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.

Please check out this very informative blog that discusses heel pain in adolescents. We see many young athletes that present in our offices with heel pain. A good majority of the time it is a growth plate injury of the heel called Calcaneal apophysitis or Sever's disease. Fortunately this is a treatable condition if recognized early.
If your child is suffering from heel pain that has not improved after a few weeks please call our offices so that we can resolve this specific injury.

http://www.drblakeshealingsole.com/2011/11/severs-disease-growth-plate-injury-in.html

Patient Education videos CFS

We have just recently release educational foot videos on our website at www.carolinafootspecialists.net.
The educational foot videos include 20 of the most common foot ailments that we see in our practice. In addition we have three minute videos hosted by our foot specialists on specific topics such as Bunions, heel pain, neuromas, and running injuries. 
We are always striving to educate our current and future patients on various foot conditions and treatment options available.

Baseball And Your Feet

Baseball And Your Feet

America's Pastime

For more than a century and a half, America has carried on a love affair with baseball. Kids slam fists in their first gloves, and dream of one day playing in the big leagues. For a few, the dream comes true. The rest of us keep the fantasy alive through youth leagues, on adult softball teams, or pickup games with friends. We pledge allegiance to our favorite major league team, sharing the triumph or agony of every win and loss.

More than following big league baseball, we all want to play the game ourselves--to hear the crack of a base hit, execute an around-the-horn double play, or shag a screaming liner. But like all vigorous exercise, baseball and softball should be played sensibly and safely. Improper preparation and technique can lead to injury, especially to the lower extremities, which take us around the bases and under fly balls.

Before the First Pitch

Most American kids begin playing organized baseball at age 6 or 7. If a child is in generally good health and has no preexisting physically compromising conditions, baseball is relatively safe with proper instruction in the game's fundamentals.

Weekend warriors who pick up the sport again in adulthood are less apt to be in optimum condition than younger athletes, and should take it slow before jumping right into a game. Anyone who is more than 40 years old, diabetic, a smoker, or has any physical disability should see a family physician before taking the field. People with existing foot problems should see a podiatric physician specializing in sports medicine, who can perform a gait analysis and assess any risk inherent in a sports regimen.

Because baseball and softball involve quick starts and stops, it's important to loosen up before the game. Even the youngest children should make sure to do some simple stretching, running and playing catch before the game to avoid muscle pulls or other problems.

Before playing pickup games, make sure the field is free of hazards like holes on the base path, which could cause a foot or ankle injury. Sticks, rocks, and other debris on the field cause players to trip, risking injuries, and should be removed.

Shoeing Up for Baseball

Young players will do well to wear molded cleats rather then steel spikes. They should be gradually introduced before being worn in a game. A young player needs to get a feel for cleats, which should not be worn off the field.

While the improved traction of cleats may enhance play, it also leaves the ankle more susceptible to twists and turns. Any child with preexisting foot conditions should see a podiatric physician before putting on cleats. Never put a child in hand-me-downs; ill-fitting cleats increase the danger of ankle injuries. When sizing cleats, make sure the feet are measured by a footwear technician, and always wear a game-size sock when trying them on.

In some competitive baseball leagues, the use of metal spikes is permitted for players more than 13 years old. Spikes must be understood as dangerous weapons on the base paths; they require a certain level of maturity to be worn safely. They are not necessary for casual play, and should not be worn unless in league competition.

Spikes, which technology has made lighter and more flexible these days, perform the same function as cleats, but engage the ground differently. They too should be worn on a limited basis until the feel of how they engage the turf is understood. Unfamiliarity with spikes can lead to ankle twists and turns in a competitive situation.

When wearing cleats or spikes for the first time, watch for irritation, blisters, or redness, which could indicate a biomechanical problem in the legs or feet. Pain is a clear indicator of a problem. If cleats cause pain, discontinue wear for two to three days; if it returns, see a podiatric physician specializing in sports medicine for evaluation.

Preventing Baseball Injuries

One of baseball's most exciting moments comes when a batter stretches a single into a double by beating the tag in a dust-kicking slide. Sliding is a fun part of the game at all levels, but proper technique is crucial to avoiding foot and ankle injuries, especially when bases are firmly secured to the infield. Coaches at all levels should make sure their players are well schooled in proper sliding. Careless slides can result in sprains and even fractures of the lower leg and feet.

Pitchers also need to be coached on the proper way to come off an elevated mound with their back foot and land on an incline with the front foot. The repetitive motion of pitching can lead to overuse injuries to the feet and ankles. Pitchers experiencing pain in their windup should take a few days off before returning to the mound.

Catchers too are susceptible to overuse injuries by squatting behind home plate for every pitch. Again, coaches should teach their catchers how to alter their stance to vary weight displacement.

Today's trend of trying to achieve perfection by year round sport participation may result in an overall increase in injury. This is not just a lower extremity phenomena but is often seen in young pitchers having both elbow and rotator cuff injuries serious enough to lead to surgery while still in high school.

Lower Extremity Injuries and Treatment

Contusions. A baseball will inevitably make contact with a player's foot and ankle, whether it's a pitched ball, foul tip, or line drive, and sliding base runners often run headlong into a infielder's legs. Usually this contact results in contusions, which are not often serious injuries. Ice packs and a few days' rest will usually help the contusions, or bruises, feel better.

Sprains and fractures. Stretched or torn ligaments, known as sprains, can occur from running the bases, or pivoting to make a play. Sprains may cause extensive swelling around the ankle just like a fracture. Immediate treatment from a podiatric physician is crucial to quick healing. Fractures, where the bone has cracked or broken, often require casting. After a sprain or fracture, a podiatric physician can prescribe a rehabilitation regimen to restore strength to the injured area before returning to the sport.

Plantar fasciitis. Catchers are particularly susceptible to arch pain, commonly traced to an inflammation called plantar fasciitis, on the bottom of the foot. A podiatric physician can evaluate arch pain, and may prescribe customized shoe inserts called orthoses to help alleviate the pain.

Heel Spur Syndrome. A related condition, to which catchers are also susceptible, is heel spur syndrome. Often related to plantar fasciitis, heel spur syndrome occurs when the plantar tendon pulls at its attachment to the heel bone. This area of the heel can later calcify to form a spur. Many times the ligament pulling on the heel creates the symptoms, and not the spur itself, especially after getting up from resting. With proper warm-up and the use of supportive shoes, strain to the ligament can be reduced.

Achilles tendinitis. The stop-and-start of baseball often creates pain and tightness in the calf, and aggravation of the Achilles tendon. Again, regular stretching of the calf muscles gently and gradually before and after the game will help minimize the pain and stiffness.

Shin splints. Shin splints usually stem from an inflammation of the muscle and tendon attached to the shin, caused by stress factors. Treat shin pain with cold compresses immediately after a game to reduce inflammation. Proper stretching and strengthening exercises should prevent the onset of shin splints.

- See more at: carolinafootspecialists.net