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The obvious negatives are the detrimental impact on the windlass mechanism as the 1st ray is shoved into a relatively dorsi-flexed position.
But does anybody use them, and if so, in what clinical circumstance?
If (and we think we know why) forefoot varus posts are that detrimental, why was this addition persisted with for decades, and why did such devices presumably not exacerbate patient's symptoms?
As clinicians, we may not know what component is working, but if something on the whole exacerbates our patient's condition, we swiftly either alter it, or dispense with the whole intervention avenue. In other words, if an orthotic device with a forefoot varus post was that terrible, the patient would have returned worse-off, forcing the clinician to change the prescription.
The only time in recent years I have used a forefoot varus or medial post is in those with a structural hallux limitus and I want to create some sort of rocker to facilitate motion.
Yes, I used to use a lot of forefoot varus posts in the early days. Patients did seem to get better - also had some dramatic failures. Those that got better, I think, did so not because of the varus post, but despite it (ie the rearfoot post; etc was the reason for symptom reduction). In those days I used to think I knew what I was doing I just do not see the dramatic failures anymore... As I said in the thread on ESWT I used to use ESWT for plantar fasciitis in few years back, but just do not need to anymore as we have got that much better with our orthotics intervention (almost everyone routinely gets valgus forefoot posting for plantar fasciitis)
When I first graduated I used to see a lot of forefoot varus and now I almost never see it. Either the human spieces has evolved since I graduated (where is Bob Kidd when you need him?) or I used to get it wrong.
The students seem to see a lot of forefoot varus, but never when I am around .... don't figure (I recall one student, Zac, who was so impressed with me as I could diagnose that a patient did not have a forefoot varus through the wall without even looking at them )
Mert Root used to experiment a lot on this. The original "Root" orthotic was very much narrower than what we use today. Mert found by trial and error that back pain often developed if first ray plantarflexion was inhibited by the foot orthoses....
We have data on a whole lot of subjects who did not need a forefoot varus post, but we gave them one anyway....we have rearfoot motion and plantar force/time data in these people with and without the post .... just have not yet analysed the data ...
We have shown that in those with plantar fasciitis, the forces needed to get the windlass established are higher - forefoot valgus posts (2-5 bars; reverse mortons extensions) reduce that force. The also induce the changes in the force/time curves I alluded to in this thread that are prospectively associated with a reduction in symptoms. Its nothing new - more and more have been changing their clinical practice to this based on experience. What is new is the research is catching up.
forefoot varus posts for polysyndactyly of halluces
greetings, i treat a family with modified forefoot varus posts, they have an autosomal dominant polysyndactyly / syndactyly bilateral / 1,2,3
for the father a 4-2 varus with a plateaued 1st ray gives him relief from his 1st mpj pain, he maintains a dorsiflexion range of greater than 65 deg. bilaterally, i am looking at them right now, all the best, mark c
Craig,
in your clinical research, did you find or explore (aside from the forefoot valgus post/bar), other mechanical devices eg. met dome, cuboid padding that reduce the force needed to activate the windlass mechanism.
Bartold states in Sport Health 1997 10(3):18 “Plantar fasciitis is predominantly a mechanical injury and the basis for treatment…elimination of the inflammatory process by reducing tension on the plantar fascia and associated structures”
Simon went on to describe a modified low Dye taping method which plantar flexes the first ray and/or everts the forefoot. .
Bartold S. Conservative Management of Plantar Fasciitis Sport Health 1997:10(3):17-20 ,P 18 Rationale of Taping Procedure.
1 reinforces the the PF both statically and dynamically
2 Facilitates the action of PL which stabilises the First Ray
3 Provides compression
4 Plantar flexes the forefoot on the rearfoot, thereby increasing the calcaneal inclination angle
5 Inverts the calcaneus beyond vertical
6 Reduces the midtarsal joint oblique and long axis motion.
Fuller E 2000 JAPMA The Windlass Mechanism of the Foot: A Mechanical Model to explain pathology. 90(1):35-46. . “Greater forces on the first metatarsal head and hallux will create greater tension on the medial slip of the PF” Fuller’s model predicts that there are two possible approaches to Tx of PF in the medial slip: Increase lateral forefoot loading and increased supination moment applied to the subtalar joint. Fuller refers to Kogler’s report regarding the use of lateral wedging (forefoot valgus wedging) to decrease tension on the PF .
