Sports injuries of the foot
Plantar Fasciitis – Heel pain
This is inflammation of the firm band of tissue on the sole of the foot (which doctors call the plantar fascia), but is usually felt as heel pain.
It’s a common injury in sportspeople, particularly those who do a lot of running or jumping, but can also affect non-sports people too. We see it in ladies and men of late middle ages, and in people after a period of time off their feet from injury (after a broken ankle for example). Other things that cause it include a recent increase in training, changing training surfaces or shoes, and biomechanical problems or calf muscle tightness.
Repetitive use of the fascia (the stiff fibrous tissue on the sole of the foot) leads to tiny little tears in all of us. Usually, the body heals up this daily damage while we rest and sleep. In this condition, sport, unaccustomed use and/or bad sleep, means damage builds up faster than it can be repaired, and chronic inflammation results. Chronic inflammation means your body has given up healing and just tried to persuade you to stop the damage by giving you pain!
You will have pain at the back of the heel on the sole of the foot. It usually starts gradually and may initially only be painful after exercise (often the following morning). As the condition gets worse the symptoms become more intrusive and may start to interfere with sport and cause pain with day to day activities. It is often terrible for the first few steps in the morning or after sitting. This is because when you rest the plantar fascia band tightens up, then the first few steps you take you are tearing it again!
If you think you have this condition it is well worth getting it checked out. I have had it badly myself and it can be really miserable. If it is not treated properly it will go on for year and years. In the meantime, you should avoid any aggravating activities which may prolong the problem. It generally won’t get better on its own.
The first thing to do is to reduce the problem activities and start a thorough program of calf stretching exercises. Anti-inflammatories and ice are helpful after exercise, but don’t use tablets to mask the damage you are doing, or the problem will get out of control.
Treatment involves first confirming the diagnosis by carefully listening to you and gently examining you. Sometimes I may suggest an MRI scan or an ultrasound scan to rule out other problems and confirm the diagnosis.
I think of treatment in three levels:
1) Tailored physiotherapy, a special sock, and rest. The exercises you need to do are Morning stretches, grasping the ball of the foot and stretching out the plantar fascia for at least five minutes before your foot touches the ground in the morning. These are really powerful but almost no-one can be bothered to do them properly. I suggest setting two alarms, one five minutes before your usual wake up time, to give you time to do these. The other exercise is calf stretching, again for five full minutes a day, timed!
The devices (orthotics) that can help are the Strassburg Sock worn at night loosely just enough to stop the foot going into a tiptoe position, and gel heel pads, for some relief. The sock stops the band tightening up in the night so that when you first walk in the morning the tearing is less. The final thing to do is to get your sleep sorted out. We simply don’t see this condition in people who get eight good hours of sleep and 2 hours of deep sleep a night. I’m really interested in sleep and its effect on disease.
2) I have found Shockwave therapy to be brilliant for treating this condition. This is a really easy, non-surgical treatment that gets your body to heal itself. It is nowhere near as painful as injections or surgery and is covered by most insurers and available to self-funding patients. In my hands when the diagnosis has been confirmed the success rate so far has been close to 100%. Click here to learn more: Shockwave.
3) Surgery is the last resort but is not something to be terrified of. The old fashioned method of open surgery was bad, but after a year in Australia, I learned and then refined, a keyhole way of doing the operation which takes about 10 minutes has a two-week recovery, a good safety record and excellent results. It is still only to be used when all else has failed! This is called Endoscopic Plantar Fascia Release.
Once you are recovered it is important to address any biomechanical problems, or other underlying factors in order to prevent it coming back and getting your sleep under control.
Stress fractures of the foot
One of the quite common causes of foot pain in sportspeople, especially runners, is a stress fracture. I’ve had a few of these myself over the years. It usually starts with pain after sport, then often pain at night, and eventually there can be pain with sport. The small metatarsal bones in the front of the foot are particularly prone to stress fractures. This injury is more common with increases in activity level or changes in shoes.
Usually, by reducing the amount of activity you do these will heal on their own, but this can keep you off sport for many months. For metatarsal fractures, a stiff shoe or a medical shoe can help.
Stress fractures of the heel bone can be more troublesome. Sometimes these need time on crutches and a protective medical boot. They need to be taken seriously.
I have used an Exogen bone stimulator to speed up the healing process on myself, and several high-level sportspeople where recovery time is really important, and these can be really handy. If you want to discuss this let me know. They are expensive!
It is a really bad idea to ignore stress fractures and, a bit like keep bending a metal paper clip, if you keep going on them then eventually, it will snap. This is why it is important to get the right advice if you think you have a stress fracture in your foot.
Big Toe arthritis
Your big toe joint is prone to lots of injuries (with funny names like turf toe and plantar plate injury) and also to arthritis. Arthritis of the big toe joint is quite common in all sorts of people and especially after years of kicking sports or dance sports, but also in runners. I have some of this myself.
There is usually a combination of some degree of stiffness along with a deep-seated aching pain. To begin with, it can be a pain at the end of a long day or pain after sport and particularly bad if the toe is bent too far. It can then progress into having pain at night time and needing painkillers to get through the day or for example to get through a round of golf. Tight shoes can be a problem and flexible shoes can also be bad. The joint can start to look deformed as bone spurs form around the margins and this also causes more stiffness.
In the early stages changing footwear can help, as can painkillers and activity modification. If things get more troublesome then injections of viscosupplements such as Durolane or Ostenil can be really good. I have had these injections myself and they were brilliant. When things are really bad surgery can be considered, either to replace the joint or to fuse the joint so that it no longer moves but all of the pain goes. Usually from the time that you first have problems to the time that you need surgery can be about 10 years, and there are lots of options short of surgery to keep you enjoying the things you love. I don’t do the surgery myself, because I specialise in knee surgery, but most people don’t need this anyway.
Pain under the big toe joint – Sesamoiditis
Underneath the big toe joint, on the sole of your foot, there are two little bones that sit in the tendons. These are called the sesamoid bones. They’re about the size of a pea. They can sometimes be the cause of pain under the ball of the foot, particularly in sports people.
It’s possible to have stress fractures of these bones, and it’s also possible to have inflammation or even arthritis. This is a commonly missed cause of foot pain and it takes quite a sharp doctor to get the right diagnosis.
The treatment is different depending on whether it is a stress fracture (predominantly needing rest) or inflammation which often responds well to an injection. Very, very rarely surgery is needed. If people haven’t managed to get to the bottom of why you’ve got the pain under your foot, then this is certainly something to consider and it’s well worth finding the right expert.
Usually, by carefully listening to you I can work out that this might be the problem, then a gentle examination of your foot will lead me to the right diagnosis. The easiest way to confirm it is with an MRI scan then I will know how to help you.
Frequently asked questions
Yes, it can be really useful if you bring your running / cycling shoes or shoes that seem to make your foot problems worse. This will help me to help you.
No, quite a lot of people don't need any scans, and before I see you we won't know if it is an MRI, ultrasound, X-ray or CT scan we need. I may be able to save you the cost! The good news is you have any old scans let my secretary know and we may be able to use them.
Sorry, but in the NHS I only have a knee clinic so I cant deal with foot problems. I can refer you on to the foot and ankle team and this can save a lot of waiting though!