Current Insights On Orthoses For Achilles Tendinosis, Plantar Fasciitis And Posterior Insertional Spurs

Author(s): 
Guest Clinical Editor: James Clough, DPM

Can orthoses have a positive impact for conditions such as Achilles tendinosis, posterior insertional spurs on the calcaneus and plantar fasciitis? Our esteemed panel weighs in with their perspectives.

Q:

Do you think orthotics can be helpful for Achilles tendinosis? If so, can you explain how they help and what you do with your devices to improve outcomes for this condition?

A:

James Clough, DPM, believes orthotics are a mainstay in the treatment of Achilles tendinosis, a problem he feels is largely related to a limited mobility of the ankle joint due to the limited motion of the first metatarsophalangeal joint (MPJ). To explain this, he uses the analogy of a scissor jack, saying if one rung of the jack is stiff, the whole jack becomes stiff, so motion is limited in all joints proximal as the first MPJ is limited.

   Similarly, Bruce Williams, DPM, feels that Achilles tendinosis is the result of an inability of the Achilles to move through its normal range of motion. He manipulates the Achilles, adding appropriate bilateral and/or unilateral heel lifts as necessary to combat leg length discrepancy and ankle joint equinus.1 If the foot is pronating excessively and this is part of the problem, Dr. Williams suggests utilizing an appropriate varus posting for the entire device as needed. However, he notes if one does not utilize manipulation along with a proper orthotic prescription, there will be little if any improvement.

   Dr. Clough’s orthotic prescriptions focus on improving the motion of the first MPJ and reducing sagittal plane motion through the midtarsal joint in propulsion. He primarily does this with a P4 Wedge (Cluffy Institute). The main thing for him is controlling the foot when it is in propulsion.

   Dr. Clough does not believe Achilles tendinosis primarily results from rearfoot problems. If symptoms do not reduce, he will use a custom device with the first metatarsal plantarflexed and minimal medial arch fill. He notes that many patients with tendinosis will also need the lateral arch plantarflexed by pushing down on the fourth and fifth metatarsals, and the forefoot valgus will also need correction.

   In contrast, Neil Horsley, DPM, is not convinced that a foot orthosis can be helpful for Achilles tendinosis. He does acknowledge that a solid ankle foot orthosis could provide temporary or long-term relief for this condition.

   “I have had very little success treating Achilles tendinosis with custom foot orthoses,” concurs Doug Richie Jr., DPM. However, he notes that in early acute phases of tendinopathy, particularly in a running athlete, foot orthoses may reduce multiplane load on the Achilles. He says in the patient with chronic Achilles tendinosis (greater than six months in duration), immobilization and aggressive heavy load eccentric stretch therapy is far more effective.

Q:

Can orthotics help treat posterior insertional spurs on the calcaneus?

A:

As Dr. Horsley points out, posterior insertional spurs on the calcaneus are a direct result of gastrocnemius equinus or gastrocnemius-soleus equinus unless there are other systemic conditions that will cause the osseous surface to form osteophytes. He believes orthoses can help to manage the abnormal sagittal, frontal and transverse plane manifestations of equinus as the three rockers of the foot are abnormally affected by this deforming force. Therefore, Dr. Horsley is not convinced that an orthosis will effectively or directly help insertional spurs on the calcaneus.

   On the other hand, Dr. Richie has had success using orthoses to treat insertional spurs, particularly when there is a Haglund’s deformity. Although these are two separate conditions, he notes they commonly occur together.

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