Foot and ankle injuries predominate in the NBA and Joakim Noah, the Chicago Bulls big man who is currently out with plantar fasciitis, is one of the latest high profile players to suffer from this nagging problem.  Noah missed his first game on January 23^rd, returned intermittently for limited minutes and has been out of action since February 27^th, a relatively long absence for a non-traumatic injury.  Athletes are prone to plantar fasciitis, particularly those who do a lot of sprinting and jumping, but even quarterbacks, just like the rest of us, are susceptible.  Eli Manning, who was diagnosed during the 2009 season, is a case in point.

What is fascia?
Fascia is a fibrous connective tissue that occurs throughout the body and overlays the muscles, organs, nerves and blood vessels.  It acts as a restraint to keep our tissues and structures in place. If you have ever prepared chicken you have seen the filmy white tissue between the skin and the meat – that is fascia.  At the bottom of the foot, (the plantar surface), the fascia is particularly fibrous and connects the heel bone to the toes.  It is prone to stresses or small tears that can result in an inflammatory (“itis”) response.

Common causes of Plantar Fasciitis
Fasciitis usually develops over time rather than from trauma and the problem is often stubborn, especially if left untreated. Tightness of the calf muscles and Achilles tendon can predispose to plantar fasciitis, as can tightness of the fascia itself.  A loss of mobility at the ankle or the big toe (not being able to flex up/back sufficiently) can also lead to fasciitis by changing our movement patterns, reducing the shock absorbency of the joints, and limiting the ability of the calf and fascia to stretch to their fullest, resulting in tightness.  Additionally, weakness of the muscles of the calf or foot/ankle impact function and lead to injury by placing more stress on all the related tissues.  Other typical pieces of the cause and effect puzzle may include structural malalignment (such as a high or low arched foot) or the presence of a heel (bone) spur.

Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle.  People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis.

Symptoms of Plantar Fasciitis
Swelling and tenderness to pressure or touch are generally complaints of those with fasciitis, as is a sharp pain in the heel area or arch of the foot.  One of the most common complaints is morning pain, particularly with the first steps from bed. During a prolonged period of rest, where the foot and ankle are relaxed (with the toes pointed downward), the plantar fascia and muscles of the calf are on slack.  The sudden stretch imposed by putting the foot on the floor and walking can trigger significant pain.  The same might occur after sitting for an extended period.  In very mild cases, after walking a bit and warming up the tissues, pain subsides. Taj Gibson, another Chicago Bull suffering from plantar fasciitis has been receiving treatment but has been able to play through it, an obvious sign that his condition is not as severe as Joakim Noah’s.

Prolonged walking and especially running, which requires a more forceful push-off, are likely to increase the pain and inflammation associated with fasciitis.  Jumping will do likewise.  Not the best scenario for Joakim Noah who, when he began his medical leave, was the NBA’s second leading rebounder.

TREATMENT
Treatment of plantar fasciitis requires a multifaceted approach to reduce inflammation, stimulate healing, stretch tight tissues, strengthen weak musculature and minimize additional stresses.  Here are some tried and true methods of care as well as some of the emerging techniques:

Rest – time off from offending activities is an important part of treatment.

Night Splint – wearing a night boot to keep the ankle at a 90-degree angle maintains some stretch of the calf and fascia and significantly reduces early morning pain.  By helping to lightly stretch tight structures over a prolonged period, resolution of plantar fasciitis is accelerated.

Deep tissue massage – performed manually and also by rolling the foot on massagers or things such as a tennis ball or frozen can of soda can be very helpful.  Deep massage with the ankle held at 90 degrees and the big toe held gently in a backwards-bent position can help to ease fascial pain and tightness.

Stretching – tight calf muscles and fascia must become more flexible to limit recurrence.

Range of motion – treatment to restore motion where it is limited may be necessary to allow for more flexibility of the attached structures.

Cushioned heel lifts – by slightly elevating the heel, stress on the tight structures is minimized during walking or prolonged standing, and the increased shock absorption of a heel lift also decreases the stress from impact.  Choice of footwear factors in here as well (notice that many surgeons and chefs wear clogs).

Ice and electric stimulation – both help to reduce inflammation and swelling

Iontophoreses – another very helpful tool used in physical therapy.  For plantar fasciitis, “ionto” involves the use of a corticosteroid medication that is driven through the skin in the region of the inflammation with a transistor size electric stimulator.  It is painfree, entails only localized use of the drug and does not entail an injection.

Taping – even after returning to competition, taping techniques are used to support the arch.  Taping can be very helpful and enable a player to compete without aggravating a condition as well as reduce the chance for recurrence after a problem resolves.

Strengthening weak muscles throughout the lower body and especially those of the calf and foot is crucial, as is building muscular endurance.  For example weak toe flexors (muscles that let you grip with your toes) are a common problem resulting in fatigue in the foot and strain on the fascia due to poor push-off.  Even the toes must be strengthened when treating foot and ankle conditions.

Balance training is vital as well, working to stabilize while standing on one foot and challenged to reach or bend.  Balance training should be progressed from stable to unstable surfaces to increase the difficulty of the tasks.

Arch supports – if flattened or high arches or other malalignment issues are part of the problem, over-the- counter or custom orthotics (shoe inserts) may be recommended.  It is generally suggested to wait until you have increased your flexibility (if it is one of the causative factors) before getting a custom orthotic because the resting position of the foot may change once greater flexibility is achieved.

Prolotherapy – Prolotherapy treatment involves injecting a sugar water solution into the involved ligament or tendon where it attaches to the bone. This is intended to cause a localized inflammation in these affected areas in order to then increase the blood supply and flow of nutrients.  It is thought to stimulate the tissue to repair itself.  I’m not sold.

Plasma Rich Platelet Therapy (PRP)– Joakim Noah recently underwent PRP and shock wave treatments. Both are relatively new.  Some recent studies on PRP were not as favorable as the original clinical impressions, showing that it was no more effective than injecting saline. Platelets are one of the four components of blood.  The others are red and white blood cells and plasma. The procedure involves taking a patient’s own blood, spinning it down to the platelets, which are said to release proteins called growth factors, then injecting that back into the injured area.  The treatment is thought to accelerate tissue and wound healing.

Shock Wave Therapy – Another emerging treatment, shock waves are said to work by inducing microtrauma to the affected tissue, which then stimulates a healing response. This healing response causes a repair process during which small blood vessels form to increase delivery of nutrients to the affected area.

Injections – Not on my go-to list of treatments for plantar fasciitis, they are still in the arsenal so are included here.  The cortisone injection is occasionally needed to jump start the rehab process by reducing inflammation and pain sufficiently so that the active treatments (such as stretching and strengthening) can be progressed without exacerbating symptoms.  With the potential side effects of injection always at issue, it should not be a first line of defense or used repeatedly in one area of the body.  Nor should cortisone be the entire treatment even if it brings relief.  That is dangerous because it gives a false sense of order when in fact the underlying causes of the problem have yet to be addressed.  Cortisone by injection at the foot is even riskier because of the more fragile nature of the tendons there and their predisposition to rupture.

Surgery – A very last and infrequently relied upon resort, surgery to lengthen the fascia is sometimes the final step when all else has failed.