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[Picture of feet.]
Tried everything?

Maybe not yet. Plantar fasciitis can be stubborn, but many people with chronic foot pain have never even heard of the best treatment options …

last updated 42 days ago, Dec 21st, 2011

Save Yourself from Plantar Fasciitis!

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Plantar fasciitis explained and discussed in great detail, including every possible treatment option, and all supported by recent scientific research

by Paul Ingraham, Vancouver, Canada BIO
Credentials & qualifications. I am a science journalist, and I was a massage therapist for ten years. I’m close to the end of a Health Sciences degree — 2 courses left! — and I am on the editorial team of Science-Based Medicine. I have spent many years studying therapy science, and my work is greatly enriched by thousands of conversations with readers and experts from around the world. I make a living from this website, selling some of my most detailed tutorials as ebooks. For more, see Who Am I to Say?

illustrations by Paul Ingraham, Lindsay McGee

What works for plantar fasciitis? What doesn’t? And why? Soon you will be able to answer these questions confidently. This is a detailed tutorial about stubborn cases of plantar fasciitis for patients and professionals — more thorough and scientifically current than any other source, and also more readable and interesting. It reviews all the theories, myths and controversies about the nature of the beast, and presents all possible treatment options. Unlike many conditions that I write about, there are some excellent treatment options, known to be effective even with many difficult cases.

Plantar fasciitis is a common and often persistent injury afflicting runners, walkers and hikers, and nearly anyone who stands for a living — cashiers, for instance. It causes mainly foot arch pain and/or heel pain, and morning foot pain is a particularly distinctive symptom. Plantar fasciitis is not the same thing as heel spurs and flat feet, but they are related and often confused.

Severe cases of plantar fasciitis can virtually stop you in your tracks.

Most people recover from plantar fasciitis with a little rest, arch support, and stretching, but not everyone. This tutorial is mostly for you: the patient with nasty chronic plantar fasciitis that just won’t go away.

The plantar fasciitis misinformation explosion

In the years since I started treating and writing about plantar fasciitis, there has been an explosion of free information about it on the internet. Unfortunately, this has not resulted in patients or health care professionals being better informed!

A lot of the information that you can find out there is simply repetition of the same points of conventional wisdom, many of which are just wrong. Misconceptions about foot pain have been spread far and wide, thanks to the miracle of the internet!1

Plantar fasciitis is famously stubborn. Although the basic formula for plantar fasciitis treatment is fairly effective for mild cases, some people face a much more challenging recovery. I have suffered from a challenging case of plantar fasciitis myself, and I have helped many of my own patients with persistent cases. So I know from both personal and professional experience that the prognosis isn’t always good!

Patients with severe and/or chronic plantar fasciitis face a challenge in finding good help

Plantar fasciitis is not well understood scientifically or biomechanically, and most health care professionals are not aware of the full range of treatment options.

Most manual therapists (physiotherapists, chiropractors, massage therapists) do not know what the latest research says, and simply cannot offer patients advanced troubleshooting. I have a modern, impressive sports injuries text on my shelf which offers even less advice — just a couple of paragraphs! — than many of the inadequate articles on the internet!

In fact, many health professionals are not even aware of the basic evidence-based formula for plantar fasciitis rehab, never mind the options for severe and/or atypical cases.

General practitioners are not prepared to treat plantar fasciitis, or most musculoskeletal conditions.2 Podiatrists (foot doctors) — especially in North America, where the profession is focussed on surgical procedures — often give poor quality advice about chronic, inoperable conditions like plantar fasciitis. The occasional tough case of plantar fasciitis is simply not on their radar.

So where can you go for help? You’ve already arrived …

Massage for plantar fasciitis is popular, for instance, but not especially effective.
Would a rub help?

If only! A foot rub is nice, and in fact it can help a little, but massage therapy is actually one of the least effective of the common therapies for plantar fasciitis.


Massage for plantar fasciitis is popular, for instance, but not especially effective.
Would a rub help?

