Plantar fasciitis in a
Professional Boxer:
Clinical Case Report for
‘The Trevor Silver Memorial Essay
Prize’
Gurjit Bhogal
MBChB (Hons) MSc MRCGP
July 2012
Total Word Count (excluding References)
2976 words
Abstract Word Count
154 words
Plantar fasciitis in a Professional Boxer
Abstract
Plantar fasciitis is a common condition that presents with heel pain. A detailed understanding of
the anatomy and biomechanics of the plantar fascia underpins assessment of patients’ affected. It
acts as cushioning for the sole of the foot, and is integral in the function of the medial longitudinal
arch of the foot. It therefore plays a vital role in dissipating the forces that are applied across the
foot on weight bearing. Plantar fasciitis causes 10% of all injuries due to running, but 80% of
cases will resolve within twelve months. In this case report, the management of a 26 year old
professional boxer is described. Professional boxers typically run and skip daily as part of their
training regime. Persistent heel pain profoundly restricted his training and he was unable to fight
professionally for eighteen months. The management of recalcitrant cases is uncertain. The lack of
evidence to support treatments, especially in athletes, is highlighted.
Introduction
Plantar fasciitis is a condition which commonly affects sedentary individuals, recreational
exercisers and elite athletes alike. 15% of all foot complaints presenting to health professionals
are diagnosed as Plantar fasciitis[1]. It is estimated to cause of 10% of all injuries due to
running[2]. Men and women are equally affected[3]. Classically, those between the ages of 40 and
60 years old have the highest incidence of the condition[4]. However runners are symptomatic
younger[5].
Typically, patients complain of inferior-medial heel pain on weight bearing. This pain is usually
worst after rest, especially after a nights sleep[4]. It may be so severe that initially the patient is
unable to weight bear on the affected foot, however as the patient attempts to walk it eases[6]. A
dull ache often persists throughout the day. For the elite athlete these symptoms will impact on
training and performance.
The anatomy and biomechanics of the plantar fascia, also known as plantar aponeurosis, is vital in
understanding Plantar fasciitis. Hicks[7], in 1954, wrote a paper on the anatomy and
biomechanical importance of the plantar fascia during the gait cycle. Much of our current
knowledge stems directly from Hick’s seminal work. The plantar fascia consists of three segments;
medial, central and lateral segments[6]. It originates from the inferior-medial process of the
calcaneal tuberosity and runs distally, to insert via the five plantar pads of the metatarsophalangeal joints in to the individual proximal phalanges[7]. The fascia is innervated at its origin
by the Medial Calcaneal nerve, a branch of the Posterior Tibial nerve[6]. The remainder is supplied
by the first branch of the Lateral Plantar nerve[6]. At its origin, in health, it measures between 1229mm in thickness[8]. The skin of the plantar surface of the heel is the thickest in the body[8].
Between the skin and calcaneus inferiorly sits a fat pad, which is an area of fat globules grouped
together in a matrix[6]. The fat pad acts as a “shock absorber.” The plantar fascia, skin of the heel
and fat pad together provide cushioning and support to the foot on heel strike during the gait
cycle[7].
The Plantar fascia has a key role in the integrity of the medial longitudinal arch of the foot, thereby
playing a vital role in supporting the foot during weight bearing activities[9]. Hicks[7] described
the “Windless mechanism” which occurs during the gait and running cycles, on each cycle
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performed. “...When the toes are extended they pull the plantar pads and hence the aponeurosis
forward around the heads of the metatarsals, like a cable being wound on to a windlass. The arch
is caused to rise because the distance between the metatarsal heads and the calcaneum is thereby
shortened[7].” The medial longitudinal arch rises on dorsi-flexion of the toes of that foot. A
pronounced arch allows the body weight to be supported more efficiently[7]. The anatomical
attachments mean that this mechanism can occur without the influence of any muscles supporting
the arch[7]. A dysfunctional “Windlass mechanism” would mean more weight would be bore
through the Plantar fascia rather than the medial arch of the foot[9]. This could mechanically
overload the fascia.
Plantar fasciitis is an ‘overuse’ injury. 7.9% of ‘overuse’ injuries identified were due to Plantar
Fasciitis[5]. This was the third most common cause. Running expedites the ‘overuse’ of the plantar
fascia. A typical elite runner will perform 10,000 steps in a single hour of continuous running[9].
