These expert panelists discuss evaluating the necessity of orthotics in athletes with heel pain, as well as shoe modifications and orthotic modifications for specific sports.
What is your initial approach for evaluating the need for orthoses in athletes with heel pain?
Patrick Nunan, DPM, FACFAS, first asks the patient what sport he or she is doing so he can understand the mechanical requirements of the particular activities with the patient’s sport, and also asks what shoe the patient is wearing for that sport. Next, he will evaluate joint range of motion as well as muscle strength. As Dr. Nunan notes, muscle tightness or weakness can lead to pain when patients wear an orthotic. He adds that body weight and foot morphology can influence the materials one uses for the construction of an orthosis.
Jenny L. Sanders, DPM, always starts with a thorough history. Has the patient had heel pain previously? Has there been any change to the training schedule? If the patient is running, she asks if the patient has increased the frequency of running, distance or switched from city streets to trail running. Has the patient recently taken up a sport (basketball, soccer) after not having participated in it since high school or college? Dr. Sanders asks about recent changes in the shoe brand or model. At work, has the patient started using a standing desk? She also asks if the patient’s commute has changed and if he or she is walking more.
As Dr. Sanders notes, the answers to those questions along with an evaluation of the patient’s sport shoes, biomechanical evaluation and in-office analysis of his or her form during sport (running, basketball, hiking, tennis, soccer, etc.) will usually identify the cause of an athlete’s heel pain. If biomechanical challenges are present (excessive pronation/internal hip rotation/external tibial torsion), she will always recommend a custom orthotic to address the underlying cause.
Lisa Schoene, DPM, ATC, FACFAS, generally does not place patients in orthotics until their plantar fasciitis pain has resolved as orthotics can take away the general compensation at the midtarsal joint for lack of ankle joint dorsiflexion, which is often present with those who suffer from plantar fasciitis. Dr. Schoene uses longitudinal metatarsal arch pads until pain has resolved. She will then discuss/dispense the orthotic when the following factors are present:
• if there have been longstanding or multiple biomechanically-related injuries over the years;
• if there is evidence of biomechanical malalignment of the foot/lower extremity; and/or
• if an exam indicates the presence of bunions, hammertoes or other foot deformities.
Dr. Nunan stresses that another important factor in an initial approach is the response of the athletes to having something placed in their shoes. For example, he says soccer players often wear shoes that are too small for their feet so they can “feel” the ball. Dr. Nunan says these patients may not be able to tolerate an orthosis in a shoe that is already too tight.
How do you handle shoe and/or orthotic modifications in athletes?
Dr. Sanders will make sure the athlete is wearing a shoe of the correct length and width. She will also match the shoe and shoe modifications to the patient’s pathology and biomechanics. For example, Dr. Sanders says a foot with a bunion should always have mesh over the medial eminence. In a cycling or climbing shoe, she says Velcro straps should not secure over the medial eminence but should be offset to the widest part of the foot.
“Athletes who pronate excessively should look for shoes with a wide waist in the plantar midsole,” says Dr. Sanders.
Dr. Nunan will try to recommend a straight last shoe for running sports while court sports require side to side stability. If there is a significant leg length difference, he notes one may need to add a lift on the outside of the shoe rather than on the orthotic. Some athletes may load excessively on the outside of the shoe so he says the connection between the upper and the midsole may need reinforcement with extra material. If one wants to use a first ray cutout with a reverse Morton’s pad on the orthotic, Dr. Nunan says the shoe will need to be deeper in the toe box. Dr. Nunan also wants to achieve a balance in the flexibility of the shoe and the rigidity of the orthotic as it relates to the sport’s requirements and to the particular athlete.
In the past handful of years, the shoe industry has modified and changed the dimensions of most of their models, notes Dr. Schoene. She notes shoes have become increasingly narrower, shallower and even have had changes to the lasts with narrowing the outsole in the midfoot/arch area.
“It appears that the shoe industry believes everyone has perfect feet and none of us need orthotics,” says Dr. Schoene.
