By Lorraine Berry
Lorraine Berry is an Assistant Editor at Training & Conditioning.
Training & Conditioning, 10.8, November 2000, http://www.momentummedia.com/articles/tc/tc1008/toetruck.htm
Most athletes don’t give a lot of thought to their feet. But, should something go wrong with one of their feet, they become all too aware of how important its structure is to their basic ability to get around. Deion Sanders, Rik Smits, Ricky Williams, Steve McNair, Larry Bird, and thousands of other professional and amateur athletes have spent part of their careers on the injured list or playing in great pain, crippled by foot injuries that have prevented them from performing at their best.
Athletic trainers treat a variety of complaints that hobble athletes—plantar fasciitis, stress fractures, turf toe, Morton’s neuroma, even blisters, calluses, and athlete’s foot. While there are a number of standard modalities that they use to ease these problems, perhaps the most crucial part of the treatment protocol for foot injuries, athletic trainers emphasize, is determining the etiology of the complaint. Otherwise, that athlete will most likely be back in the training room as soon as he or she returns to play.
In this article, athletic trainers and physical therapists discuss the most commonly seen injuries of the foot, and the modalities they use to treat the symptoms and deal with the causes. Because the majority of foot injuries are due to overuse, detective work is required to get to the bottom of the problem. But athletic trainers are not working without leads when tracking down these causes—there are a whole host of usual suspects.
WHOSE FEET HURT?
Not surprisingly, foot injuries are seen most frequently in cross country and track athletes, but it’s a problem no longer limited to runners. “Runners are probably the athletes I see the most chronic overuse injuries in,” says Michael G. Dolan, MA, ATC, CSCS, Athletic Trainer and Professor in the Department of Sports Medicine, Health, and Human Performance at Canisius College. “But we see them with football players, soccer players, even our athletes who are doing preseason conditioning.
“One of the things I’ve noticed in the past six or seven years,” Dolan continues, “is there’s more of an emphasis on preseason conditioning. But basketball players are not used to going out for a long run. They’re generally explosive athletes—they have certain physical characteristics—and they’re not used to running four or five miles. Same with ice hockey players. Our hockey coach likes to do some conditioning, but skating and running are two completely different biomechanical things. Even if the athlete is a tremendous athlete on skates, he or she may just be a terrible runner. And those mechanics perpetuate things we typically associate with runners, but we see them with all athletes as these seasons have extended.”
“Track, cross country, and recreational runners are predisposed to a lot of foot pathologies,” says Bonnie J. Siple, MS, ATC, Coordinator for the Athletic Training Education Program and Services at Slippery Rock University of Pennsylvania. “They also are the most educated when it comes to foot mechanics and shoes.
“Soccer players have the worst feet,” she continues. “They wear their shoes too tight and too small, for performance reasons; they kick a hard ball around; they get stomped on; and then they wear athletic sandals off the field, which provide no support. Where runners are predisposed to more chronic foot pathologies, soccer players are predisposed to more acute foot pathologies.”
Harrier or halfback, punter or point guard, athletes will limp into your athletic training room complaining of aching feet. In the following sections, we’ll take a closer look at two of the most common foot injuries—plantar fasciitis and stress fractures.
Athletic trainers report that they regularly treat athletes with plantar fasciitis, and, in athletic training rooms, it’s the number-one foot injury. “The key symptom we listen for from our athletes is morning pain,” says Siple. “That’s because while the pain may diminish during or after activity, it returns following periods of rest. Usually, the first few steps out of bed in the morning are the most painful since the plantar fascia tightens up after sleeping all night. This usually happens because they sleep with the ankle in a plantarflexed position.”
As the body attempts to repair the damage caused by the inflammation, often, bone spurs form, which can worsen the symptoms of plantar fasciitis. “When the plantar fascia starts to pull off the calcaneus because it shortens so severely, the body decides to grow more bone to catch up with this fascia,” says Jennifer Moshak, MS, ATC, CSCS, Assistant Athletic Director for Sports Medicine at the University of Tennessee. “That’s how you get the spur. The problem is that the spur becomes very painful, but that’s not the root of the problem. Even if you go in and remove the bone spur, you’re not solving the problem. You have to fix the plantar fasciitis or it will just come back.”
Treating plantar fasciitis draws on a number of techniques. (Fixing the root of the problem is much more complicated, and will be addressed below in “The Real Work Begins.”) The first step is to provide the athlete with some relief of his or her pain symptoms, especially those he or she feels first thing in the morning.
