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John Lackey – Pitching With Plantar Fasciitis

John Lackey, right-handed starting pitcher for the World Champion Chicago Cubs, will be 39 years old in October. He is dealing with plantar fasciitis in his right foot, yet will start Tuesday’s game against the Braves after getting some extended All Star Break rest. Lackey was effective over six innings in his last start on July 5th before going on the 10-day DL the following day. This will be his first start since being activated.

Baseball players have successfully played through fasciitis before, Albert Pujols being one of the most visible and recent examples. But eventually Pujols succumbed to surgery as his condition worsened while he continued to play (even with a reduced role as DH). The condition can be quite painful and – even for a non-athlete – get in the way of performing routine activities. However, surgery is only a last resort.

The likelihood that ten days of rest will have resolved Lackey’s problem is not great. It becomes more about how (or if) the condition can be managed enough for the pitcher – whose numbers have suffered in comparison to the 1916 season – to be effective.

The Plantar fascia

The word plantar refers to the sole of the foot, and the plantar fascia is a thick fibrous band of connective tissue in this region that extends from the heel to the forefoot. It assists with stabilization of the arch. Fascia 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.

“Itis” means inflammation, in this case of the fascia. As with tendinitis, it is generally felt that a degree of degeneration is also occurring. This is known as tendinosis when referring to tendons. It is much like what happens with conditions such as tennis elbow or patellar tendinitis, which are also due to overload.

The fascia in the foot is particularly strong and is prone to stresses and small tears. Plantar fasciitis, a common cause of foot pain, is an overuse syndrome set off by too much tensioning of the fascia’s attachments to the heel. Though there is an increase incidence of heel spurs in sufferers of fasciitis, spurs, which are generally not within the fascia, do not always cause pain. However they may contribute to a predisposition to the condition.

Weakness of the muscles of the calf or foot/ankle impact function and also predispose to injury by placing more stress on all the related tissues. There is reportedly no definitive evidence that either a high or low arched foot predisposes to plantar fasciitis.

The onset of fasciitis is usually gradual rather than from trauma, and the problem is often stubborn, especially if left untreated. Generally speaking, the faster treatment is initiated after the onset of symptoms, the more accelerated is the recovery.

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. Prolonged walking, and especially running, which requires a more forceful push-off, are likely to increase inflammation and pain. Jumping will do likewise.

The pain that occurs with this condition is often exaggerated in the morning because the fascia and heel cord (Achilles) are relaxed during sleep. Those first steps when the area is put on stretch can be especially problematic. That is why night splinting to keep the area on mild stretch is so helpful in treatment. The pain, which can be either sharp or dull, often feels like a pulling and is more common after inactivity than with movement. Hence standing for long periods worsening symptoms.

Fasciitis can involve tenderness along the band of the fascia in the arch or be more toward the heel. Putting the fascia on stretch by bending the toes back (dorsiflexion) – especially along with dorsiflexing the ankle (flexing it toward one’s head) – makes the area much more tender to touch. Plantar fasciitis must be distinguished from other conditions such as Heel Pain Syndrome, where the pain is more exclusively localized to the heel.

Treatment for plantar fasciitis focuses on relief of inflammation as well as stretching the fascia itself and reducing its soft tissue restrictions as well as stretching the calf and Achilles. Fascia stretching has proven most effective when it is non weight-bearing and specific to the area. There are many other ways in which to stretch, especially by taking a more dynamic approach and focusing on inhibiting muscles that limit the flexibility of the tight structures. One note of caution if stretching statically and when weight-bearing is to AVOID hanging the heel down off a step. This puts the midfoot structures at risk and also increases incidence of future Achilles rupture. It is best to keep the foot supported on the floor or on a wedge when stretching in in this position.

Treatment of fasciitis should also include assessment of, and attention to, areas of the foot that are related and may impact flexibility of the calf or pliability of the fascia. For instance, if the ankle or the joint at the base of the big toe lacks full mobility (into dorsiflexion) the soft tissues may not be able to stretch adequately. In these instances, restoring mobility to the joints may be necessary to get the desired result.

Though cortisone injections may provide temporary relief (studies show most patients have recurrence), they also come with an increased risk of rupture. The interesting thing is that treatment of chronic plantar fasciitis sometimes includes surgically lengthening the fascia (a procedure that Albert Pujols had), something that rupture may accomplish naturally. The downside is the time spent totally out of commission while healing in either case.

