Mastering Plantar Heel Pain In Athletes

   Plantar heel pain is one of the most common maladies we see in podiatric practice. Patients learn on their first visit that the symptoms usually respond to conservative treatment over a six- to 12-week timeframe, although some individuals may take six to 12 months to be totally pain-free. Athletes may have difficulty accepting the fact that they may have lingering pain over six to 12 months. Not only may the athlete be upset, one may also draw the ire of the coach, athletic trainer, agent or parent.    When treating an athlete with plantar heel pain, podiatrists must understand the mechanism of injury, the biomechanical demands of the sport, shoe gear and playing surface, the age of the athlete and the psychosocial effect of the sport on the athlete.    Plantar heel pain among athletes is usually due to overuse and poor biomechanics. However, traumatic causes such as slipping off a curb when running or a baseball player coming down too hard on first base can occur. Excessive pronation is often associated with plantar heel pain, although it can occur in the supinated or pes cavus foot. Muscle strength imbalance and muscle tightness have also been indicated as causes of plantar heel pain. Other possible contributing factors to plantar heel pain include loss of the plantar fat pad with advancing age, increased body weight or hard playing surfaces.1,2

Essential Keys To A Thorough Examination

   When working with students and residents, I tell them 90 percent of the time they can diagnose a patient’s problem if they listen to the patient and actually touch the patient. Obtaining a thorough patient history and performing a comprehensive physical examination are vitally important when treating athletes.    In addition to determining whether there is a family history of heel pain, the patient history should document the type of shoes the patient wears for sports and for everyday wear, the type of surfaces the patient trains and plays on, and whether there have been any recent changes in training. One should also ascertain whether the patient has experienced a recent weight gain, and note any previous injuries and prior treatment.    Clinicians should ask the patient what aggravates the injury. Does it feel worse with shoes on or off? Is it painful after rest? Does the patient have worse pain the more he or she is on their feet? Does the pain intensity increase as the patient bears weight? Does the patient’s heel pain result in swelling that occurs throughout the day? We should also find out what, if anything, makes the foot feel better.    One should conduct the physical examination in a systematic manner, evaluating nerves, muscle strength, range of motion and the location of pain.    Palpate or tap the peripheral nerves around the ankle to see if there is shooting pain. Proceed to palpate the posterior tibial nerve and sural nerves more thoroughly to see if this elicits pain. Then palpate the superior and inferior aspect of the abductor hallucis muscle to see if this elicits pain from the plantar or calcaneal nerves. Test muscle strength on both feet and record the strength along with any pain. Check the range of motion for the ankle, subtalar, midtarsal and first MTP joints as well as the hamstrings. Pain location may be the most important part of the examination.    Does the patient have medial plantar pain only or does the patient’s pain extend to the middle and lateral aspect of the heel? Is there pain with side to side compression or with palpation of the medial calcaneal nerves at the same time? Does the pain occur just with palpation of the medial wall of the calcaneus or does he or she experience pain with palpation of both the medial and lateral walls? Is the pain located around the edges or rim of the calcaneus? One should also compress the calcaneus from the posterior to anterior manner. Compression pain could indicate a stress fracture.    Proceed to evaluate the biomechanics of the athlete. I typically start a non-weightbearing evaluation by looking for the forefoot to rearfoot relationship. Then I have the patient stand as I determine the patient’s foot type, the position of the calcaneus and tibial varum. I proceed to watch the patient walk with and without shoes from the back, front and sides. Finally, I will try to watch the athlete in the sport or have him or her try to duplicate his or her movements in the sport. It is also helpful to look at the shoes and any insoles patients may have been wearing in order to detect any excessive or abnormal wear patterns.

