What do Paul Gasol, Ty Lawson, and Rip Hamilton (aptly named) have in common? They both suffered from acute plantar fascia ruptures during the 2012-2013 NBA season.
Most sports medical professionals are familiar with plantar fasciitis, the acute presentation of plantar heel pain. Plantar fasciosis, as the chronic condition is now referred, is the continuation of heel pain for 6-8 weeks or more. It has been suggested that there are approximately 2 million cases of plantar fasciitis /osis per year,(1,2). A study on injuries in the NBA found that foot inflammation was responsible for approximately 3.5% of all games missed, an estimated 90 games a year, and was 2.9% of all injuries tracked, (3).
Plantar fascia rupture is not uncommon in patients with chronic plantar fasciosis as is often the case with ruptures of tendons suffering from chronic tendinosis, think Chauncy Billups and Kobe Bryant. Non-inflammatory tissue changes with thickening of the fascial and muscular fibers and in-growth of vasculature at the level of spur insertion are commonly found histologically and through ultrasonography, (4,5) in both conditions.
Plantar fascia ruptures more often occur in athletes who run, jump and cut as part of the activity in their sport. Most ruptures, partial or complete, occur with forced plantar flexion of the foot. Repeated stress, and / or minor trauma to the fascia can cause a rupture as well, and spontaneous ruptures that happen are often associated with recent local steroid injections, (6,7,8). Plantar fascia rupture does not seem to be tracked regularly, but during this NBA season it would seem to be numerically on track with ACL injuries of the knee.
Plantar fascia ruptures usually present with the sound of a “pop”, acute pain, bruising and swelling, and inability to push-off of the foot or to fully weight-bear without significant pain. Once the fascia is ruptured, little can be done to repair it and it usually is left to form scar tissue to bridge the gap created.
Usual treatment after rupture consists of the use of a removable walking boot and crutches for the athlete to remain non-weight bearing for 1-2 weeks. Once the athlete can bear weight pain free in the walking boot, they may dispense with the use of the crutches and continue with the boot, finally transitioning to shoes when able. Daily therapy treatments, stretching exercises and OTC or custom foot orthoses are usually instituted immediately as tolerated. Platelet Rich Plasma or PRP injections are being used often now during treatment, but no long term studies have been done specifically regarding plantar fascia rupture. One study presented at the AAOS meeting in 2012 showed earlier improvement and longer lasting improvement in comparing a single injection of steroid in a group of patient’s vs a single PRP injection in a group of patients, (8). A study by Saxena and Fullem 2004 (9), looked specifically at plantar fascia rupture in athletes. They estimated a total recovery time of 9.1 weeks +/- 6 weeks. In the NBA this could translate into a loss of 10-30 games or more.
The implications of plantar fascia rupture can be significant in the foot and lower extremity. Once the fascia is healed it is almost always longer, at the medial or central band, than it was prior to rupture. While this may decrease local medial and plantar heel pain, the decrease in tension of the fascia in stance and propulsion phases of gait can prolong pronation forces in the foot, flatten the longitudinal arch and increase pressures in the forefoot, (10). Lateral column pain is not uncommon after surgical plantar fascia release, and can occur in traumatic release as well. This occurs because the medial column will now be less stable and the neuromuscular feedback will seek stability, by shifting the center of force in the foot to either the stable lateral or central metatarsals. This can lead to a higher risk of metatarsal stress fracture and potential worsening of hammer toe deformities as the toes seek to grip the ground to stabilize a hypermobile first ray, (11). To properly analyze the problem, a functional and structural scoring system must evaluate the foot to see root problems. Treating only the symptoms can manage the pain, but compensations will occur if there is not a thorough assessment of the mechanics of the foot.