If only! A foot rub is nice, and in fact it can help a little, but massage therapy is actually one of the least effective of the common therapies for plantar fasciitis.


About footnotes. There are many footnotes here. Click to make them “pop up” without losing your place. There are two kinds: fun and boring. Try one!1Footnotes with more interesting “fun” extra content are bold and blue, while “boring” footnotes (citations and such) are lightweight and gray. You can also close footnotes by just re-clicking the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.

How can you trust this information about plantar fasciitis?

What would Adam & Jamie do? You know, if they were doctors?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of plantar fasciitis. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 90 footnotes here), and I always link to the original sources.

I’ve worked hard to provide the best information about plantar fasciitis available anywhere — better researched and referenced than anything else you can find, highly readable, and even entertaining. Every issue is explained in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered.

If you’ve been struggling with a tough case of plantar fasciitis, I think this tutorial will feel like a “good find”!

Part 2

Nature of the Beast

What is plantar fasciitis?

Plantar fasciitis is a very common kind of tendinitis — especially common in women during menopause, and it hits about 10% of runners (a rather larger group)3 — but instead of a tendon it’s the plantar fascia of the foot that’s inflamed and/or degenerating.

The plantar fascia (AKA the plantar aponeurosis) is a sheet of connective tissue, similar to a ligament or tendon, that stretches from the heel to toes, spanning the arch of the foot. Plantar fasciitis is an inflammation and/or thickening4 and/or degeneration of the plantar fascia. The “itis” suffix means “inflammation” … but it is quite misleading.

The familiar terms “tendinitis” and “inflammation” are used to introduce plantar fasciitis in a simple, clear way that is close to the truth, but the truth is quite a lot more complicated. Technically, plantar fasciitis is better compared to tendinopathy or tendinosis, because the tissue is often not actually inflamed — not for long, anyway — but instead it shows signs of collagen degeneration. In 2003, Lemont et al looked at 50 cases and found so little inflammation that they declared that plantar fasciitis “is a degenerative fasciosis without inflammation, not a fasciitis.”5

In fact, this is true of so-called “tendinitis” in general — inflamed tendons are not so very inflamed. “Recent basic science research suggests little or no inflammation is present in these conditions.”6 And Khan et al wrote that “numerous investigators worldwide have shown that the pathology underlying these conditions is tendinosis or collagen degeneration. This applies equally in the Achilles, patellar, medial and lateral elbow, and rotator cuff tendons.”7

And the plantar fascia, where the degeneration is “similar to the chronic necrosis of tendinosis.”8 Necrosis is bad. It’s Latin for “tissue death.” In plantar “fasciitis,” the plantar fascia is not just hurting, it’s dying, eroding like a rotten plank.9 And this isn’t just to make you squeamish: inflammation and “necrosis” are not the same medical situation, and understanding the difference is essential for effective treatment.

[Diagram of the foot and plantar fascia to demonstrate the anatomy of plantar fasciitis]
Foot arch-ery

The arch of the foot functions like a bow (as in a bow and arrow), and the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!


[Diagram of the foot and plantar fascia to demonstrate the anatomy of plantar fasciitis]
Foot arch-ery

The arch of the foot functions like a bow (as in a bow and arrow), and the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!


So why does it happen? Plantar fasciitis is basically caused by chronic irritation of the arch of the foot due to excessive strain.

If the arch of your foot is like a bow, think of the plantar fascia as the bow’s string. The plantar fascia, along with several muscles both in the foot and in the leg, supports the arch and makes it springy. Too springy, and the foot flattens right out, overstretching the plantar fascia. Not springy enough, and the plantar fascia absorbs too much weight too suddenly.

Either way, it starts to burn with the strain.

Other than the fact that it’s on the bottom of your foot and you step on it a lot, why is the plantar fascia vulnerable to strain? Why exactly? What happens?

Getting to the root of plantar fasciitis

Clever-sounding biomechanical explanations for plantar fasciitis are as common as plantar fasciitis itself.

