by Douglas Richie, Jr. D.P.M., President Elect AAPSM (2003 - 2004)
Epidemic Of Heel Pain:
Heel pain is the most common musculoskeletal complaint of patients presenting to podiatric practitioners throughout the country. It is well-recognized that subcalcaneal pain syndrome, commonly attributed to plantar fascitis, is a disease entity that is increasing in its incidence, owing partly to the fact that it has a predilection for people between the age of 40 and 60, the largest age segment in our population.
The orthopedic and podiatric literature have been filled with original scientific investigations and anecdotal reports about the appropriate surgical and non-surgical approach to plantar fascitis. The vast majority of these scientific articles deal with the general patient population presenting with heel pain. There is a growing consensus of opinion that plantar fascitis is best treated non-surgically with the vast majority of patients becoming asymptomatic within twelve months of the onset of symptoms.
While patience, rest and tolerance of pain are virtues recommended to the patient presenting with plantar fascitis, different treatment strategies must be employed when dealing with the athlete.This article will focus on the differences in treating plantar fascitis in athletes vs. the general, sedentary population.
Subcalcaneal pain syndrome in athletes is thought to be brought on by an overload of the plantar fascia.However, the mechanism of this overload is debated.Overload causes micro-tears at the fascia-bone interface of the calcaneus or within the substance of the plantar fascia alone.The central band of the plantar fascia is primarily affected where a hypercellular, inflammatory response occurs within the fibers of the fascia, leading to degenerative changes.
A spur may result from further inflammation but is not implicated as the primary source of heel pain.Many studies have shown the presence of spurs on the heels of asymptomatic patients.One study found that only 10% of all calcaneal spurs visible on x-ray were actually symptomatic.
Other authors have attributed "painful heel syndrome" to an entrapment of either the medial calcaneal nerve or the first branch of the lateral plantar nerve.However, the mechanism of entrapment proposed by these authors is still related to overload of the soft tissue and fascial structures on the plantar and medial aspect of the calcaneus.
Although heel pain is common, there is no commonality of opinion of the biomechanical etiology of this syndrome.Contributing factors reported in the literature include leg length inequality, pronation of the subtalar joint, restricted ankle joint dorsiflexion, weakness of plantar flexion, high arched feet, low arched feet and heel strike shock.Studies have shown that decreased arch height has shown no correlation to the development of plantar fascitis in runners.In fact, it is well accepted that the common athlete presenting with heel pain has a medium to high-arched foot.
Scherer and coworkers have given the best insight into the pathomechanics of plantar fascitis.Their study proposed that supination around the longitudinal axis of the midtarsal joint is a common feature in over 100 feet presenting with heel pain.Supination about the longitudinal axis of the midtarsal joint can occur in two primary situations:when the heel everts past perpendicular (heel valgus) or when a forefoot valgus deformity is present (sometimes accompanied by rearfoot varus).
TREATMENT STRATEGIES FOR THE ATHLETE
In most cases, the goal of the athlete is to quickly return to activities to minimize loss of fitness and performance.This will put pressure on the treating practitioner to be more aggressive than treating cases of more sedentary patients.
A survey was conducted by this author of the board members of the American Academy of Podiatric Sports Medicine two years ago to compare treatment protocols for athletes vs. standard population.The following treatment pearls were elicited:
1) Assignment to alternative activity
The athlete must be encouraged to maintain cardiovascular fitness during rest from damaging activities that may delay healing.For the runner, dancer or volleyball player, this means a complete cessation from running and jumping activities until acute symptoms subside.On the other hand, the athlete should be assigned to alternative cardiovascular fitness activities that minimize impact and loading on the plantar fascia including stationary cycling, swimming, upper body weight machines, and low resistance flat-footed stair master machines.
2) Change and modulation of footwear
Footwear analysis is critical for evaluating athletes with subcalcaneal pain.The footwear may be a contributory factor and can be utilized as a powerful treatment modality.Athletesshould be placed into shoes that have a minimal 1" heel height with a strong stable midfoot shank and relative uninhibited forefoot flexibility.The American Academy of Podiatric Sports Medicine has a list of recommended footwear for the athlete that can be obtained on their web site:www.aapsm.org.It is well recognized that recent trends in athletic footwear have actually predisposed to greater frequency of plantar fascitis due to the fact that athletic shoes have weaker midsoles with newer designs.The popular "two-piece" outsoles with an exposed midsole cause a hinge effect across the midfoot placing excessive strain on the plantar fascia in the running and jumping athlete.These shoes must be eliminated if the injured athlete is wearing them.Careful attention must be paid to having the athlete keep shoes on in the house and during all standing and walking activities.Barefoot and sandal-wearing activities are prohibited.