Dr. Schoene notes changes in the shoe industry have created more challenges when placing an orthotic into shoes. Rather than compromising a prescription, posting and corrections, she finds that physicians need to eliminate most or all of the stability features that the shoe has or the shoe will compete with the orthotic. Dr. Schoene tries to suggest to patients that they shop at local athletic shoe stores, where the staff has a better handle on fitting and understanding of orthotics. Sometimes she notes patients need to go up a size or get a deeper shoe to accommodate the device. Dr. Schoene generally tells patients she will correct the foot alignment with the orthotic and work the shoe around it.
Dr. Sanders rarely makes modifications to an athlete’s shoe with the exception of modifying lacing patterns. If an orthotic causes heel slippage, she will use a lock-lacing system. If an athlete has a metatarsocuneiform exostosis, she will skip lacing around the prominence.1
Which orthotic modifications for specific sports are most effective in athletes with heel pain?
Dr. Schoene prefers a soft topcover and full length device for all sports, and typically uses 1/8-inch polypropylene style shells for most patients. She notes a heavier athlete may need a 3/16-inch shell but she prefers to use the 1/8-inch shell with some arch fill, even for the heavier patients if possible.
Dr. Schoene will use ethylene vinyl acetate (EVA) topcovers for lateral movement sports and Spenco/Nylene topcovers for runners and general athletes. She says extra heel cushions, deep heel cups or the occasional horseshoe padding may help the athlete with a thin fat pad or the athlete with fibroadipose nodules.
Dr. Nunan notes a first ray cutout with a reverse Morton’s extension will reduce the pull on the medial band of the plantar fascia. If the medial band is tight, he says a groove in the orthotic shell will reduce irritation and an arch fill will further dampen the speed and amount of navicular drop. In shoes that have less volume, such as track spikes, Dr. Nunan suggests that an intrinsic posting and thinner shell material may be necessary.
First and foremost, Dr. Sanders emphasizes that the orthotic needs to fit into the shoe, noting that an orthotic made for a running shoe will not fit in a figure skating boot or cycling shoe. The only modification she consistently makes for heel pain is to add a plantar fascia groove to the orthotics. Dr. Sanders says minimum fill positive cast corrections are effective in maximizing orthotic control but without a plantar fascia groove, irritation and occasional blisters can occur. A plantar fascial groove prevents that from happening, according to Dr. Sanders.
Dr. Sanders cautions that the exception is for dance shoes and figure skates that do not have sufficient width to accommodate a plantar fascial groove. In these cases, she will use a first ray cutout to improve first metatarsophalangeal joint motion and reduce tension on the plantar fascia.
“Properly fitting and functionally correcting devices are really of the utmost importance,” says Dr. Schone, who emphasizes the value of the biomechanical exam and alignment check to optimize fit and function. After dispensing the device, she always checks patients by having them do functional movements standing on the orthosis outside of the shoes and while in the shoes. For every patient, Dr. Schoene checks for leg length discrepancy and always corrects for that with a long lift under the short side.
Dr. Nunan is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is also a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, and the American College of Foot and Ankle Surgeons.
Dr. Sanders is in private practice at the Financial District Foot and Ankle Center in San Francisco. She is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine.
Dr. Schoene is a sports medicine specialist and certified athletic trainer who is in private practice at the Gurnee Podiatry and Sports Medicine Association in Chicago. She is a Fellow of the American College of Foot and Ankle Surgeons, the American Academy of Podiatric Sports Medicine, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Schoene has been a podiatric consultant for the DePaul University Blue Demons since 1992.
1. Sanders J. Athletic Shoe Lacing Tutorial: Lock Lacing-Offset Lacing-Increasing Forefoot Width Lacing. YouTube. Available at https://www.youtube.com/watch?v=tIK1zgozm6w . Posted Nov. 22, 2011.
For previous Podiatry Today Orthotics Q&A columns, see www.podiatrytoday.com/section/orthotics-qa .