www.intl.elsevierhealth.com/journals/jbmtBodywork andJournal ofMovement TherapiesPLANTARHEELPAINSYNDROME:OVERVIEW ANDMANAGEMENTTheplantarfasciaasasourceofpainFbiomechanics,presentationandtreatmentSimonJ.Bartold*TheUniversityofSouthAustralia,202KensingtonRoad,Marryatville,SA5068,AustraliaReceived14January2003;receivedinrevisedform6August2003;accepted8September2003Abstract Thatplantarfasciitisisoneof themostcommoncausesof heel painisbeyonddispute.Itisalsobyfarthemostcommonsportsinjurypresentingtotheofceofthesportspodiatrist(Bartold,2001,SportsMedicineforSpecicAgesandAbilities.ChurchillLivingstone,Edinburgh,p.425)andaccountsforapproximately15% of all foot related complaints (Lutter, 1997, Med. J Allina. 6(2) http://www.allina.com). The term plantar fasciitis itself has been responsible forconsiderableconfusion, sincetheconditionusuallypresents as acombinationofclinical entities, rather thanthediscretediagnosis of plantar fasciitis. For thisreason,itmaybepreferabletoconsidertheconditionasyndrome,andalterthenomenclaturetoplantarheelpainsyndrome(PHPS).Despite its wide distribution in the sporting and general communities, thereremains widespread debate on its aetiology and dissatisfaction with a lack of reliabletreatment outcomes. This paper describes the unique anatomical and biomechanicalfeaturesofplantarfasciitiswhichmayinpartexplainitsresistancetotreatment.The history and physical examination are described along with potential differentialdiagnoses.Becauseplantarfasciitisismulti-facetedinnature,treatmentmaybedirectedatthewrongfocus,resultinginpooroutcomesandprognosis.Themostcommonconservativemanagementtechniquesaredescribed,andanew,reliablemethodoftapingisproposed.& 2003ElsevierLtd.Allrightsreserved.Whatisplantarfasciitis?Plantar fasciitis was rst described by Wood in1812, andheattributedit totuberculosis (Leachetal., 1996).Sincethen,plantarfasciitisisknownby many pseudonyms, including; joggers heel, heelspursyndrome,plantarfascialinsertitis,calcanealenthesopathy, subcalcaneal bursitis, subcalcanealpain, stone bruise, calcaneal periostitis, neuritisand calcaneodynia (DeMaio et al., 1993). It isimportanttorecognizethatplantarfasciitishasamuch reported association with the specic en-thesopathiesoccurringindiffuseconnectivetissuedisease, especially rheumatoidarthritis, andthespondyloarthropathiesFankylosingspondylitisandpsoriaticarthritis. Theincitinginammationmaythereforebelocalorsystemic,andthatinamma-tionmaystemfromtheplantar fasciaproper ormaybesecondarytoinammationinsurroundingtissues. For this reason, this author believes it isuseful toconsider plantar fasciitis as asyndromeARTICLEINPRESSKEYWORDSPlantarfascia;Windlassmechanics;Morningpain;Stretching;Orthoses;Taping*Tel.: 61-8-83321788;fax: 61-8-83644650.E-mailaddresses: sbartold@sbpod.com.au(S.J.Bartold).1360-8592/$ - seefrontmatter& 2003ElsevierLtd.Allrightsreserved.doi:10.1016/S1360-8592(03)00087-1JournalofBodyworkandMovementTherapies (2004)8,214226thatmaycompriseoneormoreconditions,includ-ing the specic diagnosis of plantar fasciitis. This issimilar totheconcept of chondromalaciapatellaandits roleinanterior kneepain. Previouslythespecic diagnosis of chondromalacia patella hasbeenusedtodescribeall anteriorkneepain.Thispractise has now fallen out of favour, with the moregeneric descriptive terms of patellofemoral syn-drome or patellofemoral arthralgia in common use.DistributionPlantar fasciitis has beenreportedacross awidesample of the community. In the non-athleticpopulation, it is most frequently seen in the weightbearing occupations, especially factory workers,storemen and nurses. Lutter (1997) reports that65% of the non-sports demographic are over weight,with unilateral involvement most common in 70% ofthecases. Most of theliteratureis inagreementthatplantar fasciitisoccursmostcommonlyafterthe fth decade, and has been attributed toatrophyofthefatpad(Sherreff,1987).However,arecent studybyTsai et al. (2000) investigatedultrasoundproles of theheel fat padinplantarfasciitis patients. They concluded that the heel padthickness was not altered in the control groupcomparedtosubjects withplantar fasciitis. It isperhaps more feasible that other mechanicalproperties of theheel pad, for examplerelativecompressibilityorshockabsorbency,orchangestothe plantar aponeurosis origin as a result of alteredconnective tissue characteristics with age, maycontributetotheincreasedprevalenceofplantarfasciitis with age. It is important to note thatplantarfasciitismayhoweveroccuratanyage.There