3) Home therapy
Athletes are accustomed to designing and participating in their own training programs.They are willing participants in their own treatment programs. Heel cord stretching is central to the rehabilitation process to decrease load on the plantar fascia and encourage healing.The use of plantar fascia night splints has been well proven to be a treatment adjunct for plantar fascitis by placing the heel cord and the plantar fascia on a sustained static stretch during sleeping hours while preventing the normal contractures that occur in the relaxed foot position during sleep.Having the athlete roll or massage their foot on a golf ball or tennis ball is helpful to improve blood flow and break down adhesions in the injury site.
4) Custom foot orthoses
Intervention with semi-rigid custom foot orthoses has been well proven in many prospective and retrospective studies showing successful outcomes in patients with plantar fascitis.In the athlete, the use of foot orthoses should be considered earlier than in the average sedentary patient because of the fact that the athlete will be subjecting their feet to greater stresses during treatment and certainly after return to activity.Athletic footwear is more amenable to semi-rigid and rigid orthotic therapy than are casual shoes worn by sedentary patients.Sports podiatrists are more likely to employ arch taping procedures as a precursor to or adjunct to orthotic therapy.Athletes respond very favorably to the immediate intervention and relief obtained by expertly applied arch taping procedures.
5) Physical therapy
Athletes are amenable to referral for physical therapy because they are willing to invest the extra time to expedite recovery.Many athletes are used to going to the training room for hands on rehabilitation.Athletes appreciate a partnership between the sports podiatrist and the physical rehabilitation specialist.
6) Anti-inflammatory medication
Sports podiatrists should be cautioned against over-aggressive use of anti-inflammatories in treating the athlete.While it is tempting to utilize corticosteroid injections to expedite healing, athletes are often skeptical of receiving this treatment and are certainly at greater risk for sequela of over-ambitious use of steroid injections.There are reports in the literature of athletes undergoing spontaneous rupture of the plantar fascia after even single injections of their plantar fascia with corticosteroid.The conservative, biomechanical interventions outlined above should be implemented before considering injection therapy.
Athletes presenting with plantar fascitis must be treated aggressively because they have immediate needs and long-range goals that are different than those seen in the average sedentary patient with heel pain.It is important to be aggressive and employ a variety of modalities and treatments when formulating a treatment plan for the athlete.At the same time, caution should be made about the overzealous use of quick fixes, including corticosteroid injections because of the potential deleterious effect on athlete.
The cornerstone of plantar fascitis treatment for the athlete is biomechanical.Podiatric practitioners possess the greatest skill set and knowledge available in medicine today to adequately address the pathomechanics of plantar fascia overload.The use of properly casted and designed custom foot orthoses should be the cornerstone of non-surgical treatment of subcalcaneal pain in the athlete.
Resistant Plantar Fasciitis Treatment Program (Initial)
Contributed by Richard Bouche D.P.M. , William Olson, D.P.M., Stephen Pribut, D.P.M., Douglas Richie, Jr,. D.P.M.
PHASE 1- Acute Phase:
- Goal decrease acute pain and inflammation:
- absolute or relative rest- Decrease sports activity to avoid rebound pain
- ICE: 2 appliations of 20 minutes per day
PHASE 2- Rehabilitation Phase:
- Further decrease pain and inflammation:
- contrast baths
- Maintain/increase flexibility of injured (and surrounding) tissue:
- gentle stretching exercises: calf, hamstring, posterior muscle groups
PHASE 3- Functional Phase:
- Functionally strengthen intrinsic muscles of the foot
- closed chain therapeutic exercise
- Doming of Arch (towel toe curl)
- Protect injured area during functional activity
- stability running or other appropriate athletic shoes
- orthoses as needed
Note: this is probably the most important phase because it prepares the patient for their return to activity. Care needs to be taken at this stage not to allow the patient to overdo these exercises and stay within their limits as re-injury can easily occur.
PHASE 4- Return To Activity
Return to desired sport activity:
gradual, systematic, "to tolerance"
Initiate preventive strategies:
appropriate athletic shoewear
functional exercises (i.e., pilates, plyometrics)
revise training program
Note: Be careful in the first months return to exercise to avoid recurrence of pain.
Consider shock wave therapy if there is a 6 month failure and a failure after repeated modification and remaking of orthotics.
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