Custom foot orthoses, if prescribed correctly, can combat most of the forces that will lead to chronic plantar fasciosis as well as plantar fascia rupture before and after occurrence. In the study by Saxena and Fullem (9) they found that about 25% of the athletes prior to plantar fascia rupture used foot orthoses. More interesting to note was that post-rupture 75% of the athletes were prescribed and wore foot orthoses. Most professional athletes have and often will wear their custom foot orthoses. If these same athletes continue to suffer from plantar fasciosis symptoms then it would seem in most instances that the devices are either not being regularly worn or do not have the appropriate prescription. The use of in-shoe pressure analysis, alone or in conjunction with video analysis, can quantitate bilateral foot function. Asymmetries in function such as acceleration differences right to left, early loss of heel contact and shifting of the center of force more lateral than medial can all be recorded and documented for further review at any time. Eliminating these asymmetries via specific segmental orthosis prescription elements will, in most cases, dramatically decrease the pain and improper forces acting on the foot and lower extremity, (12). Small razor thin othoses can create subtle yet measurable improvements in foot mechanics and function from the foot and up the kinetic chain.
When dealing with a highly paid professional athletic population it does not make sense to just treat the symptoms of chronic plantar fasciosis. Overuse during a season is a given in professional sports. Interventions, regardless of which ones, should show significant improvement or should be investigated further and quantified if possible to achieve the best possible outcome for the athlete and the team. Team medical and performance staff are under a lot of pressure to keep athletes healthy, so documentation with objective data sets such as biomechanical and medical imaging is imperative.
Special Thanks To:
Pribut S. Current Approaches to the Management of Plantar Heel Pain Syndrome, Including the Role of Injectable Corticosteroids J Am Podiatr Med Assoc 97(1): 68-74, 2007
Martin J, Hosch J, et al. Mechanical Treatment of Plantar Fasciitis A Prospective Study J Am Podiatr Med Assoc 91(2): 55-62, 2001
Drakos M, Domb B, et al. Injury in the National Basketball Association: A 17-Year Overview. Sports Health: A Multidisciplinary Approach March 10, 2010.
Sarah Mahowald S, Legge B. The Correlation Between Plantar Fascia Thickness and Symptoms of Plantar Fasciitis. J Am Podiatr Med Assoc 101(5): 385-389, 2011
Lemont H, Ammirati K. Plantar Fasciitis A Degenerative Process (Fasciosis) Without Inflammation. J Am Podiatr Med Assoc 93(3): 234-237, 2003
Theodorou D, Theodorou S, et al. Plantar Fasciitis and Fascial Rupture: MR Imaging Findings in 26 Patients Supplemented with Anatomic Data in Cadavers. RadioGraphics 2000; 20:S181–S197
Kim C, Cashdollar M, et al. Incidence of Plantar Fascia Ruptures Following Corticosteroid Injection. Foot Ankle Spec 2010 3: 335
Monto R. Platelet-Rich Plasma is More Effective than Cortisone for Chronic Severe Plantar Fasciitis Paper presented at AAOS 2012 Tuesday, Feb 07, 2012, 11:06 AM -11:12 AM.
This past weekend I had the pleasure of heading to Boston for my third Boston Sports Medicine and Performance Group (BSMPG) Summer Seminar. I wasn’t sure how it was going to top last year’s line-up and I can’t say for sure that it did, but it was at least on par. I was able to hear some very informative presentations from Bill Knowles, Craig Liebenson, Sean Skahan, Dan Boothby, Pete Friesen, Boo Schexnayder, Joel Jamieson, Cal Dietz, Chris Powers and Alan Grodin. The following are the three things that I am going to implement into my program at Michigan Tech as soon as I get back to Houghton tomorrow (I am writing this on the plane trip home).
1. Subjective Athlete Monitoring
Joel Jamieson spoke about allostasis and the training process. According to Joel, Allostasis is “the varying integrated adaptive responses taken by the body in order to maintain homeostasis at all times and in all circumstances as necessary to keep the body alive.” We only have a certain amount of energy (called the allostatic reserve) to accomplish these adaptations. Training is obviously one of the stressors that can disrupt homeostasis, causing allostasis to occur. However, if the training is too much in terms of volume, intensity, or both, then that allostatic reserve can be drained and we won’t get the training adaptations that we are looking for.
Therefore, it is essential to monitor the recovery levels of our athletes and quantify their training load to maintain that allostatic reserve and ensure readiness for training. Unfortunately, at Michigan Tech we don’t have the resources for an Omega Wave or even other heart rate variability technology. I also don’t have the time to measure everyone’s vertical jump or grip strength on a regular basis. However we can use subjective measures to tell how an athlete is feeling and how they perceive their training. We will now have the athletes rate on a scale of one to ten on how ready they feel to train that day after the warm-up (it’s best to do it after the warm-up because athletes rarely feel ready before, sometimes I don’t feel fully ready until after the warm-up) and they will rate their perceived difficulty and intensity after the training session. This will allow me to quantify how they are responding to training and make adjustments as needed.
