December 2009

Heel pain relief: Expanding the playbook

by Cary Groner

The science of treating plantar fasciitis in athletes is evolving to consider the unusual demands these patients put on their feet. Although clinicians continue to rely on conservative management with rest, ice, anti-inflammatory medications, taping, and orthoses, some are embracing new approaches that seem counterintuitive but offer evidence of improved outcomes.

“We see the same basic issues in athletes as in other patients, in terms of tightness of the fascia and collapse of the arch,” said Michael Gross, PT, PhD, a professor of physical therapy at the University of North Carolina. “The athletes are typically more vigorous, however, so ground-reaction forces may be greater. Some benefit from off-the-shelf arch support, but many find that insufficient. In those cases, we make them a custom support.”

For Michael Trepal, DPM, vice president and dean of academic affairs at the New York College of Podiatric Medicine, treating plantar fasciitis in athletes is a patient-specific art.

“In most cases you’re dealing with underlying biomechanical issues; it could be nerve entrapment, an inflammatory condition, or just poor foot function,” Trepal said. “That requires a good biomechanical evaluation of the foot and then a prescription of the right device to address the problem.”

Individual athletes may require hindfoot or forefoot posting, first-ray cutouts, or other strategies to address individual pathologies, he explained.

Karl Fields, MD, professor of sports medicine at the University of North Carolina and director of the sports medicine fellowship at Moses Cone Hospital in Greensboro, wrote in the May/June issue of Training & Conditioning that only full-length and cushioned orthoses offered significant benefits to his athletic patients. Those most likely to improve with orthotic treatment included those with rigid cavus feet, runners who pronated enough to visibly affect their form, and athletes with a history of stress fractures in the high tibia or above.

In the past few years, however, a few iconoclasts have begun to talk about an entirely different way to approach fasciitis treatment after the acute phase.

“When the plantar fascia is inflamed, you have to provide support in order for it to heal,” acknowledged Irene Davis, PT, PhD, professor of physical therapy and director of the Running Research Laboratory at the University of Delaware. “Our first line of defense for our athletes is taping, along with an over-the-counter orthosis. But in the past four or five years I’ve been moving away from long-term use of orthoses because I think one of the primary causes of fasciitis is inadequate muscular support of the arch.”

Davis is one of a small but growing group of clinicians who believe that the best exercise for the foot is “barefooting”—walking or running either barefoot or in the new “foot gloves” made by running shoe companies.

“If I had a patient with a strained neck, I wouldn’t put him in a cervical collar for the rest of his life; I’d support him in the acute phase and then condition the muscles so they resist future injury,” she said. “That’s how we should be treating the foot.”

Davis recommends a variety of strengthening and stretching exercises such as heel rises and grabbing a towel on the floor with the toes. When the acute phase has passed, she eases athletes into barefooting, starting with walking so they don’t overdo it and trigger a recurrence of symptoms.

“When you take off your shoes, you automatically avoid landing on your heel when you run,” Davis said. “When you go from a rearfoot strike to a midfoot or forefoot strike, it significantly reduces impact force and load rates.”

Although her evidence is anecdotal so far, Davis has had good results with the athletes she’s treated. She added, however, that barefooting is not for those who have lost protective sensation in the feet, such as those with diabetic neuropathy.

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One Response to Heel pain relief: Expanding the playbook

  1. Harvey Johnson says:

    I see virtually every foot type and every body type, fat, skinny, young, old sedentary, elite athlete get plantar fasciitis. My one rule is if you are vertical and your heart is beating then you can get plantar fasciitis. It is inflammation pure and simple. I treat with custom biomechanical full length control and add additional shock absorption in the heel via poron and 40/45 durometer EVA.

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