Prognosis Spurs: Plantar Fasciitis

The Spurs Team Physicians are David Schmidt, M.D. and Paul Saenz, D.O. Together with Ralph Curtis, M.D., Tim Palomera, M.D., Marque Allen, D.P.M. and Richard Steffen, M.D. they comprise Sports Medicine Associates of San Antonio, whose mission is to be the preeminent provider of medical and surgical care to all athletes and active individuals.

Prognosis Spurs: Plantar Fasciitis

by Marque Allen, D.P.M.
Sports Medicine Associates of San Antonio

FIGURE 1
FIGURE 2

This season, many athletes – including the Spurs’ Tim Duncan – have suffered through nagging pain in the heel, which is one of the most common complaints of patients who seek medical treatment for foot problems. Heel pain can have many causes, but plantar fasciitis (PF) is the most common diagnosis.

PF can affect persons of all ages, sexes, activity levels, and professions. The common thread is pain mostly in the heel area with possible extension into the arch. The pain most commonly occurs after an increased demand in standing or activity over a short or long period of time. The pain may be only transient at first but may evolve into a chronic unremitting discomfort that can eventually affect normal walking and athletic activity.

The plantar fascia is a broad band of fibrous tissue that arises from the heel bone and runs along the bottom of the foot, attaching to the base of the toes (figure 1). The foot arch can be thought of as a triangle with the PF making up the base (figure 2). As we stand, the combination of our body weight, gravity, and foot mechanics moves the arch towards flattening. This flattening of the arch is opposed by the plantar fascia as it is stretched and compressed. Excessive demand upon the plantar fascia will result in pain as the body attempts to protect itself from injury.

The pain is most typical upon arising in the morning and with the first few steps. The discomfort may decrease as we walk only to return later in the day or after long periods of sitting. With continued activity, the severity of the pain will increase which usually causes the patient to seek medical help.

The diagnosis of PF is often made after a careful and detailed history from the patient, a physical exam, and exclusion of other possible causes of heel pain. Other causes of heel pain that can be mistaken for PF can range from stress fractures, inflammation of the growth plate in adolescents, or entrapment of the nerves arising from the lower back. Heel pain can also be an indicator of inherited inflammatory types of arthritis. Once an exact diagnosis of PF is made, the treatment regimen can be undertaken.

Treatments for PF are varied but all are intended to reduce the amount of inflammation within the plantar fascia either directly or indirectly.

Direct intervention is in the form of oral and/or injected medicines or topical application under ultrasound. Oral medications such as Motrin, Ibuprofen, Naprosyn and Celebrex are usually the first line of direct intervention. These medications will suppress the chemical process of inflammation, while oral steroids can directly affect the cellular events of inflammation. It should be noted that these medications are not specific for the foot and could have potentially harmful side effects throughout the body. Therefore, be sure to talk to your doctor about any other medicines you are taking before starting these treatments.

A second type of direct treatment includes injected medicines into the bottom of the foot, which introduce a large concentration of anti-inflammatory medications at the specific site affected. These medicines are most commonly in the form of short and long acting steroids. This method of treatment can also cause serious side effects but can produce a rapid and appreciable decrease in symptoms.

The application of medicines driven by ultrasound can also be considered but may have a muted effect due to the thickness of the skin on the heel.

WRAP IT UP
Tim Duncan prepped for the 2006 All-Star game.
(Andrew D. Bernstein/NBAE/Getty)
In addition to the direct treatment to reduce inflammation of the PF, the patient should attempt to identify the possible training error or increased demand which caused the inflammation. Indirect treatments such as equipment changes, new shoe gear, tapping maneuvers with or without padding, and in-shoe orthotics can help to redirect the mechanical movements of the foot and reduce stretch of the PF. The uses of night splints and stretching programs have been found to provide good results.

Lastly, patients who do not respond well to these direct and indirect treatments may need a period of complete immobilization of the foot.

Over 90% of patients diagnosed with PF can expect resolution of their symptoms with a disciplined and comprehensive program. If the symptoms persist despite intervention, then more aggressive options can be considered.

Treatment of PF in failed cases of greater than six months with restrictions in athletic activity of daily living could be candidates for either high energy sound wave treatment to the heel or surgical intervention.

High energy sound wave treatment has been met with encouraging results and quick return to activity, but in most cases requires a large monetary commitment from the patient as insurance companies have been slow to reimburse for this treatment.

Surgical intervention in the form of release of the PF should be reserved for the most chronic cases, with MRI confirmation of irreversible changes in the plantar fascia. Surgery, while providing relief of symptoms, could permanently destabilize the foot and should be used only as a last resort.