Keys To Managing Heel Pain In Basketball Players

Treating plantar fasciitis in elite basketball players is a balancing act between relieving heel pain symptoms and getting players back on the court as quickly as possible. Accordingly, these authors review the literature on current modalities with a focus on the relationship between plantar fasciitis and equinus.

New York Knicks center Joakim Noah’s struggle with plantar fasciitis led the player to state, “Plantar fasciitis s----. It feels like you have needles underneath your feet while you’re playing.”¹

Noah is just one of an increasing trend of current and former National Basketball Association (NBA) players sidelined due to heel pain. A sampling of players worldwide diagnosed with plantar fasciitis includes Damian Lillard, Pau Gasol, Jason Kidd, Marcus Camby, Joe Johnson, Ty Lawson, Nenê, Greg Stiemsma, Brandon Knight, Derrick Favors and Steve Francis. The impact of plantar fasciitis on basketball players extends to all levels of competition.

Many questions and theories surround the quandary of plantar fasciitis in athletes. Understanding the “why” of plantar fasciitis in the basketball player results in a more effective “how” (how to treat) for the “what” (plantar fasciitis). Fortunately, the answers always lie in evidence-based research. Since plantar fasciitis affects approximately 10 percent of the general population during a lifetime, there is an abundance of information that we can synthesize into a comprehensive treatment plan with the primary goal of symptom resolution without loss of playing time.²

Plantar fasciitis accounts for 25 percent of foot injuries in runners and 5 to 11 percent of all running injuries.^2–8 Di Caprio and colleagues reported a 31 percent rate of plantar fasciitis in a group of 166 runners.⁹ We can apply these rates to basketball players to get an estimate for the rate of plantar fasciitis in this group due to the similarities in activity. An estimate of an approximately 10 to 15 percent incidence rate in basketball players is appropriate.

What The Research Reveals About Plantar Fasciitis And Equinus

The relationship between equinus and plantar fasciitis is no longer debatable. Amis has written extensively on the role of equinus and foot mechanics.¹⁰ He stated, “There can be no more room for the standard thinking that these resultant foot and ankle problems arise just because we are getting older or we are obese or they are just random, or that an equinus contracture is only a part of the equation. Equinus is the equation.” Patel and DiGiovanni found 83 percent of patients with plantar fasciitis (either acute or chronic) have an underlying equinus deformity.¹¹

A study by Cheung and coworkers established a linear relationship in the tension between the plantar fascia and Achilles tendon.¹² As tension increases on the Achilles tendon due to tightness, there is a corresponding increase in tension in the plantar fascia. The increase in tension on the plantar fascia due to equinus was up to twice that of body weight. Interestingly enough, increased body weight is often associated with plantar fasciitis yet the Achilles tendon has significantly more influence on the plantar fascia. The authors concluded that lengthening of the Achilles tendon resulted in plantar fascia stress relief.

Although the majority of plantar fasciitis cases can resolve with conservative measures, several studies revealed excellent outcomes treating chronic refractory plantar fasciitis with a gastrocnemius recession.^13-19 This paradigm shift in the literature reinforces the integral role between equinus and plantar fasciitis.

There are currently no specific epidemiologic studies in regard to basketball players and their risk of developing plantar fasciitis. While basketball is more than a running sport, jumping and explosive movements are also integral basketball movements. The literature on running and plantar fasciitis is instructive for risk factors in this group. A study by McNamee and colleagues examined the risk factors for developing plantar fasciitis in runners.²⁰ The study concluded, “Our findings present strong evidence of a link between limited ankle dorsiflexion and plantar fasciitis among physically active individuals.” For the loss of every 1 degree of ankle range of motion (ROM), the risk factor for plantar fasciitis increased by 14.6 percent. Longitudinal arch angle and body mass index (BMI) did not significantly affect plantar fasciitis risk. These latter findings are in direct contrast to the commonly held assumption of a pronated foot structure and increased BMI being risk factors for plantar fasciitis.