What You Should Know About The Differential Diagnosis

   Plantar fasciitis is the most common cause of plantar heel pain in athletes. The pain is worse after periods of rest and is painful on the medial plantar aspect of the heel. Most of the time, the athlete will also relate a history of sudden increase in the level or intensity of activities. Other causes of plantar heel pain include fat pad atrophy in older patients or those with a history of multiple steroid injections.    Tarsal tunnel syndrome, calcaneal neuritis or spinal radiculopathy can also be the cause of plantar heel pain, especially if the athlete complains of burning or radiating symptoms.    If the athlete complains of pain that gets progressively worse with weightbearing and that it hurts on the entire plantar surface of the heel as well as both sides of the calcaneus, then clinicians should suspect a stress fracture. One should obtain X-rays to rule out the presence of stress fractures, cysts, tumors or arthritic patterns. It has been well established that the presence or absence of a plantar spur does not matter unless it has been fractured. In this scenario, one would see the plantar spur projecting directly plantar or posterior.    Keep in mind that tendinitis of the flexor hallucis longus, flexor digitorum longus or both can often be misdiagnosed as plantar fasciitis. The pain one experiences with flexor hallucis longus and flexor digitorum longus typically occurs in the medial arch area close to where it crosses at the master knot of Henry.    Tumors or bone cysts can also manifest as plantar heel pain as can inflammatory arthritis such as rheumatoid arthritis or Reiter’s syndrome.3 You can order advanced imaging such as bone scans, MRI and CT scans along with blood tests for arthritis if you suspect some other cause of plantar heel pain. Recent advancements in musculoskeletal ultrasound have also proven helpful in evaluating the thickness of the plantar fascia.    When treating plantar heel pain in children, one may note irritation of the growth plate, which is known as Sever’s disease or calcaneal apophysitis. The calcaneal apophysitis is due to injury from tight muscles and the pounding of the heel on hard surfaces.

Exploring The Different Treatment Options

   In most cases of plantar heel pain, athletes can reduce pain by using an ice massage for eight to 10 minutes after activities and ice packs two to three other times during the day, applying the ice packs to the heel for 15 minutes.    While one may prescribe nonsteroidal antiinflammatories (NSAIDs) to reduce pain and inflammation, exercise caution when providing NSAIDs to athletes who participate in endurance sports. There have been reports of rhabdomyolysis, especially when athletes take the medication prior to a marathon or other endurance event.4 One can use limited steroid injections if the patient has not responded to other treatments. Physical therapy has been a great adjunct in treating plantar heel pain. If the plantar heel pain is due to tarsal tunnel or calcaneal nerve entrapment, make sure the physical therapy is directed towards the nerve area and not the plantar fascia.    Clinicians may employ other techniques such as ultrasound, cold laser, electrical stimulation, phonophoresis and iontophoresis two to three times per week minimally to help reduce pain, inflammation and fibrosis. Massage therapy has also proven to help break up the fibrosis that may be present in the plantar fascia.    Instituting muscle strengthening and stretching programs can not only correct imbalances but can help prevent reoccurrence. It is important athletes understand that stretching and strengthening will become a regular part of training. Plantar fascial night braces have been helpful with facilitating stretching, especially with the recalcitrant cases of plantar heel pain.5 As stated above, I will limit the use of corticosteroids for injections in athletes. If needed, I will only give three injections with a minimum of four weeks between each one. Subotnick has advocated the use of homeopathic medications as a safer alternative to corticosteroids for injections in athletes.6    It is imperative to control any abnormal biomechanics of the lower extremities.1,2,5 One may employ over-the-counter (OTC) insoles or heel cups initially as temporary devices or in athletes who have more of a pes cavus type foot. Custom-made orthotics can be made of a variety of materials including leather, plastic, EVA, cork or graphite. Bear in mind that the athlete may be very sensitive to increased weight of the orthotic so this could influence one’s choice of orthotic material.    Shoes are also part of the equation and one must inspect them for possible modifications. One may need to remove the cleats from cleated shoes to take pressure off the heel, especially when treating children. If the shoe is too flexible, a steel shank may reduce midfoot bending strain on the plantar fascia and muscles. When it comes to soccer shoes, one should emphasize wearing non-cleated shoes as long as the ground is dry. Also, when dealing with cases that involve abnormal biomechanics, clinicians should check the shoes to see if they are causing any irritation to the underlying nerves.    The introduction of shockwave therapy has provided an excellent tool for treating chronic plantar heel pain due to insertional plantar fasciitis. This non-surgical treatment works on the concept of stimulating the healing process in the fascia through microdisruption of poorly vascularized tissue. This subsequently facilitates the release of local growth factors and stem cells to induce normal healing. Some studies have found pain relief in 80 percent of the patients who undergo shockwave therapy.7 Some have recommended that clinicians consider shockwave therapy before any surgical intervention and that it may even be preferable to steroid injections in order to avoid possible post-injection rupture of the fascia.8

Why Surgery Should Be The Last Resort

   Clinicians should reserve surgery as a last resort, especially when it comes to treating plantar fasciitis in the athlete. A plantar fasciotomy causes a loss of the windlass mechanism, which reduces the stability of the medial column and inversion of the calcaneus during heel-off.3 A recent study on the effects of a plantar fasciotomy shows a shift in peak stresses from the third to the second metatarsal and increased stress on the plantar ligament attachment of the cuboid bone. This would account for the lateral column pain that one may experience after undergoing a plantar fascia release. This can be a difficult and devastating outcome in the athlete.9    In cases with nerve involvement, one may need to consider surgical decompression of the involved nerves if conservative treatment fails.