is conicting data in the literature inrelationtogenderdistributionofplantarfasciitis.Lutter (1997) reports afemaletomalepredomi-nance of 3:1, however, several authors havereportedthereverse,withmalesmorecommonlyaffected than females (Fury, 1975; Lapidus andGuidotti, 1965; McBryde, 1984). It seems likely thatchanges in social dynamics, with more womenemployed in industry and weight bearing jobs,and especially the increased participation ofwomen in sport, may be responsible for an increaseinplantarfasciitisreportinginfemales.The second major distribution of plantar fasciitisis in the athletic population, with the same rate ofreportingFapproximately 10% of all running athle-tesFas the general population. Basketball, tennis,football and dance have all notedhigh frequenciesofplantarfasciitis,howeverlongdistancerunningis the activity most often associated with thiscondition. Thereappears tobelittlecorrelationbetweenmileageandplantarfasciitis, withcasesreportedfrombothhighandlowmileagerunners.Given the accepted preponderance for plantarfasciitistooccurinolderindividuals,middle-ageddistance runners represent the most commondemographicforthiscondition.AnatomyThe plantar fascia is perhaps more correctly calledtheplantaraponeurosis,andliessupercialtothemuscles of the plantar surface of the foot. Theplantarfasciahasathickandstrongcentral partwhichcovers thecentral muscleof the1stlayer,exordigitorumbrevisandisimmediatelydeeptothesupercial fasciaof theplantar surface. It isattached proximally to the calcaneus at theanteriorcalcanealtubercle,thesiteofthemuscleattachments,whiledistallyitblendswiththeskinatthecreasesof thebaseof thedigits, andalsosends ve slips, one to each toe. Each of these splitinto two, which pass deeply, one on each side of theexor tendons of that toe, and nally fuse with thedeeptransversemetatarsalligaments.This anatomical arrangement is integral tothepathogenesis of plantar fasciitis. Also of greatimportanceanatomicallyaretheperifascial struc-tures, most notably the subcalcaneal bursa andmedial tibial branchoftheposteriortibial nerve,ARTICLEINPRESSFigure 1 The anatomy of the plantar fascia andperifascialstructures.Theplantarfasciaasasourceofpain 215seeFig.1.Boththesestructuresmaybeinvolvedinwhat is seenas thegeneral symptomcomplexofplantarfasciitis,especiallyinthemorechroniccases. Thecalcaneal tuberositycomprises bothamedial and lateral tubercle. The larger medialtubercleprovides the attachment for the abductorhallucis, exor digitorumbrevis, andtheplantarfascia.Thecentralportionoftheplantarfasciaisthe thickest and strongest. It narrows proximally atits origin and fans out to its distal insertion into thephalanges. The foot has four layers: Supercial,2nd, 3rd and 4th. The supercial layer contains theexor digitorum brevis, abductor hallucis, abductordigiti minimi andtheplantar fascia. Manyof thefoots vital neurovascular structures areincloseproximity to this layer. The medial and lateralplantarnervestraveltogetherundertheabductorhallucis.Themedialplantarnervetravelsbeneaththeabductorhallucisdistally,whereisemergestogive off its digital branches. Thelateral plantarnerve emerges fromthe abductor hallucis andcourses obliquely through the central compart-ment. It lies betweentheexor digitorumbrevisandquadratusmuscle.BiomechanicsoftheplantarfasciaThe unique anatomical features of the plantarfascia have been described, and it is these featuresthat allow the plantar fascia to link the major tarsalbones withtheligaments of theforefoot. Inthisway,theplantarfasciaactsasamechanical truss(Kwonget al., 1988) or aplatformthatpassivelystabilisesthefoot(Cooper,1997)maintainingtheintegrity of the medial longitudinal arch. Kogleret al. (1996) made the interesting observation thatalthoughthefoot manifests anarciformappear-ance,itisnotatruearchstructurally, thatis, itcannotmaintainitsarchedshapesolelyasaresultof its own geometry. Rather, the foot arch is heavilyreliant on adjacent soft tissues to maintain itsarchedposition. Theplantar fasciaplaysamajorrole in this regard, primarily as a result of itsanatomical position, great mechanical strength andbiomechanicalproperties.Rupture and partial or complete surgical section-ingoftheplantarfascia,mayleadtoprogressivepesplanuswithassociatedcomplications(Sharkeyet al., 1998). This is, however dependent upon siteof rupture or surgical release. Changes in archconrmationafter partial sectioningmaybeverysmall, however Sharkeyet al. (1998) report thatany