Keys To Prescribing Orthoses For Limb Asymmetry And Heel Pain

Author(s): 
Guest Clinical Editor: Joseph D'Amico, DPM

   If a lift is required, he usually places it in the shoe under the orthotic. Dr. D’Amico has found that adding a lift to the orthotic itself will cause an increase in lateral rearfoot post wear due to the elevated calcaneal position. As time goes on, this creates an avalanche effect in which the rearfoot becomes laterally unstable. He says it is better to place the device on a platform that is elevated rather than pitch and elevate the device itself. This method also permits easier adjustments in the future, according to Dr. D’Amico.

   “Keep in mind that lifts are not forever and must be periodically re-evaluated to determine their appropriateness,” advises Dr. D’Amico.

Q:

Richard O. Schuster, DPM, once said that when treating biomechanically induced heel pain, the heel seat of the orthotic can never be too deep. In the management of proximal plantar fasciitis and related plantar heel pain, what modifications do you find particularly effective?

A:

In regard to plantar fasciitis and heel cup issues, Dr. Valmassy feels that a deep heel cup clearly is beneficial in treating most foot anomalies, specifically plantar fasciitis. He will be extremely cautious when having the laboratory invert the orthotic device. Dr. Valmassy also may utilize a medial calcaneal skive because, in some instances, the steepness of the skive along with the significant inversion of the rearfoot will actually place some increased pressure at the level of the medial tubercle. This may make it more difficult for the patient to adapt to the orthotic device, according to Dr. Valmassy.

   In cases in which there may be an associated infracalcaneal bursitis, he says a sweet spot or aperture pad with a soft material such as Poron embedded into the orthotic at that level will allow the patient to have a more comfortable heel strike.

   Dr. Beekman will first have the orthoses correct the two external pronatory factors, equinus and asymmetry, with appropriate heel lifts. Then when it comes to medial heel pain, he drops the first metatarsal for functional hallux limitus, narrows the lateral rearfoot post to decrease pronatory torque at heel contact and increases the rearfoot post. If this is not effective, Dr. Beekman will add an extra post to the forefoot and grind under the first metatarsal so there is a small amount of material left (approximately 1/8 inches).

   For central heel pain, Dr. Beekman adds a “U” pad under the calcaneus, subsequently grinds the area directly under the calcaneus and replaces or fills it in with something softer. Then he reinforces the area under the medial and lateral arch. For pain at the plantar posterior heel, Dr. Beekman will lift the posterior portion of the calcaneus and look for trigger points in the leg. Rarely will he find it necessary to make an adjustment for an enlarged medial or lateral condyle of the calcaneus.

   Dr. Wernick emphasizes the importance of differentiating between contact phase heel pain and propulsive phase heel pain. He says patients with contact phase heel plane would do well with a deep heel seat, cushioning materials and beveling the heel of the shoe.

   Patients with propulsive phase heel pain are another story, notes Dr. Wernick. They are being injured when the heel lifts off the ground. He says this is typical of a patient with plantar fasciitis. Since most orthotics do not function after heel lift, Dr. Wernick says it is important to establish control of the foot prior to adding a heel lift. Dr. Wernick adds that the use of a functional orthosis that controls subtalar and midtarsal movement is essential along with modifications that induce plantarflexion of the first ray while increasing dorsiflexion of the hallux. He feels the kinetic wedge design is very helpful for this type of problem. Dr. Wernick also advises physicians to be aggressive in these cases by using several modifications and other modalities such as stretching.

   In regard to the rear portion of the orthotic device, Dr. Valmassy notes a softer rearfoot post material will enhance shock absorption. For proximal plantar fasciitis and related plantar heel pain, he would consider a rearfoot post with 4 degrees of motion to allow an additional amount of movement or motion at the moment of heel contact.

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