New section (Oct 10 '12, section #5) — No notes. Just a new section. See section #5, Now what?: An action-oriented round-up of my recommendations.

Science update (Oct 7 '12, section #4.10) — References pretty much completely renovated and upgraded — and generally good news for once. See section #4.10, Know your stretches.

New section (Oct 7 '12, section #4.7) — No notes. Just a new section. See section #4.7, Ibuprofen and friends: non-steroidal anti-inflammatory medications (NSAIDs), especially Voltaren® Gel.

Like new (Oct 6 '12, section #4) — Major upgrade, with a much more detailed introduction to this part of the book, and long and useful list of summarized treatment options. See section #4, Treatment: What can you do about plantar fasciitis?

Minor update (Oct 5 '12, section #3.2) — Slightly expanded and clarified. Added a note about feeling a thickened plantar fasciitis with your fingers. See section #3.2, Ultrasonography and plantar fascia thickness.

Minor update (Oct 5 '12, section #3.1) — Several minor clarifications and improvements. See section #3.1, Several conditions that might get confused with plantar fasciitis.

New section (Sep 29 '12, section #4.15) — No notes. Just a new section. See section #4.15, Brain wrangling: what to do about sensitization.

New section (Sep 28 '12, section #2.9) — No notes. Just a new section. See section #2.9, Sensitization: the surprising role of brains in plantar fasciitis.

New section (Sep 25 '12, section #2.7) — No notes. Just a new section. See section #2.7, Where’s the fire? The inflammation myth.

Edited (Sep 25 '12, section #2.6) — Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. See section #2.6, How trigger points can hurt like plantar fasciitis.

Edited (Sep 25 '12, section #2.5) — Revision in preparation for audiobook production, with a focus on modernizing information about trigger points. See section #2.5, The general importance of muscle in plantar fasciitis.

Rewritten (Sep 18 '12, section #2.2) — Merged information on arches and pronation, rewrote for clarity, and a couple nice new supporting quotes. See section #2.2, Maybe it’s my pronation? Or flat feet?

Edited (Sep 18 '12, section #2.1) — Longer and clearer than before. In particular, I came up with a much better way of explaining the fragility of “bony” spurs. See section #2.1, Getting to the root of plantar fasciitis: could it be bone spurs?

Product upgrade (Jul 30 '12) — PDF versions of all SaveYourself.ca tutorials are now available. They are ideal for printing and offline reading on e-readers. The online version will always be the “real” version (guaranteed current) and the best way to read the books, but fresh PDF copies will always be available to customers. Announcement on my blog: Finally! PDF versions of my books, and the “technologically interesting” story of how they were made.

Science update (Jul 4 '12, section #4.19) — Added good new evidence that customization of orthotics isn’t very accurate. See section #4.19, Arch support, heel cups and orthotics.

New section (May 11 '12, section #2.8) — Inspired by something surprising that I learned writing the new surgery section, this is a brief description of another major possible explanation for persistent symptoms. See section #2.8, Plantar fasciitis in the bone?

New section (May 10 '12, section #4.4) — Substantive new section of about 1400 words, with several footnotes and new references. See section #4.4, Surgical options for plantar fasciitis: so many!

More expert opinion (May 5 '12, section #4.5) — Added a particularly strong anti-steroids opinion to the section. See section #4.5, Steroid injections are promising but problematic.

Minor update (Dec 21 '11, section #4.23) — Added some more detail to exercise description, and a whimsical ankle coordination challenge. See section #4.23, Mobilize your lower leg musculature.

Minor update (Dec 13 '11, section #4.2) — Addressed some common fears about the threat of getting out of shape while resting. See section #4.2, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Minor update (Sep 28 '11, section #4.21) — Added reference to Kong et al, about the effect of shoe wear. See section #4.21, More about reducing impact, especially with Oesh shoes.

New section. (Aug 26 '11, section #4.21) — Now officially endorsing Oesh shoes for reducing impact. See section #4.21, More about reducing impact, especially with Oesh shoes.

Minor update (Aug 22 '11, section #4.22) — Added a reference about high heels and knee pain. See section #4.22, Beware of high heels.