A Look at Achilles Tendon Injuries in Pro Sports

Baseball is barely out of the gate, with spring training games getting underway this weekend. Yet, according to CBSSports.com, there are 143 major leaguers who are out with injuries. Though some are listed as day-to-day, many will miss a good deal of spring training. Others led with season-ending surgery. I hate to think of what the list will look like in a few months…


A few NBAers are suffering from big-time Achilles injuries. Piston’s forward Jonas Jerebko tore his Achilles tendon in pre-season and Charlotte back-up center DeSagana Diop underwent an Achilles repair in January. Francisco Garcia, a guard/forward on the Sacramento Kings has been out for weeks with what coach Paul Westphal called “an epic calf strain”, and just days ago, Spurs star Tony Parker left the game with a calf contusion after a collision with Mike Conley of the Grizzlies. Celtics Big Man, Shaquille O’Neill, has been resting up for playoffs with a case of Achilles tendinitis.

Shaq’s condition appears to be a simple inflammation, an overuse issue. He isn’t getting younger after all… Parker’s injury, a muscle contusion, was clearly a result of a collision. If it is a significant bruise, it could take a good four to six weeks for him to get back up to speed. The trouble then is that Parker’s calf muscles will be somewhat de-conditioned, making them vulnerable should he return to play too early. Of course, with playoffs already in sight, that is exactly what is likely to occur.

Achilles ruptures, on the other hand, are not generally associated with contact. Most who suffer a ruptured Achilles feel or hear a “pop and think they might have been kicked. Surgery is often performed quickly, to approximate the two ends of the tendon before the tissue shortens permanently.

What is the Achilles tendon?

Tendons attach muscles to bones. The Achilles is thicker and more fibrous than most tendons and it connects the calf muscles (the bulky Gastroc in the upper calf and the smaller Soleus closer to the ankle) to the heel bone (calcaneus). The Achilles tendon and calf muscles are put on stretch when the ankle is flexed up and it is shortened when the toes are pointed. A tight Achilles or one that is overstretched can predispose to rupture.

If you think you have a tight Achilles, before stretching vigorously, it is important to identify whether the problem is actually with the tendon or if it lies with restricted ankle mobility. Have a therapist check the range of motion at your ankle with the knee flexed. The Gastroc muscle crosses the back of your knee as well as the ankle. With the knee bent, the gastroc muscle is in a shortened position and will not restrict movement at the ankle. Compare theses findings with the amount of ankle flexion range with the knee straight (with the Gastroc on stretch). The latter is a measure of flexibility. If your ankle mobility is significantly restricted, no amount of calf stretching will

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lengthen your Achilles tendon or even stretch your calf muscles. The motion simply isn’t accessible to allow that to occur.

What are the consequences of Achilles rupture?

In addition to the pain and swelling that are expected with any sports injury, disruption of the connection between the calf muscles and the heel results in an inability to contract these muscles; That means that you cannot rise up on your toes or walk with a normal push off when weight-bearing on your injured side. Running and jumping are therefore also out of the question.  However, it may be possible to actively point your toes while you are not bearing weight due to the action of other muscles that help to provide this movement.

Why do Achilles tendons rupture?

There is an area of the Achilles that has less blood flow than the rest and it is thought that this section of the tendon may not be as strong. As we age, tendons, as other tissues of the body, become less supple and may degenerate. These are some reasons why tendinitis becomes more prevalent and ruptures generally occur in people over 30, especially in middle age. Younger athletes generally experience a higher tear, well above the ankle, where the muscle joins the tendon (musculo-tendinous junction), though they too can experience a tear closer to the heel.

Some sports are more stressful to the calf muscles and Achilles than others. Those that require the powerful push-off needed for running and jumping place the greatest demand, as do those like racket sports which entail a lot of stutter-steps and quick stops and starts. Men are far more likely to suffer Achilles ruptures than women and it is thought that obesity adds to the stress on the Achilles, increasing risk of rupture. Though this is not a factor for most elite athletes, football linemen and centers built like Shaq do place proportionately greater demand on the tendon.

Other predisposing factors for weekend warriors like you and me include stepping up activity suddenly and significantly – either by increasing the intensity, frequency or duration of participation or perhaps beginning a new activity without preparation. All of these increase the stresses placed on the Achilles. It is thought that weakness of the calf muscles, particularly the Soleus, may also be a factor causing the Achilles to rupture; The Soleus can be strengthened by pointing the foot — against resistance — while the knee is bent (as in a sitting position). A history of multiple steroid injections at the Achilles may be to blame in some cases of rupture. Be aware that manufacturers of certain medications, such as the antibiotic Levaquin, name tendon issues as a potential side effect. Inform your physician if you begin to feel Achilles symptoms after beginning a new medication.

