Addressing Heel Pain In Football Players

Given the popularity of football at levels ranging from pee wee leagues to the NFL, many athletic patients will present to podiatry practices with heel pain. Accordingly, this author presents a guide to determining whether a patient has plantar fasciitis, how to recognize Baxter’s neuritis, and reviews the roles of appropriate footwear, physical therapy and injectable therapies in the management of plantar fasciitis in this patient population.

American football is the most played sport in the United States.¹ An estimated 1,088,158 players are involved in high school football. American football is a high impact sport that may cause irritation, inflammation or injury to muscles, ligaments, tendons and joints, especially around the heel and ankle.² The multiple facets of American football including sprinting, jumping, sudden starts and stops that create significant stress on the lower leg, foot and ankle, including the heel.

Heel pain of some type is a very common complaint among these athletes. Heel pain, especially plantar fasciitis, can be particularly bothersome, persistent and results in potential modification of play and possible loss of playing time. To manage heel pain effectively, the clinician needs to understand the etiology and the multiple connections associated with this heel pain, thus returning the athlete to maximum performance in the shortest amount of time.

Many football players at all levels believe heel pain is “just another part of the game.” This pain may occur in season or in the offseason. A typical football player who comes to the office believes the heel pain is plantar fasciitis. However, pain in the heel can be plantar fasciitis, calcaneal apophysitis, bursitis, a calcaneal stress fracture, an occult fracture, tarsal tunnel syndrome, seronegative arthritic induced inflammation, a bone contusion, Baxter’s neuritis, lumbosacral spine radiculopathy, or Achilles tendinitis/Achilles tendinosis.

Is The Heel Pain Actually Plantar Fasciitis?
Many football players, regardless of skill, participation and level of play, typically come into the office with a triad of symptoms of their heel. The heel pain is usually in multiple areas of the heel. It is up to you as a clinician to determine if the diagnosis is truly plantar fasciitis.

Do not let the parent, coach, athletic trainer or player in the treatment room make you assume the definite diagnosis is plantar fasciitis. Do not fall into this trap. Just because pain is on the bottom and/or side of the heel does not mean it is automatically plantar fasciitis. Due to the high prevalence of plantar fasciitis and misleading material on the Internet, there may be a tendency to assume a diagnosis of plantar fasciitis but given the variety of etiologies for heel pain, we should proceed with a proper workup and assessment.

Multiple considerations are involved in the diagnosis and treatment of plantar fasciitis. These considerations include the timing of the injury (preseason, offseason, in season, playoffs) and the competitive level of play (i.e. professional, college, high school and recreational). Access to diagnostic and therapeutic modalities is also critical. Access to physical therapy, elliptical trainers, exercise bikes, pool running and special types of treadmills can influence treatment. The type of health insurance plays a role in the diagnosis and treatment plan. The number of patient visits, types of X-rays and special studies or allowed number of visits to physical therapy can affect the treatment plan and outcome. Worker’s compensation, team physician access, family physician and access to other specialists can also affect the diagnosis and treatment of this football player.

The podiatrist should obtain a thorough history and physical, listening to all parties, including the athlete, coach, athletic trainer and parent. Getting an idea of the practice schedule and activity on and off the field is essential. Listening is critical in helping you develop a complete picture of the cause of heel pain. Have the player note the heel pain location during the game, after and the next day. Many times the football player ignores the condition of plantar fasciitis and tends to seek treatment only if the problem has become severe enough that he fears not playing. Let the athlete talk and ascertain the relevant information as you lead him.

Perform baseline bilateral standing X-rays for comparison purposes. Sometimes a non-weightbearing lateral X-ray view can give you more information regarding the origin of heel pain. Gait analysis in your office hallway can provide additional information. Your personal preference may be watching the player on the field and at practice, or watching him on a videotape.