change from normal may be enough toprecipitateacascadeofeventseventuallyleadingtosymptomaticpesplanus.Thepassivesupportroleoftheplantarfasciaistherefore established. The dynamic role of theplantar fascia, particularly its ability to assist in thepropulsivephaseofgait,iscritical tonormal footfunction.Thefunctionoftheplantarfasciaduringgait is augmented by the dynamic actions of severalother extrinsic muscles of the foot. Tibialis poster-ior is particularly important in this regard, with theanatomic location and activity prole of the tibialisposteriormuscles suggesting thatithelpsmaintainthe medial longitudinal arch during locomotion.Theactions of exor digitorumlongus (FDL) andexor hallucis longus (FHL) are also critical to archstabilityandmayassisttheactionsoftheplantaraponeurosisin the laterstagesof thestance phaseof gait. Theplantar fascia however remains themostimportantarchstabilisingstructure.Itelon-gateswithincreasingloads,andstoresthiselasticenergy, acting as a shock absorber (Wright andRennels,1964).Ithasalimitedabilitytoelongatehowever, and plantar fascial tissue stiffens withincreasingtension(Perry,1983).Thesemechanicalproperties,linkedwiththemannerofitsinsertioninto the medial calcaneus, means the plantar fasciahasavital roleinresupinationofthefootduringthepropulsiveperiodof thestancephaseof gait(Bartold, 2001). This is achieved through the socalled windlass mechanism, as rst described byHicks(1954).Duringthisaction,theplantarfasciatightens when the metatarsophalangeal jointsareextendedpassively. This pulls onthemedialinsertionof theplantar fascia at thecalcaneus,shorteningthetrussandraisingtheheightofthearch.HistoryPlantar fasciitis presents inamost characteristicmanner,andthediagnosisclinicallyisoftenmadewithin the rst few minutes of history taking.Typicallyplantarfasciitisis:*Insidious. The onset is gradual and worsens overaperiodoftime,oftenweeksorevenmonths.Eventually the pain degenerates to a stagewherethepatient is compelledtoseektreat-ment.Plantarfasciitisisinvariablyprecededbysome traumatic incident. Interestingly, if thehistory is complete enough, the examiningpractitioner will often elicit the report ofinjuries at the general region of the plantarfascia at the time the pain rst started. Anexampleofthiswouldbecatchingtheheel onARTICLEINPRESS216 S.J.Bartoldtheedgeofafootpathwhilstcrossingtheroad.Atthetimethisdoesnotcausepain, butatamicroscopic level it may be enough to causeseparationofthecrosslinkingstructureofthecollagen bres of the plantar fascia and pre-cipitatesymptomatic,chroniccondition.*Painfulinthemorningonrisingfromrest.Thepatientwill reportpain, severeonrstweightbearing in the morning or on rising after aprolongedperiodof rest (e.g. after alongcarjourney).Thispainwillinevitablyimproveafterashortperiodofwalking.Likewise,thepainisworse at the commencement of sporting activityandimprovesafteraperiodofwarmup.Thepain is, however, likely to worsen after cessationof sport. The basis of this pain after rest ispresumed to be due to the accumulation ofinammatoryby-productswhichimpingeonthenerveendings whencompressedduringweightbearing(Bartold, 1997).Thispainisabsolutelycharacteristicof plantar fasciitis andis oneofthe most reliable and characteristic featuresdiagnostically.*Localizedoverthemedial slipoftheoriginofthe fascia. A pain localized over the medial slipof theoriginof thefascia. Plantar fasciitis isusuallyaverywell localizedconditionandthisassists greatly in making the diagnosis. It isrelatively uncommon for pain to be spread over amore diffuse area, but there may be poorlydenedpaininthemid-substanceofthefasciaor even spreading up the medial and lateralaspectsofthecalcaneus(seeBox1).Physicalexamination*Local tenderness.Painwill usuallybelocalizedover a small area near the origin of the fascia attheproximal insertionintothemedial tubercleof the calcaneus. The pain response to palpationover this small area involves considerable appre-hension, evasive action may be taken by thepatient to avoid further investigation! See Fig. 2.*Commonly there will be pain over the midline ofthe plantar surface of the calcaneus, which maybe either diffuse or localized in nature. This painmaycharacteristicallybeseeninpatientswithARTICLEINPRESSBox1 ClinicalpointHeelspurs*Bonyspursarefrequentlyassociatedwithplantar fasciitis, but are generally notassociatedwiththecauseofpain.*There are no clear studies to showtheassociation of heel spurs and plantarfasciitis.