Athletes and Plantar Fasciitis Pain

It’s been described as “stabbing pain” along the inside of the heel that extends from the back to just about the start of the arch. Others have described it as feeling like walking on glass, or having their feet cut with dozens of tiny razors. Any way you want to describe it, plantar fasciitis pain is NOT something anyone wants to experience. It typically starts out being a little annoying every once in a while. The most common problem people experience is a range of tenderness to significant pain taking those first couple steps out of bed in the morning or getting out of a chair. It can (and will if left untreated) get to the point of feeling like there’s needles sticking in the heel every time you take a step. In its most severe form, the pain through the arch and up to the ball of the foot will last all day long regardless of whether one is sitting or standing.

According to American Academy of Orthopedic Surgeons, it’s one of, if not the most, common cause of heel pain. Around 2 million people are treated for this condition every year (8). While it’s still debated whether gender is a risk factor, individuals 40 to 60 years old seem to be more at risk for developing plantar fasciitis than their younger counterparts. Athletes that spend a significant amount of time on their toes (dancers, wrestlers, gymnasts, Muay Thai kickboxers), any athlete that does high amounts of running for conditioning, and bodybuilders who have tend to have higher body weights from carrying extra muscle are at a greater risk for developing plantar fasciitis because of the stresses they place on their feet (5). Let’s take a look at some anatomy to understand why.


What Is Plantar Fasciitis?
There’s five layers of muscle that run across the bottom of the foot. Being the

foundation of the entire body, just like the foundation of a house, it’s crucial this

area be as strong and reinforced as possible. The plantar fascia is a huge, dense

ligament that runs from the heel bone (the calcaneus) to the ball of the foot (the

phalanges)(a). It creates a strong mechanical link between theheel and the

toes (9), and under normal circumstances, this link acts like a shock-absorbing

bowstring supporting the arches in the foot. Just like any machine, if the tension

and stress on the support system (in this case the plantar fasciitis) exceed what it

can tolerate, it'll tear. Doing this day after day, like running on concrete instead

of a track (as seen in overtraining injuries) or landing a jump poorly, or in can

cause the plantar fascia to become irritated and inflamed (10).


Most orthopedists and rehab specialists I've met relate the plantar fascia of the foot to how a windlass mechanism raises the sail on a ship. The ball of the foot (the metatarsals), the heel (calcaneus), and the plantar fascia make a triangle. Because of the way the plantar fascia attaches to the ball of the foot, it causes the distance between the heel and arch to get shorter when the toes are lifted up (b). This pulls it taut and lifts up the arch to make the foot stable when we walk, and puts the foot in a more stable position when someone rises up on their toes to do a calf raise for instance.










Clinical Signs and Symptoms
As we said before, the pain is typically worse first thing in the morning or after long periods of sitting or lying down where weight is off the feet (like sitting at a desk). When an athlete is standing, his body weight puts downward pressure on the plantar fascia allowing it to stretch out. After sleeping all night or sitting down for a duration of time, when there’s no bodyweight being put on the foot, the plantar fascia acts like a rubber band and contracts or tightens back up. When that first step is taken, it stretches the sole of the foot putting a lot of immediate stress on a tissue that’s very tight (just like a tight muscle), and pain is felt on the inside of the heel. The pain can extend to the arch and ball of the foot in more severe cases. My boyfriend, Brian, has had it. He and every patient I’ve treated for plantar fasciitis say that it’s the worst on the way to the shower in the morning, but after standing in the warm water and stretching the foot, it feels better. Heat relaxes muscles, that’s why we do a good warm-up before exercise. It’s also why an athlete may not feel any pain in the heel during a workout, but have a lot of it about a half hour after the workout's finished (10). The plantar fascia tightens back up as the tissue cools down after the workout. When the plantar fascia is warm and relaxed, just like we said above, it can stretch and, ideally, there’s no pain.


A lot of times, athletes will get plantar fasciitis without being able to tell when, exactly, it started or what might have caused it. An example would be an athlete who's recently started running more for specific conditioning purposes. Other times, it can be caused by something traumatic like a heavy landing after a jump off of a box jump without bending the knees to help absorb the forces of the landing (remember, the plantar fascia acts like a shock absorber). The pain is usually felt on one side and not the other, which can cause a lot of problems with training. In one of our other articles, we discuss the kinetic chain and how every part of the body is connected. When something’s wrong with the foundation, everything up the chain can, and most likely will, be effected. I saw a great example on MuscleAndPerformance.com that described how plantar fasciitis could impact lifts like squats, deadlifts, and bent-over barbell rows (4). Remember that every bone is connected by joints that make a body-length kinetic chain. Think about the added stress your knees, hips, and low back on just one side would take if you routinely pushed off with, or shifted your weight to in the case of deadlifts and bent-over barbell rows, that side more than the other. It can go downhill real quick.