“We recommend that they stretch it with plantar-fascia rolls as soon as they get out of bed,” says Moshak. “Plantar-fascia rolls are where you take either a tennis ball or a can of peas and roll it on the bottom of your foot. Not only does it stretch the plantar fascia, it massages it as well. You must also stretch the Achilles tendon with it because the plantar fascia attaches to the calcaneus and the Achilles attaches to the calcaneus, so the plantar fascia can shorten the Achilles and the Achilles can shorten the plantar fascia.”
Back in the athletic training room, a number of modalities can be used by the athletic trainer. “Since plantar fasciitis is usually chronic, I let the athlete choose whether he or she wants a cold or warm whirlpool treatment, whichever seems to alleviate the discomfort most,” says Siple. “Ultrasound, massage, cross-friction massage, and aggressive static stretching of the foot and Achilles tendon are quite advantageous in treating plantar fasciitis. We can also perform arch-taping techniques, apply moleskin to the arch, or even have the athlete fit for arch supports or orthotics. Some athletes respond well to a heel lift or heel cup worn in the shoe. Athletes can also take an OTC or physician-prescribed nonsteroidal anti-inflammatory.”
“We use ice for pain management,” says Dolan. “In some cases, we use ultrasound in order to increase local temperature and local blood flow to the area. But that is generally combined with a variety of techniques, including massaging the plantar fascia. However, night splints have really become the standard of care with resistant plantar fasciitis.”
Siple also reports good results with night splints. “We have had tremendous success in treating plantar fasciitis by sending our athletes home with a night splint,” she says. “You can buy night splints or make one yourself out of orthoplast. The main thing is to secure the athlete’s involved foot in excessive dorsiflexion while he or she sleeps. The long-term, static stretch of the plantar fascia all night in a splint not only prevents the severe morning pain, but it seems to be beneficial in the overall treatment of the pathology.”
Other practitioners suggest treatments that involve a lot of stretching and strengthening of the musculature of the area. “If there’s a limitation to the range of motion, try to address that through stretches and a flexibility program,” says Tim Heckmann, PT, ATC, Administrator with HealthSouth Sports Medicine in Cincinnati. “A flexibility program will typically work the gastroc-soleus, and you should add stretches that are either weight bearing or non-weight bearing depending on how acutely painful the injury is.”
But, it’s important to openly acknowledge and forewarn the afflicted athlete, that, despite treatments, it can take a long time to resolve. “Plantar fasciitis is a hard problem to treat,” says Janice Loudon, PhD, ATC, PT, Associate Professor in the Department of Physical Therapy Education at the University of Kansas Medical Center. “The recovery can be anywhere from one to 12 months.”
If there was a competition to see which chronic injury was seen most frequently in an athletic training room, stress fractures would be toe-to-toe with plantar fasciitis. Unlike plantar fasciitis, which presents with some classic symptoms that may lead an athletic trainer to a quick diagnosis, stress fractures may take a while to make themselves apparent.
Part of the problem is that some athletes have been taught not to whine about minor aches and pains, so they may mistake the ache in their foot for nothing serious. That attitude, unfortunately, can have an enormous impact on injury outcome. “What most determines the outcome of a stress fracture is how quickly you catch it,” says Dolan. “With athletes who go ahead and report pain in their foot, we can intervene pretty early. Athletes who ignore their symptoms and continue to run on it early on because it’s not a disabling pain tend to develop a greater fracture line. Then they need to have further immobilization.”
Compounding the problem is that stress fractures are so small, and the feet are so complex anatomically, that these types of injuries can be very hard to image. In fact, most stress fractures won’t show up on x-rays for a few weeks after the athlete begins to feel pain. However, once a stress fracture has been identified, most athletic trainers recommend conservative treatment measures.
“We allow adequate time for the stress fracture to start healing,” says Dolan. “We use ice on it for pain management, and heat for comfort once the athlete is past the acute stage of it. Based on the findings of the initial and follow-up radiographs, we introduce stress back to the foot—mostly closed-chain activity. Research shows that it does stimulate bone growth, so we want people to bear enough weight on the limb to stimulate normal bone growth, but not so much that it causes pain. Then, we progress them to more functional activity as dictated by the surgeon.”
While the stress fracture is healing, it is important that athletes not be allowed to detrain. “The initial treatment for a stress fracture is non-weight bearing rest,” says Skip Hunter, PT, ATC, Owner of Clemson (S.C.) Sports Medicine and Rehabilitation. “But that doesn’t mean they can’t swim, or ride a stationary bicycle.”
“Telling an athlete to stop running doesn’t work for most competitive athletes,” says Dolan. “So we really encourage athletes to maintain their cardiovascular fitness through other activities. Since detraining starts within seven to 10 days, we use our pool and a lot of flotation devices to get athletes in the water but off their feet.”