Location, location, location is absolutely critical regarding the origin of the athlete’s heel pain. Is it central, medial, plantar lateral, at the origin of the fascia or 1-3 cm distal to the origin? When is the pain occurring? Is it first step pain, pain after prolonged standing or pain after using inadequate cleats/sneakers in certain drills? Also ask the athletes how they perceive the pain. Is it dull or sharp? Is it a shooting pain or does it feel like more of a tearing sensation? Does it feel like nerve-related pain? Clinicians should consider the playing surface as well.

When Baxter’s Neuritis May Be The Culprit
However, you may still have a difficult time making a single diagnosis. One potential diagnosis is Baxter’s neuritis, which is associated with the first branch of the lateral plantar nerve.³ The posterior tibial nerve typically divides into three branches: the calcaneal nerve, lateral nerve and medial plantar nerve in this area of the heel. In the last 20 years, Baxter, Goecker and their respective coauthors have described Baxter’s neuritis.^3,4 Confitti and Tarquinio in 2004 further described the operative outcome of plantar fasciectomy with neurolysis for recalcitrant plantar fasciitis.⁵

There is a sharp distinction in the clinical history. The player who presents with Baxter’s neuritis has substantially different heel pain than those with plantar fasciitis. There is typically no first step pain and no pronounced pain as the day goes on, or after practice or a game. Baxter’s neuritis can also affect overweight players or those with an insufficient fat pad as this exposes the nerve in this area. Wearing ill-fitting shoes, the same shoes consistently or old shoes or cleats can compress the medial heel and Baxter’s nerve, and cause the distinct symptoms of Baxter’s neuritis. Excessive pronation and how the foot sits in a cleat or training shoe may be parts of the picture.

When it comes to patients with suspected Baxter’s neuritis, palpation of this area pinches this branch of the nerve on the underside of the deep fascia of the abductor hallucis muscle and the medial margin of the quadratus plantae. This pain may be local or possibly present as a paresthesia extending distally and plantarly, or proximally. This pain may coexist again with the proximal aspect of the fascia as radiographs may or may not show a plantar calcaneal spur.

Further Insights On Diagnostic Studies
After strong clinical suspicion of plantar fasciitis and doing the appropriate tests for heel pain, one should also perform a potential electromyography (EMG) and nerve conduction velocity study to confirm the diagnosis of this lateral plantar Baxter’s nerve entrapment. The clinician may perform a diagnostic injection of lidocaine and bupivacaine with a subsequent therapeutic injection of a steroid of choice. One may provide additional therapeutic injections over a four- to six-week period.

Keep in mind that potential lumbosacral spine pain in the normal nerve distribution of L4-L5 and L5-S1 may further cloud your diagnosis even if the patient does not have back pain or typical sciatic pain/radiculopathy.

Obtaining early diagnostic studies is essential regardless of the duration, age, level of play and intensity. Do not be apprehensive to order a three-phase bone scan, magnetic resonance imaging (MRI), computed tomography (CT) scan or diagnostic ultrasound early in the evaluation process regardless of onset and duration. Sometimes it is essential to order a dynamic ultrasound examining the plantar aspect of the heel while it is in motion. Many times, the clinician does not think to order dynamic ultrasound or dynamic MRI, which commonly go underutilized.

Make sure the facility and radiologist have experience in reviewing this type of study. Not all facilities are equipped to have the appropriate ultrasound or MRI unit for the foot and ankle, thus altering the potential outcome of the study. Be comfortable with the radiologist or specialist who reads these films specific to foot and ankle. Be sure to read the disc/study and do not assume that the report from the radiologist is comprehensive or correct. Many times, a radiologist automatically gives the diagnosis and label of plantar fasciitis when, in fact, it may not be plantar fasciitis.

You as the podiatrist may see more in the study that the report does not actually dictate. If you have questions on the ultrasound or MRI imaging, follow up with the radiologist. Be sure to clarify the diagnosis first before considering appropriate treatment options.

