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Unhappy Feet

From: Gretchen Reynolds, New York Times
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Within the sports world, as elsewhere, sore feet don’t command much respect. “Athletes will play through a level of pain in their feet that, if they felt it in their knees or their shoulders, they’d be hammering at a surgeon’s door,” says Glenn Pfeffer, the director of the Foot and Ankle Center at Cedars-Sinai Medical Center in Los Angeles. Aching feet are the “forgotten stepchild” of sports injuries, he adds. Remember Lakers guard Kobe Bryant’s bout with plantar fasciitis, a painful heel condition, in 2004? Probably not, because the complaint, unpleasant as it was, didn’t constitute a very heroic sports story. When he experienced twinges in his back earlier this year, however, it made headlines.

The ignoble status that injured feet have among athletes is puzzling, because foot troubles aren’t just debilitating; in many sports they’re also common. A 2004 Duke University study of 26 N.C.A.A. men’s basketball players found six feet that showed signs of serious trauma upon M.R.I. examination. Two of the players hadn’t experienced foot pain, but the bone marrow in their metatarsals (the five long bones of the feet) was flooded with excess fluid, a possible early indicator of tissue and bone damage and often of an imminent stress fracture. One of them, in fact, developed a stress fracture not long after the study began and had to sit out the remainder of the season.

Additional research has found similar foot trauma from other sports, particularly running. A small but compelling 2003 study done in Brussels looked at the impact of running for 30 minutes a day for one week. The 10 subjects were new to the sport. Three showed slight signs of foot damage before the study. At the end of the week, half of the runners had either new or increased fluid accumulation in their bone marrow. After only seven days, the newbie joggers had pounded their feet into the earliest stages of stress fracture.

The foot is at such high risk for injury largely because it has so many small, frangible parts — 26 bones, 33 joints and more than 100 tendons, ligaments and muscles, any of which can fail. Nevertheless, under ideal conditions, feet are built to handle the abuse of even high-impact sports. “A healthy foot, like a car, has two ways to absorb pressure: it has pads and it has springs,” says Carol Frey, the director of orthopedic foot and ankle surgery at the West Coast Center for Orthopedic Surgery and Sports Medicine in Manhattan Beach, Calif. The pads are the cushiony pillows of fat beneath the heel and the ball of the foot. The springs are its tendons and ligaments, which flex and bend as the foot moves. Strong tendons and ligaments can withstand several times a person’s body weight — the force with which a foot can hit the ground while jumping or running downhill.

But as athletes reach their 30s or 40s, the fat pads that help to absorb impact start to thin. There’s no way to replump them permanently, although some foot doctors have tried injecting the soles of patients’ feet with collagen or other fillers. Meanwhile, the foot’s once-springy tendons and ligaments tighten up along with the rest of an athlete’s aging body. Foot tissues connect to those in the lower leg, particularly the Achilles’ tendon, that long, thick, tensile rope that binds the powerful muscles of the calf to the heel. If the tendon becomes inflexible, it pulls the calf muscles taut. It also strains the plantar fascia, the main ligament on the underside of the foot. Stretched too far, the plantar fascia becomes inflamed. This is the condition known as plantar fasciitis. If you’ve had it, you know how crippling this pain can be, especially in severe cases where plantar-fascia fibers shred away from the heel bone.

“I expect to return to running,” says Larry Green, a former amateur marathoner and triathlete from Orange County, Calif. “I’m not at the point where I want to give up.” But he has had reason to doubt whether it’s worth it. Last winter, Green was out for a run when he felt a sudden “ripping snap” deep in his foot. He’d partially torn some of the tissue that attaches to the plantar fascia, possibly as a result of a course of the antibiotic Ciprofloxacin, which has been associated with sudden tissue ruptures in tendons. Half a year later, he still needs his boot-size brace on occasion. “Your feet support your weight,” he says. “You don’t really think about that until they start to hurt. Then you can’t not think about it.”

