Pearls On Treating Plantar Fasciitis In Athletes

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Author(s): 
Dianne Mitchell, DPM, FAAPSM, FACFAOM

As podiatrists, we see plantar fasciitis in our offices many times each day, especially in athletes. We know what it is and have a good idea of what causes it.

   However, with the numerous treatment modalities available, why aren’t all of our patients pain-free? Why do we have patients with lingering pain? Are we treating them wrong? Are they misdiagnosed? Are they non-adherent? I will reexamine how we look at plantar fasciitis in an attempt to improve our success rates in effectively treating and eliminating this mechanically induced pain.

   What mechanism generates plantar fasciitis? There are two pathways: intrinsic and extrinsic.1,2 However, every single patient who over-trains or wears a broken-down shoe does not develop plantar fasciitis. Therefore, the more important factors to evaluate are intrinsic, such as supination of the midtarsal joint. Intrinsic factors result in torsion of the plantar fascia, generating pain and inflammation.

   Kogler and colleagues in 1999 looked specifically at which foot positions place stretch and higher strain on the plantar fascia, as these positions would presumably create pain.3 Their goal was to quantify strain through the plantar fascia tissue with different orthotic wedge combinations in static stance using a cadaveric model. The 6-degree wedge combinations included a neutral load without any wedge followed by eight additional combinations as either a varus or valgus wedge applied to the rearfoot and/or the forefoot. Plantar fascial strain was lower in the three scenarios with forefoot valgus wedges. This likely controlled midtarsal joint supination by adding a pronatory torque on the forefoot and plantarflexion of the first metatarsal. This study could be a key in effectively treating mechanically induced plantar fasciitis with functional foot orthotics.4

   There are numerous treatment options for plantar fasciitis.1,2 In 2010, the Journal of Foot and Ankle Surgery published a Clinical Practice Guideline for the treatment of heel pain.1 Once one has established the heel pain as mechanical in nature, the algorithm recommends stretching, icing, over the counter heel cups or orthotics, reduced activities, anti-inflammatories, padding/strapping, cortisone injection, weight loss, and avoiding bare feet and flat shoes. If these modalities fail, the next treatment level includes a night splint, custom orthotics, more injections or immobilization. Beyond that, consider surgery after ensuring that the diagnosis is correct and after six months of conservative care.

   Often, patients who get a diagnosis of plantar fasciitis from a primary care doctor have already tried rest, ice and anti-inflammatories with no symptom improvement by the time they arrive in the podiatrist’s office. Some come in with a padded heel cup or an over-the-counter soft or semi-rigid orthotic also complaining that the pain is still very much present. Patients may report the inability to “rest” if their jobs require standing or squatting with or without the addition of lifting items. Many athletes do not want to stop their sport and did not receive alternatives to stay active and protect the feet.

A Closer Look At The Role Of Orthotic Therapy

The research indicates that the best way to address foot mechanics is with a functional foot orthotics device. Additionally, we incorporate a gentle stretching program to address the associated structures, as an equinus component is commonly present. We also incorporate a night splint to aid in pain relief and for post-static dyskinesia. Discussions of either modified work duty or “relative rest,” specifically looking at cross-training options, are an essential treatment component. With this approach, the need for cortisone injection has diminished significantly in my experience.

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