Minor update (Jul 29 '11, section #1.1) — Added a reference about the poor overall quality of online information about common injuries. See Starman et al. See section #1.1, The plantar fasciitis misinformation explosion.

Major update (Jun 21 '11) — Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really be cleaned up in general, paving the way for efficient conversion to other formats (Kindle, Apple’s iBookstore, etc). Best of all, it is now significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

New section (Mar 20 '11, section #4.20) — Finally, long overdue, a new section on this topic (for all the running injury tutorials, in fact). See section #4.20, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Important new info (Feb 8 '11) — Where’s the fire? Recently I published a major new article about repetitive strain injuries (like plantar fasciitis), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. This significant fact of biology is not yet given proper attention in this tutorial, and it should be. I learned the science of this myself only just recently, and it is going to take me a while to revise all of the tutorials and articles that are affected by it. Meanwhile the new RSI article is available, free to all, and I have also mentioned and linked to it where necessary throughout all tutorials. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

Minor update (Jan 18 '11, section #4.19) — Added a reference to a large, interesting study that showed that custom orthotics failed to reduce injury rates in marines. See section #4.19, Arch support, heel cups and orthotics.

Improved (Sep 30 '10, section #2) — Beefed up with better explanations and science about how plantar fasciitis involves more “degeneration” of your foot than inflammation. See section #2, Nature of the Beast: What is plantar fasciitis?

New cover (Aug 6 '10) — At last! This e-book finally has a “cover.” SHOW

Expanded (Jul 16 '10, section #4.5) — Added a substantial chunk of content about a promising (but very much unproven) experimental treatment protocol. Unproven but interesting. See section #4.5, Steroid injections are promising but problematic.

Minor Update (Dec 30 '09, section #4.25) — Some new comments on Graston Technique in response to a reader’s questions. See section #4.25, Don’t bother with ….

Minor update (Dec 30 '09, section #4.10) — Added an answer to a reader question, “Are soft night splints good enough?” See section #4.10, Know your stretches.

New section (Dec 30 '09, section #4.5) — No notes. Just a new section. See section #4.5, Steroid injections are promising but problematic.

Older updates — Listed in a separate document, for anyone who cares to take a look.

1. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
2. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and they are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches and Pains. BACK TO TEXT
3. That’s from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Dan Lieberman, evolutionary biologist of “Born to Run” fame. BACK TO TEXT
4. Chandler et al. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Med. 1993. PubMed #8100639.

   Chandler and Kibler report a 10% occurrence rate of plantar fasciitis in runners.

   BACK TO TEXT
5. Karabay et al. Ultrasonographic evaluation in plantar fasciitis. Journal of Foot & Ankle Surgery. 2007.

   These researchers used ultrasonography to show that people with plantar fasciitis have thickened connective tissue on the bottom of their feet. The results were clear and unambiguous — a rare bit of clarity in a murky subject!

   See Thickened plantar fascia — really thick! for more information. BACK TO TEXT
6. Lemont et al. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003. PubMed #12756315. BACK TO TEXT
7. Andres et al. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical Orthopaedics & Related Research. 2008. BACK TO TEXT
8. Khan et al. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000. PubMed #20086639. BACK TO TEXT
9. Young et al. Treatment of Plantar Fasciitis. American Family Physician. 2001. Such degeneration is “similar to the chronic necrosis of tendonosis, which features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflamatory cells usually seen with the acute inflamation of tendonitis.” BACK TO TEXT
10. The necrosis “features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflammatory cells usually seen with the acute inflammation of tendonitis.” BACK TO TEXT
11. The arch muscles less than you might think: Basmajian et al showed in 1963 that muscles in the arch of the foot only “kick in” to under quite heavy loads: about 400 pounds. Although that sounds like quite a lot, loading may spike that high in an average person with every step, so the strength and responsiveness of the arch muscles may still be routinely important. We don’t have muscles there for nothing, of course. Nevertheless, this study pretty clearly shows that “the first line of defense” against arch collapse is the shape of the bones, the elasticity of ligaments, and probably the “stirrup” tendons from leg muscles — but not so much the strength of the arch muscles. BACK TO TEXT
12. Barrett et al. Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. Journal of Foot & Ankle Surgery. 1995. PubMed #7780393.