An average adult may take up to 10,000 steps in a day[9]. 2.8 times a runner’s body weight
passes through the plantar fascia during the stance phase of each step[10]. The plantar fascia
therefore needs to withstand considerable force in the runner. Plantar fasciitis is the pathology that
arises when it cannot. It is stretching of the ‘overloaded’ fascia, at its attachment to the calcaneus,
that has been implicated as the cause of pain[2]. Overnight, we sleep with a relatively plantarflexed foot. This shortens the Plantar fascia, meaning the first weight bearing steps on waking
cause a marked stretch and hence severe pain[2].
Plantar fasciitis implies an inflammatory pathology. However, tissues removed after surgery, in
those with recalcitrant symptoms have shown no acute inflammatory cells[8]. It is hypothesised
that chronic overload of the plantar fascia causes micro tears, which triggers an acute
inflammatory response. Continual overload prevents repair of these tears. The acute inflammatory
response persists and becomes chronic[8]. The histopathology has revealed “...disorganisation of
the collagen fibres, an increase in the amount of mucoid ground substance, and an increase in
number of fibroblasts, with minimal inflammation of fascia[6].” This appearance is similar to
achilles and patellar tendinopathy, and represents degeneration rather than inflammation[11]. The
histopathology reaffirms that Plantar fasciitis is an ‘overuse’ injury.
There are few studies which have determined risk factors for Plantar fasciitis. The biomechanics
suggest any factor that overloads the fascia may exacerbate the condition. Obesity, prolonged
standing, reduced ankle dorsi-flexion, pes planus/cavus are all implicated[12]. The association
with runners has meant a change in training regime, foot wear condition and running surface have
been suggested as factors too[1, 8].
Plantar Fasciitis is a self limiting condition. Fortunately 80% of cases will resolve in a year[1]. But
5 % of cases will need surgery[8]. For the elite athlete a year of pain affecting training and
performance is clearly unacceptable. Management of those with chronic symptoms, especially in
athletes, is uncertain. A major problem is the lack of sound controlled trials to guide management.
In this essay, I will present a case of Plantar fasciitis in a boxer, and will evaluate some of the
treatment options used, in the discussion.
Case Report
RC, a 26 year old professional middleweight boxer, presented to my General Practice surgery
complaining of right inferior heel pain for eight months. The symptoms were initially localised and
sharp in nature with no radiation. The pain was restricting his training and he had not been able to
fight for ten months. There was no history of direct trauma. His symptoms were severe at the start
of his daily morning five kilometre run, but he was able to “run the pain off” up until two months
ago. From then on, his symptoms have deteriorated; he has been unable to jog more than 100
metres, perform interval skipping or train on punch bags. He was still attempting to train daily
despite his pain. Immediately prior to assessment, RC had continuous pain “all over” his heel,
which would affect his sleep. There were no symptoms of paraesthesia in his foot. RC rated the
pain as 8/10 on a visual analogue scale. Regular ibuprofen had not provided any relief. A year ago,
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RC had started road running. Previously, his running had exclusively been on grass. Training
schedules aside from this were unchanged. His past medical history was otherwise unremarkable.
On examination, RC was noted to have an antalgic gait. He was a muscular man with a Body Mass
Index, BMI, of 22.3. Hip, knee and second ray of the foot alignment showed bilateral femoral
anteversion, tibial torsion and pronation of the feet at the subtalar joint. The medial longitudinal
arch of the foot was flattened in keeping with pes planus bilaterally. There was no skin changes
noted. Palpation revealed generalised tenderness of the inferior calcaneus, with maximal
tenderness over the anterior-medial aspect. No bony tenderness was elicited elsewhere and none
found at the insertion of the Achilles tendon or over the calcaneal fat pad. Active and passive
dorsiflexion of both ankles only reached 5 degrees bilaterally. Riddle et al[12] identified ankle
dorsiflexion of less than 10 degrees is a significant risk factor for plantar fasciitis. Reduced
dorsiflexion tends to increase foot pronation increasing the force across the plantar fascia[4].
Ankle range of movement and muscle power was within normal limits. Windlass test, both weight
and non-weight bearing, was positive in reproducing RC’s pain. This test has an excellent
specificity of 99%, but a poor sensitivity of 32% for plantar fasciitis[13]. Tinel’s test over medial
calcaneal and lateral plantar nerves was negative. Examination of the lumbar spine was normal
with unremarkable lower limb neurology bilaterally. Poor hip abductor strength and control was
noted on single-leg squat, bilaterally.
