Plantar heel pain is ubiquitous in the United States, affecting individuals spanning the entire spectrum of age, gender, race, height, weight, and activity level. Subsequently, there are as many opinions on why this condition has become so prevalent and how to treat it as there are experts. A fairly typical case has been presented, with the assumption the etiology is a repetitive overuse syndrome of a biomechanical nature without specific trauma or underlying systemic condition. The initial treatment goal of alleviating the symptoms and restoring somewhat normal function of the patient’s lower extremities, has been accomplished. The next phase of treatment is addressing the underlying biomechanical source of the repetitive overuse of the plantar fascia, while maintaining a normal lifestyle and work schedule without restriction.
There are two pathology orthotic builds present on the KevinRoot Medical website and order form that address the condition of plantar heel pain. Model P13 (Plantar Fasciitis) and model P6 (Heel Spur). The two devices are similar as you might suspect with two exceptions. The plantar fasciitis model has a full heel pad incorporated under the 1.5 mm Spenco top cover, and the heel spur model has a horseshoe shaped pad under a .75 mm Protex top cover as well as an aperture cut out of the frame material beneath of the body of the heel bone. The aperture can be left empty or filled with a viscoelastic polymer plug. Both models are built upon a polypropylene frame based on patient weight, extrinsic rearfoot posts, 18 mm heel cup depth, suede bottom covers, balanced forefoot to rearfoot corrections and full length 1.5 mm myolite extensions.
These pathology based orthotic models are designed to be coupled with a sturdy work, athletic or lace up dress shoe with a removable sock liner, firm midsole, deep heel counter with torsional stability. This criteria fits many situations that lead to plantar fasciitis, namely prolonged weight bearing on a daily basis. Adjustments to this configuration are numerous, and can be based on a variety of factors, such as body weight, activity level, shoe type as well as subjective preferences. Frame material can vary, heel cup depth can be changed, top covers and extensions can be altered or eliminated. It behooves the practitioner to have a full understanding of the particular patient's needs and objectives when determining orthotic device configuration.
The plantar fascia is essentially a tension band that divides and extends from its insertion point on the medial tuberosity of the Calcaneus distally to the joint structures of the metatarsal phalangeal joints. It is contiguous with the fibers of the distal Achilles tendon. During gait, as the heel rises off the floor during propulsion, the plantar fascia undergoes increased axial loading until toe off occurs. Excessive tension of the plantar fascia may result from either Achilles tightness or a functional limitation of range of motion of the 1st MTPJ, or both. The primary goals of orthotic control of plantar fascial overload are;
- Limit heel eversion during heel contact phase
- Maintain medial arch during midstance
- Limit reactive ground force beneath the 1st MTPJ during propulsion
In other words, control excessive pronation of the foot throughout the gait cycle and thus control excessive repetitive tension of the plantar fascia. It is important to note that many people will benefit from a slight heel lift on the orthotic device, at least initially, and especially if using the off loading features of the heel present on the P6 model. Patients may also benefit from having a shoe with a heel rise incorporated into its construction, a torsionally stable shank. It is also worth mentioning that timing of the use of the orthotic device is important, a patient having acute plantar heel pain may experience an increase in symptoms with a controlling type orthotic device and would be better served with some other method of treatment until the acute phase has been relieved.
Next week's forum post will be a general discussion of treating heel pain with orthotic devices. The use of heel cushions, heel apertures, heel lifts, plantar fascial accommodations and forefoot corrections will be addressed
