Thursday, February 6, 2020

Treatment options for chronic heel pain in runners


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.

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