Dolan says that they also use the pool prophylactically in an effort to prevent stress fractures. “With football players, after several weeks into the season, everybody is pretty fatigued. Instead of doing conditioning on the field, we’ll take them all in the pool and do water conditioning. It breaks the monotony, but it also takes advantage of the buoyancy of the water and gets weight off their feet. It essentially gives their feet a day off, but stresses their heart, lungs, and muscles in a good way.”
THE REAL WORK BEGINS
With both plantar fasciitis and stress fractures (and several other foot injuries) treating the symptoms will only go so far in taking care of the problem. “There are a lot of treatments we do that alleviate the symptoms,” says Hunter. “We can reduce the inflammation and make people more comfortable—and there’s nothing wrong with that. But you also need to treat the cause of the problem. Because if you don’t, as soon as you stop treating the symptoms, the problem is going to come right back.”
Getting to the cause of the problem may make an athletic trainer feel like a private investigator. “The acute injury is so simple,” says Moshak. “The athlete comes in and says, ‘Oh, I rolled my ankle,’ or ‘I planted and twisted and I felt a pop.’ There’s no detective work there. The detective work comes in when it’s a chronic overuse injury that’s developed over time. All of a sudden you’re playing ‘Clue’—Colonel Mustard in the library with the pipe. You’ve got to look head to toe. You’ve got to look at the athlete’s training program, his or her nutrition, footwear, the surfaces that he or she participates on. All of those in combination can contribute to the problem.”
“A lot of times, just listening to the athlete while examining him or her will give you an idea of what the mechanism is,” says Heckmann. “And, if you can identify the mechanism, it becomes much easier to identify how to manage it. Is it overuse? Is it traumatic? Is it related to alignment? Is it related to poor muscle flexibility or poor muscle strength? Also, take a look at his or her gait pattern and the type of footwear he or she is in—maybe it’s a shoe that doesn’t really provide much shock absorption or arch support.”
Whereas a traumatic injury has a definite etiology, and thus provides such information as when the injury occurred and how it was initially treated, chronic injuries can be complete mysteries. Even the athlete may be clueless as to the first time he or she felt the pain. As a consequence, getting to the bottom of the problem could be as time-consuming as treating the symptoms of the problem. But, as your sleuthing begins, there are some well-known culprits to check out first.
Shoes. You cannot put the same shoe on every foot—Publius Syrus, Maxim 596 (42 B.C.E.).
Over 2000 years ago, Publius Syrus realized something that many shoe companies have not: You can’t put every athlete on a team in the same shoe, regardless of a shoe contract. One of the first places to look when dealing with an overuse injury is footwear. “At the high school, there is a little bit more opportunity to match the student up with the proper shoe,” says Heckmann. “But when you get to the university or professional level, many institutions have shoe contracts. If I have a Reebok foot but I’m forced into a Nike shoe, I could have problems.”
It’s not just shoe contracts that can cause the trouble; it’s also the style of the shoe. “Athletes generally buy shoes because of the appearance of the shoes and how much they cost,” says Dolan. “But there are certain kinds of shoe features for certain types of feet. For example, we see a fair number of athletes who have pronated feet. Those athletes need to be in shoes with a relatively stiff heel counter that are rigid and give a little bit more support. If they wear shoes that are very flexible and allow for a lot of movement, that can certainly make their condition worse. Athletes with supinated feet have a real problem with shock absorption, and we want them in a nice soft shoe that has a lot of movement in it. If they wear a shoe that has a real solid heel counter or a rigid midsole, they generally have problems with it. We try to do some individual counseling with them, but in many cases, they look for the most attractive kind of shoes instead of what may fit them the best.”
Hunter is willing to go even further in tying foot injuries to shoes. He sees a specific type of popular athletic shoes—cleats—as a big factor in injuries. He recommends that athletes not wear cleats at all. “I’m a big believer that a lot of lower-extremity injuries in sports would be avoided if cleats were outlawed,” he says. “Cleats do one of two things. They either get stuck down in the ground, and it fixes your foot so that something up the chain goes. Or they don’t get stuck in the ground and now you’re standing atop these little stilts, and it tends to leave you with an unstable ankle. Either one of those choices is not real great. My choice of cleats are the multi-cleated ones with a large number of little squares on the bottom.”
Improper Warmup and Stretching. Another frequent offender in foot injuries is poor warmup habits. Many athletes don’t bring their heart rate up slowly and they don’t allow their muscles to get warm, which contributes to soft tissue and bones in the foot breaking down under stress. Stretching is also important, but must occur after—not during—the initial warmup.
