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Hi all,

I've been noticing a pattern of orthotic failure recently when treating a few patients with plantar fasciitis. Clinically these patients have presented with pain at the medial calcaneal tubercle on direct palpation with the ankle in maximum dorsiflexion and the hallux maximally dorsiflexed. They all follow the same pattern - ankle equinus, excessive stj pronation at heel strike, mid stance and propulsion, midtarsal instability and decreased 1st ray dorsiflexion stiffness (nearly said hypermobile 1st ray there!!! Sorry Kevin) with a gross reduction in hallux dorsiflexion nwb and wb.

My understanding of the treatment for medial plantar fasciitis is that we are attemping to control the forces which are causing the mla to elongate.
Namely, ankle equinus and its compensation, stj pronation and we are attempting to engage the windlass mechanism to allow plantarflexion of the 1st ray which effectively will create a solid lever arm for propulsion.

My treatment for this is gastroc & soleus stretches, p/f stretches and eccentric heel drops 3 times daily and casted functional foot orthotics with 4mm heel raises.

I choose a neutral suspension casting technique, applying dorsiflexion to resistance, midtarsus fully everted and hallux dorsiflexed to reduce the metatarus primus elevatus.

The 4mm polypro orthotic has a deep heel cup (16mm) a 3mm medial heel skive, a 4 degree varus post on the rearfoot, minimum arch fill and a 1st met cut out with a corex reverse mortons. I didn't feel the need for a p/f groove as the fascial band was not excessively prominant with hallux dorsiflection.

After 1 month the patient reports no improvement in symptoms.

Is it possible to help a patient with p/f whos gastroc equinus is not reducing with a daily stretching programme, who has a large degree of genu valgum bilaterally, is 70lbs overweight and has a hallux which is unable to dorsifex to re-engage the windlass effect?

Can anyone offer any advice on this one?

Cheers,
Scott Shand

Hi.
Your orthoses may be fOK, but if there are damaged soft tissue structures in the (I'd be V suprised if there weren't) you need to do something to resolve that. Orthoses and stretches are fine, but not always the complete answer.

Adhesions can and do form around damaged soft tissue, and deep transverse frictions are a good and safe way of reducing these.
Be warned though. You have to be gentle wihen applying these, and it can be a long process. I have one pt (slowly improving) with whom I have been working for 5 months. I expect complete resolution, but I estimate that this will take another 2/3 months.

Regards,
david

Dear Scott

If this person has genu valgum and hallux limitus or rigidus then how does the foot strike the ground if it is in an everted position then the 1st ray will experience rapid and early dorsiflexion moments from GRF therefore it may a good idea to look at lateral rear and f/foot posting (or perhaps vertical rearfoot) with a 1st ray c/o. This will move the CoP nearer to the lateral foot earlier in the gait cycle and so off load and reduce 1st ray d/flex moments and so reduce medial band PF tension.

Cheers Dave Smith

Scott

Sorry! meant to add - also a rocker sole for the hallux limitus /rigidus to improve saggital plane progression and reduce compesation of pronation and perhaps toeing out.

G'Day Dave

Hi Scott

Interesting stuff. I tend to feel that if I have done a good assessment and got a reasonable orthosis but there remains some residual issues then a number of thoughts occurr, the last of which is alteration to the orthosis:

1. Was I really dealing with plantar fasciitis or was it really an inflammation of some of the other muscles and tissues that arise from the same area. The orthosis has helped but essentially done all it is going to do by itself. This being the case then it is hands on work that may best be utilised. Lets face it, your patient is hugely over weight so why should there be just plantar fascial tissue involvement? . Also check for tenderness along the lower third of posterior tibialis tendon.

2. Although the pain may be focused on the origin of the fascia there is the likelihood that the remaining issue is lack of stretch in the tissues distal to the origin:

i.e the slips into the toes, the mid fascia area.

I never treat the origin ( or site of pain) alone but deal with the whole of the plantar fascia tissue. Lack of stretch (caused by possible adhesions in the slips or mid fascia) may still be affecting things at the origin.