How Can Athletes Get It?
There’s three different types of ways athletes can get plantar fasciitis. The first one includes muscle tightness and imbalances (2). The calf muscles, the gastrocnemius and soleus (c), attach just above the back of the knee and to the bottom of the heel through the Achilles tendon. They work to plantar flex the foot allowing
an athlete to

rise on his toes (d). Athletes that spend a lot of time on their toes without doing a lot of

stretching in between or after working out

run the risk of these muscles getting tight,

and it decreases the amount the ankle joint

canmove (8).  Athletes can end up habitually

walking on their toes ("toe walking”) because

the foot can’t get flat on the ground. Athletes

who aren’t ableto keep their heels on the floor

or platform during a squat or leg press show

signs of gastrocsoleus tightness (4). The

problem can also be caused by something up

higher in the kinetic chain (yes, the negative

impacts go both up and down) like having a

weak gluteal muscle(5).The glutes both extend our hips (make them straight),

and help stabilize our dynamic side-to-side balance. When a glute on one

side is weak, it causes the body to transfer weight differently when we’re

moving and walking around. The gluteus medius is responsible for keeping

our hips relatively even when we walk. When one is weak, it causes the

opposite hip to drop while taking a step (e). With this change in body position,

the knee of the supporting leg gets an uneven amount of stress put on it. It also

puts the foot in a different position to take a step and can cause limited ankle

mobility.

The second category includes foot deformities: high arches (pes cavus),

flat feet (pes planus) (f), and excessive pronation during the gait cycle (3).

Our feet go through a variety of motions while walking including a stable, rigid

position and a loose, mobile position. Athletes with high arches are said to have

“rigid feet” because their foot is “locked” in the stable, rigid position. But remember

the windlass mechanism or the bowstring example from earlier. If the bowstring

is always in a short position because the bow has a sharp angle rather than more

of a curve, it makes the string very tight and hard to stretch, right? The same idea

goes for the foot when asking the plantar fascia to stretch out when we take a step.

Flat feet are on the other end of the spectrum, where the plantar fascia is

stretched too much. Go back to the windlass mechanism again -- when the plantar

fascia contracts, it raises the arch of the foot to help support body weight. That

mechanism doesn’t work as well, if at all, in flat feet because the plantar fascia is too

loose and weak. It can’t pull the arch up to support the body weight, and so a lot of

extra stress is placed on the arches and heel of the foot, causing the heel and forefoot

to turn outward and the arch to roll inward (pronate). The same thing happens with

athletes that overpronate.

The final category is poor footwear. Whether your shoes are old and the cushion is completely gone (guilty), or you chose running shoes instead of walking shoes (you’d be surprised, there’s actually a pretty big difference), having the wrong kind or wearing old shoes during a workout or while running long distances will cause all the same problems that high arches and flat feet will. Exercising in shoes that are broken down can cause the same problems as flat feet (pes planus), whereas shoes that have too high of arches will cause the same problems as rigid feet/high arches (pes cavus). The same goes for wearing running shoes versus walking shoes. Walking shoes are more rigid and have less cushioning than running shoes because of the high impact and need for shock-absorbing flexibility when running. So it can be expected that if a runner, or soccer player, or anyone needing to run for long periods of time for conditioning wore walking shoes during a workout they would have very painful feet by the end due to the rigid, inflexible frame. The surface of the ground an athlete trains on is crucial as well. Training on a soft surface like wrestling mats or a spring floor helps increase the shock absorption the body experiences and is much better for protecting the plantar fascia than running and jumping on something rigid like concrete or a wood floor which decreases the amount of shock absorption and can cause sharp, immediate stress on the plantar fascia. I’m not suggesting to completely stop training on these surfaces. Just try to minimize the amount of time you do, and let either your personal trainer or a physical therapist know if you start to have pain at any time.

Muay thai kickboxers, wrestlers, dancers, and gymnasts are at an increased risk

for plantar fascia for a couple reasons. These sports require athletes to be on their

toes to generate power for taking shots, frequent pivoting, and elevation of the foot

while performing kicks and doing jumping skills (12). Earlier we mentioned that

athletes typically develop plantar fasciitis on one side and not the other. These sports

have a high tendency to be unilateral where athletes have a preferred, stronger side.

Muay Thai kickboxers spend a significant amount of time on their toes. When throwing

a front or roundhouse kick, the foot on their lead leg, usually the left, goes up on the

toes and will pivot depending upon the kick (12). The foot of the striking leg, usually

the right, has to repetitively push off the ground and the plantar fascia tighten perform

the kick, and also tighten when the foot returns to the ground to support the body

weight coming back (12). A dancer’s or gymnast’s foot requires the same muscle

control when doing pirouettes, leaps, and jumps. All of these sports also have a lot of

ballistic movement which causes a sharp, immediate increase in pressure directly on the

plantar fascia and can lead to irritation, microtears, and inflammation of the ligament (10).

