August 2013

Plantar fasciitis: Unique challenges in basketball

8plantar-shutterstock_130576100v2Not only do basketball players have many of the same risk factors for plantar fasciitis as the general population, they also have the added challenge of a grueling season and very little opportunity to rest. That means practitioners have had to be creative when it comes to treatment.

By P.K. Daniel

Marcus Camby, Joakim Noah, Pau Gasol, Joe Johnson, Ty Lawson, Nenê. Aside from being handsomely paid professional basketball players expected to compete in what potentially could be a 110-game National Basketball Association (NBA) season, they have something else in common–experience dealing with plantar fasciitis.

Plantar fasciitis appears to be a growing problem, on the court and off. With two-thirds of an aging US population either overweight or obese,1 coupled with a propensity to wear unsupportive shoes, some practitioners have even called the foot condition an epidemic. And NBA players are not immune.

Although there are no studies looking specifically at plantar fasciitis in basketball players, practitioners point to several components, including some cited in the general population, that might explain why basketball players seem to be predisposed to this painful condition. Age, size, and repetitive movement are among the factors that can cause irritation or microtears to the band of tissue that runs along the bottom of the foot.

The average age of an NBA player is 26.7 years. Camby, the veteran New York Knicks center, is 39. Chicago Bulls center Noah is 28. Los Angeles Lakers center Gasol is 32. Brooklyn Nets guard Johnson is 31 and Washington Wizards center Nenê is 30. Lawson, who tore his fascia completely, is younger than the age average at 25. But he is an anomaly. Standing 5 feet 11 inches and weighing 197 pounds, the Denver Nuggets point guard falls under the height and weight averages, too.

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“Very similar to the general population,2 the older the player, the more we see plantar fasciitis,” said Michael Lowe, DPM, who’s been the team podiatrist for the Salt Lake City-based Utah Jazz for 34 years.

An aging player with a large frame and large feet, practitioners say, is a recipe for plantar fasciitis. A towering 6-ft-7-inch NBA player is the average. He’s also typically weighs 220 pounds and wears a shoe size just shy of 15. Camby is 6 feet 11 inches, 245 pounds. He was plagued by plantar fasciitis for most of the 2013 season, which concluded in June when the Miami Heat defeated the San Antonio Spurs in a seven-game Finals series. Camby, used sparingly in the postseason, played in only 24 regular-season games for the Knicks, averaging a paltry 1.8 points and 3.3 rebounds in about 10 minutes per game.

Noah didn’t mince words when he spoke to reporters during the Chicago–Brooklyn first-round playoff series in April that saw both him and Johnson hampered with the same issue.

“Plantar fasciitis sucks,” he said. “It feels like you have needles underneath your foot while you’re playing. That’s what it feels like, so you can imagine. You need to jump, you need to run, you need to do a lot of things while you’re playing basketball, so you don’t want needles underneath your foot, right?”

Prevalent pronation

Joel Segalman, DPM, who just completed his first season as a consulting podiatrist with the New York City-based Knicks, found that almost every Knicks player he examined had some degree of pronation. Pronated foot posture has been associated with chronic plantar heel pain in the general population,6 and Segalman has observed the same relationship among his Knicks patients.

“There are a lot of factors here,” Segalman said. “To start, you have very big people. There’s a lot of torque being put on the foot, more than an average person. It’s very difficult to have a foot maintain an arch with that height, weight, and length of foot. You’re asking that tendinous piece of fascia to hold up quite a bit. I think that’s why they’re predisposed to it, they’re just big guys.”

San Leandro, CA-based Steven I. Subotnick, DPM, a US Olympic team podiatrist formerly with the Golden State Warriors, echoed Segalman.

“Most pro basketball players have very big feet with low arches and tight calf muscles and hamstrings,” he said. “They jump higher with this anatomy, but they are more prone to plantar fascia injuries.”

Bulls podiatric consultant Lowell Weil Jr, DPM, addressed how increased body mass index plays a causal role in plantar fasciitis. In the general population, those whose body mass index (BMI) is greater than 30 kg/m2 are at increased risk.3,4

“Many of these players have added weight through muscle, which has increased their body mass index,” Weil said. “Increased BMI has been implicated in the development of plantar fasciitis, mostly in the truly obese. But carrying excess weight, even if [it’s] muscle, can increase the stress on the plantar fascia.”

A 2001 study published in the International Sports Medicine Journal found that older NBA players and players with a BMI of 26 or higher were more likely to miss playing time as a result of injury than were younger players and players with a BMI of 25 or lower.5

Weil noted that though female athletes are typically more flexible than male athletes, reducing the issue of tight calf muscles, they tend to have higher BMI numbers than men. In general, however, practitioners don’t distinguish between genders with regard to plantar fasciitis.