2. Lowering Hurdle Height for Plyometrics
In our second, third and fourth phases of plyometric training we use hurdles to jump over and in the past we have allowed our athletes to bring their knees up, sometimes all the way to their chest in order to clear the hurdle. During Boo Schexnayder’s presentation, he repeatedly discussed the importance of posture while jumping and that the set should be stopped if posture is lost at any point.
Year after year, Art Horne and the gang at the Boston Sports Medicine and Performance Group host their anual Summer Seminar. Having heard nothing but positive feedback from colleagues who have attended in the past, I decided that this would be the year to finally attend. Living in Western Canada, it certainly isn’t easy to travel across the continent both from a time and financial perspective, but I felt that in order to continually better myself as a professional, attendance was a must. Like many of my previous educational endeavors, it was important for me to be 100% confident that this event was grounded in “educational conducivity” and not just a place where many of my friends were going to be. However, upon looking at the speaker lineup, it was more difficult to convince myself not to attend.
Perhaps the most challenging task however, was deciding which sessions to attend. So aside from the keynote lectures where all delegates were present, I found myself attending lectures from the following: Sean Skahan, Dr. John DiMuro & Mark Toomey, Art Horne & Dr. Pete Viteritti, Joel Jamieson, and Keith D’Amelio. So…
Continue to read this review by Jeff Cubos by clicking HERE
TopCoder's Clinton Bonner will be guiding an in-depth panel discussion and presentation on sports performance and sports medicine today at 4pm-5:15 during our VIP Workshop. A revolution is coming in how not only do coaches and therapists approach performance and injury, but how technology is going to disrupt legacy approaches. Moneyball ten years go was a milestone for sport, but analytics and algorithms is still embryonic now in our profession. Attendees will leave with a blue print on getting started with data driven methodologies and how they are giving a competitive edge to the best teams in the world.
During this session Jose Fernandez and Dr. Bruce Williams will do an assessment of an athlete, followed by group discussion on best practices with screening. A focus on gait and lower body mechanics is the highlight, supported by both biochemical and biomechanics monitoring. Evidence based medicine and the latest advancements of technology, therapy, and sports performance methods will be covered. With the advent of Moneyball, Jose and Bruce will show how they look at risk analysis with athletes in team sports from both a time management perspective and decision making process.
Catch up with Jose, Bruce, and the rest of the country's top sports medicine and performance professionals at the 2012 BSMPG Summer Seminar May 19-20th!!
Victor, the mobile market is a very disruptive movement to many software companies. How has Dartfish continued to succeed with more and more competition?
Actually it helps the overall picture because many coaches had not realized before how important video was. An app is only once piece of a total solution and if you do not answer all the needs (or most of the needs) of an organization, you will not be successful. Dartfish has been serving this community for more than 10 years and we have listened to our client’s needs. This why we continue to be the driver in this market. We have developed apps as well and will continue with new ones to come, but always in a fully integrated and complementary approach (cloud, software and mobile).
Dartfish.tv allows users to monetize their skill sets with revenue streams similar to the iTunes store. How do you see coaches take advantage of this in the world of sports performance? Many private facilities are looking for both a competitive edge and a way to keep profits from dissolving to their competition. How does this help coaches on salary such as college and professional ranks as well?
There are many ways where coaches can create additional revenue or at least show a very professional image with great technologies. Coaches can sell video clips online (clips, drills, etc.,), they can start remote coaching services, they can post videos of camps and clinics, they can ask parents to subscribe to competitive events. We have clients with thousands of videos on their dartfish.tv platform today.
Many coaches want instant feedback or analysis live during training sessions. Most experienced coaches feel just the opposite that athletes should be viewing outside the field, court, pool, or track. Shouldn't analysis be more in the office and not in the field? What problems have you heard regarding this practice?