It is generally considered that history and examination alone is sufficient to diagnose plantar
fasciitis[1]. From this assessment other differential diagnoses were unlikely, such as achilles
pathology, nerve compression, fat pad pathology and enthesopathies. RC complained of nocturnal
pain and has a history of repetitive distance running so bony pathology, such as calcaneal stress
fracture, was necessary to exclude. Plain radiograph of the right foot and ankle was normal. RC’s
symptoms were limiting his occupation and quality of life, so the decision was made to refer him to
a local foot surgery specialist. MRI was arranged which showed no evidence of stress fracture but
did show oedema, intra-fascial tears and increased signal uptake around the aponeurotic insertion,
at the calcaneus on the T2-weighted scan. These features are typical of plantar fasciitis[1] and
confirm the diagnosis.
Treatment and rehabilitation began immediately prior to the results of the imaging. Acutely, RC
was advised absolute rest and prescribed Naproxen, a more potent anti-inflammatory medication.
RC was taught a series of stretching exercises, targeting both the plantar fascia and Achilles
tendon/triceps surae complex, by the physiotherapist. A programme of strengthening to improve
the load bearing capacity of the foot was shown. This consisted of strengthening Tibialis Posterior,
the plantar-flexors of the ankle, the intrinsic muscles of the foot and the proximal hip musculature,
including the hip abductors. Arch tapping was used to the right foot. It was immediately effective,
reducing RC’s pain score to 6/10 on the visual analogue scale. A referral for full podiatric
assessment was made via the Orthopaedic Foot clinic.
Three weeks later, custom made orthotics were measured for and ordered. A corticosteroid/Local
anaesthetic injection was administered by the Orthopaedic surgeon. The injection was transiently
effective for 2 weeks but by three weeks post intervention, RC’s pain score was 8/10. This was
despite compliance with his rehabilitation programme and use of orthotics. Two interventions were
discussed by the Surgeon; surgery, consisting of endoscopic fasciectomy with denervation, or a
single treatment of Extracorporeal Shock-Wave Therapy (ESWT). RC opted for the less invasive
ESWT and was privately referred to a centre in London experienced in the technique.
Eight weeks after initial medical assessment, RC received a single treatment of high energy ESWT
under Local anaesthesia. He was discharged with analgesia and instructions to continue the
rehabilitation programme and use of his orthotics. RC had dramatically improved at his follow up 6
weeks later. His pain score was now 2/10 and for the last fortnight, RC had walked two miles daily.
He now recorded improved dorsi-flexion of 10 degrees bilaterally. A negotiated graduated return to
training programme was formally constructed, after a multi-disciplinary meeting where RC and his
trainer attended. Road running was agreed to stop and initially RC would be allowed to jog 400
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metres, or to the point of pain, on grass. Aerobic fitness would be maintained by swimming and
cross training. Boxing specific training was also adapted to reduce weight bearing. Weekly reviews
would guide progression of training.
The supervised regime meant within three months RC was fit enough for a Professional fight. At
that point, RC would run one kilometre on grass and swim 2500 metres per day. All boxing specific
training was back to his pre injury intensity. In November 2011, RC’s severe right heel symptoms
reoccurred and his return fight was cancelled. He is due for elective right endoscopic fasciotomy in
January 2012.
Discussion
RC’s case illustrates the uncertain prognosis of those with recalcitrant Plantar fasciitis. The key
issue is the lack of consensus in how best to manage these cases, especially in elite athletes. The
literature describes approximately twenty individual interventions, ranging from rest to the use of
autologous blood injections[14]. The evidence for the majority of these interventions is limited
with few controlled trials supporting their efficacy. All aspects of RC’s treatment are included in
published guidelines[15] for the treatment of the general public, as well as reviews looking at the
management of elite athletes[4]. I will review some of the aspects of RC’s management referring
to the literature, to show what evidence there is for this.
Rest is often advocated. Wolgin[16] found that 25% of sufferers found rest gave them their
greatest relief of symptoms. This study was based on subjective opinion, however there are no
controlled trials analysing the affect of rest, absolute or relative, in isolation. For the elite athlete,
relative rest is often more appropriate to maintain fitness. The comparison of absolute versus
relative rest may be a pertinent subject for future research.