Riddle and coworkers evaluated risk factors for plantar fasciitis.²¹ Ankle joint dorsiflexion of ≤ 0 degrees had an odds ratio of 23.3 in comparison to ankle joint dorsiflexion ≥ 10 degrees. A BMI of ≥ 30 kg/m² resulted in an increased odds ratio of 5.6 in comparison to BMI ≤ 25 kg/m². Likewise, increased activity level resulted in an increased odds ratio of 3.6 in comparison to those with a more sedentary lifestyle. Equinus was a significantly higher risk factor for developing plantar fasciitis in comparison to the other factors although researchers found all three factors to be statistically significant. Sullivan and colleagues also found that abnormal BMI and decreased ankle joint dorsiflexion along with reduction in foot and ankle strength increased the risk of plantar fasciitis in the general population.²²

Regardless, the dominance of equinus as a risk factor is a common theme to both the McNamee and Riddle studies.^20,21 One may question the relevance of BMI in a high-level basketball player. These athletes are rarely considered obese but due to their muscle content, their BMI may classify them as obese. This flaw of utilizing BMI solely as an indicator for obesity in an athletic individual is well known.

There is a wide range of definitions for equinus in the literature and various authors have described 23 different methods of measuring ankle joint dorsiflexion.²³

Gatt and colleagues examined the relationship between static ankle joint dorsiflexion/hindfoot measurements (it is impossible to separate the ankle and subtalar component of dorsiflexion) and dynamic function, which is the critical piece of the equinus puzzle.²³ Their findings shed light on a proper definition for equinus. First, however, the authors describe the proper method of static measurement. The commonly accepted method of examination, based on “locking” the midtarsal joints while maintaining the subtalar joint in neutral position, has poor inter- and intra-rater reliability.

A variance of ankle joint/hindfoot dorsiflexion can be between 8.5 and 10 degrees based on the subtalar joint being fully pronated (more midtarsal dorsiflexion) or fully supinated (little to no midtarsal dorsiflexion).²³ When the foot is maximally supinated, midtarsal ROM is reduced to a statistically insignificant amount of 2.5 degrees (see photos above at left and below at right). Although there is no current device that places the axis of the hinge collinear with the ankle joint axis, full supination of the foot alone produces a more accurate evaluation of ankle joint/hindfoot dorsiflexion. The study concluded that ankle/hindfoot dorsiflexion of < -5 degrees with the knee extended produced reduced available dorsiflexion during late midstance, resulting in an abnormal gait pattern. Therefore, with proper measurement technique, functional abnormality results with ankle/hindfoot dorsiflexion of < -5 degrees with the knee extended.

Factors such as age and the intensity of activity level combined with a high level of frequency in activity are causally associated with the onset of plantar fasciitis in elite basketball players. There has been no scientific evidence to date to support these hypotheses. One must question what the difference is in the majority of players who do not develop plantar fasciitis with those who do. Certainly, both groups get older and participate at the same activity level. Individual factors (especially equinus and possibly BMI), as opposed to global factors, must be the overriding risk factors for plantar fasciitis.

A Closer Look At The Effectiveness Of Stretching And Night Splints

Now that we understand the “why” of plantar fasciitis, we can discuss “how” to treat the “what.”

The “Heel Pain-Plantar Fasciitis: Clinical Practice Guideline,” published in the Journal of Orthopedic Sports Physical Therapy (JOSPT) in 2014, is a meta-analysis using levels of evidence to provide grades to various plantar fasciitis therapies.²⁴ For example, a grade “A” would be supported by evidence obtained from high-quality diagnostic studies, prospective studies or randomized controlled trials containing at least one Level I study. Treatment of plantar fasciitis in the elite basketball player should begin with equinus management if the player does indeed have equinus. The JOSPT guideline 2014 update gave both stretching and the use of night splints grades of “A.”