Pertinent Pearls In Managing Plantar Fasciitis In Football Players
The management of the football player with plantar fasciitis should include appropriate diagnosis, treatment and rehabilitation including an activity schedule on and off the field. While awaiting the results from diagnostic studies, one can proceed with some preliminary treatments and determine initial modifications or a temporary halt of playing time. Plantar fasciitis can wax and wane, and be persistent and recalcitrant. Early intervention with diagnostic studies and treatment is imperative whether you are treating the football player during the season or the offseason.

After making a proper diagnosis of plantar fasciitis, take an aggressive, multidimensional approach to alleviate the heel pain. However, if you are still uncomfortable with the definitive diagnosis of plantar fasciitis, refer the patient to another podiatrist or a foot and ankle orthopedist for cross-consultation.

The treatment must be a comprehensive 24/7 treatment plan. We call it “the theory of relative rest,” which ensures controlled, modified activity on and off the field without complete cessation. Rarely is a football player with heel pain not playing. So many times the clinician and professionals managing the injury do not consider off the field treatment for the football player. This is extremely critical.

The football player with chronic and persistent plantar fasciitis often has an equinus deformity. More often than not, it is a gastrocnemius equinus deformity. It is common for these players with chronic plantar fasciitis to have hamstring issues as well as glute weakness, muscle imbalance and compensation. Accordingly, one should evaluate for these contributing factors as well as the lumbosacral spine.

Keys To Ensuring Proper Footwear For Football Players
The football shoe is required to meet a number of demands with both internal and external factors involved.

The athlete should avoid going barefoot and tie shoes tightly. The patient will tie and retie laces throughout the day, including at practice and games. All synthetic or partially synthetic laces can lead to loosening and excessive motion. It is so common for football players not to lace appropriately. Discontinue all old shoe gear on and off the field. Athletes should change shoes numerous times throughout the day to avoid stresses and strains to the foot/ankle with the same shoe. They should also discontinue the use of old shoe gear on and off the field. Evaluate the athlete’s shoe gear and educate him and the professional athletic staff. If a particular shoe works for the athlete, then he should not change this brand or type of shoe regardless of sponsorship, the fact that a friend has that shoe, whether the cleat or sneaker is on sale, etc.

The literature clearly notes that the effects of cushioning, compressibility and curvature under the heel can have a significant impact in reducing the peak pressure under the heel in regard to the design of athletic shoes and footwear types.⁶ More compressible and more conforming surfaces of heel cushioning materials reduce the peak pressure under the calcaneus, redistributing the load to peripheral aspects of the heel.⁶

The introduction of artificial and synthetic playing surfaces may be among the most significant transformation in sports history.⁷ Authors have studied the relationship of surface properties to injury and this is of great controversy.⁸ The modeling of shoes looking at the surface-shoe-foot interface for the optimal design has been the subject of study.⁹ Many shoe companies are designing shoes to be lightweight and low profile. The lightweight approach to shoe manufacturing can pose many changes in the shoe, especially compromising the potential stability of the shoe. Authors have documented the difference in rotational stiffness of the football cleat and peak torque with the shoe-surface interface.¹⁰ Selecting the appropriate highly specialized football cleat is important for both the safety and athletic performance of the athlete.

Style, material and the price of football cleats come in a wide range. These include low cut, mid-rise and high-top cleats, molded or detachable, and synthetic or leather. One would typically select cleats based on what the football player’s position requires and his personal preference. Typically, a heavier football player with high impact requires a high-top football cleat. Running backs and receivers typically like a mid-rise or low-cut football cleat for maneuvering and speed.

Cleat length and the number of cleats on the bottom of the shoe are of personal preference, and may be based on surface and weather conditions. Do not always think or assume a playing shoe with more cleats and shorter cleat length is best on artificial surfaces. Aside from weather conditions, the height of the surface synthetic grass blade and base layer underneath the turf surface can determine the appropriate and preferred type of cleat.

If the cleats do not provide appropriate support, cushioning or are improperly sized, athletes may increase their risk of heel pain. They cannot go by size but must go by fit. Typically, cleats run smaller in both width and length, thus requiring a larger size for proper fit.