Actually there is a fine line between doing too much on the field and not doing enough with video. A quick visual feedback on the field is very beneficial to the muscle memory learning experience (seeing is believing). However, doing too much can be disruptive and you will lose the impact according to our best users. Deeper analysis should be done after the training session to find out additional facts and reinforce what was communicated on the field.
Fusion of data sets such as EMG and Force plates can be done with your system; can you share why this is going be a major and more common practice in the future?
What is essential here is to be able to have the full picture. Too many times, athletes and coaches are presented with data and it is very complex to really understand what is going on just by looking at the numbers. We say that your data needs video! As more and more data systems are available to larger audiences, the fusion with video will help the understanding and communication process. It is an additive process. A picture or video may worth a thousand words, and the data/words are worth a lot, but the combination is worth a million words.
Speaking of the future, without giving away too much can you identify the problems coaches and therapists have with video analysis with a busy team or clinical setting that will be alleviated with the innovations you are working on currently?
We are working on offering a product for every step of the process. 3 Key elements are important for therapists and coaches: Communicate, analyze, and then share. The key is to have the solutions that are fully integrated within their processes. It is always difficult to first embrace something new (people hate changes) but as soon as you have your workflow well established and you see that you can reap the benefits (patients doing better, medals won, increased revenue) there is no more doubt. When the first vehicles were introduced, many moving companies resisted and kept their horses and carts….we don’t see them on the roads anymore.
Interview courtesy of Carl Valle
A few seats still remain for the 2012 BSMPG Summer Seminar - sign up today to avoid disappointment this Sat!
The fusion of sports and medicine becomes a more potent mixture each day. Using tools that gauge performance with a high degree of accuracy allows us to quantify our results in almost any fashion imaginable. Tracking minute changes in the body such as heart rate, function, mobility and mechanics provides us information on our athletes that we can rely on to develop customized programs for each athlete. Real-time reporting functions provided by today’s latest technology make it simple and efficient to make evidenced based decisions in any setting.
Doctors, physicians and trainers are all working closely with one another to bring the most comprehensive care an athlete can hope for. Student athletes are among the top demographic to benefit from this union of sports and medicine where coaches and trainers regularly evaluate hundreds of students regularly. Coordinated care breeches team practices in addition to advising on lifestyle choices and curriculum.
Outside of institutions, merging is evident in private facilities where athletic development is the number one priority. Through the eyes of Dr. Thomas Lam, Director of Athletic Development at FITS Toronto, an environment focused on sports-science and coordinated care is a premier destination for training and therapy. Located in the hub of Canada, Dr. Lam’s two Toronto locations service every level of athlete, each equipped with a sports science lab. Tracking manipulations to the nervous system by evaluating the results in through changes to the biomechanical system, Evan Chait of Kinetic PT brings his discussion to OptoSource’s Fusion Track workshop.
For attendees of the Boston Sports Medicine & Performance Group, the Fusion Track will be the ideal chance to learn about incorporating data collection into sports performance planning and get a look at the best tools for managing all of the streams of information sports performance programs rely on today.
Speakers for this presentation include:
Dr. Thomas Lam of FITS Toronto on integrating objective analysis into an existing sports performance and medicine program.
Evan Chait of Kinetic PT will discuss The Chait Neuropathic Release Technique (CNRT), a multidisciplinary diagnostic and treatment process that focuses on 3 tiers of health. The 3 Tiers include the nervous system, biomechanical system, and the movement pattern system.
What to expect:
Using the cloud to safely and efficiently manage data.
Incorporating multiple streams of objective analysis into existing programs.
Tracking and trending change for coordinating care.
Take a sneak peek into Bruce Williams' presentation, New Concepts in Foot Function & Gait Analysis Assessments & Treatments, at the 2012 BSMPG Summer Seminar.
Space is still available - Register today before the last seats are gone!
Most athletes and coaches think podiatrist means someone who makes orthotics, could you dispel that myth and talk about the holistic approach with foot care and how you even work with injuries in the low back? Many don't understand your profession deals with biomechanics, surgery, and even manual therapy.
Podiatry is a very interesting profession. Surgery is really the highlight of what Podiatrists do and are trained to do at the present time. All Podiatrists receive about a year of biomechanics while in school. They are all trained to cast for orthotics and write prescriptions as well. Some podiatrists utilize manual therapy in their practice, but probably less than 5%.
