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HEEL PAIN IN THE RUNNING ATHLETE - The Podiatry Institute

HEEL PAIN IN THE RUNNING ATHLETE - The Podiatry Institute

HEEL PAIN IN THE RUNNING ATHLETE - The Podiatry

HEEL PAIN IN THE RUNNING ATHLETElntroductionThomas F. Smith, D.P.M.Dennis Martin, D.P.M.Millions of Americans are runninB or are involved insome form of athletic activity and will suffer from someform of injury. Aside from the knee joint, the heel and itsassociated tendons and ligamentous attachments is themost f requent site for injuries to occur. The athlete stressesthe body and specifically the foot and heel tissues toa far greater extent than more sedentary individuals. Toappropriately assess and treat conditions of the heel inathletes, the podiatrist must possess a thorough knowledgeof the f u nction and anatomy of the heel and relatedstructures. He must be able to translate that knowledgeto the foot function involved in the activity such as running,baseball, football, ballet, or aerobics. The gait cycleand f u nctionalfootdemandswillvary marked lyf rom sportto sport and activity to activity. The stress or demand m u stbe u nderstood in order to logically assess and treat cond i-tions and complaints about the heel in athletes.ln the paragraphs that follow we will concentrate on theath lete and heel p rob Iems. Anatomy, f u nctio n, and b io m e-chanics of the athlete and in particular the runner will bereviewed. Gait cycles and tips on evaluation are included.Points of interest concerning history taking of sports relatedactivity are reviewed. Recent advances in sports relatedresearch are included to highlight diagnosis andtreatmentapproaches. An anatomical approach to the differentialdiagnosis of conditions of the heel is presented.BiomechanicsRunning is basically a series of coordinated hops fromone foot to the other as a cycle of air-borne and supportphases takes place. During running the foot contacts theground 800-2000 times per mile at a force 2-4 times bodyweight(1). A range of possible strike patterns to absorbthis force atthe moment of footto grou nd contact are possible.Thefoot strikeof a runnervariesdepending on individualrunning style and class of runner. The heel is notnecessarily the point of initial grou nd contact. Actual footstrike can occur by any of three means:'1. forefoot strike,2. midfoot strike, and3. heel strike.Forefoot strike type ground contact during running isbest exemplif ied by a sprinting runner for maximal shortdistance speed. Approximately 57% of all runners areforefoot strikers. They tend to stress heel tissues not bygrou nd contact but by placi ng excessive stretch and stresson the Achilles tendon and plantar fascia as the ball of thefoot accepts ground contact at impact. Likewise midfootstrikers fail to assume body weight through the heel padexclusively. Cround force is assumed through the midfootregion as the entire foot contacts the ground from heelthrough forefoot. Th is bestdistributes theground contactforces and minimizes their effects on any particular areaof the foot.Approximately 15-20% of runners are midfoot strikers.Heel strikers comprise the majority of runners nearly 75-S0% (D. Milch personal communication). The ground-contact forces are assumed through the soft tissues andosseous structures of the heel and transferred proximallyinto the leg and d istally into the forefoot. This type of ru n-ning gait has manysimilaritiesand dissimilaritistowal ki ngtypegait. The walki ng and ru nn ing gait cycles are u niq ueand yet related events.The majority of runners utilize a heel contact much thesame as awalking type gait cycle. The forces placed on theheel are much greater in running than walking. The practitionershou Id observe the activity or ru n ning of a particularpatientto note the patient's running style. Once heelcontact has occurred, motion at the subtalar joint aids inshock absorption much as in walking gait. The amount ofcompensatory subtalar motion, however, differs significantlyfrom a running to walking type gait. Much moremotion of pronation and supination occurs during runningthan walking. The base of gait or distance betweenmalleoli at each step du ring the gaitcycle is a major reasonfor this increased subtalar motion in the running typeof gait.Normallythe baseof gait is2-3 inches in awalkingtypegait. This is narrowed to 0 inches or even a negative valueduring running. The negative value denotes a runningstyle where the foot is placed on the opposite side of acentral line of progression in a scissors type pattern. Carefulfrontal plane evaluation of running is needed to evaluatethis occurrence. A side to side lurch may be observedin pathologically severe negative base of gait striding patterns.The zero or mildly negative base of gait of the averagerunner places the heel strike at a greater degree ofvarus than does a normal walking gait cycle.249

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