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13 Articles in Volume 18, Issue #1
Applying a Collaborative Care Model to the Treatment of Chronic Pain and Depression
Assessing the Pain Triangle
Emerging Technologies in Rehabilitation Medicine
Gaming as a Tool for Pain Relief
Honoring Dr. Forest Tennant’s 50-Plus Years in Pain Management
Is There a Chronic Pain Personality Profile?
Managing Musculoskeletal Pain in Endurance Athletes
Managing Perioperative Pain
Nonparenteral Oxytocin, Erythromelalgia...Letters from the Minds of Peers and Patients
OSKA PEMF Pain Relief Device: A Mini Review Trial
Patient Communication & Opioid Prescribing in the New Year
What Opioid Shopping Means for Pain Practitioners
Would Patients Benefit from a Glucosamine/Chondroitin Supplement to Manage Knee Osteoarthritis Pain?

Managing Musculoskeletal Pain in Endurance Athletes

PCPs may play a crucial role in the correction and rehabilitation of sports-related abnormalities before acute pain becomes a chronic condition.
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Reported by Kristin Della Volpe

The popularity of endurance sports has grown steadily over the past several decades. From running and rowing to Ironman and century cycling events, the options for endurance training and competitive events are many. With the months of intense training required to compete in these events comes an increased risk of overuse sports injuries and resultant musculoskeletal pain. While prevention is the best treatment, equally important is early diagnosis of acute and chronic pain conditions and referral to sports medicine/musculoskeletal pain specialists and rehabilitation specialists.

Endurance athletes frequently first present to their primary care provider with acute/subacute, and sometimes chronic, injuries, such as musculoskeletal tendonitis or lower back pain, making a greater awareness of treatment options for common musculoskeletal pain conditions essential to care in this setting. In addition, it is important for primary care physicians to convince their patients of the importance of rehabilitation to correct musculoskeletal abnormalities and avoid improper training before acute/subacute conditions become chronic.

In endurance athletes, musculoskeletal injury occurs when repetitive, cumulative forces exceed the tissue’s ability to withstand such forces either due to isolated macrotrauma—such as a rotational injury to a joint, blunt trauma, or sudden overload causing a tear—or repetitive microtrauma—such as tendonitis, nerve compression, or stress fractures. Often, specific biomechanical or physiological factors predispose an athlete to injury.

This review provides treatment options for three isolated, but common sports-related musculoskeletal injuries in endurance athletes: plantar fasciitis, rotator-cuff tendonitis, and spine-related pain conditions. The authors discuss management from the perspective of a musculoskeletal pain physician and a physical therapist to provide a wide spectrum of approaches.

Case: Plantar Fasciitis


A 33-year-old woman training for her first half Ironman event presented with pain in the medial part of her distal heel that increased in severity when running and upon taking her first steps in the morning. She reported the pain as “stabbing” and “excruciating” in the heel segment. She was one-year postpartum, and 15 pounds over her prepregnancy weight.

The pain increased in severity over six weeks prior to presentation when she increased her running distance from 15 miles to more than 30 miles per week. She had no history of foot or ankle fracture, but reportedly “had twisted her ankle” in high school and college. At home, she walked barefoot on hardwood floors and purchased new running shoes at a chain sports store two months prior.

Her primary care provider prescribed oral nonsteroidal inflammatory drugs (NSAIDs) and suggested using a topical anesthetic, with little improvement found at two-week follow-up. The provider referred her to a physical medicine and rehabilitation (PM&R) specialist, who observed tight heel cords with mobility, and point tenderness with palpation, as well as positive Tinel’s sign at the right medial aspect of distal heel on the calcaneous.

The patient was diagnosed with subacute plantar fasciitis after the specialist noted thickening of the right plantar fascia (one-third to one-half larger in diameter compared to the left foot) on diagnostic ultrasound, with no abnormalities found on x-ray or motorsensory testing.

The PM&R physician administered a localized injection of anesthetic with a corticosteroid into the plantar fascia using ultrasound guidance, which lowered her pain score from 7 to 4 (out of 10), and advised her to stop running and switch to biking or swimming for two to four weeks. She was referred to a physical therapist who fitted her with orthotics and recommended wearing cushioned footwear (eg, sneakers) at home. She also was advised to purchase new sneakers with improved rear heel stability and motion control from a running store.

The physical therapist assisted her with active and passive stretching, recommended home stretching exercises and icing, and fitted her with low-dye taping at each visit to allow her to resume running, starting with short distances. Her symptoms resolved after four to six weeks and she was able to gradually increase her distance to her preinjury level over a period of two months, and eventually competed in a half Ironman event with no further symptoms.


Inflammatory stress syndrome typically presents as pain at the medial calcaneal origin of the plantar fascia (plantar aponeurosis). This syndrome, as exhibited in the case, is believed to be related to stress on plantar fascia from the weight of an activity combined with weight transfer up onto the toes, leading to metatarsal phalangeal joint extension with a windlass effect on the plantar fascia.1 It is a common cause of heel pain in runners, particularly in those with biomechanical abnormalities, such as excessive pronation or supination.2,3

Management Approaches

Relative Rest

Patients may be advised to decrease speed work and running hills or stairs, as well as the overall intensity, duration, and/or frequency of their exercise to permit healing. Biking or swimming may offer good options for cardiovascular exercise in patients determined to keep training.

Stretching & Strengthening

Calf and plantar fascia stretches should be gentle at first and more aggressive as inflammation decreases (see Figure 1A). Roller devices may be used in the office or at home to assist in stretching the plantar fascia, gastrocnemius, and soleus.

Once inflammation has subsided, patients may begin calf raises starting in a seated position and progressing to a standing position and eventually off an incline (eg, a step or platform) with weights added. Therabands also may be used to strengthen the calf, foot, and peroneal muscles.

Kinesio Taping & Low-Dye Strapping

Kinesio taping may be used to support the plantar fascia and arch. Rigid strapping may be used to hold and support the arch, allowing the patient to continue training (see Figure 1B).


Custom made or over-the-counter orthotics should be use to correct biomechanical abnormalities, such as excessive pronation or supination. Heel lifts and soft-gel heel cup inserts to reduce stress on the plantar fascia, as well as shoewear with rear heel motion control/stabilization, may be recommended.

Regenerative Medicine

In severe recalcitrant cases, platelet-rich plasma (PRP) or stem cell injections may be used to regenerate torn or pathological tendon/ligament tissue.


Icing, NSAIDs (oral or topical), cross-fiber/deep tissue massage, therapeutic ultrasound, transcutaneous electrical nerve stimulation (TENS–for modifying pain receptors, releasing endorphins, or stimulating muscle relaxation), gait analysis, and night splints or walking boots (if severe) may be helpful at the discretion of the clinician.

Last updated on: January 31, 2018
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