In my practice I figured out very quickly my orthotic outcomes were not what I wanted them to be. I set out to understand how I could do a better job for my patients and that lead me down a very interesting path of self- education. I found a mentor to assist me in the use of in-shoe pressure and video capture technology. He also happened to expose me to the use of manual therapy in the foot and ankle. The use of the technology and the therapy really opened my eyes to what I was missing in practice. The use of the quantitative data from the in-shoe pressure really exposed me to the way the foot will function and react to a shoe and to an OTC or custom foot orthosis. This has helped me to realize my limitations in practice while also allowing me to move past most of my peers in the understanding of the foot’s importance in walking, and athletic gait.
Most of my sports medicine podiatry peers are great collaborators with physical therapists, strength and conditioning coaches, athletic trainers and massage therapists. We all realize that we are just a piece of the puzzle in the process of enabling our athletes to compete at their highest levels.
Barefoot training and minimalist shoes seem all the rage right now, can you share some objective pros and cons to what athletes may benefit and risk wise when diving into this territory?
Barefoot is the thing right now, just as toning / rocker bottom shoes were a few years back. In moderation and in certain specific situations I see benefit for patients and athletes from both types of shoes. The biggest problem I have with the minimalist / barefoot shoe debate is that there is very little proof that doing workouts barefoot will have the amazing results that so many people say they have had.
I use a lot of technology to quantitate my outcomes, good or bad. I would appreciate it if others would utilize similar technology to do the same. Enthusiasm is wonderful, but there is a need to realize when something is not working the way we hoped it would and realize a different take is needed to get a successful outcome. I have seen a lot of people chasing rainbows the last few years and it confuses me. I appreciate the capacity of strength and conditioning to improve outcomes for athletes, but, there are limitations to what can be achieved and maintained. I see the limitations daily with what I do and I try to refer to P.T. and strength coaches to assist my patients and athletes to achieve an overall better outcome.
I am regularly amazed that so many in the sports industry seem very anti-foot. I’m not really sure why this is, but my suspicion is that every podiatrist and many P.T.’s will put patients and athletes in an orthotic and often they do not work. Podiatrists are very bad about this and often don’t have a specific reasoning or a plan for why they chose to use their devices. I have a very specific reasoning pattern and evaluation process for doing what I do for my patients. I really try to have a method to my madness. I have a very good success rate, but not perfect by any means. I am always looking for a new way to improve my outcomes whether it is through a new modification to a device, a new mobilization technique or through partnering with a better team of sports minded individuals so that we can all work together to benefit our athletes.
When the foot hits the ground a complex reaction of joints, muscles, and neurological responses happen. Could you share your approach with both technology and experience when working with athletes?
I use F-Scan in-shoe pressure and Dartfish as well as another older video capture technology. I am starting to experiment with wireless emg and a nodular motion capture technology. In-shoe pressure can give you a tremendous amount of insight into how an athlete’s foot and lower extremity functions. There are however limitations to what the data can indicate. This is why I use video capture and why I’m experimenting with the nodular motion capture. It is important to know what the position of the hips, knees and lower extremity in general are doing for each step. Relating this to the trunk position can give you insight as well. Once you have enough gait data from the trunk on down, then you can really start to incorporate a plan for the athlete from the ground up. As you track going forward you should see what is working and what is not.
Wearable technology is being used now and will be utilized even more in the near future. It is important to start to work with this technology or to partner with those who do use it regularly. There are great benefits to quantifying evaluations and using wearable tech to validate plans of interventions is going to become the gold standard as we move forward.
You are familiar with different screens such as the FMS and traditional orthopedic assessments. Could you share your perspective on how some additional information from your methodology can help athletes reduce injuries?
FMS is a great screening tool and can give you quite a bit of information to help practitioners to formulate a plan for an athlete’s rehab or for their regular conditioning.
I have a basic screening tool that can assist or expand on the FMS as far as for evaluating the foot, ankle and lower extremity. If you can gain a better understanding of how the foot is structured and functions then you can start to get a much better understanding of how your interventional plans will work and whether you can expect realistic improvement.
