A 42-year-old male construction worker from Mumbai presents with severe heel pain that is worst in the morning when he first steps out of bed. The pain improves slightly with activity but worsens by evening. On examination, there is tenderness over the medial calcaneal tuberosity and pain on passive dorsiflexion of the toes. Plain radiographs show a calcaneal spur. The patient has a high BMI (28.5 kg/m²) and works on hard surfaces for 8–10 hours daily. Which anatomical structure is primarily affected in this condition?

Explanation

## Diagnosis: Plantar Fasciitis ### Anatomical Basis **Key Point:** Plantar fasciitis is inflammation of the plantar fascia, a thick aponeurosis that originates from the medial calcaneal tuberosity and extends to the metatarsal heads, supporting the medial longitudinal arch. ### Clinical Features in This Case - **Morning pain with first steps** — classic presentation due to overnight shortening and stiffening of the fascia - **Tenderness over medial calcaneal tuberosity** — the primary attachment point of the plantar fascia - **Pain on passive dorsiflexion of toes** — stretches the plantar fascia (positive Silfverskiöld test variant) - **Calcaneal spur on X-ray** — traction osteophyte at the fascia insertion site ### Risk Factors Evident 1. Prolonged standing on hard surfaces (occupational) 2. Elevated BMI (mechanical overload) 3. Age 40–60 years (peak incidence) ### Pathophysiology Repetitive microtrauma at the calcaneal insertion leads to: - Chronic inflammation and microtears - Calcification and spur formation - Fascia shortening and stiffness overnight **High-Yield:** The plantar fascia is NOT a muscle but a thick fibrous aponeurosis. It is the primary load-bearing structure of the medial longitudinal arch. Inflammation at its calcaneal attachment (enthesopathy) is the hallmark of plantar fasciitis. **Clinical Pearl:** Morning pain that improves with activity is pathognomonic — the fascia "warms up" and stretches as the day progresses, reducing pain initially, but fatigue and continued stress worsen it by evening. ### Management Approach - Rest and ice - Plantar fascia stretching (calf stretches, towel curls) - Orthotic insoles to support the arch - NSAIDs for pain and inflammation - Corticosteroid injection (if conservative measures fail) - Extracorporeal shock wave therapy (ESWT) or plantar fascia release (surgical) for refractory cases