Injuries to the plantar fascia and connected tissues are the most common foot ailment in athletes over 30. Many people, feeling the first stabs of heel pain from an injured fascia, switch to softer, looser athletic shoes, thinking that will cosset the foot and correct the problem. It does the opposite. “Adding soft cushioning beneath your feet increases instability,” says Douglas Richie, a podiatrist in Seal Beach, Calif., and a former president of the American Academy of Podiatric Sports Medicine. The unsupported foot rolls too much, and the tight tissues get pulled even tighter.

The best way to prevent and treat early-stage plantar fasciitis is simple and cheap: “Stretch, stretch, stretch,” Pfeffer says. “You need to loosen the tight calf and foot muscles.” Though some researchers have questioned the efficacy of stretching in general, that’s not the case when it comes to feet. The regimen of stretches recommended by most foot specialists isn’t strenuous: it involves such established exercises as dangling your heel from a stair step or grasping your bare toes and pulling them toward you. But it does require commitment. “I’d like to see people stretching three to four times a day,” Pfeffer says, “not two or three times a week, which is probably what most people consider enough.” (You can find stretching instructions at footankleinstitute.com.) Those with a more feckless attitude can invest in a ProStretch, a crescent-shaped plastic device that “does the stretching for you,” Frey says. It’s available at many drugstores and Web sites for less than $50.

Extremely tight Achilles’ tendons might respond to a technique called heavy-load eccentric training, in which you perform stretching exercises while carrying extra weight, like a backpack. To avoid injuring yourself further, though, don’t try this without the help of a physical therapist or trainer.

If stretching doesn’t provide relief, more drastic measures might be required, including a brace like the one Green uses. Custom orthotics, which raise the heel and reduce pressure from a tight Achilles’ tendon, can also help, but they’re pricey (often $400 or more), and some research has indicated that they’re no better in the long term for treating plantar fasciitis than the gel inserts you can buy at any Walgreens. A reputable sports podiatrist can tell you if your degree of injury calls for custom orthotics.

Two additional treatments for intractable heel pain have shown promise: one uses a radio-frequency probe to break up scar tissue along the fascia, and another merely deadens the nerves in the heel. “Plantar fasciitis is almost always self-limiting,” Richie says, meaning that it forces you to stay off your foot until it heals. “This technique allows the patient to get through the pain until the condition finally resolves.”

Not all foot problems, of course, involve the fascia. Millions of athletes suffer from such uncharismatic ailments as blisters, bunions, hammertoes, pinched nerves and that distance-runner’s nuisance, black, loosened toenails. Some of these complaints are caused by innate deficiencies in a person’s gait — landing on your toes and not your midfoot or heel, for instance, which sends the full jolt of the impact through the skinny bones of the forefoot and can cause stress fractures and other damage; or overpronation, a common problem in which the foot rolls too far inward during each stride. If you have low arches, you probably have a tendency to overpronate, so look for shoes that promise “motion control.”

Many foot injuries are, in fact, the result of wearing the wrong shoes or the wrong shoe size. Studies have suggested that Americans too often wear shoes that don’t fit, and athletes are no exception. Shoes that are too narrow through the toe box contribute directly to the formation of blisters and bunions. Those that are too short lead to hammertoes and blackened nails, and those in which the flex point of the shoe doesn’t hit exactly at the flex point of the foot can cause pinched nerves and stress fractures. To ensure that your shoes fit, shop at the end of the day, when feet are at their largest, and have your feet measured. “You can add a shoe size or more during adulthood,” Richie points out. If you have plantar fasciitis or other heel pain, he says, choose shoes that also have at least an inch of lift in the heel.

As for those balletic types who land on their toes while running, most foot experts suggest a consultation with a coach or trainer to correct your stride. With few exceptions, you could generate more power and speed, and avoid many metatarsal stress fractures, by learning to strike the ground nearer to your heel.

“The majority of sports-related foot injuries are preventable,” Pfeffer says, somewhat forlornly, “if people would just start paying attention.”

Dr. Douglas Richie graduated from Samuel Merritt College (SMC) California School of Podiatric Medicine (CSPM) formerly known as California College of Podiatric Medicine (CCPM), in 1980.

This article was originally posted in the New York Times. View the original article
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