I like to use a basic scale to discern the structure and stiffness of the foot along the medial and lateral columns. It is good to know the standing heel position of the foot, if there is any limb length difference left to right, and also the available range of motion of the big toe joints and the ankle joint. Just having these few basic points of information can start to give insight to why an athlete may be prone to stress fractures of the metatarsals, chronic ankle sprains, and even if they may be prone to knee injuries. Adding ranges of motion of the hips, and knees in static and walking gait can multiply your available knowledge base even more.
There are reasons and patterns for why some athletes get injured and why some do not. Quantifying as much of the structural components of the foot and lower extremity function is the best way to start to identify those patterns.
But for all the things and subject matter they disagree about, there is one thing that every coach certainly would agree on.
It's not sets or reps.
It's not the use of Olympic lifts, or periodization method, or even conditioning protocols.
The one thing that all coaches agree on is the struggle to program and plan for large number numbers of athletes in a consistent and easy manner.
It's the one thing that ALL strength coaches would agree upon.
And now, thanks to Cal Dietz and XL Athlete, coaches can spend more time on the floor coaching and less time plugging numbers into excel files or adjusting programs because of an athlete's injury or because a sport coach changed training times.
Click HERE to learn more about the XL Strength Program Developer.
See Cal Dietz along with more of the nation's top hockey strength coaches and keynote speakers including Craig Liebenson and Chris Powers at the 2012 BSMPG Summer Seminar this May 19th and 20th.
See Highlights from Coach Dietz's talk at the 2011 BSMPG summer seminar below.
There are only two weeks remaining before our 2012 BSMPG Summer Seminar, May 19th and 20th!!! We are almost at capacity, so register today before the last remaining seats are scooped up!
DO YOU WANT TO BE A LUCKY WINNER??
BSMPG will be hosting a VIP gathering Friday, May 18th during the afternoon and early evening featuring:
Seminar speakers, performance coaches from the NBA & NHL, college strength coaches from the top programs across the country, select area athletic trainers, and physical therapists as well as representatives from the top sport science companies... and hopefully YOU!!!
This is a closed event but BSMPG is opening its doors to 8 lucky registrants.Register prior to Friday, May 11th at Midnight and be eligible for additional lectures and breakout sessions Friday afternoon. In addition, winners will be invited to our pre-seminar speaker social Friday night!
What happens if I don’t get my name picked?
Don’t worry – with BSMPG everyone is a winner! Join seminar speakers and attendees for a post-seminar social Saturday night at Symphony 8 Bar and Restaurant immediately following the last lecture of the day. Hey... learning is hard work and you deserve some food and drink provided by OPTOSource.
Attendees will also be placed in a drawing for a chance to win sponsor prizes! Where else can you get free gear and free food?
Pre-Season Screening for Sport May 18th 4:00 - 5:15 pm
During the afternoon Jose Fernandez and Dr. Bruce Williams will do a live assessment of an athlete, followed by group discussion on best practices with screening. A focus on gait and lower body mechanics is the highlight, supported by both biochemical and biomechanics monitoring. Evidence based medicine and the latest advancements of technology, therapy, and sports performance methods will be covered. With the advent of Moneyball, Jose and Bruce will show how they look at risk analysis with athletes in team sports from both a time management perspective and decision making process.
Speaker Social to follow.
Winners will be informed of locations and additional details after drawing.
Friday Social Sponsored by:
TopCoder is the world’s largest competitive Open Innovation Community of digital creators with over 400,000 members representing algorithmists, software developers and creative artists from over 200 countries. The TopCoder Community creates digital assets including analytics, software and creative designs and solutions for a wide-ranging client base through a competitive, rigorous, standards based methodology. Combined with our extremely talented Community this groundbreaking methodology results in superior outcomes for our clients. For more information about sponsoring TopCoder events and utilizing TopCoder’s software services and platforms, visit www.topcoder.com.
“The residents who live here, according to the parable, began noticing increasing numbers of drowning people caught in the river’s swift current and so went to work inventing ever more elaborate technologies to resuscitate them. So preoccupied were these heroic villagers with rescue and treatment that they never thought to look UPSTREAM to see who was pushing the victims in.”
Learn what is hurting your feet and your performance, and how to finally train your feet the way they were meant to be.