Should Albert Pujols have foot surgery?

Sydney Yau, DPM @sydneyyau

Los Angeles Angels baseball player Albert Pujols has been suffering with plantar fasciitis on and off for 7 years.  It has recently prevented him from playing on the field as a first baseman, as he is limited to being a designated hitter.  It is bothering him so much that he is now considering surgery in the offseason to help his problem.  As reported by Bill Shaikin in the Los Angeles Times, Pujols may be considering surgery to help relieve him of this problem.

The question is: Should Pujols have foot surgery?

What is plantar fasciitis and what can cause it?

The plantar fascia is a strong ligament on the bottom of the foot that attaches to the heel bone (calcaneus) and fans towards the toes of the foot along the arch.  It consists of 3 main bands of tissue - the medial band along the inside of the arch, the central band along the center of the arch and the lateral band along the outside of the arch.  The plantar fascia is a strong and elastic ligament and is responsible for maintaining the arch during gait.  Plantar fasciitis occurs when the ligament becomes inflamed mainly from overuse.  The medial band is the one that is most often affected.  The plantar fascia can be overused from abnormal loads on the foot or from normal loads repetitively on a mechanically faulty foot.  Flat feet, for example, cause the plantar fascia to elongate when weight bearing, causing the ligament to pull at the heel bone.  This may cause micro-tears and scarring in the fascia causing pain.  Another cause of plantar fasciitis is a tight Achilles tendon.  The Achilles is the strongest tendon in the body and tends to tighten as we get older.  Since the Achilles also attaches to the heel bone, it indirectly pulls at the plantar fascia, causing it to tighten further.

How is plantar fasciitis treated? 

Plantar fasciitis improves with conservative treatment most of the time.  Physical therapy to help reduce inflammation in the heel and to help stretch the calf muscle aids in reducing the tension and pain in the fascia.  An orthotic, or custom insole, can help reduce strain along the fascia by supporting the arch.  Steroid injections can also help reduce inflammation, but that is often more of a band-aid solution as it does not address the underlying cause of the issue.  Steroid injections can also weaken the fascia if done too often.

Now, Pujols has had this issue on and off for 7 years and he has quality professional trainers and therapists at his disposal.  It was reported that he has recently tried orthotics to reduce strain on the fascia as well.  However, despite conservative treatments, he is still in pain and unable to play in the field.  Why?

Chronic plantar fasciosis 

When conservative treatment does not help it is thought that the problem has become a chronic problem and the acute phase of plantar fasciitis becomes plantar fasciosis.  Plantar fasciosis is a non-inflammatory problem.  The acute phase, or inflammatory phase, of plantar fasciitis lasts anywhere from 3 to 6 months.  During the acute phase, the body sends various inflammatory cells to the area of injury to help with healing.  After a period of time, the body stops responding to the area of injury if it does not appear to be working and the area may begin to degenerate.  Pujols reportedly has had this problem on and off for 7 years and likely has plantar fasciosis - not plantar fasciitis.

How is plantar fasciosis treated? 

Plantar fasciosis is treated by converting the chronic problem into an acute problem.  For the plantar fascia, this is done in a variety of methods.

Shockwave therapy 

Shockwave therapy has shown promising results in various studies (1-4).  Shockwave treatment involves a series of low-energy (or sometimes high-energy) waves that are applied to the plantar fascia.  This promotes new blood growth into the area and effectively changes the chronic problem into an acute problem.  

Platelet-rich plasma injection

Several authors have found positive results with platelet-rich plasma injections for plantar fasciosis (5, 6).  Platelet rich plasma is plasma that consists of many of the body's growth factors and inflammatory cells that are present in an acute phase of an injury.  The platelet rich plasma is derived from the patient's own blood and separated from the rest of the blood through a centrifuge.  Once the platelet rich plasma is isolated, it is injected into the plantar fascia and effectively creates a local acute inflammatory
response that will help heal the fascia.

Topaz micro-ablation 

Topaz is another method to create an acute injury in a chronically painful plantar fascia by poking small holes into the fascia through the skin with a special probe.  This special radiofrequency probe is able to stimulate the tissue and stimulate new blood flow and inflammatory cells to the plantar fascia.

Release of plantar fascia 

If all else fails, the last resort for plantar fasciosis is to surgically release the plantar fascia and has had good success rates as well (1, 9).  This can be done through small incisions with an endoscopic camera to visualize the fascia before it is cut.  Only part of the plantar fascia (medial band) is cut so that other portions of the ligament (central and lateral bands) can still support the arch.  However, by cutting the medial band of the fascia, the integrity of the fascia is weakened and it may lead to pain along the outside of the foot.

Conclusion - what should Albert do?

So should Albert Pujols have surgery?  If so - which surgery would be most successful?

Since Pujols has been suffering from this ailment on and off for 7 years, I believe he has plantar fasciosis which is a chronic, or non-inflammatory, problem.  Due to this, most conservative treatments (which focus on reducing inflammation) do not work as there are no inflammatory cells to reduce.  Therefore, the chronic problem needs to be changed back into an acute problem for the best results.  I think Albert Pujols would benefit from shockwave therapy, platelet-rich plasma, or topaz micro-ablation in the off season.  These methods do not affect the integrity of the arch and all have minimal side effects.  Releasing the fascia would also be effective, but the procedure is more invasive and requires compromising the integrity of the fascia.  I believe that releasing the fascia should be a last resort should the other procedures fail.  Pujols should have plenty of time to recover from any procedure he does in the off season and hopefully we'll see him out on the field more often next year and not solely as a designated hitter!

References:

1. Saxena A, Fournier M, Gerdesmeyer L, Golleitzer H.  Comparison between extracorporal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete.  Muscles Ligaments Tendons J. 2013, 21; 2(4): 312-316
2. Chuckpaiwong B, Berkson EM, Theodore GH.  Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.  J Foot Ankle Surg.  2009; 48(2):148-55
3. Ogden JA, Alvarez RG, Marlow M.  Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.  Foot Ankle Int. 2002; 23(4):301-8
4. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H. 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.
5.  Martinelli N, Marinozzi A, et al.  Platelet-rich plasma injections for chronic plantar fasciitis.  Int Orthop.  2013; 37(5):839-42
6. Regab EM, Othman AM.  Platelets rich plasma for treatment of chronic plantar fasciitis.  Arch Orthop Trauma Surg.  2012; 132(8): 1965-70
7. Weil L Jr, Glover JP, Weil LS Se.  A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis.  Foot Ankle Spec. 2008; 1(1): 13-8
8. Sorensen MD, Hyer CF, Philbin TM.  Percutaneous bipolar radiofrequency microdebridement for recalcitrant proximal plantar fasciosis.  J Foot Ankle Surg. 2011; 50(2): 165-70
9.  Lundeen RP, Aziz S, Burks JB, Rose JM.  Endoscopic plantar fasciotomy: a retrospective analysis of results in 53 patients.  J Foot Ankle Surg 2000; 39(4): 208-17