Many therapists and articles on the internet will insist that you must treat the “root cause” of plantar fasciitis. It would certainly be a good idea — there’s no disputing that. Now, if only it were possible to identify the root cause!

Unfortunately, there are so many possible root causes of plantar fasciitis — probably several of them happening at the same time — that it is effectively impossible (or just extremely impractical) for therapists to make a confident biomechanical diagnosis. The biomechanics are simply too complicated, and the scientific literature is riddled with contradictions.

For instance …

Could it be heel spurs?

Bone spurs on the heel (aka heel spurs and calcaneal spurs) are common — about 20% of the population has an extra bit of bone (sort of10) growing on the front of the heel.11 They are routinely blamed for plantar fasciitis because it seems logical that having a bony outcropping on your heel would cause heel pain, for much the same reason that you wouldn’t want a rock in your shoe. Even more interesting, they are often found in people with plantar fasciitis.

Seems straightforward, right? Wrong.

Unfortunately for common sense, things just aren’t quite that simple. In fact, there are quite a few more people with bone spurs than there are people with plantar fasciitis, and there is good evidence that it’s not the spur that hurts but the plantar fascia itself or other soft-tissue structures around the spur.1213 Surgically removing bone spurs does not necessarily relieve pain, for instance!14 (They also tend to grow back.)

It’s clear that spurs may be more painful and problematic when other tissue factors are present, but those factors can and do also cause plantar fasciitis symptoms whether you have a heel spur or not — and heel spurs may be completely painless without those factors!

So, as tempting as it is, it turns out that you just can’t count on a nice straightforward connection between heel spurs and plantar fasciitis. This was reaffirmed once again in a 2007 study that concluded, “Overall, the presence of a calcaneal spur [was] not correlated with patient satisfaction and recurrences.”15

Unfortunately for common sense, a bone spur is not like a rock in your shoe.

Perhaps I have plantar fasciitis because of high arches …

Or too low. One therapist will blame high arches, and the next will say it’s flat feet that cause plantar fasciitis. And sometimes they seem to have trouble deciding whether a given foot has a flat arch or a high arch.16 Why are experts contradicting each other? Probably because both flat and high arches are likely causes of plantar fasciitis.171819

For years, I incorrectly told plantar fasciitis clients with high arches that they were exceptional, because (I thought) plantar fasciitis usually only afflicts the flat-footed. Now that I know better, it seems relatively obvious that the plantar fascia is also irritated by an excessively high arch. If the arch is high, it means that the arch-support system may not be springy enough, and absorbs too much force too quickly.

This is what I call the “Goldilocks” syndrome: the strong need the body has for things to be “just right” in between two extremes.

And now for another example of the Goldlilocks syndrome …

My physiotherapist said I’m a pronator

Pronating (rolling the foot inward) too much is routinely cited as a mechanical cause of plantar fasciitis. Personally, I think therapists just like to accuse their patients of “pronating” because it makes us sound like we know what we’re talking about.

The truth is that excessive supinating (rolling the foot outwards) is probably just as much of a problem20 — but that gets ignored. You never hear about supinating. It’s like the unwanted child of plantar fasciitis research.

Probably my calves are too tight

Could be. Tight calves are another classic plantar fasciitis scapegoat, and the gastrocnemius and soleus muscles (the big calf muscles) certainly can put a strain on the plantar fascia.21 This situation is typical for people with a leaning-forward “ski jumper” postural pattern. And of course it is a standard side-effect of wearing high-heeled shoes.

But hold on to your muscle tone, because it turns out that it’s amazingly difficult to even define “tight calves,” let alone blame them for plantar fasciitis. Why?

END OF FREE INTRODUCTION

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Part 2.5

Appendices

Acknowledgements

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 stores. 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.

