More than just a pebble in your shoe

Tuesday, October 6, 2009

The ability to run is usually taken for granted. One foot goes in front of the other. Some people run faster, some slower. Elite athletes can combine speed with the ability to turn or twist on a dome. Unfortunately, pain is the great equalizer. A small injury to a structure in the foot causes pros and fans alike to slow down. Quarterback Eli Manning has found that plantar fasciitis caused him to come to a screeching halt.

The plantar fascia is a dense band of tissue that runs from the heel to the base of the toes, forming a bow string with the bony arch of the foot and acting as a shock absorber for the forces that are generated when the foot strikes the ground. If the tension on the fascia increases, repetitive stretching can cause small tears resulting in inflammation, the “itis” of plantar fasciitis. Regardless of whether it is a quarterback, construction worker or a recreational walker, the pain that is associated with that inflammation results in enough pain that limping occurs.

Limping is the body’s way of telling the brain that there is something wrong. Walking or running with untreated plantar fasciitis worsens the inflammation and just reminds the patient to stop the activity that is making the situation worse. Often, the pain of plantar fasciitis has a gradual onset on the sole of the foot at the heel and may radiate towards the toes. Usually the pain is worse after resting, so the first few steps in the morning can be extremely painful.

Mr. Manning had acute onset of pain while planting his foot to throw the football. The alternative diagnoses that could be considered included a stress fracture to a bone in the foot or a torn tendon or ligament. His diagnosis was confirmed by MRI; though “normal” people who don’t have $97 million contracts to play a game often have the diagnosis made by physical examination.

RICE is the first line treatment for plantar fasciitis including rest, ice, compression and elevation. Ibuprofen as an anti-inflammatory will help with the pain. A physical therapist may be the key person in directing the treatment team. Stretching exercises and taping may be helpful. Night splints may also be worn to protect the foot. Orthotics or shoe inserts may help cushion the foot and relieve stress during the weight bearing phase of walking. Ionophoresis may be the next step, where an electrical current helps drive steroid creams deeper underneath the skin. Steroids may also be injected into or near the areas of inflammation.

The goal of therapy is to return the patient to their level of function. Usually it means being able to walk without pain. For Eli Manning, he will need the ability to run, twist and turn to evade 300lb defensive linemen. Recommendations suggest that activity be limited by pain symptoms and return to practice should be gradually increased, again based upon pain. It may take weeks for complete healing and chronic pain can occur if return to play is rushed. For the non-elite athlete it may take up to a year to become pain free.

Pro football players tend to ignore the textbook when it comes to injury rehabilitation. They measure their return from knee surgery in days, not weeks. Broken bones aren’t a reason to miss practice. But while Manning’s will may be strong, the amount of force generated by running may cause enough pain to become his Achilles’ heel…or make it his plantar fascia.

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