We get much more in-depth with this topic in another article.


Cold Laser Therapy and Plantar Fasciitis
According to the Mayo Clinic, most people recover from plantar fasciitis with conservative treatments like rest, ice, and physical therapy in several months (3). Athletes can’t afford to rest and lose out on months of training at a time. Cold laser therapy has been shown to significantly decrease pain and help repair the plantar fascia in as little as 20 days. In a study by Hronkova et. al., subjects were divided into two groups: 1) those that got cold laser therapy (10 laser therapy sessions, 1 session every other day) and those that got a placebo treatment (6). At the end of the 20 days, 64% of subjects that had laser treatments said their pain was completely gone versus only 18% of subjects that had a placebo treatment, and only 10% of subjects that had laser treatments reported no change whereas 40% of patients in the placebo group stated they felt no effect at all. In another study by Kiristsi et. al., subjects had 18 treatments spread out over six weeks (9). When the authors compared the differences in pain scores, the group that received cold laser therapy reported pain numbers  significantly lower than the placebo group. After the six weeks of treatment, the plantar fascia had normalized (repaired) in seven out of 15 individuals that had cold laser therapy whereas only one out of 10 had normalized in the placebo group. These findings, in addition to another study done by the same group that showed similar results, suggest that cold laser therapy may play a part in healing the plantar fascia by giving extra energy to the powerhouse of the cell and triggering the repair process, in addition to increasing the circulation of our natural pain-relieving endorphins decreasing pain from the condition (9). Many orthopedic doctors will immediately suggest trying a cortisone injection to the plantar fascia to relieve inflammation and decrease pain. We encourage athletes to consider cold laser therapy as a choice before steroid injections because of their well-known function of contributing to tissue breakdown.

At iThinkFit Gym, we’ve treated two men and two women with plantar fasciitis pain. The men fared better with treatment than the women did, however both women had severe cases whereas the men had mild to moderate cases. While all individuals that we have treated are extremely active, one woman was a tennis player who later found out she had actually torn the plantar fascia, and the other woman was a marathon runner who had poor bone structure causing repetitive injuries from the impact during her runs (she’d had surgery for this problem in her other foot one year prior). All four patients had very similar descriptions of their pain, and specific improvements they reported include decreased pain during FitCamps and personal training sessions, and a consistent improvement in the pain and stiffness when getting up in the morning or after sitting for a long period of time (more than 45 minutes). The treatments have consistently been more beneficial when done after strenuous activity.
One patient reported after her first treatment and another after his third treatment they felt improvement in the pain and stiffness that lasted until the next time they exercised (up to 3 days later). The suggested treatment bout for plantar fasciitis consists of 10 - 18 treatments depending upon the severity and duration of the condition, so this pattern of relief followed by pain after strenuous activity early on in treatment is common. The marathon runner who ultimately had surgery was able to stand as a pet groomer for 8 hours, get a cold laser treatment, and within 3 hours be able to take her dog on a 10 - 15 minute walk on concrete with decreased pain. She, just like the other two patients, had increased pain following the activity, but this was a marked difference compared to her pain before beginning cold laser therapy.

Other suggestions
Corticosteroid injections may help with initial, short-term pain relief for things like tennis elbow (“lateral epicondylitis”) by decreasing inflammation, but have little effect on pain at 6 and 12 months (3, 11). A systematic review by Coombes et. al. shows that corticosteroid treatment might delay the recovery process that’s naturally stimulated by interventions like cold laser therapy and specific guided exercise programs (6, 11). Non-steroidal anti-inflammatory drugs also have no credible way to promote tissue healing and are rarely successful in resolving plantar fasciitis pain as well (11).

Other, more beneficial tactics that can be combined with cold laser therapy to help with pain from plantar fasciitis include stretching of the gastrocnemius and soleus (c) in addition to stretching one toe up at a time while keeping the rest of the foot flat to relieve tension and help with better movement patterns. Two of our patients wore splints at night which kept their foot in dorsiflexion (their foot flexed up) and the Achilles tendon and plantar fascia stretched out throughout the night. They both reported a lot of reduction in pain in the morning when they combined this with cold laser therapy. Evidence shows that the stress placed on muscles, tendons, and bone during specific guided eccentric exercises, like eccentric wrist extension for lateral epicondylitis, can help signal the cells in a tendon to heal the tissue (11). Physical therapists also have the ability to identify specific muscle weaknesses that are causing plantar fasciitis, and prescribe specific exercises to help strengthen those muscles. Finally, choosing temporary alternative types of aerobic training that have less impact than plyometrics and running can only further help protect and heal the plantar fascia while having minimal loss of conditioning. Some suggestions to help maintain endurance include swimming, biking, using a rowing machine, or doing punching combos on a heavy bag (1).


