Plantar Fasciitis in Sport

Plantar Fasciitis in Sport

21

Yousef Alrashidi, Alexej Barg, Manuel Kampmann, and Victor Valderrabano

Abstract

Plantar fasciitis is a common musculoskeletal condition among sport-active people. Careful history taking and appropriate clinical examination is essential to exclude other causes of plantar heel pain. Following a step-wise approach is recommended in plantar fasciitis treatment, as it is usually self-limiting condition. Inadequate response to non-operative treatment and persistence of symptoms more than 6 months may warrant surgical intervention. Provision of health instructions to athletes would help in prevention of plantar fasciitis. Athletes should watch for their training mistakes and should maintain good muscular strength and balance. Keywords

Plantar fasciitis • Plantar fasciopathy • Plantar fasciosis • Plantar fasciitis in athletes • Overuse foot injuries • Foot injuries • Heel pain in athletes

Introduction Plantar fasciitis (PF) is a common musculoskeletal condition among athletic and non-athletic people. It is characterized by the presence of morning plantar heel pain that is located at Y. Alrashidi, MBBS, SB-Orth (*) Orthopedic Surgery Department, Taibah University, College of Medicine, Almadinah Almunawwrah, Saudi Arabia Orthopaedic Department, SWISS ORTHO CENTER, Schmerzklinik Basel, Swiss Medical Network, Basel, Switzerland e-mail: [email protected] A. Barg, MD Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA e-mail: [email protected]

the inferomedial calcaneus, increases with walking initiation, disappears shortly after few steps, and goes back at the end of ambulation activity and at rest [1–3]. The onset of symptoms is usually preceded by activity change, shoe modification, weight change, or simple pedal trauma. Moreover, gastrocnemius-soleus contracture, tibio-talar joint stiffness and calcaneal spurs may be found in common with chronic cases that may lead to physical and financial negative consequences. Numbness, nocturnal pain, and swelling are ­occasionally ­present. [4]

Incidence

M. Kampmann Department of Musculoskeletal Radiology, Basel University Hospital, Petersgraben 4 CH-4031, Basel, Switzerland e-mail: [email protected] V. Valderrabano, MD, PhD Orthopaedic Department, SWISS ORTHO CENTER, Schmerzklinik Basel, Swiss Medical Network, Basel, Switzerland e-mail: [email protected]

It has been reported that one-tenth of people may suffer from symptoms of plantar fasciitis during their lifetime [5]. Bilateral PF may present in less than one-third of the cases [4]. Moreover, such a condition is one of the common chronic pedal overuse injuries especially in sports that involve repetitive trauma and complex motions [6, 7]. Up to authors’ knowledge, there is not clear reported figures showing the incidence rate among non-elite and elite athletes [6].

© Springer International Publishing Switzerland 2016 V. Valderrabano, M. Easley (eds.), Foot and Ankle Sports Orthopaedics, DOI 10.1007/978-3-319-15735-1_21

[email protected]

