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How the media is still years behind in understanding heel pain.

The USA today recently ran an article discussing why plantar fasciitis is sidelining athletes. Albert Pujols is currently the most prominent plantar fasciitis victim, with the Los Angeles Angels announcing Monday that the 33-year-old, $240-million first baseman/designated hitter will sit out the rest of the season so that his foot might heal and give him a chance to report healthy to spring training next year. “I’ve been dealing with this for nine years,” Pujols says. “This was the worst of all the years. Hopefully, with rest, it will be fine.”
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Nine years. Unbelievable. Plantar fasciitis (see my related blog post on plantar fasciitis) is an epidemic that our society struggles with as a result of our fashion driven shoe gear and misconceptions of need for support. These factors lead individuals to walk, run, stand, and function in a manner that is not natural leading to weakness in our foot musculature as well as overuse injuries. Part of me finds it really hard to believe that someone could be suffering with this for nine years, but the other half of me understands. If you continue to treat the condition with orthotics, motion control shoes, and NSAIDS, you will inevitably get caught in a circle of reducing inflammation and creating it, over and over again. Orthotics and motion control (or stiff shoes) create the cause. What is the cause? Bad form. Our feet are not designed to be “immobilized” into shoes and plastic inserts that prevents the necessary motion from occurring. As surprising as it may sound, a barefoot working in conjunction with the achilles tendon, ankle joint, knee joint and proprioceptive mechanisms,can reduce more shock then a cushioned heel alone. By altering all these shock absorptive capacities through orthotics and motion control shoes, the muscles in the feet overtime will work harder, when required to with different activities, because they end up becoming weaker.

Robert Klapper, chief of orthopedic surgery at Cedars-Sinai Medical Group in Los Angeles and host of a radio show about sports injuries suggests that “athletes who have symptoms of plantar fasciitis need to wear stiffer-soled shoes”. I challenge that to be supported with current literature.

According to the USA today article, “It is one of the most difficult athletic injuries to heal, partly because there is so little blood flow around the heel and also because any sort of running or jumping continues to offset the various treatment options, primarily physical therapies and anti-inflammatory medicines. Even after extended rest, recurrence is common.” I’m not sure where they have gathered this fictitious information, because anatomically speaking there is no decrease of blood supply to the heel. In fact, the calcaneous (heel bone) is a bone that when fractured heals almost all of the time with no increased incidence in none unions because it is “highly vascular”.

Another interesting fact is that when chronic plantar fasciitis patients were biopsied, there was no histopathologic evidence of inflammatory cells in the plantar fascia. Does this mean there is no such thing as plantar fasciitis? Consider the other muscular attachments to the heel (which by the way are highly vascular). There are three muscles which originate on the heel bone in the same area as the plantar fascia. They are the abductor hallucis, flexor digitorum brevis, and flexor digiti minimi. If these muscles become overused they can develop a tendonitis like condition which explains the classic heel pain that occurs in the morning when first arising from bed. It’s a common finding to have patients with tendonitis complain of pain after periods of rest when the muscles and tendons are not warmed up, and then find that it decreases as they begin some motion which warms the tissues up. Eventually the pain returns with continued use.
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The articles features comments from an orthopedic surgeon adding shoes can resolve plantar fasciitis.

Bal Rajagopalan, a Beverly Hills, Calif., orthopedic surgeon, agrees that proper shoes can help athletes avoid chronic plantar fasciitis. “Naturally flat-footed people are more prone to plantar fasciitis,” he says. “They should be wearing sneakers with high arches. Sometimes you see athletes wearing these minimalist shoes with little or no cushioning. That’s horrendous. They are bound to have problems.”

Are they? Or is it they are forced by society to wear stiff rigid dress shoes with pointed toe boxes that immobilize the foot and alter a natural gait? Along with the notion this altered gait is carried over into their running and athletic competition.

In regards to treating these patients with cortisone injections to calm the inflammation, I am repeatedly asked, “isn’t cortisone a temporary fix for the problem? I want to fix the problem. Cortisone injections will fix the inflammation, but if the CAUSE of the inflammation remains, then yes, it will be temporary. In simpler terms, if you strike your thumb with a hammer you’ll create inflammation. If you treat this inflammation with ice, NSAIDs, or a steroid, the inflammation will resolve. If you continue to hit your thumb with a hammer the inflammation will return. The same applies to planter fasciitis. The challenge is to find out what the hammer is and stop hitting it.

What about surgery? The standard of care for treating plantar fasciitis surgically involves cutting the fascia from its insertion site in the heel bone to relieve the “tension”. It involves a small incision typically in the medial side of the heel (inside) where the abdcutor hallucis muscles is frst encountered and then moved to access the fascia. Only two thirds of the plantar fascia is released and the patient is then typically no weight bearing for three weeks. Is cutting the fascia the answer, or is it that the injured and inflamed site be becomes more acutely inflamed from the surgery and the heals through as a result of this cascade of events.

Recently I had a runner in the office with an acute onset of plantar fasciits. We discussed training patterns and intensities, surfaces, shoes, and current treatment options. I spent 30 minutes with her and she left with an understanding of why running injuries occur, in this case plantar fasiciits and what variables to keep constant to avoid it it the future, as well as to help improve it now. Most physicians will typically spend a few minutes, advise orthotics, then send to a local running shoe store to by a motion control shoe to fit these orthotics, despite no literature that supports this.

It’s not surprising to hear that a MLB player has been sidelined given the way most are treating plantar fasciitis. It’s an epidemic in our society and it’s easily brushed off as being treatable with an insert and shoes. I can tell you from experience this is not the answer. I have seen many patients with bags of shoes and inserts to go with them present to my office with unresolving chronic heel pain. I think it’s pretty clear that this treatment option is not working if professional athletes in multiple sports are being sidelined for periods of time over several years. One can recover from a complete Achilles’ tendon rupture faster then the amount of time these athletes are taking to resolve their pain as described in tis article.

 

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