Case Study - Injury Prevention and Acute Intervention

Foot pain in an elite veteran triathlete – Initial management and prevention strategies

Summary

A forty year old male triathlete reports pain in his right foot which is aggravated by running especially at the beginning of a training session and for the first thirty minutes in the morning on rising. The discomfort was first perceived about eight weeks prior to his initial appointment, after significantly increasing his mileage in preparation for the upcoming Olympic and half ironman distance triathlon season. The pain progressively got worse as he persisted with his current training schedule until about two weeks before his initial assessment, when he stopped running altogether due to the discomfort. At this point he attended physiotherapy for an initial assessment. The author’s first perception was plantar fasciitis.

This case study will focus on the initial assessment, treatment and the prevention strategies which allow for the earliest return to sport without re-injury.

 Introduction

Plantar fasciitis is a degenerative, overuse condition of the plantar aponeurosis common in runners, with the discomfort mostly located at the posteromedial calcaneal tuberosity (Lemont, Ammirati & Usen, 2003), though it may be felt along the entire plantar surface and around the metatarsal heads. This condition accounts for about ten percent of all injuries that occur in running (Ballas, Tytko & Cookson, 1997) and is the third most common injury observed in runners over a two year period (Taunton, Ryan, Clement, McKenzie, Lloyd-Smith, & Zumbo, 2002).

The plantar fascia maintains and supports the arch during weight bearing as well as contributing to the ‘windlass mechanism’ where it acts as an energy-conserving spring during dynamic gait (Aquino & Payne, 1999). The cause of plantar fasciitis is probably multifactorial however the high incidence among runners suggests that microtrauma maybe a major contributing factor (Buchbinder, 2004). Intrinsic factors may include equines (Rome, 1997), which may or may not include a tight gastrocnemius soleus complex as well as pes cavus and excessive pronation (Krivickas, 1997), as present in this triathlete. These are all commonly cited as potential risk factors in plantar fasciitis; however Wen, Puffer & Schmalzried, (1998), reported that minor biomechanical variations do not appear to be major contributors to overuse injuries in runners which is similarly reported for plantar fasciitis by Taunton, et al., (2002). Age has been reported to be proportional to injury rate for plantar fasciitis, especially with athletes between forty and sixty years old (Taunton, et al., 2002), this may be attributed to reduced tissues integrity. Extrinsic factors cited include increased training load, hard surfaces and poor footwear (Rome, 1997), but evidence for these factors is limited.

It is important to determine the extent of the injury early as well as to discuss any differential diagnosis. The challenge is to distinguish between a typical plantar fasciitis injury and some other pathology (Buchbinder, 2004). Failing to identify the correct cause may result in prolonged rehabilitation time and frustration for both the athlete and the practitioner.

Assessment

The main aim at the assessment was to take a history and examination to determine the extent of the injury as well other potential factors contributing to this problem. A clinical assessment will often diagnose plantar fasciitis with reasonable certainty (Buchbinder, 2004). The triathlete reported gradual, non-specific heel pain, worse at the start of activity as well as a diffuse ache in the morning on rising and walking bare-foot. It was particularly bad during sessions requiring transition from bike to running, all of which is highly indicative of plantar fasciitis (Singh, Angel, Bentley & Trevino, 1997). He also indicated that he had increased his running load three weeks before he felt the first symptoms however this was not out of character from previous seasons. He was adamant that his footwear were adequate even though he recently changed from his normal training shoe to a lighter racer-trainer.

Range of movement and strength tests were unremarkable and although the gastrocnemius soleus complex was tight, the author did not consider this significantly abnormal. Palpation revealed an area of acute tenderness over the medial calcaneal tuberosity, which extended into the mid-portion of the plantar fascia. The triathlete reported that that was his pain, again which is indicative of plantar fasciitis (Singh, et al., 1997).

Although different investigation modalities exist and can assist in confirming or refuting the diagnosis (Buchbinder, 2004), the author felt confident that plantar fasciitis was clearly the most likely diagnosis. If the triathlete did not improve as expected once the treatment plan was started, radiographic images could confirm if any bony abnormalities are present (Young, Rutherford & Niedfeldt, 2001).            

Intervention with Clinical Reasoning

Although plantar fasciitis is regarded as an overuse condition, the signs of acute aggravation were clearly evident in the triathlete. Due to the increased irritability, offloading the triathlete and the initiation of cryotherapy and NSAID’s were initiated. In a study by Wolgin, Cook, Graham & Mauldin (1994), twenty five percent of the patients with plantar fasciitis reported that rest was the treatment that benefited them the most. It is more difficult to achieve complete rest in a highly competitive athletic population, so relative rest using cross training and in this case focusing on the swimming and cycling elements while significantly decreasing the aggravating event, tends to improve athlete compliance (Young, et al., 2001). Cryotherapy is often suggested as an early intervention in plantar fasciitis however there is limited available evidence that says it does anything other than act as a short term analgesic. In a study by Wolgin, et al., (1994), over three quarters of the patients treated successfully were using NSAID’s as part of their treatment regime however it is also important to be aware of the harmful systemic effects caused by these drugs. (Young, et al., 2001).

