Squash Magazine Articles
by Michael Schumacher, DPM, FACFAS
The alarm goes off, and you sit up in bed, still half asleep. As you stand, you feel a piercing pain in your heel. You groan, as this has been going on for about 6 weeks. Your significant other looks at you like you are 120 years old. Sure, you have been increasing your squash training for the big tournament, but why do your heels hurt so much? As you hobble to the kitchen to put the coffee on, you wonder what is causing this awful pain, and what can you do about it?
This condition is called plantar fasciitis, the most common cause of foot pain in all athletes and quite common in squash players. The disease was diagnosed over two million times last year--excluding the number of people still out there limping.
Generally, an athlete with Plantar Fasciitis has a history of heel pain, often occurring first thing in the morning or after a period of rest. Sometimes the athlete complains of pain in the Achilles tendon insertion at the back of the heel. The pain usually decreases after a few minutes of walking and may return, depending on the level of activity. X-rays often reveal a heel spur, which is a symptom of the disease and rarely the main cause of the pain.
Basically, Plantar Fasciitis is an overuse injury. The repetitive pounding up and down the squash court can cause this. Additional factors could include a sudden increase in the amount of training, a change in training surface, and poor shoe gear (how old are those squash shoes, anyway?). Biomechanical factors also play a role in Plantar Fasciitis. Athletes with flat feet (over pronators) and those with high arches (over supinators) can be unusually susceptible to Plantar Fasciitis.
To understand Plantar Fasciitis, it helps to have a grasp on the specific anatomy of the foot. The plantar fascia is a tough, fibrous band that lies deep to the skin on the sole of your foot. It begins at the bottom of your heel bone (calcaneus), and attaches at the balls of your feet (metatarsal-phalangeal joints). Some fibers may extend from the bottom of the heel to the back of the heel, joining fibers from the achilles tendon. It both supports and protects the deeper structures of the foot, such as muscle, blood vessels, bone and nerves.
In a nutshell, Plantar Fasciitis is an inflammation of the plantar fascia at its insertion on the heel bone.
Treatment of Plantar Fasciitis is divided into two methods, conservative and surgical. Before anyone panics, conservative care is successful in over 90% of cases.
Conservative care is primarily concerned with decreasing the inflamed plantar fascia if after six months the conservative care has not relieved the pain, surgical management could be necessary. The surgery removes the tension on the plantar fascia (and the accompanying pain) by cutting it at its attachment at the bottom of the heel bone. As with knee surgery, there are both "open" and "scope" (endoscopic) surgeries that may be performed. The last point is this: if you are suffering from this type of pain, find a physician who has experience in treating it.
Plantar Fasciitis: Conservative Care
Rest and a decrease in activity are a good place to start. Cycling and swimming are two excellent nonweightbearing alternatives.
Ice therapy is an effective anti-inflammatory agent. Patients should ice their heel after activity or in the evening. 15 minutes on, 15 minutes off, repeating twice. Be careful about leaving the ice on too long, as frostbite could develop.
Ibuprofen and other NSAID's also are good antiinflammatory agents. As always with Ibuprofen, it is important to take it with food to avoid stomach upset and to take it as directed.
Stretching the achilles tendon and the plantar fascia are very important to help decrease tension in the fascia.
Avoid walking barefoot. Walking without shoes or sneakers leaves your arch unsupported, causing undo stretching and strain on your plantar fascia, thereby increasing the level of inflammation and pain. Drastically decrease the amount of time spent barefoot and make sure supportive shoes are worn at all times.
Cortisone injections also are very effective in reducing the inflamed area. A series of three at most is what I recommend.
Custom molded orthotics help in cases where the pain is caused by biomechanical imbalances. Custom orthotics are a simple non surgical way to control the abnormal biomechanics that are often the underlying cause of plantar fasciitis.
Night splints, utilized to keep the tension off the plantar fascia while sleeping, are another device to resolve the pain.
Casts, with no weightbearing for two to four weeks, are the last resorts of conservative care.