Reader Comments

Here is what some readers have said about the plantar fasciitis tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


I’ve been practicing in podiatry for 16 years and I have successfully treated thousands of cases of plantar fasciitis. The condition is often misunderstood, and there are a myriad of theories out there, but this tutorial is one of the best things I’ve read on the subject. It provides an excellent overview of the latest treatment and self-treatment options, and makes sure that patients know when to see a medical professional. The crucial point Paul makes that I would like to back up is that plantar fasciitis can be successfully treated, but often requires multiple therapies and persistence.

— Mark Heard, Podiatrist D.App.Sci, M.A.Pod.A., Australia


Plantar fasciitis successfully treated with your advice. Now pain free for almost a year.

— Nicole Villen, cashier who was having trouble working


Really interesting reading. I quickly found information I haven’t seen anywhere else, and it was referenced. No one has ever even suggested that the lower leg muscles might be involved. I have often wondered about that.

— Steven Coombs, plantar fasciitis sufferer


Thank you! There is more and better information here than anything else I could find. What a relief to find a truly comprehensive resource. I was so sick of reading all the same old advice that I’d already tried.

— Jan A., triathlete, Oregon


It was (almost literally) killing me that I couldn’t walk. I’d gained weight, morale was very low. Thanks a million for this article, it’s so much more informative than anything else I could find it’s just crazy. Why isn’t this information more available?

— Janice Campbell, mother of five, enthusiastic recreational walker, Oregon


I have been waking up to pain for almost ten years, and I’d been through every popular remedy, and there are a lot of them. Not once in all that time did I know science. Not once did any doctor or therapist inform me what the latest research says about this condition. Thanks for finally correcting that! (And, yes, I’m finally feeling better, probably because of the night splints, which I actually hadn’t tried before.)

— Andrew Hall, IT guy, Ithaca, NY


I came across your article about plantar fasciitis and you have managed to diagnose what my doctor could not. Impressive! Many thanks for publishing your clear and concise explanation.

— anonymous reader



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.


Further Reading

If you found this tutorial useful, you may also be interested in some other articles I’ve published:

Other interesting reading:

  • If this tutorial doesn’t quench your thirst for plantar fasciitis information, here’s one that might: HeelSpurs.com presents a truly gigantic article — several times the size of this one, if you can believe it, really more of an actual full-length book that just happens to be published online — billed as “the most extensive document on heel pain, plantar fasciitis, and heel spurs that is available.” I have no doubt that is in fact true, and the quality of the information seems generally good, or at any rate better than the average. However, there are several problems: it hasn’t been updated since 2004, the author’s credentials are poor, the writing is a bit awkward, the website is ugly (text cramped and hard to read), there are no footnotes whatsoever. Still, the author is well-informed, and it so thorough that it’s worth reading if you really want to know everything you possibly can.

What’s new in the Plantar Fasciitis tutorial?

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 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 16 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Minor update (Dec 21 '11, section #42)Added some more detail to exercise description, and a whimsical ankle coordination challenge. See section #42, Mobilize your lower leg musculature: What can you do about plantar fasciitis?

Minor update (Dec 13 '11, section #25)Addressed some common fears about the threat of getting out of shape while resting. See section #25, Resting: What can you do about plantar fasciitis?

Minor update (Sep 28 '11, section #39)Added reference to Kong et al, about the effect of shoe wear. See section #39, More about reducing impact, especially with Oesh shoes: What can you do about plantar fasciitis?

New section. (Aug 26 '11, section #39)Now officially endorsing Oesh shoes for reducing impact. See section #39, More about reducing impact, especially with Oesh shoes: What can you do about plantar fasciitis?

Minor update (Aug 22 '11, section #40)Added a reference about high heels and knee pain. See section #40, Beware of high heels: What can you do about plantar fasciitis?

Minor update (Jul 29 '11, section #2)Added a reference about the poor overall quality of online information about common injuries. See Starman et al. See section #2, The plantar fasciitis misinformation explosion.

Major update (Jun 21 '11, section #2)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. See section #2, The plantar fasciitis misinformation explosion.

New section (Mar 20 '11, section #38)Finally, long overdue, a new section on this topic (for all the running injury tutorials, in fact). See section #38, Should you run naked? On faddish running styles and running shoes (or the lack thereof): What can you do about plantar fasciitis?