201

202

Y. Alrashidi et al.

Etiology and Pathomechanism

Symptoms

It is generally agreed that PF is a result of chronic process of frequent micro-tearing and inflammation due to tensile overload at the longitudinal plantar fascia, but recently it is more accepted to be a result of multiple factors [4, 8]. Histologically, the inflammatory cells are not seen in advanced cases. Failed attempts of tissue healing would result in disorganised vascularity along with areas of both regeneration and degradation. That also would result in additive damage at the cellular level [4]. The limited length of such a fascia and the tendency to plantar flex the ankle joint during dorsiflexion of the first toe could increase the loading forces on the plantar fascial insertion. Consequently, forefoot loading forces and time would increase. As a result, micro-injurymay persist and the process becomes chronic [9]. According to a level II prognostic study, it has been observed that PF is found in common with ankle dorsiflexion limitation as in gastrocnemius-soleus shortening, high body mass index, and jobs necessitating prolonged weight bearing (Table 21.1). Riddle et al described the association between PF with dorsiflexion limitation and body mass index as “dose dependent”[5]. Cavus deformity of foot may predispose to PF owing to the low flexibility of medial arch [10]. Moreover, longitudinal plantar arch morphology and hindfoot malalignment, which were believed to be important factors in development of PF, have been studied but conclusions were not decisive [2]. Some studies suggest that leg length inequality may predispose to development of compensatory motions that might increase the risk of pedal injuriesin runners [11]. Other studies found that competitive athletes are more liable to PF due to the use of spike sport-shoes and not due to grade of activity [10]. Overuse appears to be the likely factor in development of PF in sporty people [12]. When we look at PF as an overuse sport injury, there is no scientific agreement on how much sport exposure time that is considered as a risk factor for the development of such a condition. In other words, several previous reports represented exposure time units as years or seasons that do not necessarily indicate the actual time [6]. In fact, such types of studiesstudies may be liable to bias and inaccurate measurements [7].

Patients usually report plantar-medial heel pain, typically after a long weight-bearing phase. PF shows also a starting pain after resting or in the first steps in the morning, which alleviates after warming-up and, however, gets worse after significant stress load.

Table 21.1  Risk factors of plantar fasciitis 1. Ankle dorsiflexion limitation (e.g. gastrocnemius-soleus shortening) 2. High body mass index 3. Jobs necessitating prolonged weight bearing 4. Competitive sports using spike sport-shoes 5. Overuse 6. Cavus foot (not fully proved) 7. Flatfoot (not fully proved) 8. Limb length discrepancy in athletes

Classification In literature, up to authors’ knowledge, there is not yet a clear useful classification for PF. However, it is generally agreed to label a patient with persistent symptoms for more than 6 months in-spite of conservative therapy as “recalcitrant”. Moreover, a recent study proposed to classify PF as “insertional” or “non-insertional” depending upon the ultrasonic picture. Such a classification may help revisit the current therapeutic guidelines [13].

Diagnostics PF is an important differential diagnosis for plantar heel pain. So, careful history taking, appropriate physical examination and investigations should aim to rule out other causes such as stress fracture, compression neuropathies (e.g. Baxter’s nerve entrapment), infection of calcaneus, calcaneal bursitis, systemic arthritis syndromes, localised osteoarthritis [14]. The classical tender point of PF is plantar-medial, distally of the plantar medial calcaneal tuberosity. Comparted to it, Baxter’s nerve entrapment (first branch of the lateral plantar nerve) has the typical tender point more proximally and medially [15]. In junior athletes, PF could be mistaken for apophysitis of calcaneus where the tender point is clear on the calcaneus [16]. One of the useful tests is the toes dorsiflexion test, which cause a stretch pain on the plantar fascia. Further examination shall include assessment of a possible heel cord contracture (with knee extension and heel varisation), hindfoot alignment and foot arch evaluation. Plain radiographs are less likely to help in reaching the diagnosis. However, calcaneal spur may be found radiologically at the medial calcaneal tuberosity, anatomically corresponding to the origin area of the flexor digitorum brevis muscle and not plantar fascia (Fig. 21.1). But its presence may not indicate the origin of patient’s complaint [16]. However, presence of calcaneal spur may reflect chronicity of the problem and longer time needed for recovery [17]. Magnetic resonance imaging (MRI) can confirm PF diagnosis and rule other causes of plantar heel pain because of its significantly high sensitivity and specificity. Thickening,

[email protected]

21  Plantar Fasciitis in Sport

203

Fig. 21.2  MRI diagnostics. Sagittal PD fs image in a 52-year-old female that demostrates calcaneal spur, ill-defined calcaneal bone marrow edema, diffuse soft-tissue edema superficial to origin of plantar fascia, and hyperintense signal within plantar fascia close to its origin