Richie Dr. Douglas Richie, DPM for Podiatry Management Magazine. August, 2002
"As Kogler’s work has shown, and from a simple understanding of the truss mechanism of the plantar fascia, the application of a medial post under the forefoot will actually increase strain in the plantar fascia for most foot types."
Taping: Torg J,Pavlov H, Torg E, Overuse injuries in Sport :The Foot. Clinics in Podiatric Medicine and Surgery. 1987 4(4):939-968
P 940-1 emphasizes Low Dye Strapping technique with plantar flexion of the first ray.
Whitesel J., Newell S., The Physician and Sportsmedicine 1980 Modified Low-Dye Strapping 8(9):129-130. Empahsise plantar flexion of the first ray
Consistently I have found that with the heel inverted and the toes dorsiflexed, palpation of the medial part of the PF reproduces the heel pain. WIth the same toe position and the first ray plantar flexed or if you like forefoot everted, palpation shows that there is less heel pain. I usually apply tape with the first ray plantar flexed ( to replicate my none weight bearing palpation) and acheve the same reasult. Hence my orthoses have a first ray cut out to lnatar flecx the first ray and or a reverse morton's pad (2-5) to help evert the forefoot.
Met domes and cuboid elevations also reduce the force to get the windlass established ..... working on the publication now (along with a lot of others..... problem is the students are back today for clinic :( )
Sean
Maybe Craig can answer that one.
Having said that,I assume that if planatar flexing the first ray allows the first mpj to go through its full range of motion, then pressures would be evenly distributed (ie within normal for that individual )
A question that keeps begging to be asked, is does activating the windlass inrease or decrease the peak pressures under the 1st mpj??
Common sense tells me that good windlass activation must increase peak pressures under 1st MPJ. Windlass is associated with plantar-flexing 1st ray, which brings 1st met-head further 'into' the ground. Also if we think of an efficient windlass, we think of low force dorsi-flexing the hallux. Conversely, a high force dorsi-flexing the hallux would 'spread' the pressure between the 1st MPJ and plantar aspect of the distal phalanx of the hallux.
I think that yeah if you take a prefab and stick a varus wedge on it that is full width under the 1st ray you might get problems with 1 ray dorsiflexion in a lot of cases but NOT all. F-Scan has shown this to me.
However if you take a NWB plaster cast of a foot and capture a large degree of forefoot inversion and dont balance it then you can get an orthotic that does diddly squat. Ive seen orthotics with higher lateral arches than medial arches because of this Rx mistake.
If the posting is a gradually applied thing curving steadily to the talo-navicular area rather than an brupt curve under the 1st met and you utilise a 1st cut-out I dont find moderate varus ff posts giving any problems.
When I 1st started using F-Scan I copied a protocal given to me by Bruce Williams who was taught it by Dananberg. This involved making a heat-moulded temporary device. This was moulded semi-weightbearing with the foot in "neutral" this almost always involved the foot inverted to the ground and had the net effect of capturing an inverted forefoot. The protocol called for the temporary device to be ground so ff to rf was "balanced" and thus I found in most cases I was grinding in a forefoot varus post. When used with a cutout under the 1st ray this almost always was great at sorting the signs of functional hallux limitus or problematic windlass. And NO the patient wasnt "laterally avoiding": the pressures under the 1st met increased, lateral forefoot pressure decreased, the COP line came more medial and force-time cuves became more classically shaped. I initially was confused and kept quiet as I used very little forefoot valgus posts such as the great and the good suggest are needed to facilitate the 1st ray function. Now Im telling everyone because ive realised I like shaking apples out of trees! I figure this whole line of thinking came from people "discovering" sagittal plane blockade with in-shoe pressure systems so if my in-shoe readings showed FHL gone with forefoot varus posts (+ cut-out) then we must be doing the same things but describing it in a different way. I dont care what an anatomist has shown with a cadaver foot Im dealing with dynamic data and patients with symptoms.
Mert Root wouldnt worry about using ff varus posting but his devices were always very narrow and allowed good 1st ray function. So I feel the key is to support the arch or prevent MTJ pronation in some manner - a forefoot varus post or heel skive and allow the 1st ray to do what it desires to do - rotate as the body moves over the top of it. The simplest way to do this is with a 1st cut out, a more complicated way of doing this is a forefoot extension under 2-5 and even more complicated thing would be to call that a forefoot valgus post.