“I have seen no difference at all in the strategy of treatment or etiology of the process in either male or female athletes,” said Lowe, who, as a consultant for athletic department at University of Utah in Salt Lake City, worked with its women’s basketball team.

Added to the size factor is the amount of force experienced by a player’s heels when he or she moves. The impact of running and jumping can be significant, creating three to six times the body weight force.6,7

“The jumping aspect and the stopping and starting burst aspect of basketball influences plantar fasciitis,” Weil said.  “When landing from a jump, the toes are extended [dorsiflexed], which puts the plantar fascia under maximum tension, potentially leading to the microtears that lead to plantar fasciitis [acute] and ultimately plantar fasciosis [chronic].”

The grind

And then there’s the lengthy basketball season, which includes a regular season that runs from October until April and playoffs that culminate in the NBA finals in June.

“The most significant factors related to plantar fasciitis in basketball players is the stress placed on the foot in the course of an 82-game season in the NBA, along with additional practices and conditioning workouts,” said Thomas O. Clanton, MD, who is a foot and ankle specialist with The Steadman Clinic in Vail, CO, and medical consultant to the Houston Rockets.

Brian Cole, MD, an orthopedic surgeon at Midwest Ortho­paedics at Rush in Chicago, and team doctor for the Bulls, also pointed to the NBA schedule as a risk factor.

“With various levels of schedule compression that we have seen in the NBA with back-to-back games, and sometimes up to four games in a single week, the relative risk for these types of injuries may increase,” said Cole, who in 2009 was selected as NBA Team Physician of the Year.

But whether the incidence of plantar fasciitis is higher in basketball players than in the average population is debatable. Harvey Johnson, CO, with Eno River Orthotics in Hillsborough, NC, doesn’t think it is. Johnson said the majority of his patient population, which is neither basketball players nor athletes, suffers from plantar fasciitis.

“I tell people who have it, that all you have to do is have a beating heart and be vertical to get it,” said Johnson, a consultant with Duke University Athletics in Durham, NC. “Young, old, fat, skinny, active, sedentary, pronators, and neutral foot types all get it. It is extremely prevalent in the general population.”

According to Weil, 6% of the average adult population has with plantar fasciitis at any time, and 10% will experience it in their lifetime.8 However, he observed the Bulls players suffered at a rate that was two to 2.5 times higher than the average population.

“In looking at recent experience with the Chicago Bulls, twenty to twenty five percent of players have had some plantar fasciitis over the last three years,” he said. “This is a small sample size, but could present a trend.”

Segalman suggested the uptick may be happening in both the general population and in the basketball demographic.

“There’s no question that we’re treating it more,” said Segalman, who’s also been a staff doctor for the Boston Marathon for the past 25 years. “In the last twenty years, more people are running, playing sports. But I think there is [a higher incidence in the NBA]. Looking at the Knicks, it haunts them. Obviously, there are the high-profile players who get it, but to some degree almost everyone has some form of heel pain.”

Simon Lee, MD, a foot and ankle surgeon at Midwest Ortho­paedics at Rush, said that, while basketball players and those who take part in other high-impact, highly repetitive activities probably have a higher incidence of plantar fasciitis than the general population, the nonactive individual is also at risk.

“It should also be noted that plantar fasciitis typically happens in the two extremes of activity—sedentary, overweight, nonactive people, and on the other end of the spectrum, high-impact, repetitive athletes,” Lee said.

Treating plantar fasciitis can be challenging. The recovery process can be lengthy. And there is new information,9 Lowe said, that suggests plantar fasciitis is not so much a disease primarily of inflammation as was previously thought, but rather a degenerative change to the tissue from microtrauma, microtears, and ongoing damage.

“Normally, the body would repair and recover from this injury, but, like ongoing chronic Achilles’ tendinitis, the stress to the plantar fascia is greater than the repair potential, and it seems to just hang around longer than most other injuries,” Lowe said.

An injury that hangs around isn’t particularly convenient for a player who is paid millions and expected to be durable. Yet, the surest way to heal the heels is to rest them.

“Rest is the most important, because they are going to traumatize [the heel] every time they play,” Weil said.

When rest isn’t an option

So what’s an NBA player to do? He may not have the luxury of resting as much as would be ideal, but there are measures that can help get him back on the floor faster, such as addressing shoe type, frequency of replacements, use of custom orthoses, and undergoing certain therapies.

“Shoes that have a weak midsole in the midfoot are likely to be far less supportive, and therefore increase stress to the midfoot,” Johnson said.

