How bad is Pepe's injury?

Of all the injuries Pepe's suffered with over the last year, perhaps the current episode of plantar fascia pain has the potential to be the most difficult. Last season he suffered with severe bruising of the thigh muscles; and this season he's already had two similar occurrences. As a defender, Pepe's going to be involved in a lot of physical contact so none of these really come as any surprise. This latest problem, however, isn't directly related to physical contact and is more of an overuse injury; with symptoms aggravated by repetitive movements and / or impact running. Pepe's condition has been reported in some quarters as being plantar fasciitis; while others including the official Real Madrid website describe the injury as being discomfort to the plantar fascia in his right foot. He last played against Real Betis ten days ago and hasn't trained since; he didn't play against Espanyol and neither has he been included in the squad for this weekend's game away to Granada.

Plantar fasciitis is the most common cause of heel pain in adult footballers and often results from altered biomechanics (D'Hooghe, 2015). The description refers to a chronic inflammation of the tissues on the underside of the foot, known as the plantar fascia. This is a long strap of fibrous tissue running from the base of the heel to the toes. It can easily be affected by repetitive movements and is inflammatory in nature. The origins of plantar fasciitis are difficult to diagnose. The player will report that the pain worsens with rest and is nearly always present first thing in the morning as is normal with inflammatory conditions. Once the player ‘gets going' the condition usually eases. Often players are able to train and play throughout the early stages of plantar fasciitis until it gets to the point where this becomes too painful. This happens because they don't tend to report the discomfort that occurs first thing in the morning since they've usually shrugged off the initial symptoms as being "tightness" or "stiffness" and by the time they get to the training ground the symptoms have eased. Differential diagnoses include stress fracture of the metatarsal bones or secondary inflammation as a result of Achilles tendinitis or tendinopathy (depending on the length of time symptoms of the Achilles have been present. The condition can also present as a strain or a minor tearing of the tissue and this can also result from overuse mechanisms leading to an excessive load being placed on the fascia itself.

Plantar fasciitis is typically associated with biomechanical imbalance and overload of the knees or calf muscles, frequently accompanies or is derived as a result of ‘shin splints', or arises as a direct result of over-pronation / supination of the foot. Normally over-pronation resulting from low arches presenting as a "flat foot" is more associated with plantar fasciitis than from supination arising from high arches. The condition tends to affect players who suffer with repeated lower limb injuries or in those with recurrent biomechanical issues or frequent strains of the leg muscles. Tightness of the posterior leg muscles - hamstrings add calf - has also been shown to be a contributing factor (Bolivar et al, 2013).

Plantar fasciitis can also arise after surgery for example as a result of training overload on return to active rehab. Although the common impression is of a straight-forward inflammation of the heel pad, true plantar fasciitis can strike anywhere between the heel and the insertion of the fascia as it meets the toes. It's probably most common in the middle part of the underfoot or in the heel pad; but can often affect both at the same time. It's an incredibly difficult condition to shake off and more often than not, just when you think you have shaken it off it returns with a vengeance.

Surgery is only indicated as a last resort once all other treatment options have been exhausted; but players suffering from plantar fasciitis are prone to frequent recurrence and this is something that anyone else suffering from it needs to bear in mind. Treatment options nowadays include injection therapy in addition to the usual physiotherapy treatment of stretching and massage but the condition is renowned for it's tendency to recur. Shockwave therapy, which can be an extremely painful although effective treatment is another option in cases of chronic recurrent plantar fasciitis, but an ultrasound scan is essential beforehand to ensure that the injuries tissues haven't been ruptured.

Shockwave therapy as treatment technique has been discussed at length over the past few years and differing opinions as to it's effectiveness are common. However, any player suffering with plantar fasciitis should also have a full biomechanical screening to identify any gait problems or muscle imbalance; since these are normally the most likely causes of symptoms. The condition is generally thought to resolve by itself in the fullness of time with treatment tailored to suit the individual circumstances of the player affected (Orchard, 2012).

Unfortunately I don't have the details of the exact condition that Pepe is suffering from at the moment, since I can only go on the medical reports released by the club. Perhaps understandably in today's climate football clubs don't want to give out too much information about players' injuries other than a basic description and this can make discussing injuries in depth difficult in terms of accuracy. However, reading between the lines it does appear that he's suffering from plantar fasciitis and as they say, his recovery will continue to be assessed. With regards to estimating when Pepe is likely to return to the team, this is even more difficult without having the relevant information to hand regarding the true extent of the injury. Symptoms of plantar fasciitis are so variable between different people that accurate comparisons with others who have had the condition are virtually impossible due to the variance between individuals. So in Pepe's case then, it's going to be very much a case of continuous assessment and ensuring that his rehab is only progressed at the appropriate stages

References:

Bolivar YA, Munuera PV, Padillo JP (2013). Relationship between Tightness of the Posterior Muscles of the Lower Limb and Plantar Fasciitis. Foot & Ankle International. Vol. 34 (1); 42 - 48.

D'Hooghe P (2015). Foot problems in football. In: Volpi P (2006). Football Traumatology; Current Concepts from Prevention to Treatment. Milan, Springer. 359 - 370.

Orchard J (2012). Plantar Fasciitis - Clinical Review. BMJ Online. BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6603 (Published 10 October 2012)