Current Insights On Conservative Care For Heel Pain

Author(s): 
Tim Dutra, DPM, MS

   Try to avoid the trap of fitting the orthotic to the shoe. I will usually have patients wait to get any new footwear until they have their orthotics to help ensure a good fit. Then I will have patients bring in their new footwear and check for fit and control with the orthotic. I always advise the patient with heel pain to avoid flip-flops or sandals due to lack of support and cushioning. It is surprising how often a patient will be in flip-flops when he is she is being treated for a foot problem.

   Night splints are also a good alternative for treatment to help retain the plantar fascia tension by providing constant force. However, patients may not tolerate the night splints for a prolonged period of time. One can set the night splints for positioning with dorsiflexion commonly from 5 to 15 degrees. This reduces the effect of post-static dyskinesia by reducing the effect of shortening of the plantar fascia and intrinsic muscles of the foot.

Emphasizing The Value Of Proper Footwear And Fit To Combat Heel Pain

Proper footwear is essential for the patient with heel pain. Often, part of the cause of heel pain is an improper shoe for that patient. Usually, the proper athletic shoe will be a great benefit. There are many brands and models of shoes out there so it is best to give your patients some qualitative guidelines. Most patients find they have gravitated to a particular brand that tends to fit their foot. However, it is often not the best model or size for them.

   Depending upon the foot type and biomechanics, patients will typically need guidance toward one of the following shoes: motion control, stability or cushion shoes. I typically do a shoe exam that checks for heel counter rigidity, midfoot torsion stability and forefoot flexion of the shoe. Ideally, a removable sock liner or inner sole will allow for easy placement of an orthotic and allow the heel area of the orthotic to sit flat in the shoe.

   Typically, a pes cavus foot type will do best in a cushion or neutral type of shoe. A pes planus/hyperpronated foot type will need a moderate to maximum motion control shoe. A normal foot type will usually do well with a stability or mild motion control shoe. One needs to address the shoes before even getting to the orthotic stage. At this point, there is no evidence that toning shoes or rocker bottom shoes provide any benefit for dealing with heel pain. The American Academy of Podiatric Sports Medicine has a helpful section on its website (www.aapsm.org) on athletic footwear recommendations, which can help the practitioner keep current on models and styles.

   Have patients try on shoes in the afternoon or evening when their feet will be the largest. Measure patients with a Brannock device while they are standing. Use the measurements as a guide or reference only as different brands can run relatively different sizes. One can also use the shoe fit test to trace the foot and then the shoe, and compare for overlap. Patients should be wearing a similar style of sock. If they have an orthotic device, they should have it in the shoe. There should be a finger width between the end of their longest toe and the shoe. I always have them try on a half size bigger shoe to compare the fit.

   I do not recommend breaking in shoes as this tends to break in the feet. Have patients wear the new shoes indoors for a day or two to make sure they feel comfortable. I will then repeat the three-point shoe exam with them to help make sure it is the proper shoe for them. Most patients do best in a running shoe as they offer the best support and cushioning (see “Keys To Ensuring A Good Fit With Athletic Shoes” above).

Comments

All interested might want to check out a systematic review by van de Water et al. (published earlier this year) about the effects of taping on plantar fasciosis.

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