These expert panelists discuss their orthotic decision making process for patients with heel pain, touching on when to use custom devices and when prefabricated orthotics are sufficient.
There appears to be lack of agreement among peers about when they institute any type of foot orthotic therapy for plantar heel pain. What is your criteria? How do injury duration and severity of symptoms impact your prescription? What about the activity level of the patient? Are insurance restrictions a factor?
“I am a strong advocate of urging my podiatric colleagues to approach their treatment of plantar heel pain as an ‘expert’ of the foot and ankle,” says Doug Richie, Jr., DPM, FACFAS. “By that, I mean that we should rise above the boilerplate treatment recommendations made by primary care providers to their patients who present with heel pain: ice, stretching and a night splint.”
Dr. Richie says those “boilerplate” treatments and many others are easily available on the Internet and patients have often already implemented them before they go to the trouble to make an appointment to see a doctor. Since DPMs understand the foot, and know the biomechanics of the lower extremity better than any other specialty, Dr. Richie says podiatrists should be able to implement effective treatment plans that address the mechanical cause of plantar heel pain.
For those reasons, Dr. Richie does not hesitate to implement custom foot orthotic therapy for most patients presenting with plantar heel pain. He has found custom foot orthotics to be “extremely efficacious in eradicating plantar heel pain.” Dr. Richie’s criteria for not implementing custom foot orthotic therapy would be a patient with heel pain of less than one month’s duration and/or a patient with daily pain below 3/10 on the Visual Analogue Scale (VAS). He will also hesitate implementing custom foot orthoses for a patient who will not or cannot wear the appropriate footwear necessary for custom foot orthotic therapy.
On the other side of the spectrum, says Dr. Richie, are patients who commonly present to his practice with heel pain of at least three months, which has significantly affected their quality of life. At the first office visit for these patients, he will recommend custom foot orthotic therapy. While waiting for the fabrication of custom devices, he uses low Dye taping to initiate the mechanical treatment. Dr. Richie emphasizes that all patients who present with heel pain in his practice will, at the first office visit, get some type of mechanical intervention, whether it is low Dye taping, prefab orthotic or both.
For patients with heel pain, Brian Fullem, DPM, says his approach depends on how many treatments the patient has already tried. If patients have not had any treatment, he will talk about inserts during the initial patient visit and most times will tape the foot, and see how the patient responds to taping, icing, stretching and good shoes for a few weeks. At that point, if patients have found that taping helps, Dr. Fullem would consider adding an OTC type insert. If the patient has already tried OTC inserts and Dr. Fullem feels the patient may benefit from orthotic devices, then he might consider using a more customized device sooner.
Dr. Fullem says the patient’s activity level does not matter as much to his orthotic prescriptions but he tries to treat all patients as if they are athletes.
As Bruce Williams, DPM, notes, plantar heel pain can have multiple causes. After determining that a patient’s heel pain is not related to the tarsal tunnel or medial calcaneal nerve, he will consider orthotic therapy as a primary treatment option.
Following a thorough segmental biomechanical exam, Dr. Williams will almost always tape and accommodate the patient, noting that he will tape to mimic the planned orthotic prescription. If the patient responds well to the taping, he will cast for orthotics. Dr. Williams will consider injections for plantar heel pain if the patient’s pain level is above 7/10 on the VAS. He adds that patients at that level of pain will not respond to taping. Dr. Williams notes the injection tends to decrease a patient’s pain in most instances to a level where he can use taping to determine if mechanical or orthotic therapy will likely succeed.
Most insurance companies in Dr. Fullem’s area do not cover orthotic devices but that does not play a part in his decision making. If he feels a custom orthotic device will help, then he will offer orthotics, saying it is up to patients to decide if they wish to pay out of pocket to cover the expense. Dr. Richie tries not to use “ability to pay” or insurance coverage to dictate his treatment plans. If he believes patients will benefit most from custom foot orthotic therapy, Dr. Richie will present custom devices as the best option and let patients decide if they want to proceed. He will offer prefab orthotics as a backup option if patients decline custom orthotic treatment.
“I never offer both and then let the patient decide. I offer what I know will work best and that is custom foot orthotic therapy,” says Dr. Richie.
If you do implement foot orthotic therapy, how often do you start with prefab versus going straight to custom?
Dr. Williams “rarely” starts with prefab devices unless the devices are modified or customized to fit the final prescription that he arrived at through his segmental biomechanical segmental exam. Taping works better for Dr. Williams and the use of customized prefabs often is successful enough for many of his patients that they will put off purchasing a custom device. If insurance will not cover orthotics or patients cannot afford or choose not to purchase a permanent pair of orthotics, Dr. Williams will use the customized OTC devices for many patients.
