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 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. 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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