Therapy Fig. 21.1  Conventional X-ray. Lateral view in a 51-year-old female which shows a calcaneal spur

partial tears and edema of the fascia are characteristic MRI changes in PF (Fig. 21.2) [4]. Bone scan (Technetium-99) or single photon emission computerised tomography (SPECT-CT) may help to differentiate PF from calcaneal stress fracture (Fig. 21.3) [4, 18]. It may show localised high uptake over the medial calcaneal surface in case of PF but non-localized with higher intensity in calcaneal stress fracture. Bone scan is less specific than MRI [4]. Ultrasound is a very useful and promising modality of imaging. It is a fast tool to confirm the diagnosis and not painful. It can be used for follow-up and monitoring the improvement after initiation of therapy. However, it is operator-­dependent. The presence of hypoechoic foci and discontinuity of fascial bundles are characteristic ultrasonic changes for PF [4]. Laboratory workup should be considered in bilateral cases, in case of failed non-operative therapy and if a systemic disease is suspected. Moreover, advanced neurological assessment has to be kept in mind in the presence of significant neurological findings [4, 17].

PF is well known to be usually a self- limited condition that may resolve within 12 months. So, efforts should be directed towards a simple, a safe and low-cost way of treatment [8]. In-spite of use of different combination of treatments, about one tenth of cases may fail to respond to conservative treatment [4]. In fact, there is not enough studies to support superiority of one modality of treatment over others (Table 21.2). For plantar heel pain management, the first level of treatment would include the use of non-steroidal anti-inflammatory drugs (NASAIDs), specific physical exercises, foot insoles, night splints, and patient’s instructions to lose weight, restrict some activities, and not to use flat shoes or walk barefoot [17]. According to a randomized clinical study, it has been suggested that the use of NSAIDs in the non-operative protocol might help decrease suffering of patients in terms of good pain relief and better function [19]. Because of the negative impact of heel cord tightness on the plantar fascia through windlass phenomenon and through increasing forefoot loading, heel cord-specific stretching exercises have been recommended [9]. However, those exercises are not unique for recreating windlass phenomenon and are usually done after the initiation of walking. In other

[email protected]

204

Y. Alrashidi et al.

a

b

Fig. 21.3  SPECT-CT diagnostics. (a) Sagittal reconstruction of CT scan and (b) fused colored SPECT-CT in a 53-year-old female. Note the calcaneal spur. The scan also demonstrates increased bone turnover at the origin of the plantar fascia related to a plantar fasciitis. Also, there is

an incidental finding of degenerative changes of TMT joint. Abbreviations: MRI magnetic resonance imaging, SPECT-CT single photon emission computerised tomography, CT computerized tomography, PD fs proton density weighted fat saturated, TMT tarso-meta-tarsal

Table 21.2  Treatment recommendation Step-wise recommended approach for plantar fasciitis treatment First level 1. NSAIDs 2. Physiotherapy (Achilles and plantar fascia specific exercises) 3. Insoles to deload the calcaneal plantarprint and correct medical arch deformities Second level 1. ESWT Third level 2. PRP injection Fourth level 3. Corticosteroid injection (only once) Fifth level 4. Temporary immobilization (cast/walker) with PWB Sixth level 5. Surgery

Evidence: grade of recommendation [14] B A B A C B C [17] C

NSAIDs non-steroidal anti-inflammatory drugs, ESWT extracorporeal shock wave therapy, PRP Platelet Rich Plasma, PWB partial weight bearing

words, according to a level I randomised controlled trial, it is recommended to do plantar fascia-specific stretching maneuvers before initiation of walking in the morning in order to help inhibit the process of inflammation and micro tearing [20]. Moreover, those specific maneuvers are so advantageous in terms of improving the compliance of patients because those maneuvers can be done at any time before initiation of walking and theyare not weight bearing [20]. The goal of prescribing foot insoles in PF is to lower stress loading on the longitudinal plantar fascia through hindfoot elevation and supporting the medial arch. In addition, they help in distributing and absorbing weight of the body over the plantar fascia attachments [8]. The aim of night splints is to keep the Achilles tendon and longitudinal fascial length in an extended position during night [17];so, that would give a chance for tissue healing at a good length and appropriate tension [12]. There is not enough high level studies to support significantly the use of acupuncture, ice therapy, heat therapy, or magnetic insoles in PF. [8].

