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.
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?
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.
Can orthotics help treat posterior insertional spurs on the calcaneus?
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.
“I am not sure how orthoses work for this condition but they do,” notes Dr. Richie. He says we can assume that the devices are reducing frontal plane motion of the calcaneus and therefore reducing the load of the Achilles at the insertion site. He also wonders if the heel cup of the device changes the shoe dynamics to reduce friction or pressure on the posterior calcaneus.
“Either way, foot orthotic therapy for insertional calcaneal spurs can be helpful for the athletic patient who wears closed shoes most of the time,” maintains Dr. Richie.
For Dr. Clough, orthotics are a mainstay when treating posterior insertional calcaneal spurs. As he explains, this condition develops mainly due to excessive tension of the Achilles tendon in propulsion from a lack of ankle joint plantarflexion. The pull of the Achilles on the posterior heel becomes eccentric rather than concentric, which he says results from a lack of motion of the first MPJ, comparing it to his aforementioned scissor jack analogy. Furthermore, Dr. Clough says a lack of motion of the first MPJ results in lack of motion of the ankle, knee, hip and lower back. The tension of the Achilles pulls against the heel that will not rise properly and he says this will result in a spur at the retrocalcaneal area.
Dr. Clough will often use a P4 Wedge with an OTC device initially to improve motion of the first MPJ. If this is not effective, he uses a custom device. To correct this problem with plantarflexion of the first metatarsal, he suggests using minimal orthotic fill. In addition, Dr. Clough corrects any forefoot valgus by plantarflexing the fourth and fifth metatarsals and adds minimal fill in the lateral arch just as he would do medially. He uses a P4 wedge in all of these cases.
“Very often, you also need to spend a few moments with your patients to get them to start to roll through the first MPJ and take a longer stride and walk faster without shuffling,” says Dr. Clough. “Very few of these problems require surgery at the initial stage but if large spurs have developed, they become a source of injury to the tendon fiber and conservative care, in this case, is much less effective.”
Dr. Richie recommends a deep heel cup (16 to 22 mm) and adds a ¼-inch heel lift to a rearfoot post, which is inverted 2 degrees with 2 degrees of motion. For the non-athletic patient, particularly a female, he prefers prescribing an open, elevated clog style shoe and forgoes the orthotic.
Have you had success in using orthoses for patients with plantar fasciitis?
Dr. Williams uses ethylene vinyl acetate (EVA) orthoses for the majority of his patients with plantar fasciitis. For patients who are extremely overweight and/or have extremely flat flexible feet, he uses polypropylene, noting that EVA often will not support the load effectively.
In addition, Dr. Williams uses a Cluffy type digital skive (Cluffy Institute) under toes one through five in most patients with plantar fasciitis to preload the plantar fascia, especially the medial band. He says this makes the toe less likely to plantarflex in late midstance. Dr. Williams will utilize a 3 mm heel lift bilaterally in patients with limited Achilles dorsiflexion or an equinus type deformity. This decreases the load on the Achilles and he notes that an overloaded Achilles can cause peroneal dysfunction, which in turn can lead to functional hallux limitus issues.
Dr. Clough typically sees a 70 percent decrease in pain in about three weeks with plantar fascia stretches, ice and insoles. With insoles, OTC devices are his preferred choice unless there is significant rearfoot eversion. He uses a P4 Wedge to control the first ray and allow the foot to transition from a loosely packed position at heel contact to a closed packed position at toe off.
If this transition cannot occur and the foot stays in the loosely packed position during propulsion, Dr. Clough points out there is pathologic pressure on the plantar fascia, abductor hallucis and flexor digitorum brevis, and subsequent pain in the heel. He notes the stable higher arched foot with the foot in the closed packed position provides relief of the strain of the plantar fascia and subsequent pain reduction.
“So long as the first ray functions and I have a moderate contour of the arch to the foot, I see tremendous results,” says Dr. Clough. “In rare, very difficult cases, an orthotic with minimal fill is required to get a good contour of the device to the foot structure along with a P4 Wedge.”
Dr. Williams will use a metatarsal pad for most patients with plantar fasciitis along with a kinetic wedge modification. When necessary, he will use a forefoot valgus post for those with large amounts of lateral column dorsiflexion excursion.
Dr. Clough is in private practice in Great Falls, Mt. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. Dr. Clough is the inventor of the Cluffy Wedge (P4 Wedge) and the President of the Cluffy Institute.
Dr. Horsley is an Assistant Professor and the Department Chair of Podiatric Surgery and Applied Biomechanics at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Past President of the American Academy of Podiatric Sports Medicine, and a Fellow of the American College of Foot and Ankle Surgeons. Dr. Richie is in private practice in Seal Beach, Calif. He also writes a monthly blog for Podiatry Today at www.podiatrytoday.com/blogs/doug-richie-jr-dpm/feed .
Dr. Williams is in private practice in Merrillville, Ind. He is a Diplomate of the American Board of Podiatric Surgery. Dr. Williams is also a Past President and Fellow of the American Academy of Podiatric Sports Medicine.
1. Dananberg HJ, Shearstone J, Guillano M. Manipulation method for the treatment of ankle equinus. J Am Podiatr Med Assoc. 2000; 0(8):385-9.