All said in my personal opinion and well meant!
Lawrence
We have data on a whole lot of subjects who did not need a forefoot varus post, but we gave them one anyway....we have rearfoot motion and plantar force/time data in these people with and without the post .... just have not yet analysed the data ...
Just finished the preliminary number crunching.... looks as though a forefoot varus post in those who don't need one (pretty much everyone) has the effect of the rearfoot being more inverted at heel contact/early stance (which was surprising)....but no effect later in the stance phase. (this more inverted position may or may not have something to do with symptom relief when I used to use them a lot)
When it came to the pressure and force/time data, the forefoot varus posts move many of the parameters in the direction of what we consider indicative of windlass function being stuffed up...(this finding may or may not have something to do with the miserable failures I sometime got when I used to use them a lot)
What are the in-shoe parameters that indicate "stuffed up windlass" to you?
I have found a "forefoot" varus post can often move the COP line medially, increase pressure under the 1st mtp relative to 2/3 mtp, make F/t curves become more "m" shaped and symmetrical. Is that windlass stuffed up? From what Ive been told from other users of FScan who are attempting to improve sagittal plane function these would be positive signs signifying less "functional hallux limitus". Bear in mind the posting would be used in conjunction with a cut-out under the 1st ray and relatively small posts.
When you say hardly anyone needs a forefoot varus post why is that? On a casted device how do you treat over-pronation secondary to RF varus? I seem to remember reading in Kevin Kirby's book his opinion on orthotics to deal with "over-pronation" were relatively ineffective unless inverted to some degree and he advocates the use of varus posting to increase support (not Blake inverted devices but traditional posting). Paraphrasing and some over-simplification of course, Kevin will no doubt slap me down here.
I know your probably thinking - "looking through the lenses of the old paradigm" but no just saying what i have found with use of an in-shoe system clinically.
What are the in-shoe parameters that indicate "stuffed up windlass" to you?
This is still work in progress, but we have done a number of things to inhibit and enhance windlass function and compare pressue and force/time parameters. At this stage indicators of inhibited windlass fucntion include delays in timing of the heel and forefoot peak forces; delayed heel unloading ---- we still got no clear picture of what happens in forefoot - still working on that one.
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When you say hardly anyone needs a forefoot varus post why is that?
Forefoot varus is rare.
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On a casted device how do you treat over-pronation secondary to RF varus?
With a rearfoot varus post - the amount of posting is determined by the amount of force needed - stopped worrying about the angle of rearfoot varus a while back.
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"functional hallux limitus".
...this may deserve its own thread, but we stopped thinking in terms of FHL lately - we working on the model/hypothesis that FHL is a and/or of 2 very distinct entities - a high force to get the windlass established and/or a delay in onset of windlass action --> both clinically have the characteristics we previously ascribed to FHL
I guess you would be using very flexible materials so that the orthotic bends in the middle? With your varus rearfoot post this would give you a inverted heel cup and a distal edge bending to make contact with the supporting surface.
I have seen pre-fab devices such as the "Interpod" which have a "varus rearfoot post" incorporated in them i.e. an inverted heelseat/cup. But the distal edge is flat on the supporting surface. To get this shape with a casted device would require a forefoot varus post done intrinsically to the cast. Forefoot varus posts are not just for forefoot varus (if it exists or is measurable)
I know I sound like a old hander stood here with a bucket of plaster, pack of nails and an angle finder but it is the case that more rigid materials (e.g. 4.5mm poly, 2.5mm TL2100) rock up and down with only a varus rearfoot post and no forefoot post.
I think its all about how hard you push on the medial side of the foot. A forefoot post that "balances" the orthotic ie does not allow it to rock will push harder than a varus rearfoot post that does allow it to rock. Therefore in my method of semi-weightbearing forming a device and adding 2-3 degrees of forefoot posting ground in + 1st ray c/o equals the same as 4-6 degrees varus rearfoot posting.
We moved on from doing it that way a while back. The evidence is getting clearer - we usually don't use rigid devices as much as in the past - the RCT's are showing that outcomes are the same. We commonly have forefoot valgus posts assocated with the varus rearfoot post - as that is what is needed to change the parameters that have been shown to be prospectively related to better outcomes (I will post thread here soon with the hard data).