The extracorporeal shock wave therapy (ESWT) is considered after exhausting all of the previous conservative modalities over more than a half a year [17]. ESWT is considered to be very advantageous and a good alternative to the surgical options. According to recent high-level studies, ESWT is a safe and effective way of treatment in chronic PF. In addition, it has minor complications and short time to recovery as it is a non-invasive modality [21–23]. Moreover, it can be used as an outpatient treatment [22]. Consequently, it can help in reducing health care expenses and jeopardy of work-­time [23]. It was proposed that patients during or after ESWT treatment are not in need to stop their daily life works or even their athletic activities [22, 23]. The effective and safe therapeutic protocol of radial ESWT has been found to be three consecutive doses (3 × 2000 impulses, 0.16 mJ/mm2) focused on the area of maximum tenderness without the need for any anaesthesia [22]. In addition, according to level I studies, the utilization of focused ESWT has been found to be effective in PF treatment especially if given in high doses [21].

[email protected]

21  Plantar Fasciitis in Sport

205

Platelet Rich Plasma (PRP) injection seems to be a safer modality of injection than corticosteroids. It is suggested that PRP effect addresses the collagen catabolism and disturbed vascularity in chronic PF [4]. According to a recent randomised blinded study, it is recommended to continue on specific stretching exercises after PRP injection in order to get the best outcome. A recent systematic review suggested that PRP injection may be of a superiority over a pure nonoperative therapy in the course of treatment PF [24]. However, further high-level studies are needed to estimate the appropriate candidate, timing, injection dose, local efficacy and systematic impacts on the body [4, 24]. Corticosteroid injection is suggested that it modulates the ultrasonic picture of the disease by decreasing the thickness of plantar fascia and formation of hypoechoic foci. Corticosteroids can be administered in the form of a single dose injected from medial to avoid fad pad atrophy. [14]. However, potentially serious complications have been documented like plantar fascia rupture [4]. Other possible complications include fat pad atrophy post-procedure pain and calcifications of the plantar longitudinal fascia [14]. If minimal or no positive response to previous modalities, limb immobilization for 4–6 weeks can be considered by using a splint or a walker [14].