Plantar fascia-specific stretching produced excellent results in all outcome measurement categories, especially in the first eight weeks of therapy, in comparison to Achilles stretching alone.²⁵ The two-year follow-up results were not statistically significant between groups with both groups reporting 92 percent total satisfaction or satisfaction with minor reservations.²⁵ In a Level I study by Lee and coworkers, the use of a night splint combined with an over-the-counter (OTC) orthotic vs. an OTC orthotic alone demonstrated statistically superior outcomes for pain, disability and activity level at both two weeks and eight weeks of treatment.²⁶ Similarly, Sheridan and colleagues, in a Level I study, demonstrated the addition of a dynamic dorsiflexion splint during sleep proved a statistically significant difference for pain improvement.²⁷

A Level II study by Beyzadeoglu and colleagues consisted of two groups receiving standard conservative therapy for plantar fasciitis, but one group also utilized a night splint at 5 degrees of dorsiflexion for eight weeks with a follow-up of approximately 33 months for both groups.²⁸ The night splint group had significantly higher improvement in Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Recurrence rates were statistically, albeit insignificantly, lower for the night splint group (13.6 percent in comparison to 29 percent). An interesting side note on this study showed the presence of a calcaneal plantar heel spur, bilateral involvement and BMI did not correlate with patient satisfaction or recurrence. The duration of symptoms until treatment did correlate with recurrence.

Night splints and manual stretching are both effective, but there are limitations with both when it comes to achieving maximal effectiveness.

The amount of time required to stretch daily varies from 30 seconds to all night in the literature. Radford and colleagues analyzed the literature in an attempt to solve this unanswered question.²⁹ The study noted a trend toward the longer the stretch, the more ankle joint range of motion. The authors concluded, “Calf muscle stretches provide a small but statistically significant increase in ankle dorsiflexion, particularly after 5–30 minutes of stretching.” The runner’s stretch is the commonly used method for manual gastroc-soleus stretching.

Although no specific study has been published on the bilaterality of equinus, both limbs typically have similar ankle joint dorsiflexion measurements as demonstrated by Johanson, Macklin and their respective coworkers.^30,31 Many studies recommend stretching at least six to eight weeks to increase ankle joint ROM effectively.^24-31 Subtalar position influences the location of the dorsiflexion force (a pronated subtalar joint results in dorsiflexion through the midfoot while a supinated subtalar joint isolates the dorsiflexion force to the hindfoot).²⁹ This thereby significantly affects the treatment outcome (see above photos). Adherence is the limiting factor for manual stretching due to the aforementioned factors.

Different factors curb the effectiveness of night splints. Patients who wear night splints while sleeping most often sleep on their side with their knees bent. The gastrocnemius is not stretching with this sleeping position, compromising therapy. Wearing the night splint for a prescribed period of time with the knee extended is an alternative approach. Fully extending the knee while dorsiflexing the ankle is uncomfortable and most often results in less than a fully extended knee position (see photo on page 34). Anterior night splints additionally allow plantarflexion of the forefoot relative to the hindfoot, making these models even less effective than posterior night splints.

One solution to address the ineffectiveness of treatment with both manual stretching and night splints is the Equinus Brace™(IQ Med). The Equinus Brace is the only brace that extends above the knee to hold the knee in full extension while dorsiflexing the ankle. It allows for precise dorsiflexion control with adjustable ankle hinges and engages the windlass mechanism to supinate the subtalar joint and externally rotate the tibia, allowing for full knee extension. The recommended use for this brace is one hour per day for eight to 12 weeks, adjusting the dorsiflexion monthly (90 degree, + 10 degree and + 20 degree settings). Once complete deformity correction occurs, maintenance therapy of one to three days per week is recommended for lifetime wear.

What You Should Know About Taping, Orthotics And Manual Therapy

Those treatments also receiving an “A” grade by JOSPT were manual therapy, taping and foot orthoses.²⁴ Lower extremity soft tissue mobilization and stretching resulted in superior results in comparison to iontophoresis in a Level I study.^32,33 A Level I study by Renan-Ordine and coworkers compared two groups of patients with plantar fasciitis.³⁴ Both groups used a self-stretching home protocol but one group also received trigger point manual therapy. Both patient groups showed substantial improvement but the manual therapy and stretching group’s improvement was significantly better.