The profession is way to hung up on positions, angles and motion when the research is showing that altering these are not associated with outcomes. Forces, not motion damage tissues. Alteration of the forces is associated with the better outcomes. You don't have to alter motion, positions or angles (though you can) to alter the forces.
I have seen pre-fab devices such as the "Interpod" which have a "varus rearfoot post" incorporated in them i.e. an inverted heelseat/cup. But the distal edge is flat on the supporting surface. To get this shape with a casted device would require a forefoot varus post done intrinsically to the cast. Forefoot varus posts are not just for forefoot varus (if it exists or is measurable)
Is that a relative forefoot valgus incorporated in the device?
A device that inverts the rearfoot significantly, thats distal edge is flat surely pronates the midfoot?
Keep shaking those trees Lawrence. BTW, you should start an 'old hander's (aka casting) thread.
Last edited by Admin : 23rd February 2005 at 05:14 AM.
For forefoot valgus posts am I to read 2-5 extensions such as 3mm EVA/korex? Are u also using pre-fabs predominantly?
I hardly ever measure any positional morphology just make an attempt to identify it, after all if its not FnHL but a high force opposing the windlass or late engaging why is that happening?
I agree that the orthotic is a means of applying a force to the sole of the foot to alter foot and therefore lower extremity moments. But measuring that is probably even harder!
I make my own orthoses and often see casts with humungous ff varus (>>15 degrees) and you would treat this with a ff valgus post !!!!!
sorry i dont understand why one would pronate the foor more to treat xs stj pronation its like cooking a burnt chicken in order to make it taste better .
please explain i would love to know the rational behind this method of rx
Craig, I wonder if you could possibly supply the RCT refs showing outcomes are the same for rigid and non-rigid appliances which you quote. In the context of this statement, what outcomes are you referring to, changes in forces, motion, symptoms etc.
I think we not only get ‘too hung up on positions, angles and motions’ but also on the idea that one thing is ‘wrong’ and another thing ‘right’. Rearfoot varus posts (if on the medial side of the axis) will reduce pronatory moments across the STJ. This in turn may 'reduce' the effect of the ‘reverse windlass’ which can be one of the courses of a FnHL. A forefoot valgus post may help to ensure medial COF progression and so aid in first ray propulsion. By its very construction it may also allow for the first ray to plantarflex (reduce dorsiflexion 1st ray moments if you'd rather), essential again for first ray propulsion and windlass. All makes sense, as does balancing a Root prescription with a 25% ‘creep’ (effectively a first ray cut out and a 2-5 'shell bar’, obtained by the varus post and 2-4 scoop). Some people will need different amounts of angles added, extensions and cut outs to obtain these results. Is your research demonstrating another way of doing the same old thing? Did your varus post comparisons have a 1st ray cut out or 25% first ray section? Sorry Craig, lots of questions, but that's what good research always brings!
Also, What was your sample? For example, I’ve spoken to Eric Fuller in the past and he doesn’t forefoot valgus post a maximally pronated foot in stance. This is a fair percentage of my patients. I have tried forefoot valgus posting this foot type and assessed using video analysis and in-shoe F-Scan. I would not have let the patients walk out with these appliances.
Paul & Lawrence - get back to you later -- bit busy at moment (...deadlines looming!).
Will respond to this:
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I make my own orthoses and often see casts with humungous ff varus (>>15 degrees) and you would treat this with a ff valgus post !!!!!
Are you sure its a forefoot varus? It more likely to be a forefoot supinatus, in which case a varus post is the last thing needed!
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sorry i dont understand why one would pronate the foot more to treat xs stj pronation its like cooking a burnt chicken in order to make it taste better
Who said they pronate the foot more? Pronation is a motion. Motion don't damage tissues. Forefoot valgus posting/2-5 bars etc lower the force to establish the windlass mechanism (we have shown its higher in those with a supinatus) --> more efficient first ray planatarflexion --> etc etc
Will respond to this: Are you sure its a forefoot varus? It more likely to be a forefoot supinatus, in which case a varus post is the last thing needed
excuse my ignorance but why ? surely if you int post you allow the ff to drop (in a flexible foot) and therefore slowly get rid of the supinatus (in 15 years of practice i have seen patients improve there ff varus with an int post ff )
how does a ff valgus cause a supinatus ? i can not picture the mechanics if you could referr me to appropriate papers it would be appreciated.
thanks
yehuda
Last edited by Admin : 24th February 2005 at 02:52 AM.
excuse my ignorance but why ? surely if you int post you allow the ff to drop (in a flexible foot) and therefore slowly get rid of the supinatus
..in which case you are not adding a forefoot varus post.