flatfoot [25]. It has been suggested to limit the fascial release up to 40% to minimize the risk of medial arch instability, lateral column pain, and consequently gait changes [25]. However, complete release of plantar fascia with proximal and distal release of tarsal tunnel is recommended in patients with history of partial release surgery or if plantar fascia is attenuated. This way may address the underlying pathological aetiology [15]. Minimally invasive techniques are advantageous over open technique in terms of simplicity, cost-effectiveness, faster recovery, fewer complications and have a good to excellent outcome [25]. Intra-operatively, percutaneous release of medial part of the plantar fascia has to be done while toes are in a dorsiflexed position and confirmed by feeling the fall of medial band tension [27]. Moreover, endoscopic release is a promising alternative to open procedures in PF and seems to be a safe modality [25]. Postoperative complications of endoscopic techniques may include persistent hindfoot pain, stress fractures, skin problems, entrapment of nerves and infection [28]. Moreover, many of relevant studies have some limitations; so, there is a need for further high-quality studies to ascertain the best procedure candidates, best portal system and timing of intervention [28]. Outcome studies of plantar fasciitis release in athletes are limited [29]. In a study by Leach et al, fourteen out fifteen Surgical Treatment athletes were able return to full sport activity within 9 weeks after they underwent open plantar fascia release followed by The necessity of surgical treatment in PF is rare (around in 2 weeks of limb immobilisation postoperatively [30]. It is 5 % of the cases). Inadequate response to non-operative treat- still believed that limb immobilization after surgery may ment and persistence of symptoms more than half a year may play a major role in decreasing the after-surgery consewarrant surgical intervention [15, 17, 25]. Presence of medi- quences [29]. In a comparative study by Zimmerman et al, it cal comorbidities, infection, inadequate limb vascularity, has been found that patients who started immediate postopshort or deficient conservative course of treatment, non-­ erative weight bearing in a cast for 2 weeks after endoscopic compliance of patient to non-operative treatment, or unclear release had a shorter time to return to sports and favourable patient’s expectations are relative contraindications for sur- patient’s satisfaction [31]. gery. However, the need for nerve decompression should be considered in the presence of neurologic manifestations [15]. Plantar fascia release can be done by an open or minimally Rehabilitation and Back-to-Sports invasive techniques [25]. The open technique may involve debridement, extensive After surgery, weight-bearing is allowed as tolerated accordor partial release of the plantar fascia [25]. Such a technique ing to individual patient’s pain. Slight careful physiotherapy offers generous view of the anatomic structures [26]. Under exercises are important to maintain the fascia release. After 2 general or local anaesthesia, a transverse 3 cm skin incision is weeks of sports break, low-impact sports are permitted, indimade over the medial side of the hindfoot. Then, careful dis- vidually increasing to force and endurance training and highsection is carried out until the medial part of the plantar fascia impact sports. is reached. Once the plantar fascia is identified, a transverse incision of about one third of the medial part is made using a blade or Mayo scissors. Then, irrigation and closure in layer Prevention is done. Such a procedure may also involve excision of calcaneal spurs in the area of the flexor digitorum brevis origin As any overuse injury, PF prevention in sport active people is [27]. Possible complications are not limited to nerve injury, recommended. Athletes should watch for training mistakes pain syndromes, infection (superficial or deep), wound dehis- and not use extremes of load. Good muscular strengthening cence, stress fracture (calcaneal or metatarsal) or iatrogenic of lower limbs may help prevent muscular imbalance that

[email protected]

206

Y. Alrashidi et al.

could be a factor in overuse injuries. Furthermore, full recovery from any injury is advised before engaging in any competitive sport [32]. An appropriate clinical assessment of sport-active people and providing health instructions would help to prevent plantar fasciitis especially in athletes who have a history of such a condition [33].

Evidence Table 21.2 shows grades of evidence in Plantar Fasciitis different modalities of treatment. Literature source for evidence: –– Martinelli N, Bonifacini C, Romeo G. Current therapeutic approaches for plantar fasciitis. Orthop Res Rev. 2014;6:33–40. –– Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg: Off Publ Am Coll Foot Ankle Surg. 2010;49 (3 Suppl):S1–19.

Summary 1. Plantar fasciitis is a common musculoskeletal condition among sport-active people. 2. Careful history taking and appropriate clinical examination is essential to exclude other causes of plantar heel pain. 3. Following a step-wise approach is recommended in plantar fasciitis treatment, as it is usually self-limiting condition. 4. Inadequate response to non-operative treatment and persistence of symptoms more than 6 months may warrant surgical intervention 5. Provision of health instructions to athletes would help in prevention of plantar fasciitis. Athletes should watch for their training mistakes and should maintain good muscular strength and balance.

References 1. Greve JM, Grecco MV, Santos-Silva PR. Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis. Clinics. 2009;64(2):97–103. 2. Ribeiro AP, Trombini-Souza F, Tessutti V, Rodrigues Lima F, Sacco Ide C, Joao SM. Rearfoot alignment and medial longitudinal arch configurations of runners with symptoms and histories of plantar fasciitis. Clinics. 2011;66(6):1027–33. 3. Kindred J, Trubey C, Simons SM. Foot injuries in runners. Curr Sports Med Rep. 2011;10(5):249–54. 4. Monto RR. Platelet-rich plasma and plantar fasciitis. Sports Med Arthrosc Rev. 2013;21(4):220–4.

5. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85-A(5):872–7. 6. Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse injuries in sports: a systematic review. Scand J Med Sci Sports. 2013;23(6):669–86. 7. Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int. 2008;29(7):671–6. 8. Stuber K, Kristmanson K. Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials. J Can Chiropr Assoc. 2006;50(2):118–33. 9. Harty J, Soffe K, O’Toole G, Stephens MM. The role of hamstring tightness in plantar fasciitis. Foot Ankle Int. 2005;26(12):1089–92. 10. Francesco D, Caprio RB, Massimiliano M, Antonino C, Sandro G. Foot and lower limb diseases in runners: assessment of risk factors. J Sports Sci Med. 2010;9:10. 11. Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc. 1988;20(5):501–5. 12. Karagounis P, Tsironi M, Prionas G, Tsiganos G, Baltopoulos P. Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols. Foot Ankle Spec. 2011;4(4):226–34. 13. Ieong E, Afolayan J, Carne A, Solan M. Ultrasound scanning for recalcitrant plantar fasciopathy. Basis of a new classification. Skeletal Radiol. 2013;42(3):393–8. 14. Martinelli N, Bonifacini C, Romeo G. Current therapeutic approaches for plantar fasciitis. Orthop Res Rev. 2014;6:33–40. 15. DiGiovanni BF, Dawson LK, Baumhauer JF. Plantar Heel Pain. In: Coughlin MJ, Saltzman CL, Anderson RB, editors. Mann’s Surgery of the Foot and Ankle. 1. 9 ed. Philadelphia: Elsevier Saunders; 2014. p. 688. 16. Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999;31(7 Suppl):S470–86. 17. Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg. 2010;49(3 Suppl):S1–19. 18. Nathan M, Mohan H, Vijayanathan S, Fogelman I, Gnanasegaran G. The role of 99mTc-diphosphonate bone SPECT/CT in the ankle and foot. Nucl Med Commun. 2012;33(8):799–807. 19. Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-­controlled study. Foot Ankle Int. 2007;28(1):20–3. 20. DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85-A(7):1270–7. 21. Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med. 2014;48(21):1538–42. 22. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil Jr L, Weil Sr L, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36(11):2100–9. 23. Kudo P, Dainty K, Clarfield M, Coughlin L, Lavoie P, Lebrun C. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. J Orthop Res Off Publ Orthop Res Soc. 2006;24(2):115–23. 24. Franceschi F, Papalia R, Franceschetti E, Paciotti M, Maffulli N, Denaro V. Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull. 2014;112(1):83–95.

[email protected]

21  Plantar Fasciitis in Sport

207

25. Nery C, Raduan F, Mansur N, Baunfeld D, Del Buono A, Maffulli N. Endoscopic approach for plantar fasciopathy: a long-term retrospective study. Int Orthop. 2013;37(6):1151–6. 26. Mook WR, Gay T, Parekh SG. Extensile decompression of the proximal and distal tarsal tunnel combined with partial plantar fascia release in the treatment of chronic plantar heel pain. Foot Ankle Spec. 2013;6(1):27–35. 27. Fallat LM, Cox JT, Chahal R, Morrison P, Kish J. A retrospective comparison of percutaneous plantar fasciotomy and open plantar fasciotomy with heel spur resection. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg. 2013;52(3):288–90. 28. Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int. 2004;25(12):875–81.

29. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25(12):882–9. 30. Leach RE, Seavey MS, Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle. 1986;7(3):156–61. 31. Zimmerman BJ, Cardinal MD, Cragel MD, Goel AR, Lane JW, Schramm KA. Comparison of three types of postoperative management for endoscopic plantar fasciotomy. A retrospective study. J Am Podiatr Med Assoc. 2000;90(5):247–51. 32. Fredericson M, Misra AK. Epidemiology and aetiology of marathon running injuries. Sports Med. 2007;37(4–5):437–9. 33. Rome K, Howe T, Haslock I. Risk factors associated with the development of plantar heel pain in athletes. The Foot. 2001;11: 119–25.

[email protected]