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(inf lammatory and noninf lammatory) could potentially be involved in the condition. Fiber degeneration in the plantar fascia can happen anywhere along its course, but the primary site of involvement is the proximal attachment at the anterior calcaneus. The attachment site is particularly painful because the plantar fascia blends in with the periosteum around the calcaneus at the attachment site. The periosteum is one of the most pain-sensitive tissues in the body, so pulling on it produces significant pain. Repetitive tensile stress on the calcaneal attachment site can also cause an exostosis (bone spur) to develop. Plantar fasciitis may exist without bone spurs, and bone spurs may exist without plantar fasciitis. Several mechanical factors play a role in the onset of plantar fasciitis. Overpronation is a recognized cause of plantar fasciitis. Ordinarily, the tibialis posterior muscle aids the plantar fascia in shock absorption. The muscle's function is often compromised in overpronation, and the plantar fascia has to take on a more significant role in shock absorption in the lower extremity. Hypertonicity or myofascial trigger points in the triceps surae (gastrocnemius and soleus) muscles may also set up dysfunctional tension patterns in the foot muscles, which can contribute to plantar fasciitis as they limit the spring action in the foot. A sudden change in activity levels, such as that with new military recruits, is routinely linked to plantar fasciitis. Significant weight gain, especially over a short period, may also put additional stress on the plantar fascia and longitudinal arch. For example, plantar fasciitis is increasingly common in the later stages of pregnancy when rapid weight gain occurs over a short period and relaxin hormone levels are elevated in the bloodstream, decreasing connective tissue strength. Footwear and ground surface also play important roles in cumulative trauma of the plantar fascia. Certain types of shoes, such as high-heeled shoes, decrease the shock-absorbing quality of the plantar fascia because they significantly alter foot mechanics. Likewise, steel-shanked construction boots decrease the foot's f lexibility and may lead to cumulative trauma, especially if the person walks or stands on a hard surface all day. So, improper footwear and repetitive loading produce a double dilemma that may lead to plantar foot pain. NERVE ENTRAPMENT IN THE FOOT Another cause of foot pain is nerve entrapment. Here are a few pathologies that fall under this category. Tarsal Tunnel Syndrome Tarsal tunnel syndrome is a nerve entrapment problem that produces pain and other neurological sensations on the bottom surface of the foot. Because of the pain location, it is commonly mistaken for plantar fasciitis. Like carpal tunnel syndrome in the wrist, tarsal tunnel syndrome involves a nerve passing through a fibro-osseous tunnel created by a binding retinaculum. The tibial nerve courses through the lower leg in the deep posterior compartment. As the nerve exits the deep posterior compartment, it passes around the medial side of the ankle on its way to the toes. Near the medial malleolus, the tibial nerve divides into three branches. The medial calcaneal nerve is primarily a sensory branch that serves the posterior and bottom surface of the heel. The other branches— the medial and lateral plantar nerves—carry motor and sensory signals to the plantar surface of the foot and into the toes. Just after the tibial nerve divides into these three branches, they all pass under a fascial band on the medial side of the ankle called the f lexor retinaculum or laciniate ligament (Image 2). The retinaculum is connected superiorly to the medial malleolus and inferiorly to the medial side of the calcaneus. This space under the retinaculum is the tarsal tunnel. In L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 23 2 The tarsal tunnel region. Image courtesy of Complete Anatomy. Flexor retinaculum Long flexor tendons Tibial nerve and branches