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Plantar Fascitis

Plantar fascitis involves chronic inflammation of its origin at the plantar medial calcaneal tuberosity on the anteromedial aspect of heel. In proximal plantar fasciitis, the athlete notes pain at the plantar medial heel that is worse after rest and with the first steps in the morning. The pain actually lessens with activity only to recur after rest. In the chronic setting, the athlete can complain of radiating pain up the medial side of the heel and occasionally across the lateral side of the foot. It is important to question the athlete regarding lateral swelling of the heel that would suggest a stress fracture of the calcaneus and radicular symptoms suggestive of a discogenic source of pain.

Plantar fascitis, even in the chronic setting (up to 9 months), is treated nonoperatively. Aggressive Achilles tendon stretching (ATS).

 We spend a significant amount of time educating our athletes on the relationship between a tight Achilles tendon and plantar fasciitis. We have found that athletes must believe that ATS will cure the ailment before they will comply with the stretching. Also, we advocate an aggressive stretching program of 2 to 4 minutes.

We also use nonsteroidal anti-inflammatory medications, soft heel pads (silastic), and arch taping to help with the symptoms during athletic activity. We will occasionally prescribe custom orthotics for the in-season athlete with a medial heel wedge and first metatarsal lift to relieve the medial fascia and correct pronation deformity. Judicious injections with long-acting steroid preparations may benefit the in-season athlete (usually one to three per year). We have noted excellent results with this approach in approximately 95%.

We reserve operative treatment for athletes who have failed an aggressive nonoperative approach as outlined previously for 9 to 12 months. Occasionally, because of timing for the competitive athlete, we will proceed with an operative release of the proximal fascia and release of the deep abductor fascia after 6 months of treatment. Our operative approach is open, as described by Baxter and Pfeffer. If a spur is noted on the lateral radiograph, it is resected. Postoperatively, we splint the ankle with a molded arch for 2 weeks, then begin mild stretching.

Calcaneal Apophysitis

Calcaneal apophysitis (Sever's disease) presents in a similar fashion in the skeletally immature athlete, but the pain can be posterior or inferior. Treatment is similar to the nonoperative approach used for acute Achilles tendinitis. We rarely use a custom orthosis but prefer a Silastic heel lift. Ice is very beneficial in these athletes.