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how does a ff valgus cause a supinatus ?
It dosen't.
BTW - a forefoot supinatus is NOT caused by a rearfoot pronating past vertical (just analysed that data yesterday --- need to do more as conference abstract deadlines looming -get back to you later)
Brain teaser:
Under Root theory the defined normal alignment, the plantar plane of the forefoot should be perpendicular to the posterior calcaneal bisection. How many of those feet that we call "normal" or "ideal" alignment started life as a forefoot valgus, but became a supinatus (relative to the valgus position) - so are in this defined normal alginment, despite being a supinatus..... think about it.
All very interesting...and high tech... Try this?
Grab a mobile foot that pronates a little much and for too long in gait and has plantarfasciitis pain.
1. Put it in T-N congruence (STJ neutral assumed)
2.Dorsiflex the 1 st met shaft as much as you can and check the tension in the plantar fascia.
3. Now plantarflex the 1st met shaft as much as you can and check the tension in the plantarfascia.
When you P/F the 1st met the distance between the calc tubercle and the 1st mpj decreases.
4. If "heel spur" enthesopathy and plantarfasciitis are traction related injuries or tensile stress damage then this is what you want to do.
5. In order to maximally plantarflex most 1st met shafts in gait then a posterior focussed high point under the navicular with the steepest possible angle of descent under the met shaft assissted by a forefoot valgus post (and usually increased lateral column support by grinding out the cuboid to some extent) is the most effective way to decrease the linear distance between the calc med tubercle and the 1st MPJ during stance.
In many feet you can feel the change from soft tissue structures being the load bearers to the bones being the load bearers during propulsion...(when a successful MTJ lock has been facilitated by what you have done} have a look at foot prints in sand and see the relative depth positioning of various parts of the foot and what parts are load bearing.
Not very scientific....but it works.
Regards Phill Carter
1. What do you make of PF grooves. Surely they get the line between A (insertion) and B (origin) shorter. As you are no doubt aware, a straight line between 2 points is shorter than a curved line. Shorter in this instance equals less tensile stress.
2. What do you make of devices (DC wedges) and their components (skives) that push into or near the medial tubercle? Where the plantar-fascial problem is near its origin (enthesopathy), should we avoid them? Or if such a force is bearable to the patient, do these devices/components 'straighten the line between A and B?'. I remember you making a good point about what a skive does to the arch in relative terms, and accordingly, a skive may remove the need for a groove (in my mind??).
1. What do you make of PF grooves. Surely they get the line between A (insertion) and B (origin) shorter. As you are no doubt aware, a straight line between 2 points is shorter than a curved line. Shorter in this instance equals less tensile stress.
Its another one of those....that we not published yet, BUT plantar fasical grooves do lower the force to establish the windlass mechanism (and we also know that this is associated with better outcomes).
Try this - get a foot and push up in the arch on a prominent bit of the plantar fascia ... then try and dorsiflex the hallux ---- see how hard it is? - wonder what the orthotic might be doing to that process if it pushes on a prominent plantar fascia.
We also found that the groove did not always work, as it was often in the wrong place. Hold a foot at 90 degrees - dorsiflex the hallux - note where the plantar fascia is prominent --> thats where the groove should be. I have been grinding a lot of deep and very anterior plantar fasical grooves into orthostics lately...
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What do you make of devices (DC wedges) and their components (skives) that push into or near the medial tubercle? Where the plantar-fascial problem is near its origin (enthesopathy), should we avoid them? Or if such a force is bearable to the patient, do these devices/components 'straighten the line between A and B?'. I remember you making a good point about what a skive does to the arch in relative terms, and accordingly, a skive may remove the need for a groove (in my mind??).
Problematic. At the end of the day if the force needed to supinate a foot is high, you need to incorporate design features into the orthoses to overcome that force. With insertional plantar fasciitis/enthesopathy, as you allude to, the pain is in the area where those design features put most of their force ---- so it has to be a compromise.
