Epidemic of Heel Pain
in the running population
Heel pain is the most
common complaint that we see in our office. The typical ages of complaints of
heel pain are between the age of 40 and 60, which is the largest age segment in
our population.
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.
During this time of the
year many of our patients are training for upcoming races such as the Cooper
River Bridge run and various ½ and full Marathons. We would like to discuss our
experience with treating heel pain in our running population and state of the
art treatments if heel pain is a chronic issue.
PATHOMECHANICS
Contributing factors are
tightness of the achilles tendon, overload of the soft tissues, leg length
inequality, excessive flattening of the arch, high arched feet, and high impact
sports. It is well accepted that the common athlete presenting with heel pain
has a medium to high-arched foot.
TREATMENT STRATEGIES
FOR THE ATHLETE
In most cases, the
goal of the athlete ie. runners is to quickly return to activities to minimize
loss of fitness and performance. In our practice we see a high volume of recreational
and seasoned competitive runners
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 running population that suffers from
heel pain we try to encourage cross training to lessen the load on the feet. The
goal should be assigned to alternative cardiovascular fitness activities that
minimize impact and loading on the plantar fascia including stationary cycling,
swimming, yoga, pilates, upper body weight machines, and low resistance
flat-footed stair master machines These activities help to maintain physical aerobic
fitness as well as keep the ligaments and tendons flexible. In addition if you
are currently training for a road race lessening the amount of days with
respects to your running schedule can be a big help. Personally I was suffering
with some minor heel pain and was training for the Charleston ½ Marathon. I changed
my frequency of training during the week in which I ran two shorter runs during
the week and a longer run on the weekend. This was a three day a week training
schedule for 8 weeks and it made all the difference in the world for me.
2) Change and
modulation of footwear
Footwear analysis is
critical for evaluating athletes with chronic heel pain. The footwear may be a
contributory factor and can be utilized as a powerful treatment modality. Athletes
should 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.
We recommended around the house to wear oofos or vionic sandals especially if
you have hard wood floors.
3) Home therapy
Runners 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. We recommend runners 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. We
like our runners to be fitted for plantar fascial and achilles foot sleeves
which help to take the strain and stress off the plantar fascia while running. We also teach our patient about specific
taping methods such as low dye taping that can be applied on the bottom of the
foot to take the strain off the plantar fascia. arch taping procedures.
5) Physical therapy
Physical Therapy is an
effective modality for runners because investing this time can help to maintain
and increase flexibility. We are big fans of ultrasound, cupping, dry needling,
and iontophoresis.
6) Anti-inflammatory
medication
Anti-inflammatory
medications and cortisone injections can be used in the right situations to
decrease inflammation and reduce soft tissue swelling. We typically will start
with a short term course of oral NSAIDS and if the heel pain is severe enough
will consider a series of cortisone injections to not exceed three in a given year.
7) EPAT (Shockwave
Treatment)
The EPAT procedure is
a state of the art non-invasive treatment for chronic plantar fasciosis and
achilles tendonitis. The procedure is performed in the office setting without
anesthesia. The procedure involves sending high energy sound waves into the
heel to break up scar tissue and increase circulation so that the body heals itself.
This is becoming the standard treatment for chronic heel pain and has a 85%
resolution of heel pain 8-10 weeks out from the initial treatment. We have had
a great number of runners suffering from chronic heel pain over the past few
years do very well with this in office procedure.
CONCLUSION:
Runners 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
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.