Do You Have Plantar Fasciitis?
M&B Wellness Solutions offers multiple services to help relieve the burning, sharp pain and heal the specific sources of mild to moderate cases of plantar fasciitis. Whether it’s cold laser therapy, traditional, insurance-based physical therapy, or our PT Squared Program where our physical therapist works together with the highly experienced trainers at iThinkFit to design the perfect plan that will help athletes train through the recovery process, we have what it takes to help athletes recovery quickly and stay at the top of their game.

The best way to start your road to recovery is to see a healthcare professional specializing in movement and rehabilitation who can assess your range of motion, strength, and quality of movement to determine if your pain is due to chronic overuse, from strength and flexibility imbalances, or something more severe. Stop by M&B Wellness Solutions located inside iThinkFit Gym for an evaluation with a licensed physical therapist so we can get you on your way to moving the best you possibly can.


Michaela Cantral, PT, DPT

                                                                                                                                                                                                March 21, 2017


References:

(1) B. How to Treat (and Prevent) Plantar Fasciitis Injuries. Muay Thai Pros: made in Thailand. http://muaythaipros.com/how-to-treat-plantar-fasciitis/. Published September 26, 2015. Accessed March 19, 2017.


(2) Borawski Jenkins B. Plantar Fasciitis - Prevention and Treatment. Breaking Muscle. https://breakingmuscle.com/learn/plantar-fasciitis-prevention-and-treatment. Accessed March 19, 2017.


(3) Chapter 10: Specific Injuries By Anatomic Site. International Association of Athletics Federations. https://www.iaaf.org/about-iaaf/documents/medical. Published October 23, 2012. Accessed March 15, 2017.


(4) Escalante G. Common Foot Injuries for Bodybuilders. Muscle & Performance. http://www.muscleandperformance.com/article/common-foot-injuries-for-bodybuilders-6125. Published August 24, 2011. Accessed March 19, 2017.


(5) Escalante G. Heal your Heels: Plantar Fasciitis Treatment. Bodybuilding.Com. https://www.bodybuilding.com/fun/heal-your-heels-plantar-fasciitis-treatment.html. Published September 8, 2015. Accessed March 19, 2017.


(6) Hronkova H, Navratil L, Krymplova J, Knizek J. Possibilities of the analgesic therapy of ultrasound and non-invasive laser on plantar fasciitis. Laser Partner. No 21. May 2001. www.laserpartner.org


(7) Jeran D. Wrestling and Running: Change your Shoes & Save Your Feet. Long Island Wrestling Association. http://www.longislandwrestling.com/liwa/sportsmedicine/runningshoes.htm. Accessed March 19, 2017.


(8) Kadakia AR, Fischer SJ, Haddad SL. Plantar Fasciitis and Bone Spurs. OrthoInfo: Your Connection to expert orthopaedic information. http://orthoinfo.aaos.org/topic.cfm?topic=a00149. Published June 2010. Accessed March 19, 2017.


(9) Kiritsi O, Tsitas K, Malliaropoulos N, Mikroulis G. Ultrasonographic evaluation of plantar fasciitis after low-level laser therapy: results of a double-blind, randomized, placebo-controlled trial. Lasers in Medical Science. 2010;25(2):275-281. doi:10.1007/s10103-009-0737-5. PMID: 19841862.


(10) Mayo Clinic Staff. Plantar fasciitis . Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/home/ovc-20268392. Accessed March 19, 2017.


(11) Scott A, Khan KM. Corticosteroids: short-term gain for long-term pain? The Lancet. 2010;367(9754):1714-1715. doi: http://dx.doi.org/10.1016/S0140-6736(10)61308-6.Vaseenon T. Foot and Ankle Problems in Muay Thai Kickboxers. Journal of the Medical Association of Thailand. 2015;98(1):65-70. https://www.ncbi.nlm.nih.gov/pubmed/25775734. Accessed March 18, 2017. PMID: 25775734.


(12) Vaseenon T. Foot and Ankle Problems in Muay Thai Kickboxers. Journal of the Medical Association of Thailand. 2015;98(1):65-70. https://www.ncbi.nlm.nih.gov/pubmed/25775734. Accessed March 18, 2017. PMID: 25775734.


PHOTO CREDIT

(a) http://www.footankleknee.co.uk/plantar-fasciitis-jim-carmichael.html

(b) https://www.pinterest.com/pin/324892560594859616/

(c) http://differentialdiagnosislowerleg.weebly.com/gastrocnemiussoleus-straintear.html

(d) http://www.emedicinehealth.org/script/main/art.asp?articlekey=110211

(f) http://drmarkgalland.com/tag/pes-cavus/


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