“Although I think sometimes stretching can be overrated,” says Hunter. “I do think it’s important for the feet.” He recommends that athletes stretch trouble spots throughout the day, not just as part of warming up. “Stretching your heel cords is one of the more vital stretches that people don’t do enough. People need to get bricks and bring them in their houses. Put them beside their phone, in front of the mirror, places where they know they’re going to stand anyway and stretch their heel cords on those bricks.”
Weakness. Loudon recommends adding upper-body strengthening, as well as stretching, to every athlete’s training regimen. “I think the majority of foot and ankle problems are due to faulty biomechanics and weakness in the trunk’s core,” she says. “Besides treating the foot problem, we spend a lot of time on abdominal and hip strengthening. We also work to improve any muscle imbalances that might occur up the chain.”
Poor Biomechanics. In talking with athletic trainers, one of the most frequent culprits that contributes to an athlete’s foot problems is poor biomechanics. Some athletes just have bad feet, or problems further up the kinetic chain, but with a little help, a lot of chronic problems can be resolved.
“Plantar fasciitis can occur due to overpronation or a rigid foot-type where the individual underpronates,” says Loudon. “Overpronation causes excessive tensile stresses to the plantar fascia, whereas, in a rigid foot, since the foot isn’t pronating as it should, the plantar fascia undergoes increased shock attenuation.”
Faulty biomechanics can also be a contributing factor in stress fractures. “Stress fractures occur because, mechanically, the person is putting more weight on one spot than he or she should be,” Hunter says. “So, you do a mechanical exam of the foot to make sure it’s in the proper position to function as best as it can. The usual way to do this is to lay the athlete prone and put his or her foot into a subtalar neutral position. Examine the foot in that position; see where it sits and where it wants to sit by looking at its relationship to where it would be if it had to get down on the floor. See whether it’s going to roll in or out to get down on the floor. If there’s an excessive amount of roll, that can affect the mechanics of the foot and make it bear weight to where it shouldn’t be. The thing you do to address the mechanics of the foot is to try to make an athlete bear weight a little more equally across his or her foot rather than on that one spot, and usually orthotic therapy will help that.”
Training Errors. “About two thirds of foot injuries relate to training errors: Too much, too fast, too soon,” says Heckmann. “We typically see these injuries among athletes when they move from high school to the first year of college, because the amount of mileage significantly jumps.”
And Dolan says that athletes can create training stresses on their feet by changing the surface they run on or the type of course. “If the athlete is going from a relatively long slow distance to interval work and sprinting, training needs to be altered slowly,” says Dolan. “Sometimes though, they may not change the actual mileage, they change the terrain. They might be used to running a four-to-five mile workout, but then they decide to run at one of our local state parks and run the same distance on hills. That’s a dramatically different running activity from a biomechanical standpoint.”
Poor Nutrition. Research has shown a correlation between eating disorders and stress fractures. Because of the prevalence of eating disorders, or even just poor nutrition, among female athletes, it’s important to question them about their diets, especially if they seem to be underweight.
But, it’s not always easy to tell whether the athlete you’re working with is dangerously underweight. “I would characterize most of the female athletes that I take care of as being thin; that is, relatively ectomorphic,” says Dolan. “I certainly don’t think that eating disorders are the cause of all these stress fractures, but if I have kids who have chronic injuries and are very thin, I do question them about their eating habits.”
Asking athletes to keep a food diary may help you pinpoint the nutritional deficiencies that are showing up as chronic injuries. Sometimes, a chronic foot injury can be the canary in the coal mine that alerts you to a potentially serious nutritional problem, so it’s important to keep it in mind.
Overtraining. As Vern Gambetta has pointed out in these pages before, overtraining is more than simply training too much—it’s pushing the body beyond its limits without adequate rest or recovery, often to the point of serious harm. Nutritional deficiencies go hand-in-hand with overtraining, since the athlete won’t consume enough to support his or her level of work. Other common symptoms of overtraining include stress fractures, sleeplessness, irritability, susceptibility to illness, worsening performance, and other injuries.
For more specific information on:
• Biomechanics of the foot and how stretching and orthotics can help, see “The Agony of the Feet,” Training & Conditioning 9.9, December 1999.
• Stress Fractures, see “The Stress Before the Fracture,” T&C 7.4, August 1997.
• Training errors, see “Leading the Pack,” T&C 10.7, October 2000.
• Eating disorders, see “Back on Track,” T&C 8.2, April 1998.
• Overtraining, see “The Perils of Overtraining,” T&C 10.2, March 2000.
Each of these articles may be accessed at our Web site www.athleticsearch.com by entering a keyword, such as “eating disorders,” or the title of the article, into the search box.