Addressing Other Causes Of Heel Pain

   In order to promote faster healing of stress fractures, one should emphasize cast immobilization and non-weightbearing. I have found bone stimulators to be helpful in accelerating bone healing. After employing these treatments for stress fractures, be aware that patients may still have symptoms of plantar heel pain so emphasize appropriate physical therapy and orthotics.    Children with calcaneal apophysitis may have to stop playing the sport for three to four weeks if the pain is severe. Shock absorbing heel cups, inserts or orthotics are often necessary for these patients. With these children, it is also important to stretch not only the gastrosoleus complex but the hamstrings as well.    On occasion, the athlete’s plantar heel pain may be caused by compression or impingement deformities in the spine. In these cases, it is important to refer to a back specialist and work in conjunction with him or her.    If the pain is secondary to an inflammatory arthritis, one may obtain a rheumatology or internal medicine consult. If athletes do have arthritis, they may have to completely change or greatly modify their sport. When treating patients with heel pain due to arthritis, soft protective orthotics and shock absorbing shoes will help prevent damage to the calcaneus.

Emphasizing Alternative Training

   As I noted earlier, many athletes will not be happy if their injury interferes with their sport and/or training. The “runner’s high” is a very real phenomenon that people experience with increased adrenaline from activities. It is important to suggest alternative training for athletes while you are treating them for plantar heel pain. Elliptical trainers seem to place less stress on the feet as most of the physical work involves the leg muscles. Swimming or running in the deep end of a pool is a great non-impact way to maintain aerobic capacity.

In Conclusion

   It can be quite challenging to treat plantar heel pain in the athlete. Ensuring a proper diagnosis is paramount for instituting the proper treatment plan. The first phase of treatment is to reduce the pain and begin the healing process. The second phase is to remove or reduce the deforming factors and prevent reoccurrence.    Be sure to communicate openly with the athlete and any coach, trainer, parent or other healthcare provider who may be involved in the athlete’s care. One may recommend an alternate exercise program to help athletes maintain their fitness level while they are being treated for plantar heel pain. The goal is to resolve the injury and return the athlete safely to his or her sport as soon as possible. Dr. Nunan is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is also a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, and the American College of Foot and Ankle Surgeons. Dr. Nunan has a private practice in West Chester, Ohio.
 

References:

1. Simons SM. Foot Injuries in the Runner. In: O’Conner FG, Wilder RP, eds. Textbook of Running Medicine. New York: McGraw-Hill, 2001: 222-224.
2. Agosta J. Foot Pain. In: Bruckner P, Khan K, eds. Clinical Sports Medicine 2nd edition. Sydney: McGraw-Hill, 2001, 584-587
3. Pfeffer GB. Plantar Heel Pain. In: Baxter, DE, ed. The Foot and Ankle in Sport. St. Louis: Mosby-Year Book, Inc., 1995: 195-205
4. Hamer R. When Exercise Goes Awry: Exertional Rhabdomyolysis. Southern Medical Journal 5:1997.
5. Julien PH. The Painful Heel. In: Julien PH ed. Sure Footing, Atlanta 1998, 15-22.
6. Subotnick S. Heel Injuries. In: Sports & Exercise Injuries: Conventional, Homeopathic and Alternative Treatments, Berkley: North Atlantic Books, 1991, 174-176.
7. Hammer DS, Rupp S, Kreutz A, et. al. Extracorporeal Shockwave Therapy (ESWT) in Patients with Chronic Proximal Plantar Fasciitis. Foot and Ankle International. Volume 23, 4:309-313, April 2002.
8. Ogden JA, Alvarez RG, Marlow M. Shockwave Therapy for Chronic Proximal Plantar Fasciitis: A Meta-Analysis. Foot and Ankle International. Volume 23, 4:301-307, April 2002.
9. Cheung JTM, Zhang M and An KN. Effects of plantar fascia stiffness on the responses of the ankle-foot complex. Clinical Biomechanics, Volume 19, 8:839-846, October 2004.