In Dr. Richie’s practice, less than 10 percent of patients start with a prefab foot orthotic before moving to a custom device. Usually, he says patients get a prefab orthosis based solely upon their reluctance to pay for custom devices and they normally stay with the prefab after that time. Anecdotally, Dr. Richie says these patients do not recover as quickly as the patients who use custom foot orthotics.
Most of the time, Dr. Fullem will start with prefabricated devices unless the patient has already tried them unsuccessfully or if the patient’s foot type deviates a significant amount from “normal.” If the patient has a higher or lower arch type, he says most OTC inserts will not match the foot well.
In regard to prefabricated orthoses, what brand(s) have worked well in your experience?
Dr. Fullem dispenses Powerstep and Redi-Thotics inserts. He also recently began using the ProTech Light Orthotics (Powerstep) that offer more customized devices. He has also found Spenco and Superfeet to be “well made and reliable.”
Citing the CP 3000 prefabricated orthotic developed by KLM Labs over 20 years ago, Dr. Richie notes this device has been incorporated into many other branded prefabs such as Powerstep. He uses the CP 3000 shells. Dr. Richie notes the device has a well-designed shape that matches the majority of foot types and has a proven track record.
Dr. Williams prefers full-length Pure Stride Orthotics, noting that they work well with his customization process.
For custom orthotics, what are your prescription criteria? Do you use a rigid, semi-rigid or flexible shell material? Do you post the rearfoot? Do you post the forefoot? Do you use additional enhancements?
During his career, Dr. Richie has moved from rigid foot orthoses to semi-rigid devices when treating plantar heel pain. He has also eliminated rearfoot posting from all custom foot orthotic devices for patients with plantar heel pain. This post will increase hardness of the device directly under the most painful area of the calcaneus for patients with plantar fasciitis.
“I am amazed how often patients with plantar heel pain feel worse with custom orthotics and suddenly feel better when the rearfoot post is removed,” says Dr. Richie.
Dr. Richie asks his lab to balance the forefoot to rearfoot deformities intrinsically so he does not need to use forefoot posting. As he notes, most patients with plantar heel pain have a mild to moderate forefoot valgus deformity. He says balancing out the forefoot valgus diminishes the load on the central band of the plantar aponeurosis. As medial arch contour is also important, Dr. Richie will ask the lab to provide minimal cast dressing or minimal arch fill.
Dr. Williams casts patients partially weightbearing with a foam box. He will then scan the cast with an occipital iPad scanner for production. He does not like non-weightbearing scans. With these scans, Dr. Williams points out the foot often will elongate somewhat but not fully in partial weightbearing casts in comparison with a non-weightbearing cast.
Dr. Williams usually uses semi-rigid to semi-flexible polypropylene devices. He will post the forefoot and rearfoot as necessary according to his evaluation. Dr. Williams uses heel lifts, usually about 3 mm, on the majority of his patients. He uses the ankle joint lunge test to evaluate for equinus. As he has found, most adult patients have less than 2 degrees of dorsiflexion when it comes to ankle range of motion with the knee extended. Dr. Williams will use forefoot wedging in the patients who have increased dorsiflexion excursion of the lateral column via his exam. He will use first ray cutouts with PPT backfill as well in those with functional hallux limitus. Dr. Williams will also use digital wedging in most patients.
Dr. Fullem’s prescription criteria varies depending on the foot type and injury. Most often, he has a cork/ethylene vinyl acetate (EVA) device fabricated. As he says, the cork molds well to the foot and patients tolerate the devices well. Dr. Fullem says these orthoses are “extremely effective.” Dr. Fullem also makes a semi-flexible type device and occasionally make a rigid shell type device. He will often post the rearfoot and the forefoot, sometimes including an EVA post to the sulcus. For a person with a functional hallux limitus, he prefers a semi-flexible shell with an external rearfoot post and a first ray cutout with a valgus forefoot post to the sulcus with a reverse Morton’s cutout.
“The most important aspects of orthotic therapy are that the device first and foremost has to be comfortable and then ideally, it should eliminate any pain,” maintains Dr. Fullem.
Dr. Fullem is a Fellow of the American Academy of Podiatric Sports Medicine. He is in private practice in Clearwater, Fla.
Dr. Williams is the Director of Gait Analysis Studies at the Weil Foot & Ankle Institute. He is a Past President and Fellow of the American Academy of Podiatric Sports Medicine. Dr. Williams is the Director of Breakthrough Sports Performance, LLC in Chicago.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice in Seal Beach, Calif.
For further reading, see “Orthoses For Plantar Fasciitis: What The Evidence Reveals” in the November 2015 issue of Podiatry Today, “A Guide To Conservative Care For Plantar Fasciitis” in the November 2016 issue or “A Guide To Conservative Care For Plantar Heel Pain” in the November 2013 issue.