Important new info (Feb 8 '11, section #38)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. See section #38, Should you run naked? On faddish running styles and running shoes (or the lack thereof): What can you do about plantar fasciitis?

Minor update (Jan 18 '11, section #37)Added a reference to a large, interesting study that showed that custom orthotics failed to reduce injury rates in marines. See section #37, Arch support, heel cups and orthotics: What can you do about plantar fasciitis?

Improved (Sep 30 '10, section #5)Beefed up with better explanations and science about how plantar fasciitis involves more “degeneration” of your foot than inflammation. See section #5, Nature of the Beast: What is plantar fasciitis?

New cover (Aug 6 '10, section #5)At last! This e-book finally has a “cover.” SHOW See section #5, Nature of the Beast: What is plantar fasciitis?

Expanded (Jul 16 '10, section #32)Added a substantial chunk of content about a promising (but very much unproven) experimental treatment protocol. Unproven but interesting. See section #32, Steroid injections are promising but problematic: What can you do about plantar fasciitis?

Minor Update (Dec 30 '09, section #44)Some new comments on Graston Technique in response to a reader’s questions. See section #44, Don’t bother with …: What can you do about plantar fasciitis?

New section (Dec 30 '09, section #32)No notes. Just a new section. See section #32, Steroid injections are promising but problematic: What can you do about plantar fasciitis?

Minor update (Dec 30 '09, section #27)Added an answer to a reader question, “Are soft night splints good enough?” See section #27, Know your stretches: What can you do about plantar fasciitis?

Older updatesListed in a separate document, for anyone who cares to take a look.

Notes

  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. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

    Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

    More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

    BACK TO TEXT
  3. Chandler et al. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Med. 1993. PubMed #8100639. Comments: Chandler and Kibler report a 10% occurrence rate of plantar fasciitis in runners. BACK TO TEXT
  4. Karabay et al. Ultrasonographic evaluation in plantar fasciitis. Journal of Foot & Ankle Surgery. 2007. Comments: 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
  5. Lemont et al. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003. PubMed #12756315. BACK TO TEXT
  6. 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
  7. 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
  8. Young et al. Treatment of Plantar Fasciitis. American Family Physician. 2001. BACK TO TEXT
  9. 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
  10. Technically it’s a calcification of the plantar fascia, not actual “bone.” It’s hard and brittle, but it’s also thin and relatively insubstantial. It’s not much more like bone than tinfoil is like a sheet of steel. BACK TO TEXT
  11. Barrett et al. Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. Journal of Foot & Ankle Surgery. 1995. PubMed #7780393. Comments: This study found that 21% of 200 random selected Americans had heel bone spurs. BACK TO TEXT
  12. 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. Comments: From the abstract: “ ... the key radiological features that differentiate the groups were not spurs but rather changes in the soft tissues.” BACK TO TEXT
  13. Tountas et al. Operative treatment of subcalcaneal pain. Clinical Orthopaedics & Related Research. 1996. PubMed #891316. Comments: 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
  14. Onwuanyi. Calcaneal spurs and plantar heel pad pain. Foot. 2000. Comments: 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
  15. Beyzadeoglu et al. The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis. Acta Orthop Traumatol Turc. 2007. BACK TO TEXT
  16. That sounds strange, but it’s true. It’s 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 can 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
  17. Huang et al. The relationship between the flexible flatfoot and plantar fasciitis: ultrasonographic evaluation. Chang Gung J Med. 2004. PubMed #15455545. Comments: 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
  18. Kwong et al. Plantar fasciitis: Mechanics and pathomechanics of treatment. Clin Sports Med. 1988. PubMed #304461. Comments: 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
  19. Bolgla et al. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of Athletic Training. 2004. PubMed #16558682. Comments: 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
  20. 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
  21. 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 61 more footnotes in the full version of this book.
I like footnotes, and I try to have fun with them.


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