Other important shoe characteristics include the width of the toe box, the number and location of cleats, shoe flexibility or stiffness. Most importantly, when athletes walk out of the store, the football cleat should be comfortable. It is unlikely that the cleat will break in as the athlete wears it more.

The newer materials used for making the upper part of the cleat or “skin” are usually a synthetic hybrid, prohibiting stretching of the football cleat over time. Typically, these football cleats have minimal memory, giving a feeling of putting on brand new cleats each time athletes wear them. Be aware that straight ahead running and sidestep cutting may increase the incidence of heel pain. Research has shown that cleated and turf shoes show significant differences in regard to friction, safety implications, playing conditions and surfaces.¹¹ Each player should have at least two different pairs of cleats as surface/turf type and playing conditions vary.

As we noted earlier, it is critical to control the athlete on and off the field with the treatment plan. Football players with plantar fasciitis can use surgical shoes, a controlled ankle motion (CAM) walker boot or night splint when they are not on the field, at night or both. A tall CAM walker boot seems to be more effective in my practice. In severe cases of plantar fasciitis, the foot and ankle will be in a cast for 10 to 23 days with multiple cast changes for maximum effectiveness, again also depending on the time of year. Spell this out to the athlete, coach and the supporting cast.

Athletes can use a variety of pads and off-the-shelf insoles or orthotics. Many inserts/orthotics are available and athletes should try many types prior to casting for custom orthotics. In our opinion, athletes can use custom orthotics on and off the field. In our experience, athletic taping of the foot and heel with padding on and off the field can be beneficial in the treatment and recovery of patients with plantar fasciitis.

The athlete should avoid slip-on shoes, prolonged use of the same shoe and loafers, which seem to aggravate plantar fasciitis symptoms. Typically, flat shoes or platform style shoes also make plantar fasciitis symptoms worse. Shoes and shoe gear including sneakers should have a small heel. In order to address a difference in heel size, the clinician may suggest evening up the opposite foot with a heel lift or Evenup device (Evenup Corp.), which aids in ambulation.

A change of gait can cause further compensation issues that may affect the lumbosacral spine and the sacroiliac joint. One must address this. Otherwise, this can be quite bothersome to the patient and it may be a problem when playing or returning to play.

How Effective Is Physical Therapy In Addressing Plantar Fasciitis In Football Players?
The Active Release Technique (ART) and Graston technique with traditional physical therapy are also part of the treatment plan. Athletes must use the ART and Graston techniques with traditional manual therapy aggressively and consistently. Prescribe appropriate exercises for the painful heel and share them with the athlete’s professional staff as well. The athlete should demonstrate these exercises in front of the staff to make sure he is doing them correctly.

Many times, the athlete is doing exercises incorrectly or at the wrong time throughout the day. This is especially critical when doing eccentric loading exercises off the edge of a step, which many times can cause further injury to the plantar fascia and Achilles tendon if patients do them incorrectly, too much or too aggressively. This very commonly exacerbates plantar fasciitis or causes of continuation of symptoms. Patients can also use an AlterG treadmill (AlterG) to keep training without further aggravation of existing symptoms. Pool therapy such as running in a swimming pool or on an underwater treadmill can also aid in the treatment process.

Assessing The Roles Of NSAIDs And Injectable Modalities
A variety of nonsteroidal anti-inflammatory drugs (NSAIDs) are available. It is important to change the anti-inflammatory medication early if the first choice is not significantly effective. One may order a customized topical agent using a combination of topical anti-inflammatory, muscle relaxant, antihypertensive such as verapamil 5% to 10% and lidocaine 1% plain to influence blood flow in the plantar fascia. Apply only a small amount of topical compound three to five times per day for 90 seconds per application. Aggressively rubbing the compound into the site is critical to be completely effective. Patients can change these compounds, depending on their response, to keep efficacy high. Athletes may use this customized compound concurrently with physical therapy, manual therapy, ultrasound and moist heat.