Dear Atlas and others,
My 2c on p/f grooves is that if you need one your orthosis is the wrong shape. In 5 yrs of prescribing and making devices as a podiatrist and 15yrs before that solving problems in fitting ski boots I have never prescribed or needed to insert a P/F groove. If the angle of descent of the 1st met is steep enough (and from posterior enough) impingement won't occur....I think anyway...and practice seems to bear me out.
The skive as Kevin Kirby describes it in his earlier writing is something that I have issues with and the whole STJ axis line and torque thing I basically agree with but 1st ray function does over ride this at times I think.
Particularly in respect to P/F of the 1st met....if you elevate the lateral side of the forefoot which by Kevins reckoning should pronate the foot, what you can get is facilitated p/f of the 1st met which actually helps supinate the STJ.
I don't for a moment think I have this all figured out but I also think that the DC wedge concept of adding plaster to the plantar lateral heel rather than cutting it off the plantar medial heel has the effect of maintaining a greater relative height difference between the plantar surface of the heel and the navicular when you put the foot on it.
This in turn contributes a component of resistance to pronation in the saggital plane not just the frontal plane, among other things.
As far as position of the calc tubercle goes even though it is called the medial tubercle it is still a fair bit lateral and posterior to the navicular and base of 1st met, so I think you can do a fair bit of work with an orthosis plantar to the more anterior "neck" of calc and the navicular.
And yes maybe the shortest difference between two points is a straight line but (no sarcasm or rudeness intended) I don't see too many straight lines in feet. Clearly the medial slip of the plantar fascia is able to follow some curves when it is not under too much tension and I think if you really get the 1st met p/f'ed then you have got the tension off it, which means it will tolerate impingement better and allow d/f of the hallux with less difficulty.
I hope this makes some kind of sense to you.
Regards Phill Carter
I suspect that what Craig is saying about large anterior P/F grooves is similar to me saying get that angle of descent steep enough....either way you have got bulk out of the orthosis under the medial plantarfascial slip and facilitated 1st ray plantarflexion....thats where I like to go back to Root and say that IF we achieve this 1st ray P/f then we have achieved resupination of STJ probably which is helping MTJ lock, propulsion with a rigid lever and greater foot efficiency......all of which helps to reduce loads of different symptoms.
Regards Phill
Met domes and cuboid elevations also reduce the force to get the windlass established ..... working on the publication now (along with a lot of others..... problem is the students are back today for clinic :( )
Craig;
Could you expound on this please? You know of my interest in Metapads that extend to under the cuboid from the podiatry list serve.
Also, I would suggest that you consider a small study, maybe with me, that looks at changing the casting position of the foot, modified Root method.
In other words, instead of maximally pronating the 5th ray while the foot is in STJ neutral, and while plantarflexing the medial column - you should instead plantarflex the 5th ray / lateral column as well.
I think you will see, as did I, that the ability of the 1st ray to plantarflex becomes very limited in this position, as opposed to when the lateral column is maximally pronated and the medial column seems at times to have no end in ability to plantarflex.
I think you will also find that the need for reverse moton's extension will be greatly limited as well with this new technique.
I am finding great results w/ a very limited metatarsal pad utilizing my Amfit scanner. I remove the pad from under the 1st met and also the 5th met, and extend it to the apex of the tarsal arch for support of both the navicular and cuboid. This seems to "fill" the transmetatarsal arch, while providing an intrinsic varus post in most patients. The varus post is only 2-4 though.
I see so much less need for drastic use of heel lifts utilizing these modifications w/ plaster or scanner. LLD seems to resolve or drastically decrease, as would be expected if the MTJ were indeed in its most stable and supinated position instead of allowed to pronate at the lateral aspect.
To me it just seems appropriate to position the midtarsal joint in its most stable position this way, instead of maximally pronating the lateral column, and automatically destabilizing the MTJ as we have all been taught thru the years.
Looking forward to your response(s)! ;-)
Sincerely;
Bruce Williams, D.P.M.
Indiana, USA
Is forefoot varus posting an anachronism?
I just do not see the dramatic failures anymore... As I said in the thread on 
(I recall one student, Zac, who was so impressed with me as I could diagnose that a patient did not have a forefoot varus through the wall without even looking at them 
)
Forefoot valgus posts for plantar heel pain
Linear Mode
