Happy Friday {{first_name}}!!
We had a few readers reach out and kindly ask to bring back the old format. Where I shared the full case, and not just a few snippets. They didn’t feel it was fair to pay for the article since they couldn’t use the CE in their states. I understand that.
So I’ve made a few tweaks. From now on, you’ll find an abridged version here in the newsletter. And find the full PACE focused article in the TCC Members hub.
If you are reading the newsletter, and want the CE’s, become a TCC Member today. (it’s on a discount for labor day, see the end of the newsletter for details).
The Case:
R is 41. Recreational marathoner, four years in, fourteen weeks out from her fall race. Six weeks of insidious right plantar heel pain: a sharp 7/10 on the first steps out of bed, easing after ten minutes of walking, quiet during her easy runs, aching for hours after the long ones.
The Trap:
Every heel pain in a runner gets labeled plantar fasciitis in the first five minutes of an encounter. Tell me you weren’t thinking it...
The runner points at the heel. We hear "worse in the morning." We palpate somewhere in the neighborhood, find tenderness, and hand over calf stretches and a frozen water bottle. Ninety seconds, and the differential never happened.
The reasoning error is anchoring. Plantar fasciitis is the most common cause of plantar heel pain, so it becomes the only one considered. But the fat pad and the calcaneus live in the same square inch of real estate, and they fail under the same training loads that irritate the fascia. Prevalence is not diagnosis. Miss the fat pad and your patient gets a fascia protocol, then comes back in a month "not responding to conservative care." Miss the bone and she keeps running on a calcaneus that is asking for help.
The Workup
Palpation mapping — medial tubercle vs. central pad vs. calcaneal walls. This is the anchor finding, and location does most of the diagnostic work. Medial tubercle is fascia. Central pad is fat pad. Calcaneal walls are bone. Three structures, one thumb. R was sharp and focal at the tubercle, minimally tender centrally, non-tender on the walls to firm pressure.
Windlass test. Passive great toe extension in weight bearing reproduced her exact sharp medial heel pain. Tensioning the fascia reproduces fascia pain. Neither the fat pad nor the calcaneus cares about great toe extension, so a positive windlass points at one diagnosis and away from the other two.
Calcaneal squeeze. Ten seconds. That is the whole cost. A positive squeeze in a runner with a recent mileage spike is a calcaneal stress reaction until proven otherwise, and it flips the plan from loading to offloading. Skipping it is how bone stress injuries get six weeks of stretching.
Single-leg hop. Ten hops, mild fascia-origin discomfort only. Nothing deep, nothing diffuse. Impact intolerance is the signature of bone stress. A runner who cannot hop on that heel does not get a loading program. She gets an MRI, and remember a negative X-ray does not clear the bone.
Single-leg heel raise. Diagnostic and therapeutic in the same breath. Her right calf cannot handle her training load. That number is why the heel hurts, and it is the rehab target for the next six weeks. Her ankle dorsiflexion was limited and asymmetrical on that side, feeding the overstriding heel strike I watched on the treadmill.
Plantar fasciitis is a WARM-UP condition, brutal first steps, better with easy activity, achy afterward.
Fat pad syndrome is a SURFACE condition, barefoot on tile is worse than cushioned shoes, and the windlass does nothing to it.
Calcaneal stress reaction is a DOSE condition, it does not warm up, it accumulates through the run.
Now, are you following the pattern? Ask one question about each profile and the history starts sorting itself before your hands touch the heel.
The Plan
Foundation: Full stop on running. Calm the calf and intrinsic muscles down, then start pre-tensioned heel raises with the toes on a towel. Slow tempo. Add dorsiflexion and great toe mobility. Aerobic base stays alive on the bike and in the pool, and she will hate every minute of it.
Loading: Progress to heavy, slow single-leg work. The fascia adapts to load, not to stretching. Layer in intrinsic control and frontal-plane work, and build daily walking volume to a real threshold before anything jogs. Every progression answers to the next-morning rule: pain up to 3/10 during exercise is acceptable, a worse first step tomorrow means yesterday was too much.
Sport-specific: Rebuild elastic tolerance before you rebuild mileage — hops and rope work first, then a criteria-based walk-jog progression with cadence correction and cushioned shoes. Return to volume on the 10 percent rule, long run capped at a third of weekly mileage. The mileage spike caused this. The mileage plan prevents the sequel.
Dry Needling and the instruments earn their place here. But they only open the window. Loading walks through it.
Clinical pearl: Palpate like the differential depends on it, because it does.
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The Practice
The Performance Doctor: Precision palpation and a squeeze test cost you nothing. No equipment, no imaging, no extra visit. What they buy you is a patient who progresses on criteria instead of one who cycles through a flare-up every training block. That second patient is expensive. She burns visits, she tells her running group you did not help, and she eventually shows up somewhere else with a fracture line that started under your thumb.
The other half is the imaging decision, and in a cash practice that decision has a dollar sign attached. R's squeeze and hop were negative, so I did not order an MRI. What I did do was document the reasoning and tell her exactly what would trigger one: deep night ache, pain with hopping, or a plateau at four weeks. Not imaging today is only defensible if you have defined what tomorrow's trigger looks like. Write the contingency and the chart defends itself.
It also changes the room. She stops asking whether we should scan it, because she knows the plan has a tripwire in it. Then she goes and does the boring work.
That is the retention piece, and it is the whole practice-growth argument in one line. Runners do not stay with the clinician who gives them stretches. They stay with the one who gives them an honest map. The patient sets the goal, the tissue sets the timeline, and you tell the truth about both.
This weekend at SmartCARE
LABOR DAY SALE SITE WIDE!
You work hard. You deserve a break!
SAVE 30% this weekend ONLY! Use code: Labour26 at checkout
Sale ends Monday at midnight 9/5/2026.
Keep showing up, we’ll keep leveling up together.
In health and strength,
Dr. Thomas Kauffman, DC, CDNP, CSCS, USAW
The Clinical Coach™ a SmartCARE Education™ publication
The Clinical Coach™ is a clinical education publication produced by SmartCARE Education™. Content is for educational purposes and CE credit. Always exercise independent clinical judgment with individual patients.
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