The treatment of heel pain has been a hot topic for many years, with seemingly as many treatment protocols as there are practitioners. Pathology within the proximal insertion area of the plantar fascia is by far the most common source of heel pain. It also happens to be the most amenable to biomechanical based treatment. My recommendations here are based on the following assumptions: there is negligible or no complicating factors such as bone marrow edema, plantar fascia rupture, Baxter’s neuropathy, seronegative arthropathy, lumbar radiculopathy, tarsal tunnel syndrome or any other potential cause for plantar heel pain. It also assumes that symptoms, including pain, have been successfully mitigated by whatever means the practitioner prefers. Mild to moderate over-pronation has been determined to be causative for the plantar fascia overuse. Any significant calf tightness issues have been addressed, if not, then adding a heel lift to the orthotic devices, at least temporarily, may be considered.
In a previous post I discussed what I termed my “Go-To” orthotic device. A semi-rigid polypropylene frame with extrinsic rearfoot post, intrinsic forefoot post, and full length padded extension. The objectives of the orthotic are to control excessive or unnecessary motion occurring during heel contact, midstance and propulsive phases of gait into toe off. The extrinsic rearfoot post should control excessive heel eversion thus allowing the foot to enter into midstance somewhat neutral without restricting shock absorption. The correction of the rearfoot, based on the extrinsic rearfoot post can vary from individual to individual and can be increased with an additional intrinsic medial skive if necessary. A minimal arch fill is preferred when attempting to limit the tension on the plantar fascia, and a plantar fascia accommodation (channel) should be used when addressing a bowstrung fascia. Forefoot correction of deformities (either intrinsic or extrinsic or combination corrections) is vital in limiting tension on the facia during the propulsive phase. Locking down the first ray by a variety of means, restricting ground reactive force and promoting hallux dorsiflexion works wonders in preventing plantar fascial overloading
Convincing a skeptical patient that putting a hard piece of plastic in their shoe will keep their heels from hurting, can be a challenge. It is counterintuitive, soft padding should be better, don’t you think? You should be able to explain to your patient in simple terms their heel pain stems from too much tension on the tissues connecting to their heel bone and the orthotic device or orthosis is intended to address the cause of the problem directly. Cushioning can be added, but in many cases this is only for comfort, not necessarily curative. Patients should also be instructed the orthotic devices may be initially uncomfortable, especially if they are still symptomatic, and a proper break in period should be observed. The orthotic devices are intended to be a long term solution for plantar fasciitis, treating the root cause of the condition, and should provide years of prevention of recurrence.