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He suspects some the current designs on the market will lead to more plantar fascia issues.

“With the recent craze in lightweight shoes [both basketball and training shoes], I expect the same kinds of problems. Firm, supportive midsoles that tie in the hindfoot to the forefoot reduce stress on the plantar fascia [and] will go a long way to reduce stress on the midfoot in general,” he said.

Unlike the general population, NBA players frequently replace their shoes. Lowe said players with the Jazz are expected to replace their basketball shoes every two to three weeks, at a minimum. This is particularly important for players experiencing or at risk for plantar fasciitis, he said.

“Shoes that are worn out do not give adequate support and thus put more stress on the fascial area,” Lowe said. “[Shoes] get very wet from sweat, uppers stretch out from the moisture and from the ballistic multiple changes of direction, and midsole fatigue also compresses—especially with players weighing greater than 250 pounds, which is most of them [now].”

Many NBA players use custom foot orthoses, which can cost between $400 and $600 and aren’t typically covered by insurance, in their shoes as either a preventive measure or as part of the treatment process.10 At least half of the Knicks players and the majority of the Bulls use orthoses. High-tech pressure measurement technology with Bluetooth capability is being used to guide orthosis fabrication and assess the effectiveness of an intervention by comparing pre- and post-treatment scans.

“Most all of our players, especially if they have a history of fasciitis, use orthotics full time for prevention, which has been very helpful,” Lowe said.

Treatments for both NBA players and the general public may include nonsteroidal anti-inflammatory drugs (NSAID), icing, ultrasound, night splints, massage, laser treatments, walking boots, short-term (in the NBA) or longer-term (in the general population) casting, foot orthoses, and, in some cases, cortisone injections. Surgery is seldom an option for either group.11-13

NBA players are more apt than the average patient to receive advanced treatments, such as electrogalvanic stimulation, extracorporeal shockwave therapy, platelet-rich plasma therapy, and targeted radiofrequency therapy.14-16

“The main difference is that the average person, we would tell them to stop activities that can aggravate their issues until we get them under control, while in a professional athlete we try to have them continue to perform and participate even though their symptoms are not completely gone,” Lee said. “So, typically for a lot of NBA players, their symptoms do not completely go away until the season ends and they get a chance to give the plantar fascia a break.”

P.K. Daniel is a freelance sportswriter and editor based in San Diego, CA.

REFERENCES

1. Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307(5):491-497.

2. Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006;9(1-2):11-22.

3. Irving DB, Cook JL, Young MA, Menz HB. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord 2007;8:41.

4. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003;85-A(5):872-877.

5. Orchard J, Hayes J. Using the World Wide Web to conduct epidemiological research: an example using the National Basketball Association. Int Sport Med J 2001;2(2).

6. Nilsson J, Thorstensson A. Ground reaction forces at different speeds of human walking and running. Acta Physiol Scand 1989;136(2):217-227.

7. Özgüven HN, Berme N. An experimental and analytical study of impact forces during human jumping. J Biomech 1988;21(12):1061-1066.

8. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(4):A1-A18.

9. Lemont H, Ammirati KM, Usen N. Plantar fasciitis. A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93(3):234-237.

10. Roos E, Engström M, Söderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int 2006;27(8):606-611.

11. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-S19.

12. Brosseau L, Casimiro, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev 2002;(4):CD003528.

13. Gum SL, Reddy GK, Stehno-Bittel L, Enwemeka CS. Combined ultrasound, electrical muscle stimulation, and laser promote collagen synthesis with moderate changes in tendon biomechanics. Am J Phys Med Rehabil 1997;76(4):288-296.

14. Aqil A, Siddiqui MR, Solan M, et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res 2013 Jun 28 [Epub ahead of print]

15. Ragab EM, Othman AM. Platelet rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg 2012;132(8):1065-1070.

16. Brook J, Dauphinee DM, Korpinen J, Rawe IM. Pulsed radiofrequency electromagnetic field therapy: a potential novel treatment of plantar fasciitis. J Foot Ankle Surg 2012;51(3):312-316.

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2 Responses to Plantar fasciitis: Unique challenges in basketball

  1. teri green says:

    Great post. Tons of useful info. One thing that I believe that they are not doing is keeping their Achilles tendons flexible. Will all that pounding the Achilles will shorten up. Wonder if wearing a night splint or a heel lift would make any difference.
    Teri

  2. My brother plays a lot of basketball and developed plantar fasciitis and this tendon stretcher helped him a great deal. He was miserable before he got it and then after using it said the pain was greatly reduced. Always remember to properly stretch before you get up and go!

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