One exercise I strongly suggest you avoid is strengthening the Gastroc muscles of the upper calf by hanging the mid-foot and heel off a step or raised platform and doing heel-raises from this position of maximum stretch. Repeatedly lowering the heel below the level of the step (with your body weight and gravity loading the Achilles tendon), puts the tendon at greater risk of rupture and jeopardizes the structures of an unstable mid-foot. This is an exercise I see so often in the gym. Yes, it is important to strengthen the calf, but it is recommended to do so from the more neutral foot–flat position.

How is an Achilles rupture diagnosed?

Physical exam is often pretty conclusive. The first test is simply to squeeze the belly of the calf muscles and observe whether the foot points as the muscles are manually shortened. Another obvious sign is when the examiner can move the ankle excessively into a dorsiflexed position (toes toward your nose) – with the knee straight. As previously discussed, this motion is generally restricted by the tightness of the Achilles and in the case of rupture it is not. A third test involves observing the motion of a needle inserted into the tendon as the foot is passively moved up and down. An ultrasound exam and/or positive x-ray findings — particularly those in a lateral (side) view – support the diagnosis.

What are the treatment options?

Small tears may do well with immobilization. Casting is generally done with the foot in a pointed position, which shortens the tendon allowing it to heal. Bracing that restricts motion is an alternative. Athletes are not good candidates for conservative management, and those who do not undergo surgery should expect a long recovery (up to a year) before returning to sports.

Operative treatment is the gold standard for athletes, younger patients and those with a complete rupture. Both treatments are followed by periods of decreased weight-bearing, though the surgical patient progresses at a much faster rate. Rehab includes work on overall strengthening, cardiovascular conditioning and flexibility, as well as a focus on restoration of normal mobility in the ankle and foot, which become restricted from prolonged immobilization.

Outcomes

According to Wheeless’ Textbook of Orthopaedics, non-operative patients have an average re-rupture rate of 18% and can expect a decrease in strength and muscle endurance of 30%. 83% of surgical patients and 69 % of immobilization patients can expect to resume their pre-injury level of activity. Wheeless also reported that 93 % of surgical patients were satisfied with the results of treatment, while only 66% of conservatively managed patients felt likewise. Because of the positioning of the foot with the tendon in a shortened position while casted or braced, non-operative treatment generally does not restore the Achilles tendon to its full length. In contrast, if immobilized with the ankle in a neutral position, the tendon is generally lengthened, leading to a poor outcome.

Follow Abby on Twitter @abcsims

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Kalin Lucas and the Debilitating Nature of an Achilles Tendon Rupture

Fifth seeded Michigan State managed a huge win on Sunday over fourth seeded Maryland on a three-point buzzer-beater by Korie Luscious. The biggest surprise was that the Spartans did it without the services of Kalin Lucas who went down with 2:28 left in the first half while clutching his left foot. Though reports have not yet clarified the details of Lucas’ newest injury, Coach Tom Izzo was quoted after the game as having said that he was 99% certain that his star would be out for the balance of the season after what appeared to be an Achilles tendon rupture.

If his coach is correct, Kalin Lucas should give David Beckham a call for a Q & A on what to expect next. Mr. Beckham was headed to his fourth World Cup,

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a record for an English soccer player, when he left the field in tears on March 14th after he too suffered an Achilles rupture. Beckham wasted no time in having surgery, flying to see a specialist in Finland early the next morning for an Achilles repair.

Both Lucas’ and Beckham’s injuries were non-contact, typical of Achilles ruptures. Lucas claimed not to have felt or heard the “pop”, often associated with Achilles injury, though he reportedly did think he might have been kicked — a sensation that is also classic for a rupture. Beckham looked behind him when his injury occurred, as though he too may have suspected a kick to the calf. Both players also likely experienced sharp pain. Post-game, a teammate said that Beckham felt the muscle begin to come up. This too is common; it is almost like firmly pulling an elastic band until it breaks and seeing the top half retract. Surgery is often performed quickly, exactly for that reason to approximate the two ends of the tendon it is often recommended to act before the tissue can shorten permanently.

What is the Achilles tendon?
Tendons attach muscles to bones. The Achilles is thicker and more fibrous than most tendons and it connects the calf muscles (the gastroc in the upper calf and the soleus closer to the ankle) to the heel bone (calcaneus). The Achilles tendon and calf muscles are put on stretch when the ankle is flexed up and it is shortened when the toes are pointed. A tight Achilles or one that is overstretched can predispose to rupture.