Taping is a commonly utilized therapy for plantar fasciitis in the general population and empirical evidence would support its use in the athletic population with plantar fasciitis, especially for quick relief of symptoms. Three Level I studies found that taping reduces pain at one week, especially when one combines it with stretching.^35-37 In a Level II study, taping reduced plantar pressures when walking and pain when walking and jogging in comparison to controls.³⁸ Several studies demonstrate that tape improves foot biomechanics.^39-43

The role of foot orthoses in the treatment of plantar fasciitis is well documented but the lingering question is custom versus prefabricated. A Cochrane review by Hawke and colleagues examined multiple questions for the role of custom and prefabricated orthoses in the treatment of plantar fasciitis.⁴⁴ They concluded that “short-, intermediate-, and long-term improvements occur regardless of specific orthotic design and findings that custom foot orthoses may be no better than prefabricated foot orthoses in those with heel pain/plantar fasciitis.”⁴⁴ The JOSPT “A” grade for foot orthoses was based on four Level I, three Level II, two Level III and four Level VI studies, concluding that either custom or prefabricated orthoses support the medial longitudinal arch, cushion the heel and reduce heel pain in both the short- and long-term.^24,26,45-56

All other treatments received a grade of “C” or lower. These modalities included electrotherapy, low-level laser therapy, phonophoresis, ultrasound, footwear, education and counseling for weight loss, therapeutic exercises and neuromuscular re-education, dry needling, extracorporeal shockwave therapy (ESWT) and corticosteroid injections.²⁴ The latter two treatments require more discussion.

The literature describes more than 10 different types of injection therapy for plantar fasciitis.⁵⁷ Corticosteroid injections are the historic injection therapy of choice but in the athlete, do not ignore consideration for potential plantar fascia rupture and fat pad atrophy, both of which are potentially career threatening to an elite basketball player.^36,46,58-61

A systematic review by Tsikopoulos and coworkers concluded the following on injection therapies: “For pain relief and composite outcomes, the micronized dehydrated human amniotic/chorionic membrane had the highest probability of being among the best injection treatments in the short-term. However, there was a lack of information about the efficacy and safety of this treatment at 2 months and beyond.⁵⁷

“Botulinum toxin-A injections provided significant pain relief to patients who suffered from plantar fasciopathy at the 6-month follow-up. This result remained robust after controlling for the risk of bias of the included trials.⁵⁷

“Pooled results showed that platelet-rich plasma injections were effective for the treatment of plantar fasciopathy at 0–6 months. However, conclusions about this therapy were limited by the quality of the included head-to-head comparisons on platelet-rich plasma.”⁵⁷

The literature on ESWT remains mixed for several reasons but a meta-analysis of randomized controlled trials show focused shockwave therapy can relieve pain in chronic plantar fasciitis with little or no risk and no requirement of activity limitation.⁶²

Surgery for refractory plantar fasciitis in the elite basketball player should be a rarity. This topic requires a deeper dive than this space allows but an article in an upcoming issue of Podiatry Today will address the surgical approach to plantar fasciitis.

In Conclusion

When treating an elite basketball player (or any type of athlete) for plantar fasciitis, resolution of symptoms while allowing the athlete to maintain his or her playing time is the ultimate goal. Achievement of this goal best occurs by understanding the “why” of plantar fasciitis to effectively complete the “how” (treatment) of the “what” (plantar fasciitis).

Dr. Thompson is affiliated with Hoosier Foot and Ankle in Indianapolis.

Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis and is the founder of Step by Step Haiti.
 
Dr. DeHeer has disclosed that he is the inventor of The Equinus Brace™ and an owner of IQ Med.

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For further reading, see “Managing Common Basketball-Related Injuries” in the January 2013 issue of Podiatry Today, “Maximizing Orthotic Success With Basketball Players” in the April 2006 issue or the DPM Blog “Orthoses And Basketball Players: What I Have Learned Over The Past 15 Years” at https://tinyurl.com/y8ypb4q4 .