3. Pain at the tubercle aspect of the calcaneum may be referred from trigger points in the proximal medial Gastrocnemius, Pain along the medial border of the heel may be referred from the medial distal aspect of soleus. In both instances they can respond to dry needeling acupuncture and gentle frictions massage combined.

4. Someone weight bearing in the way described may well have consequent restriction of joint rom due to a repeated tissue compression and consequent restriciton in the AJC. Friction the ligaments in the AJC and STJ areas. You could also mobilise the STJ, indeed all the joints of the foot to improve likely rom.

There are other things but hopefully this will fuel ideas befor the need to alter orthoses.


As a bit of a hobby horse of mine, and as someone who thinks everyone can benefit from orthotic intervention at some point in their lives, I do think our reliance on them as a modality can disenfranchise us of professional self esteem by making us forget our hands on work!!
Cheers
Ian

Thanks Dave,

I included a 1st cut out and corex reverse extension.Should this not aid sagital plane progression as much as a rocker?

Thanks

Thanks for the advice Ian,

Trigger point therapy it is then!

Regarding your closing statement. I can relate with what you are saying, "generally" as a profession we do prescribed foot orthotics to be the wonder cure for all foot related problems and this is clearly a shortsighted approach,not one that should be adopted.I didnt want to put across the message that if orthotics dont work for p/f then thats it.What really I was saying was that when you have a patient with ankle equinus,genu valgum,excessive stj pronation and hallux limtus, who is 70lbs overweight is it possible to succeed with orthotic therapy
My conclusion is it is unlikely that complete resolution of symptoms would follow given the inability of this device to control/limit the excessive force.

You may say that a more rigid shell with a greater degree of rearfoot varus posting,deeper heel cup,midfoot fill,met bar,medial flange with p/f groove etc would have worked but remember this is is a women unwilling to change to mens footwear or orthopaedic footwear!

Within the realms of possibility that was all of the correction that I could get away with, without bulking out the shoe too much.

Anyone seen similar problems?

Thanks again

Some patients that have long standing plantar fasciitis, are grossly obese and have occupations that demand long hours of standing or walking activities on hard surfaces, in my experience, do not do well with even the best foot orthoses. Alternative treatment options used along with foot orthoses generally work well for these patients such as a below knee cast or cam-walker style brace for 4-8 weeks, putting the patient on temporary disability from work to allow the plantar fascia to rest, cortisone injections, night splints, ESWT and then, finally, partial plantar fasciotomy.

Another treatment option, which I have thought may be a little inconvenient, is to tie about 10 large, helium-filled weather balloons to their belt so that the magnitude of ground reaction force on their foot and tensile forces in their plantar fascia are reduced to more physiologic values. I would imagine that this treatment option would make it quite difficult to get around inside the house, but could be a nice way to start conversations with strangers.......

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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Voice: (916) 925-8111 Fax: (916) 925-8136
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Scott
"I included a 1st cut out and corex reverse extension.Should this not aid sagital plane progression as much as a rocker?"

Is the limitus functional? if it is c/o and reverse ext should do it. If not, a rocker works better. What is the orientation of the foot to the ground at heel strike?

Cheers Dave

Dave,

unfortunately the blockage isnt functional,its limited to 15 degrees nwb.

I dont think her shoe wil accomadate a rocker.


cheers

scott

Kevin,

Do you currently sell these balloons through your lab?

Great idea,why didnt someone think of it earlier!!!!

I'll suggest it next week when i see her for a follow up.

Guess if I lose my job i can start a sideline in podiatric balloon therapy!!!

Cheers

Depending on how far the degeneration has progressed in the fascia, I feel a false plantar fascia taping can improve pain levels. I find that teaching a family member the taping seems to work if the skin is getting irritated and is best used on a daily basis. We have also found that soft orthoses (EVA) have seemed to work very well compared to harder EVA. We never use any functional foot orthoses for plantar fasciitis as have found the patients feel these to be too had, even with softer top cover's. This throws the BMx out the door, but is similar to what Craig has found in his research from what I understand.

You could also try plantar fascia stretches, there was an article in the Journal of Bone and Joint Surgery (American ed), try searching on here for it. I would do this in between the tapings.