What are the consequences of Achilles rupture?
In addition to the pain and swelling that are expected with any sports injury, disruption of the connection between the calf muscles and the heel results in an inability to contract these muscles; That means that you cannot rise up on your toes or walk with a normal push off when weight-bearing on your injured side. Running and jumping are therefore also out of the question.  However, it may be possible to actively point your toes while you are not bearing weight due to the action of other muscles that help to provide this movement.

Why do Achilles tendons rupture?
There is an area of the Achilles that has less blood flow than the rest and it is thought that this section of the tendon may not be as strong. As we age, tendons, as other tissues of the body, become less supple and may degenerate. These are some reasons why ruptures generally occur in people over 30 (Beckham is 34), and especially in middle age. Younger athletes generally experience a higher tear, well above the ankle, where the muscle joins the tendon (musculo-tendinous junction), though they too can experience a tear closer to the heel.

Some sports are more stressful to the calf muscles and Achilles than others. Those that require the powerful push-off needed for running and jumping place the greatest demand, as do those like racquet sports which entail a lot of stutter-steps and quick stops and starts. Men are far more likely to suffer Achilles ruptures than women and though it is thought that obesity adds to the stress to the Achilles, increasing risk of rupture, that is clearly not a factor for elite athletes.

Other predisposing factors for weekend warriors like you and me include stepping up activity suddenly and significantly – either by increasing the intensity, frequency or duration of participation or perhaps beginning a new activity without preparation. All of these increase the demand placed on the Achilles. It is thought that weakness of the calf muscles, particularly the soleus, may also be a factor causing the Achilles to rupture; The soleus can be strengthened by pointing the foot — against resistance — while the knee is bent (as in a sitting position). A history of multiple steroid injections at the Achilles may be to blame in some cases of rupture. Be aware that manufacturers of certain medications, such as the antibiotic Levaquin, name tendon issues as a potential side effect. Inform your physician if you begin to feel Achilles symptoms after beginning a new medication.

One exercise I strongly suggest you avoid is strengthening the gastroc muscles of the upper calf by hanging the mid-foot and heel off a step or raised platform and doing heel-raises from this position of maximum stretch. Repeatedly lowering the heel below the level of the step (with your body weight and gravity loading the Achilles tendon), puts the tendon at greater risk of rupture. This is an exercise I see so often in the gym. Yes, you should strengthen the calf, but it is recommended to do so from the more neutral foot flat position or not fully weight-bearing if on stretch.

How is an Achilles rupture diagnosed?
Physical exam is often pretty conclusive. The first test is simply to squeeze the belly of the calf muscles and observe whether the foot points as the muscles are manually shortened. Another obvious sign is when the examiner can move the ankle excessively into a dorsiflexed position (toes toward your nose) with the knee straight. This motion is generally restricted by the tightness of the Achilles and in the case of rupture it is not. A third test involves observing the motion of a needle inserted into the tendon as the foot is passively moved up and down. An ultrasound exam and/or positive x-ray findings — particularly those in a lateral (side) view – support the diagnosis.

What are the treatment options?
Small tears may do well with immobilzation. Casting is generally done with the foot in a pointed position, which shortens the tendon allowing it to heal. Bracing that restricts motion is an alternative. Athletes are not good candidates for conservative management, and those who do not undergo surgery should expect a long recovery (up to a year) before returning to sports.

Operative treatment is the gold standard for athletes, younger patients and those with a complete rupture. Both treatments are followed by periods of decreased weight-bearing, though the surgical patient progresses at a much faster rate.

Outcomes
According to Wheeless Textbook of Orthopaedics, non-operative patients have an average re-rupture rate of 18% and can expect a decrease in strength and muscle endurance of 30%. 83% of surgical patients and 69 % of immobilization patients can expect to resume their pre-injury level of activity. Wheeless also reported that 93 % of surgical patients were satisfied with the results of treatment, while only 66% of conservatively managed patients felt likewise. Because of the positioning of the foot with the tendon in a shortened position while casted or braced, non-operative treatment generally does not restore the Achilles tendon to its full length. In contrast, if immobilized with the ankle in a neutral position, the tendon is generally lengthened, leading to a poor outcome.

The Spartans of Michigan State will meet up with Cinderella Northern Iowa, a ninth seed, this Friday. Tom Izzo is a great guy and a great coach. His team has stepped up under pressure before, just as they did on Sunday. Kalin Lucas will either be with them in spirit or cheerleading from he bench. Maybe they can pull this one out in his honor.