*Heel spurs arefrequently present intheasymptomaticpopulation(1030%).*Fatpadatrophymaybeaconsequenceofsubdermalinltrationofcortico-steroid.Inthisinstance,heelspursmaybesymptomatic.*Heel spurs may fracture secondary todirectheeltrauma.*Heel spurs have been noted in greaterproportionsintheobesepopulation,lend-ing weight to the theory they are asso-ciatedwithtractionastheenthesis.*Heel spurs may be associated with systemicdisease(Fig.1).Figure2 Theareaofpainisoftenverylocalizedoverthemedialoriginofthemedialbandoftheplantarfascia.Theplantarfasciaasasourceofpain 217weight bearing occupations (nurses, storemenetc.) andprobably represents someinamma-tionofthesubcalcanealbursa.*Thereisoftendiffusetendernessupthemedialor lateral aspect of the calcaneus, which istypical of the more severe inammatory pro-cesses. This needs to be differentiated fromcalcaneal stressfractureor referredpainfromthesubtalarjoint,seeFig.3.*Positive windlass manoeuvre, i.e. pain withpassivedorsiexionofthehallux,therebyload-ing the plantar fascia. This positive windlass testis often quoted in the texts, but in reality is seenin only a tiny percentage of cases, and then onlythemost severe. Apositivewindlass responsemayindicateruptureofasignicantproportionof the fascia. In this instance, signicant gappingin the plantar fascia may be palpated, see Fig. 4.*No swelling. Swelling with plantar fasciitis isrelativelyrareandusuallyreservedtothemostsevere cases or an acute fascial injury. Thepresence of swelling, however, can be animportant diagnostic clue and may indicateotherinjuriessuchasfracture,muscleinjuryorrupturetothefascia.*Nodularchangetothefasciaisaverycommonnding and represents fascial granulomataformedastheresultof repeatedfascial injurywhichhashealedwithscarring.Thesegranulo-matacanbecomequitelarge(thesizeofagolfARTICLEINPRESSFigure3 Thereisoftendiffusetendernessupthemedialorlateralaspectofthecalcaneus,whichistypicalofthemoresevereinammatoryprocesses.Thisneedstobedifferentiatedfromcalcanealstressfractureorreferredpainfromthesubtalarjoint.Figure4 Positivewindlassmanoeuvre,i.e.painwithpassivedorsiexionofthehallux,therebyloadingtheplantarfascia. This positive windlass test is often quoted in the texts, but in reality is seen in only a tiny percentage of cases,andthenonlythemostsevere.Apositivewindlassresponsemayindicateruptureofasignicantproportionofthefascia.Inthisinstance,signicantgappingintheplantarfasciamaybepalpated.218 S.J.Bartoldball is not uncommon), and therefore veryuncomfortable during weight-bearing. If theselesions cannot be accommodated with theappropriate orthotic devise, surgical interven-tionisappropriate.*Painwithpassivetalocrural jointdorsiexion.Becauseofthe intimateanatomicalrelationshipbetween the plantar fascia and the tricepssurae, dorsiexion of the ankle joint willcommonly elicit pain. Stretching of a tightposterior groupismandatoryintherehabilita-tionofplantarfasciitis(Plate1).DifferentialdiagnosesAs with any sporting injury, making an accuratediagnosis is of the utmost importance. This isparticularly highlighted when one considers thatsome of the more serious systemic diseases andtumours can present as simple overuse injuries suchas plantar fasciitis. The practitioner must thereforealways take the most complete history and listen tothepatientforthecluesthatmayindicateamoresinister diagnosis. Thefollowingaresomeof thediagnosesthatmayresultinheelpain:*Completeruptureoftheplantarfascia.*Subcalcanealbursitis.*Medialcalcanealnerveentrapment.*Tarsaltunnelsyndrome.*RupturefatpadSeversdisease.*Calcanealstressfracture.*Seronegativearthropathy,e.g.ankylosingspondylitis.*ReitersSyndrome.*Psoriaticarthritis.*Diffuse connective tissue disease especiallyrheumatoidarthritisbutincluding.*BehcetsSyndrome.*SystemicLupusErythematosus.*Necrotizing vasculitis and other vasculopa-thies.*Sj. ogrensSyndrome.