Oral steroids such as prednisone 10 mg over 15 days with titration dosage or a traditional 4 mg Medrol dosepak can be effective. A traditional steroid injection of your choice in a specific localized area can be part of the treatment plan.

Other Conservative Therapies To Consider
Platelet rich plasma (PRP) with ultrasound guidance can provide additional relief of symptoms. Dry needling performed by the podiatrist, a specialist or a physical therapist can be part of the treatment armamentarium. Stem cells are also in use now.

In my experience, extracorporeal shockwave therapy can be helpful in the treatment of plantar fasciitis after one has properly diagnosed the condition. When one has exhausted conservative care, the clinician can explore appropriate surgical options.

In Conclusion
Heel pain may initially be a diagnostic dilemma that the foot and ankle specialist can overlook. Heel pain may be a result of numerous etiologies. It is up to the clinician to determine the exact etiology of heel pain and link the causal factors in order to potentially decrease the prolonged nature and intensity of heel pain, and the frequency of episodes of future heel pain. It is critical to obtain a thorough history and physical. One should focus on listening to the patient, surrounding staff and coaches, and correlate the observations with strong knowledge of the anatomical areas of the plantar heel and clinical experience. In most cases, conservative care is effective in the management of plantar fasciitis.

Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is the team podiatrist for the Philadelphia Phillies, as well as the United States Olympic and World Cup Men’s and Women’s soccer teams. Dr. Romansky is in private practice in Media and Phoenixville, Pa.

Special thanks to Martyn Shorten, PhD, at BioMechanica LLC for assisting with the preparation of this article.

References

1.     Jeffrey TP. Football is the top sport in the U.S.: 1,088,158 high school players. CNS News. Available at https://cnsnews.com/news/article/terence-p-jeffrey/football-top-sport-us-1088158-high-school-players . Published February 2, 2014.
2.     Mich H. Heel pain from football. Livestrong. Available at https://www.livestrong.com/article/417291-heel-pain-from-football/ . Published April 8, 2011.
3.     Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of first branch of lateral plantar nerve. Clinical Orthopedics. 1992; 279:229-36.
4.     Goecker RM, Banks AS. Analysis of release of the first branch of lateral plantar nerve. J Am Podiatr Med Assoc. 2000; 90(6):281-6.
5.     Confitti JA, Tarquinio TA. Operative outcome of partial fasciectomy and neurologic to nerve abductor digit minimi muscle for recalcitrant plantar fasciitis. Foot Ankle Int. 2004; 25(7):482-7.
6.     Mientjes M, Shorten M. Contoured cushioning: Effects of surface compressibility and curvature on heel pressure distribution. Footwear Science. 2011; 3(1):23-32.
7.     Shorten MR. Sports Surfaces and Injury: The Missing Links. BioMechanica LLC, Portland, Oregon, 2011, pp. 1–20.
8.     Drakos MC, Taylor SA, Fabricant P, Haleem AM. Synthetic playing surfaces and athlete health. J Am Acad Orthop Surg. 2013; 21(5):293-302.  
9.     Shorten MR. Finite Element Modeling of Soccer Shoe Soles. BioMechanica, LLC, Portland, Oregon.
10.     Livesay GA, Reda DR, Nauman EA. Peak torque and rotational stiffness developed at the shoe-surface interface. Am J Sports Med. 2006; 34(4):415-22.
11.     Heidt RS Jr., Dormer SG, Cawley PW, Scranton PE Jr, Losse G, Howard M. Differences in friction and torsional resistance in athletic shoe-turf surface interfaces. Am J Sports Med. 1996; 24(6):834-42.

For further reading, see “Inside Insights For Tackling Football Injuries” in the December 2005 issue of Podiatry Today, “Conquering Posterior Heel Pain In Athletes” in the November 2006 issue or “A Guide To Conservative Care For Recalcitrant Plantar Heel Pain” in the November 2014 issue.

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