I have been more thorough in my subjective assessment after reading an article on neurogenic heel pain. Any numbness when driving, or when lying in bed, sitting with fee on floor. (underlying position is the foot in plantarflexed and inverted position, compressing structures in the tarsal tunnel). Haven't got time to describe further, but light touch causing pain and tinels sign at the medial branch of the calcaneal nerve suggests there is possibility this nerve branch is the cause of pain.

Good luck!

Had similar experiences lately. However, the patients are not obese.
Only common thread I have found with these patients is rearfoot control (skive). Maybe there is certain structures and stages of planatar fasciitis that do not respond well to medial rearfoot control. Although all these patients meet the classic definition of plantar fasciitis, and present with all the right pains in the right places, they all have a level of unpredictable outcome. I have a feeling that plantar fasciitis is unfortunately to broad a term that includes many pathologies in the plantar medial heel. Further research is need to determine what structures are involved and we can clinically identify condition appropriately. With better understanding of structures involved then therapy can be more sharply refined to provide better patient outcomes. Just some ramblings that are bouncing around the cranium.

One thing that I would like to add is assessment of STJ axis position. There are some patients who have a more laterally deviated STJ axis that will respond with increased pronation in gait to a medial heel skive. So look at gait with and without the orthoses. Is there more supination with the orthoses? Although, significant genu valgum is rare with a laterally deviated STJ axis, it can happen.

I'm not familiar with the term eccentric heel drops. If this is standing with the forefoot on a stair and lowering the heel this would really strain the fascia.

We all have these patients. It sure looks like plantar fasciitis from what you have said.

Eric

The New Balance 925 has a geat intrinsic rocker and may not be bad for a large person. It is availabe in many widths. I almost always take the lace out and start on the 2nd eyelet for people having pf. The sooner you can get them off their 1st MT joint during gait, I believe the more help you can be in terms of reducing stress on the pf, assuming the orthoses are well designed to do that. From a problem solving ppoint of view, sometimes the shotgun method works for some of the really hard to solve patients having pf....that is the more options you can fling at the problem, sometimes, the more likeky these folks are to get better. Has anyone used the Strasburg sock with any amount of success?
regards,
Freeman

Could you explain the reasoning behind this???
Thanks

I take the lace out of the bottom eyelet, because a good number of people tie their shoes far too tight ( as well as fitting themselves too short.) A lace which is tied tighlty at the very bottom can act as a block to both desireable plantarflexion and dorsiflexion of the first ray. Like a misplaced retinaculuum. Years ago I can remember a person telling me they had less pain in their Birks than with their shoes on...I tried that lace method and had immediate improvment. This works very well for many met problems as well. I have had had very few people say it does not feel better. The purpose of shoe gear is to protect the foot from a harmful or uncomofrotable environment, not block function.
Regards
Freeman

Dear Scott (footdoctor),

You state below, "........ excessive STJ pronation at heel strike..." Are you saying that at heel strike the foot was not supinated at all?

Robert Scott Steinberg, DPM

Yes Robert,thats right!

I guess secondary to the excessive weight the patient is carrying,gross genu valgum and medially deviated stj axis her calc approaches the ground vertically but rapid calc eversion is shown on initial contact phase.Not really a suprise,do you find this abnormal considering the biomechanical status?

Scott

Scott,

I have a much better picture, now. At heel strike the calc is already at vertical. And, with her very large thighs, her legs are not under her hips, thus giving her an excessively wide base of support.

As you are finding out, this makes treating her PF very difficult. I wish I had a "magic bullet" for you, but I don't. I read the suggestions in this thread, and they should all be tried. Injections are appropriate. You need to tell the patient to have patience. If, at the end of 6 months her pain is at the level of 8/10, then it would be time to try high energy ESWT. Still, the fact that she is bearing all her weight on the medial plantar aspect of the calc does not bode well for her body to be able to repair the PF. I hesitate to suggest that should the ESWT fail, a partial release would be in order because, as I describe to my paitents, a partial release is like cutting a cable on the Golden Gate Bridge. It might not fall, but it will be unable to carry much weight. This brings us to the obvious, the patient needs to loose weight.

Robert Scott Steinberg, DPM