*Tumour.ManagementPlantar fasciitis remains one of the most frustratingsports injuries despite the high number of con-servativeandsurgical optionsavailablefortreat-ment. The tendency towards chronicity of thisdisease process, frustrates athletes andphysicians alike. This notwithstanding, Lutter(1997) reports that 85%of patients withsympto-maticplantarfasciitiswillrespondtoconservativemanagement, with surgery indicated for the re-maining 15%. However this reports concludesthatplantarfasciitisisadegenerative,notinam-matory process, which contradicts the bulkof theliterature andthepathology andimagingstudies.ConservativetreatmentTheimmediatetreatmentforplantarfasciitisisaswithalloveruseinjuries,i.e.activitymodicationor rest, ice, compression and medication to reduceinammation and control pain (Bartold, 2001). Thespecic management revolves around a sequen-tiallyphasedregime;*Activity modication and stretchingFthis isarguablythesinglemost important componentof treatment for plantar fasciitis. Trainingtechniquesneedtobecarefullyreviewed, andpotential contributingfactors, for examplehillrunning,runningonnon-supportivesurfacesforexamplesand,stairclimbing,bounding,suddenincrease in training or sudden changes to trainingroutine, should be addressed. Stretching remainsthesimplecornerstoneoftreatmentforplantarfasciitis. A report by Pfeffer (1997) to theAmericanOrthopaedicFoot andAnkleSociety,supports this comment. In this prospectiverandomizedblindedstudyof 256patients withisolated heel pain syndrome, 72% improved overthe8weekstudyperiodwithstretchingalone.Thisnumberincreasedto88%withtheadditionofasimple,off-the-shelf,heelinsert.ARTICLEINPRESSHeel Pain Plantar Heel Pain Syndrome (PHPS) Nerve Entrapment Subcalcaneal Bursitis Plantar Fasciitis Bony Injury Plate1Theplantarfasciaasasourceofpain 219Specicstretchingshouldbetothegastrocne-mius/soleus complex, the hamstrings and theplantar fasciaitself. DeMaioet al. (1993) recom-mends specicstretchingtothesemusclegroupsbeforeconsiderationofnightsplintsorashortlegwalking cast. Non-ballistic stretching of the gastro-cnemius/soleuscomplexisdemonstratedinFig.5.Stretching of the plantar fascia itself may beachieved by rolling the foot over an ice lledbottle as shown in Fig. 6. Stretching continuesindenitely and is prescribed for 10 min three timesper day. Concomitant strengthening of the footintrinsicmuscles,andtibialisposteriorinparticu-lar, is also recommended, see Fig. 7. Stretching theplantar fascia and Achilles complex by passivelydorsiexing the foot with a towel around theforefoot should be performed in the morning beforeweightbearing.Orthoses in the treatment of plantar heelpainsyndromeTheuseof orthoses inthetreatment of plantarfasciitis is based on the principle of reducing tissuestress. Orthoses come in many forms, and mayinclude heel cuffs, viscous elastic heel pads,accommodativeinlays, prefabricatedandcustommadeorthoses.Inmanycases,theprimaryreasonorthoses have been used in the treatment ofplantar fasciitis has beenbasedontheassumedassociationbetweenexcessivefootpronationandthedevelopment of thecondition. Many authorslabelled excessive foot pronation as a cause ofplantar fasciitis, with Kwong et al. (1988) andKosmahl andKosmahl (1987) statingthatsubtalarjoint pronation everts the calcaneus and lengthenstheplantarfascia,thereby increasingtheintrafas-cialtension.Inaddition,pronationispresumedtocauseincreasedmobilityofthefoot,andtherebyincreasethelevelofstressappliedtothemyofas-cial and related tissues to the plantar fascia(CornwallandMcPoil,1999).TriggerpointtherapyMyofascialpainMyofascial painsyndrome(MPS)isquitecommon,but it can be quite difcult to recognize anddistinguish from underlying entities. It is frequentlyconfused with bromyalgia, a syndrome comprising16%ofallrheumatologyvisits(Goldenberg,1992).Fibromyalgia is more frequent in females and tendstohaveamorewidespreadpresentation.Myofas-cial painsyndromebycontrastisamoreregionalcondition,affectingmenandwomenequally,andhas a much better prognosis than bromyalgia(Wolfeetal.,1990).MyofascialpainsyndromeMyofascial pain syndrome (MPS) has been dened asamuscular paindisorder involvingregional painby trigger points (TrPs) within the myofascialstructures, local or distant fromthe origin ofpain (Travell and Simons, 1983). The reportedARTICLEINPRESSFigure5 Non-ballisticstretchingofthegastrocnemiusand Soleus is an essential part of the managementprogram.Figure6 Stretchingoftheplantarfasciaitselfmaybeachievedbyrollingthefootoveranicelledbottle.220 S.J.Bartoldprevalence of MPS varies greatly ranging frombetween 5% and 93% of the population (Auleciems,1995; Fomby and Mellion, 1997; Simons, 2000). Thisvarianceisdueinparttonon-uniformdiagnosticcriteria (Simons, 2000), lack of satisfactory labora-tory or imaging tests (Simons, 2000) and moresimply,becauseofthesheernumberandlocationsthatTrPscanexistthroughoutthebody.There is a large body of evidence in the literatureofTrPsandMPSintheupperbody,withrelativelylittle attention devoted to the lower extremity.Given its reported prevalence, MPS remains animportant differential diagnosis to consider inpatients with persistent pain, especially