The majority of the treatment time was spent on the correction of biomechanical and functional risk factors specifically focusing on stretching and strengthening. Due to the tightness in the gastrocnemius soleus complex a rigorous stretching programme was introduced. The author was unable to find any evidence pertaining to which specific manual therapy techniques were most effective however, anecdotally cross frictions over the plantar fascia and early morning towel stretches seem to indicate the most benefit. Wolgin, et al., (1994) reported that over eighty percent for patients who did stretching as part of their treatment improved. Strengthening of the intrinsic muscles was reported by more than one third of patients, as the most effective treatment for plantar fasciitis (Martin, Irrgang & Conti, 1998), which included towel claws in this case.

The defining moment in this case occurred while discussing the triathlete’s shoes. Although his shoes were new and in good condition, two factors indicated that they may be contributing to his problem. The shoe was a racer-trainer, a light weight, neutral shoe which lacks the support of a normal training shoe and although his previous shoe was not a racing shoe, it was clearly an anti-pronation shoe of which he had used a similar version for the last five years. This coupled with the increase in mileage significantly stressed the tissue and resulted in the development of the plantar fasciitis. Suggesting a return to his original brand and model occurred at three weeks post assessment. Although the other treatments may have assisted in the resolution of this condition, the change back into the original shoes resulted in the most significant change.

Outcome

Despite the treatment period lasting four and a half weeks, the most significant changes occurred at three weeks after changing his shoes. He returned to a reduced level of running at four weeks and felt no ill effects. At his last session his running progression was discussed and the importance of a phased introduction back into his training regime. Following up at six weeks, the triathlete reported no discomfort and was running at about sixty percent intensity. At writing this case study, the author contacted the triathlete, who has just completed an Olympic distance triathlon with no issues pertaining to his foot.

Athletes who participate in running especially at high intensity need to pay close attention to their overall training load and especially when increasing their overall mileage as well as complimenting hard training days with lighter days or cross training (Taunton, Ryan, Clement, McKenzie, Lloyd-Smith, & Zumbo, 2003). Training with injuries should always be discouraged. Although stretching is a common adjunct to athlete participation it is not substantiated to prevent injuries by most studies (Fredericson & Misra, 2007). Although not widely discussed, muscle imbalance, especially in the hip abductors may predispose athletes to overuse injuries (Niemuth, Johnson, Myers & Thieman, 2005).

Discussion

Although resolution of plantar fasciitis is expected, especially in an athlete population, the evidence seems to lack specificity with regard to the best practice management (Buchbinder, 2004). It appears to the author that good randomised controlled trials need to be conducted to determine the most appropriate management, however even with the lack of evidence, management plans can be developed and progressed following a recognised, if not anecdotal pathway. Many other types of treatment options exits, however they were not the focus of this case study and were not discussed in favour of management used.  

Conclusion

Plantar fasciitis is a common problem that can affect athletes. It tends to be a frustrating condition which occurs when athletes are attempting to improve and this result is an overuse injury. Due to it slow progression, it is often not assessed until the discomfort outweighs the desire to train and compete. Resolution is expected, but this can take time and can require deep investigate to highlight potential risk factors contributing to the condition.

References

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Lemont, H., Ammirati, K.M. & Usen, N., (2003). Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 93, 234-237.

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Niemuth, P.E., Johnson, R.J.,  Myers, M.J. & Thieman, T.J., (2005). Hip muscle weakness and overuse injuries in recreational runners. Clinical Journal of Sport Medicine. 15, 14-21.

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Singh, D., Angel, J., Bentley, G. & Trevino, S.G., (1997). Plantar fasciitis. British Medical Journal. 315, 172-175.

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Taunton, J.E., Ryan, M.B., Clement, D.B., McKenzie, D.C., Lloyd-Smith, D.R. & Zumbo, B.D., (2003). A Prospective study of running injuries: the Vancouver Sun Run “In Training” clinics. British Journal of Sports Medicine. 37, 239-244.

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Wolgin, M., Cook, C., Graham, C. & Mauldin, D., (1994). Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle International. 15, 97-102.

Young, C.C., Rutherford, D.S. & Niedfeldt, M.W., (2001). Treatment of plantar fasciitis. American Family Physician. 63, 467-478.