Non Steroidal Anti-inflammatory Drugs (NSAIDS) are effective in reducing inflammation. The
histopathology of Plantar fasciitis is degenerative not inflammatory. Initially there may have been
an acute inflammatory phase[11] however the effectiveness of NSAIDS in recalcitrant cases is
doubtful. NSAIDS are analgesics too and their use in management is likely to be centred on this.
But their relative benefit as compared to other simple analgesia, such as paracetamol, is uncertain
in Plantar fasciitis. Again there are no trials that have examined the effect of NSAIDS in isolation.
29% state that stretching the plantar fascia improves symptoms[16]. Stretching is commonly
recommended, but the majority of studies have combined stretching programmes with other
interventions, like taping, night splints and orthotics. DiGiovanni[17] compared stretching of the
plantar fascia against stretching the Achilles tendon. After eight weeks, both programmes
improved pain, but the plantar stretch was significantly beneficial as compared to Achilles stretch.
This study has formed the basis of recommendations, where both the plantar fascia and Achilles
are stretched. However this study was limited by a high “drop out” rate of 28% in the Achilles
stretching group and lack of blinding.
Kibler’s[18] analysis of Plantar fasciitis’ patients concluded that plantar flexor strength deficits
were noted in the majority of subjects. Kibler’s work is cited as indirect evidence of the potential
effectiveness of planter flexor strengthening. The use of intrinsic muscle strengthening of the foot
is also commonly used. Logically they may improve the function of the medial longitudinal arch.
The evidence for strengthening is indirect at best.
Injection of corticosteroid, with or without local anaesthetic, is a convenient intervention for
clinicians. Crawford[19] compared a local anaesthetic injection against corticosteroid and local
anaesthetic. After a month the corticosteroid group had significantly improved pain, but after three
months and a year, no difference was noted between the groups. Two recent control trials have
reinforced that corticosteroids have short term benefits and appear to be superior to autologous
blood injections[14, 20]. Indeed the use of iontophoresis, an electrical current to administer the
steroid which is in solution, can improve symptoms six-fold in 2 weeks[21]. There is evidence to
support the use of steroid injections short term which may be useful to athletes, however concerns
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exist that steroids are associated with plantar fascia rupture[22]. There is no evidence that they
facilitate long term recovery. RC had minimal benefit after his steroid injection.
Extracorporeal Shock-Wave Therapy (ESWT) provided RC with his greatest benefit in symptoms.
ESWT uses high energy sound waves and has been hypothesised to stimulate an acute
inflammatory response, which triggers the healing process[1, 4]. Double blinded control trials have
been performed in this area[3, 23-26]. Results have been variable but a meta-analysis has shown
ESWT is marginally more affective versus placebo[25]. A study exclusively of runners showed
significant improvement of symptoms with ESWT versus placebo[26], more so than other trials.
The authors suggested that runners may be more sensitive to the effects of ESWT, through an
unknown cause[26]. Promisingly, Alvarez[27] found that 65% of the 20 cases he studied were
pain free after 2 years. For RC, ESWT did not produce the long term relief. Currently ESWT is not
available routinely on the NHS.
All these initial interventions were poorly effective for RC. This is not surprising when looking at
the evidence for each of them. Night splints[28-29], “botox” injections[30] and autologous blood
injections[14, 20] have been trialled and all provide short term benefits. Surgical evidence,
whether open or endoscopic, is based on case series rather than control trials. Success rate appear
high (75%) with the Open fasciotomy with denervation procedure[31]. However 25% may suffer
from persistent pain, secondary to the change in biomechanical function of the foot[31].
Endoscopic procedures have quicker recovery rates[32]. Post surgery, rates of return to elite sport
are unknown. This data would be important in establishing the benefits of the surgical option for
elite athletes.
Ultimately, we are trying to facilitate a return to work, in this case professional sport, in those with
Plantar Fasciitis. Dyck[4] concludes that “...aggressive management using combination treatment
is most efficacious and affords athletes the best opportunity for a quick and full recovery.” This is a
reasonable conclusion; however I would contest that we do have the knowledge about the effect of
basic interventions to advise appropriate evidence based “combination treatment.” If we did RC’s
boxing career may not be under threat as it is. Further research with appropriately controlled trials
must be the future aim particularly with regard relative rest and surgical interventions.
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