those thathavenotrespondedtomoretraditionaltreatmentfor the provisional diagnosis. Travell andSimons(1983) dene a TrP as a hyper-irritable spot,usuallywithinatautbandofskeletal muscleinamusclefascia. Thespotispainful oncompressionandcangiverisetocharacteristicreferredpain,tendernessandautonomicphenomena.Thisde-nition describes the cardinal sign of a trigger point,that is referredpain, inother words thetriggerpoint sending paintosomeother site. This is areason conventional treatment of pain so oftenfails. TrPs can be characterized as active, latent orsatellite.WithanactiveTrPdescribingasourceofon going pain that is familiar to the patient, alatent TrPis produces unfamilar painwhencom-pressed, anda satelliteTrPdevelops withinthearea of referred pain of an other active TrP(Starlanyl andCopeland, 1996). Thepathophysio-logical mechanismbehind the formation of TrPsremains controversial. Most authors accept thetheorythat implicates theinteractionof calciumwith adenosine triphosphate (ATP). Followingeither acuteor chronictrauma, thesarcoplasmicreticulum in the muscle cell is damaged leading to arelease of calcium, which binds to triponin andresultsincontractionofthemusclebre.Becausethe sarcoplasmic reticulum is damaged, it issuggested that the re-uptake of calciumcannotbe facilitated and the muscle bre remainscontracted. High levels of calciumincrease theenergy demands for ATP, and this may lead tolocalizedhypoxia.Thedisabledcalciumdepositedinthesarcoplasmicreticulumisthoughttoperpe-tuatethis cycle. Thehypoxiamayresult inlocalinammatoryresponseandthereleaseof seroto-nin, histamine, kinins and prostaglandins. Thesesubstancesarepainmediatorsandarebelievedtosensitizemusclenociceptorswhichconvergewithothervisceral andsomaticinputsandarethoughtto lead to the perception of local and referred pain(Rachlin,1994;Schneider,1995).It is important torecognizethat TrPs andMPSmay contribute to heel pain, mimicking plantarfasciitis.OneofthemostcommonlocationsforaTrP is in either muscle belly of gastrocnemius, or inthesoleus. This may refer paintotheheel andresult in symptoms leading to the incorrectdiagnosis of plantar fasciitis. The diagnosis isfurther clouded by the fact that biomechanicalabnormalitiescanleadtoanincreaseinstressonthe musculoskeletal systems and promote theformation and perpetuation of TrPs (Fomby andMellion, 1997). There is also an element of chickenandegg inrelationtotheformationof TrPsandARTICLEINPRESSFigure 7 Concomitant strengthening of the foot intrinsic muscles, and tibialis posterior in particular, is alsorecommended. Inthis instance, arubber bandis usedfor activeresistancetrainingof tibialis posterior andtheperoneals.Theplantarfasciaasasourceofpain 221biomechanicalabnormality.Forexampleheelpaincan radically alter a gait pattern, which may resultinthedevelopment of anabnormal muscleringpattern and the development of a TrP, in, forexample the soleus muscle. In this instance thediagnosismayonanon-goingbasisbeassumedtobeplantar fasciitis andwill beresistant tomostformsoflocaltreatmentsincethepainisactuallynoworiginatingfromthesolealTrP.Physiotherapyismostusefulinthetreatmentofheel painreferredfromaTrPandtherapies mayinclude the spray and stretch technique whichinvolves the use of a vapocoolant spray as adistraction to block the reexspasm and sensationofpain(Auleciems,1995).Cryotherapyviaanicepackovertheareaofreferredpainhasalsobeenshowntobeeffectiveinreducingpain.Oneofthemostimportanttreatmentmodalitiesisdeepcrossbre friction or ischaemic compression which allowfor a mechanical reduction of the taut muscular orfascial bands associated with a TrP. The use of heatand manipulation is effective on its own or incombinationwiththespray andstretchtechnique.Miller (1994) has alsocommentedontheuseoftranscutaneous nerve stimulation (TENS), phono-pherisis, iontophoresis and cold laser. In relation toplantar heel pain referred from TrPs, passivestretchingofthegastrocnemius/soleuscomplexisveryimportanttoallowforquickerrehabilitationandalsotolimittherecurrenceofMPS.TrPs mayalsobetreatedviainjectiontherapyand this is regarded as the denitive treatment forrecalcitrant cases of MPS whichrepresents some2030% of all cases (Kantu and Grodin, 1992).Injectiontherapymaycomprisetheso-calleddryneedling (acupuncture) or wet needling whichinvolvesinltratingtheareawitheithersalineorlocal anaesthetic. This latter techniquehelps todisrupt the brous banding within the TrP and Honget al. (1997) has reportedthat this