1. Plantar Fasciitis/Fasciopathy

2. Normal Anatomy Plantar fascia consists of type 1 collagen Plantar fascia aponeurosis consists of 3 bands Lateral Medial Central Central band originates from the medial tubercle of the calcaneus and attach into the proximal phalanx on each toe When the toes are extended the plantar fascia is shortened (windlass effect) The windlass effect assists supination of the foot during late stance phase of gait

3. Normal Anatomy Close anatomical connection between plantar fascia, Achilles tendon and paratendon Tensile load through the plantar fascia is increased with windlass mechanism plus achilles tendon loading Strain through tissue can promote mechanotransduction 1% strain through plantar fascia with stretching 4% strain through plantar fascia with 55kg Achilles tendon loading Load, Time, Frequency for optimal mechanotransduction is not determined

4. Pathology The plantar fascia’s tissue capacity is less than the load applied to it This causes the fascia to go through a degenerative process Similar to that of tendinopathy Deterioration of Type I collagen fibres Increase in ground substance proteins Focal areas of fibroblast proliferation Increased vascularity Inflammation is rarely present

5. Mechanism of Injury Insidious Increased load bearing Increased weight bearing, running, new shoes, new environment

6. Risk Factors Intrinsic High BMI Limited dorsiflexion range of motion Weak intrinsic foot muscles Extrinsic Increased running Running on a hard surface Poor footwear

7. Subjective Examination Medial plantar heel pain Pain first few steps in the morning Painful first few steps after period of inactivity Painful following prolonged weight bearing No night pain (night pain would be indicative of bone problem)

8. Objective Examination Pain on the medial tubercle Pain on the middle central band before it splits into the proximal phalanx of the toes Pain with passive great toe extension Restricted ankle dorsiflexion

9. Further Investigation MRI

10. Management Conservative management always considered Treated similar to tendinopathy Goal is to Reduce the load through the plantar fascia Increase tissues capacity to accept load via mechanotransduction (Type 1 Collagen can remodel when subject to appropriate stress)

11. Conservative Reduce Pain Ice Massage Isometrics (Ankle plantarflexion with Toes in 45  of extension) Heel pad orthotics/change footwear Reduce BMI Reduce standing/weight bearing/running Night Splint Restore Normal Range of Movement Ankle (dorsiflexion commonly) Soft tissue massage Joint Mobilisations Joint Manipulations Stretches

12. Conservative Restore Normal Muscle Activity Single leg Ankle plantarflexion with Toes in 45  (3 x 12 every 2 days, increased to 5 x 10 every 2 days, increase weight over time, double leg if high BMI) Intrinsic Foot Muscles Ankle Dorsiflexion Restore Normal Dynamic Stability Proprioceptive exercises Return to sport/activity specific exercise Gait re-education Gradually increasing running time/distance

13. Plan B Corticosteroid injection Platelet Rich Plasma Injection Focal Extracorporeal shockwave therapy

14. References Berbrayer, D. and M. Fredericson (2014). "Update on evidence-based treatments for plantar fasciopathy." Pm r 6(2): 159-169. Martin, R. L., T. E. Davenport, S. F. Reischl, T. G. McPoil, J. W. Matheson, D. K. Wukich and C. M. McDonough (2014). "Heel pain-plantar fasciitis: revision 2014." J Orthop Sports Phys Ther 44(11): A1-33. Rathleff, M. S., C. M. Mølgaard, U. Fredberg, S. Kaalund, K. B. Andersen, T. T. Jensen, S. Aaskov and J. L. Olesen (2015). "High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up." Scandinavian Journal of Medicine & Science in Sports 25(3): e292-e300. Rathleff, M. S. and K. Thorborg (2015). 'Load me up, Scotty': mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis). Br J Sports Med. England. 49: 638-639.