Heel pain (PHP) is a complex multifactorial disorder with many factors involved.  The etiology of PHP is often not well understood, leading to uncertainty about its most effective management and making the condition difficult to treat effectively Treat. Many questions have arisen in this series on PHP, which can now be answered in light of the literature discussed.
Why Call it Plantar Heel Pain Syndrome?
A number of terms have been used to describe subheel pain, but most of these terms are associated with specific pathologies, even though the actual underlying pathology of subheel pain remains largely unknown.  While many clinicians focus on the plantar fascia Complaints of pain under the heel, but there is now enough evidence that the plantar fascia is not the only culprit.  Accordingly, the descriptive term Plantar Heel Pain Syndrome (PHPS) was proposed to describe painful conditions under the heel in which there is no There is a differential diagnosis.  
Why does stretching the posterior calf muscles help people with PHPS?
Manual palpation of the plantar flexor muscles at the posterior calf of the affected leg in a patient with PHPS revealed soft tissue stiffness, non-compliance, and pain.  These myofascial limitations of the posterior calf muscles are associated with the development of PHP because it interferes with The stretchiness of muscles and fascia prevents optimal muscle function.  Damage to the muscle during an injury prevents optimal contraction (dilation) and relaxation (lengthening) of the muscle, and muscle tissue heals through less elastic and more fibrous scar tissue than muscle tissue.
Deep Friction Massage (DFM) supports effective muscle contraction and expansion as it breaks the adhesions between muscle fibers that limit contraction.  However, it is stretching that allows the muscle to return to its full length, thereby improving its ability to relax and contract. 
Why is the central heel region more sensitive to pressure in the tenderness threshold study?
In the pressure pain threshold (PPT) study by Saban and Masharawi  (Fig. 1), it is not entirely clear why the central heel region is so sensitive, especially considering that there is little soft tissue in the heel region. There is no conclusive evidence that fat pads can be source of pain.  Anatomically, the medial calcaneal branch of the tibial nerve enters the heel medially and terminates at the heel skin, providing sensory innervation to the heel skin , which may explain the sensitivity of this area to pressure increase (Fig. 1).
Figure 1. PPT test sensitivity and neuroanatomy 
What risk factors are associated with PHPS?
A literature review of risk factors associated with PHPS found no specific risk factors for the development of PHPS. But the individual is:
- Under exercising/sedentary
- Over exercising
The risk of developing PHPS may be slightly higher. 
What treatment techniques are effective in the management of PHPS?
From a review of the literature on PHPS treatment, it is clear that many commonly used treatments for PHP are ineffective or superior to placebo in the management of PHPS.  However Saban et al.  found that using deep massage therapy combined with stretching And nerve mobilization is an effective treatment for PHPS. Since other commonly used techniques have not been proven effective for PHPS, they will only mislead patients and make them more passive in their treatment. 
A “new protocol” for PHPS:
- Rely on our existing physiotherapy skills
- Improve our assessment and treatment skills
- Is a low tech and low cost intervention
- Simple but not easy as it requires extensive knowledge
- what we are doing
- Why we do it this way (clinical reasoning based on knowledge of anatomy)
- dealing with different patients
- How to Build and Manage Therapy Sessions
In summary, key concepts introduced and explored in this course include:
- PHPS Basics – Role of the Heel in the Gait Cycle PHPS Pain Locations and Behavioral Prevalence
- An in-depth literature review on risk factors for PHPS and their assessment and treatment (Fig. 2)
- Clearly identified the need for a different approach to effectively manage PHPS
Figure 2. Known variables in PHPS risk factor assessment and treatment literature review 
The “new protocol” began by looking at a poorly understood response to two commonly used assessment tests: the heel rise test and the mini squat test. Ultimately, it provides means to enhance PHPS administration by:
- Assessment tool (Figure 3)
- Manual therapy (Figure 4)
- Exercises (Figure 4) 
Figure 3. Clinical trials in the assessment tool 
Figure 4. Treatment after the new regimen 
- ↑ Jump up to:1.0 1.1 Sullivan J, Pappas E, Burns J. Role of mechanical factors in the clinical presentation of plantar heel pain: implications for management. The Foot. 2020 Mar 1;42:101636.
- ↑ Jump up to:2.0 2.1 Thomas MJ, Whittle R, Menz HB, Rathod-Mistry T, Marshall M, Roddy E. Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use. BMC musculoskeletal disorders. 2019 Dec;20(1):1-8.
- ↑ Jump up to:3.0 3.1 3.2 Riel H, Cotchett M, Delahunt E, Rathleff MS, Vicenzino B, Weir A, Landorf KB. Is ‘plantar heel pain’ a more appropriate term than ‘plantar fasciitis’? Time to move on. Br J Sports Med. 2017; 15(22):1576-1577.
- ↑ Cotchett M, Rathleff MS, Dilnot M, Landorf KB, Morrissey D, Barton C. Lived experience and attitudes of people with plantar heel pain: a qualitative exploration. Journal of foot and ankle research. 2020 Dec;13(1):1-9.
- ↑ Ríos-León M, Ortega-Santiago R, Madeleine P, Fernández-de-Las-Peñas C, Plaza-Manzano G. Topographical pressure pain sensitivity maps of the feet reveal bilateral pain sensitivity in patients with unilateral plantar heel pain. Journal of Orthopaedic & Sports Physical Therapy. 2019 Sep;49(9):640-6.
- ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 Saban B, Deutscher D, Ziv T. Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual therapy. 2014 Apr 1;19(2):102-8.
- ↑ Jump up to:7.0 7.1 Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018 Mar 1;34:11-6
- ↑ Chaves P, Simões D, Paço M, Pinho F, Duarte JA, Ribeiro F. Pressure Applied during Deep Friction Massage: Characterization and Relationship with Time of Onset of Analgesia. Applied Sciences. 2020 Jan;10(8):2705.
- ↑ Farooq N, Aslam S, Bashir N, Awan WA, Shah M, Irshad A. Effectiveness of transverse friction massage of Flexor digitorum brevis and Calf muscle stretching in Plantar fasciitis on foot function index scale: A randomized control trial. Isra Med J. 2019;11(4):305-9.
- ↑ Jump up to:10.0 10.1 Saban B, Masharawi Y. Pain threshold tests in patients with heel pain syndrome. Foot & ankle international. 2016 Jul;37(7):730-6.
- ↑ Jump up to:11.0 11.1 11.2 11.3 11.4 Bernice Saban. Conclusion of Plantar Heel Pain Syndrome with Practical Demonstrations. Plus Course. 2021
- ↑ Zhang Y, He X, Li J, Ye J, Han W, Zhou S, Zhu J, Wang G, Chen X. An MRI study of the tibial nerve in the ankle canal and its branches: a method of multiplanar reformation with 3D-FIESTA-C sequences. BMC Medical Imaging. 2021 Dec;21(1):1-1.
- ↑ Van Leeuwen KD, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British journal of sports medicine. 2016 Aug 1;50(16):972-81.
- ↑ Menz HB, Thomas MJ, Marshall M, Rathod-Mistry T, Hall A, Chesterton LS, Peat GM, Roddy E. Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain. Rheumatology. 2019 Feb 1;58(2):237-45.
- ↑ Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British journal of sports medicine. 2019 Feb 1;53(3):182-94.
- ↑ Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM, Altman RD, Beattie P, Cornwall M, Davis I. Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy. 2014 Nov;44(11):A1-33.
- ↑ Jump up to:17.0 17.1 Saban B, Masharawi Y. Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise. Physiotherapy. 2017 Jun 1;103(2):237-44.