techniqueisassociated with signicantly reduced post-injectionsorenesscomparedtoacupuncture(seeBox2).TapingforplantarfasciitisSpecic taping techniques are available for thetreatmentofplantarfasciitis,andtheyrepresentone of the most reliable short-termtreatmentoptions. Thetechniquedescribedinthis text hasbeen developed by the author and it is most usefulinthemanagementoftheacutephaseofplantarfasciitis. This method is also used as a tool to guidetheshorttomediumtermtreatmentregime,andspecicallytoconrmor otherwiseamechanicalrole inthe generationof symptoms. This tapingmethod can be used to predict the success ofpotentially costly orthotic therapy, and is animportant indicator to specic goals of orthotictherapy.Therationaleofthisspecictapingtechniqueisbasedonitsabilityto;*Reinforcetheplantarfasciabothstaticallyanddynamically.*Facilitatetheactionof peroneus longus whichstabilisesthe1stray.*Providecompressionoverthesiteofpain.*Plantar extheforefootontherearfoot, there-by increasing the calcaneal inclination angle(CIA).*Invertthecalcaneusbeyondvertical.*Reduce motion through the midfoot, and inparticularthroughthemidtarsaljoint.Thistapingtechniqueisdesignedspecicallytoaddress the factors present that may increasetension in the plantar fascia. It is particularlyaimedat themobileor pronatingfoot, whichispresumedtobeacontributingfactor.Thistechni-queiscontraindicated in acavusor supinatedfoottype.Whenappliedcorrectlyitisamosteffectivetreatmentmethod.MethodThis method uses rigid 1.5 and 2.0 inch taping. It isimportant to ascertain previous plaster allergyARTICLEINPRESSBox2 PracticepointsPlantarheelpainsyndrome*Early, aggressive, non-surgical treatmentoffersthebestchanceofagoodoutcomeinPHPS.*It is critical to rule out systemic disease ofnerveentrapment.*Patients withidiopathicheel painshouldbe screened for sero-negative and sero-positivearthritidesandsarcoidosis.*Thefootissecondonlytothekneeasthesiteofpresenceofrheumatoidarthritis.*Men under 40 presenting with bilateralheel painshouldbeevaluatedforReiterssyndromeandankylosingspondylitis.222 S.J.Bartoldreactions to zinc oxide tape since underwrapcannotbeusedwiththistechnique.The method of application of tape is critical,especiallywithdirectionoftapeapplication. Thetechnique will fail if the tape is applied frommedial tolateral whereitshouldbeappliedfromlateraltomedial.Therst stripis appliedusing 1.5 intapeandextendsfromthebaseofthe5thmetatarsalheadalong the lateral border of the foot behind thecalcaneusbutonitsposteriorsurfaceandnishesatthebaseofthe1stmetatarsalhead,seeFig.8.The tape must be applied from lateral to medial asthis helps to apply a supinatory moment to thecalcaneus.Atthesametimethe1strayshouldbeheld in the plantar exed attitude so that thetapingwill nishsomewhat dorsallyover the1stmetatarsal head. Thesecondstripof 1.5 intapestarts dorsally over the 1st metatarsal head, medialto the 2nd metatarsal head. Maintaining a plantar-exion pressure over the 1st ray, the tape is pulledplantarly(tofurtherplantarexthe1stray). Thetape is then placed frommedial to lateral andnishesdorsallyoverthe5thmetatarsalhead,seeFig. 9. This has now induced an everted position oftheforefootwithaplantarexed1stray.The1stray is unable to dorsiex signicantly and isstabilizedandfacilitated by peroneus longus. Inaddition due to its plantarexed attitude, thetension of the plantar fascia has now been reduced.The third strip of tape runs from lateral to medialfrom below the lateral malleolus, nishing distal toARTICLEINPRESSFigure9 Thesecondstripof1.5 intapestartsdorsallyoverthe1stmetatarsalhead,medialtothe2ndmetatarsalhead. Maintaining a plantarexion pressure over the 1st ray, the tape is pulled plantarly (to further plantarex the 1stray).Thetapeisthenplacedfrommedialtolateralandnishesdorsallyoverthe5thmetatarsalhead.Figure8 Therststripisappliedusing1.5 intapeandextendsfromthebaseofthe5thmetatarsalheadalongthelateral border of the foot behind the calcaneus but on its posterior surface and nishes at the base of the 1st metatarsalhead.Theplantarfasciaasasourceofpain 223themedialmalleolus.Onceagainthisstripinvertsthecalcaneusandcareshouldbetakentoachievethis inversion whilst applying the tape. This strip isapplied very tightly and should cover the areaof maximal discomfort providing signicantcompression.The next stage in this taping method is a series ofve(or four inasmaller foot) 1.5 intapestripsrunning longitudinally from the metatarsal heads totheposterior surfaceof thecalcaneus. Therststrip