    This study found that 21% of 200 random selected Americans had heel bone spurs.

    BACK TO TEXT
13. Some bones spurs are undoubtedly thicker and harder than others, just like some people have much larger calluses than other people. But regardless, the spur tends to disintegrate the further it gets from the heel. BACK TO TEXT
14. Osborne et al. Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis. Journal of Science & Medicine in Sport. 2006. PubMed #16697701.

    From the abstract: “ ... the key radiological features that differentiate the groups were not spurs but rather changes in the soft tissues.”

    BACK TO TEXT
15. Tountas et al. Operative treatment of subcalcaneal pain. Clinical Orthopaedics & Related Research. 1996. PubMed #2663678.

    This paper reports on a study of twenty patients in the years after surgical removal of bone spurs. Although most of the patients had "excellent" or "good" results about three years later, their spurs had often reformed, and analysis of the soft tissues showed that “changes within the fascia, rather than the spur, are primarily responsible for the pathogenesis of the syndrome.”

    BACK TO TEXT
16. Onwuanyi. Calcaneal spurs and plantar heel pad pain. Foot. 2000.

    From the abstract: “Calcaneal spurs cause plantar heel pad pain, but the roles of other co-morbid factors are significant. The excision of these spurs does not necessarily abolish pain.”

    BACK TO TEXT
17. Fishco et al. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. Journal of the American Podiatric Medical Association. 2000. PubMed #10697969. In this study, surgical outcomes were similar — and generally good — with or without heel spur removal. BACK TO TEXT
18. Beyzadeoglu et al. The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis. Acta Orthop Traumatol Turc. 2007. BACK TO TEXT
19. Overpronation: Accurate or Out of Date Terminology? Griffiths. www.kinetic-revolution.com. 2012. BACK TO TEXT
20. That sounds strange, but it’s true. When I worked as massage therapist, it was pretty common for people to come into my office with so-called “flat” feet, convinced by a previous therapist that they have no arch left, when in fact I could still easily get my finger under their arch up to the first knuckle — something that you simply can’t do on someone who really has flat feet. Similarly, though not so common, I have often seen people accused by another professional of having high arches, when in fact they look nothing like it to me. So take such diagnoses with a grain of salt. BACK TO TEXT
21. Huang et al. The relationship between the flexible flatfoot and plantar fasciitis: ultrasonographic evaluation. Chang Gung J Med. 2004. PubMed #15455545.

    From the abstract: “There was a higher incidence of plantar fasciitis in the flexible flatfoot group than the normal arch control group in this study.”

    BACK TO TEXT
22. Kwong et al. Plantar fasciitis: Mechanics and pathomechanics of treatment. Clin Sports Med. 1988. PubMed #3044618.

    This is an expert opinion paper — not original research — which simply states that excessive pronation in the foot (part and parcel of having flat feet), is "is the most common mechanical cause of structural strain resulting in plantar fasciitis." This is debatable. The relevance of the reference is simply to demonstrate the diversity of opinion on the subject. It may well be that pronation and/or flat feet is the most common cause of plantar fasciitis, but it is certainly not the only mechanical factor that does so.

    BACK TO TEXT
23. Bolgla et al. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of Athletic Training. 2004. PubMed #16558682.

    From the article: “A review of the literature reveals that a person displaying either a lower- or higher-arched foot can experience plantar fasciitis. Patients with lower arches have conditions resulting from too much motion, whereas patients with higher arches have conditions resulting from too little motion.”

    BACK TO TEXT
24. Hertling et al. Management of Common Musculoskeletal Disorders. 1996. amazon.com p434. “Functionally abnormal supination is a failure of the foot to pronate, resulting in a foot unable to compensate normally. There is prolonged supination during the stance phase and a delayed pronation during the gait cycle. Stress fractures, metatarsalgia, plantar fasciitis, and Achilles tendinitis are common in this type of foot.” BACK TO TEXT
25. Cheung et al. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon). 2006. PubMed #16288943. BACK TO TEXT

There are 112 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.

ZOOM

WEB  PDF  AUDIO
secure, instant digital delivery
money-back guarantee
call 778-968-0930 for assistance