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 
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