runs fromthe 1st metatarsal head to theheelFthefthstripfromthe5thmetatarsalheadto the heel. As they pass over the posterior surfaceof the calcaneus, the tape strip should overlapcompletely, see Fig. 10. Once again these strips areappliedwith considerable tension, plantarexingthe forefoot on the rearfoot. It will be necessary toplantarextheforefootontherearfoottogetthetape to conform to the arch. This part of the tapingmethodoffers considerablereinforcement of theinjuredplantar fasciawhileenablingittorestsincenearlyallthetensionhasnowbeenremovedfromthefascia.Thenal stageofthetapinguses 2 inrigidtape.Stripsareplacedfrommedial tolateral commen-cingasfardistallyaspossibleandoverlappingbyonehalf until about themidfoot. This process isthencontinuedrightuptotheposteriorheel,butwrappingfromlateral tomedial. This onceagainmaintains the heel in an inverted position. The nalstripof2 intaperunsfromthestyloidprocessonthe lateral aspect of the foot, posterior to the heeland nishes medially and distalto the site of pain.This is demonstratedinFig. 11. Firmpressureisonce again applied to provide compression. Toconcludethisisatightstrapping,andneedstobeso for success. All taping loses contact the skinfairly quickly andtoachieveits goal this tapingneedstoberm.PrecautionsandcontractionsThis is not an effective method with a rigid forefootvalgus foot type or rigid plantar exed 1st ray foottype.PlantarfasciitisinthesefoottypesisoftenARTICLEINPRESSFigure10 Thenext stageinthis tapingmethodis aseriesofve(orfourinasmallerfoot)1.5 intapestripsrunninglongitudinallyfromthemetatarsalheadstotheposterior surfaceof thecalcaneus. Therst striprunsfrom the 1st metatarsal head to the heelFthe fth stripfromthe5thmetatarsal headtotheheel.Astheypassover theposterior surfaceof thecalcaneus, thetapestripshouldoverlapcompletely.Figure11 Thenal stageof thetapinguses2 inrigidtape.Stripsareplacedfrommedialtolateralcommen-cing as far distally as possible and overlapping by one halfuntil aboutthemidfoot.Thisprocessisthencontinuedright up to the posterior heel, but wrapping from lateralto medial. This once again maintains the heel in aninvertedposition.224 S.J.Bartoldcaused by repetitive shock based trauma andmakingthefootevenrigidwillnothelp.This taping method places the foot into whatcouldbeconsideredanabnormalorevenpatholo-gical position. It is designed to unload to theplantar fascia by inducing the forefoot plantarex-iononrearfoot andinvertingthecalcaneus. It isfor theshort-termmanagement of acuteplantarfasciitis or as atrial for thepotential success oforthotic therapy. It should not be considered for thelong-termmanagement of the condition. It maysafelybeappliedintheacutephasefor3to4dayperiodsforupto2weeks.Therealisticpatencyofthe tape is 4872 h. Used in this manner this tapingtechniquehasbeenofgreatsuccessinshorttermmanagement and shaping long-term protocol.Becauseof its abilitytoalmost completelyelim-inate midfoot motion, it is also very effective in thetreatment of forefoot varus based posterior medialshinpain.Theeffectivenessofthistapingtechni-quewill begreatlyimprovedwithaconcomitantstretching programme as described above, and alsotheroutineuseofcryotherapy.SummaryPlantar fasciitis in its many forms remains anenigmaticconditionfor thetreatingsports physi-cian. Confusionreigns tothis day, withdisagree-ment on the aetiology, histopathology investigationnatural historyandtreatmentofthistroublesomecondition. However, most researchers and clini-cians alike agree that athletes with insertionalplantarfascialpaincanachievegoodresultswith-outresortingtosurgery.Thereisnoagreementonone treatment of choice for plantar fasciitis,however, it appears that early, aggressive, non-surgical treatment within 12 months of the onset ofsymptoms offer the best change of a good outcome(Martinetal.,1998).Thereappearstobealowerchance of a good prognosis, the longer non-surgicalmanagementhasbeenunsuccessful. Despitethis,most research indicates that conservative manage-ment is preferable to surgical intervention, andthat the indications for surgery in insertionalplantar fascial painarethereforelimited. Educa-tion and encouragement are key components to themanagementplanforplantarheelpainsyndrome,sincepainresolutioncanoftenbeveryslow.ReferencesAuleciems, L.M., 1995. Myofascial pain syndrome: a multi-disciplinaryapproach.NursePractitioner20(4),1828.Bartold, S.J., 1997. Conservative management of plantarfasciitis. 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