Plantar Fasciitis & Foot Orthotics

Yes. We treat a lot of plantar fasciitis. There is a lot of foot pain out there. While performing a literature review of heel pain in 2005 (follow this link to READ MORE), I made reference to several articles about the prevalence of heel pain. One United States study estimated that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. This disorder appears in the sedentary and geriatric population, it makes up one quarter of all foot injuries in runners, and is the reason for 8% of all injuries to people participating in sports. As many of you know, all that we do regarding foot orthotic fabrication and physical therapy is with good, evidence-based reason. I fabricate custom foot orthotics based on sound biomechanical principles and evidence-based research. Patients are always asking me “so how will foot orthotics help my plantar fasciitis?” Here is the answer! I have included both a clinical description as well as a more basic description in the video. This will allow you to refer your doctor and/or PT as well as a relative who may ask WHY or HOW we made your foot orthotics. I have included references for several articles that have had a profound influence on my treatment and fabrication philosophy regarding plantar fasciitis.  I would like to share my insights with you.

It has been my experience that positive results can be achieved much more quickly for cases of plantar fasciitis using the combination of softer materials to cushion the foot in combination with stiffer, denser materials to redistribute pressures on the foot. My direct molding techniques produce a total contact orthotic which reduces weight bearing pressure on both the heel and forefoot.  These findings for total contact orthoses have been confirmed by both Mueller et al10,11 and Ki et al12. As you can see from my samples on the video, I utilize softer materials as a top layer with the addition of a heel pad on the bottom.  I reinforce the arch in order to redistribute pressures up against the talonavicular joint (or midfoot).  I utilize a forefoot valgus post (higher on the outside of the forefoot) with a slight reverse Morton extension (ledge under toes 2-5) in order to plantar flex the first ray (big toe lower than the other four toes) and unload both the fascia and 1st MTP joint (big toe joint)  As I tell my patients, the foot orthotic is only as good as the shoe you put around it. Our best results with the over-pronating foot are achieved via the combination of motion control shoes and custom orthoses.

In regards to prefabricated orthotics such as ALine, it is one-shape-fits-all and only utilizes rearfoot posting “to help align the leg from foot to hip” per the website. The concept of rearfoot posting for biomechanical control is a much debated topic in the literature. Forefoot modifications are not an option. It is also a very rigid material against a painful heel.  It has been my experience that prefabs such as ALine or Powerstep are a good option for the younger, athletic patient.

Don’t forget, our custom foot orthotics range in price from $120 to $165. I direct mold, fabricate, educate and issue in one hour!  All adjustments included. Our WalkWell guarantee since 1997!!

Research findings continued……

Research done by Kogler1,2,3 et al has been instrumental in determining the appropriate type of rearfoot and/or forefoot posting for foot orthotics for plantar fasciitis. Kogler showed that rearfoot posting had little effect on plantar fascia strain, forefoot varus posting increased the stress, and forefoot valgus posting actually decreased the strain.  Kogler concluded that foot orthotics which raised the talonavicular joint and prevented dorsiflexion of the first ray were most effective in reducing the strain on the central band of the plantar fascia. I recently made orthotics for a patient who said her doctor issued bilateral heel lifts “to take the stress off of the fascia”.  Kogler actually showed no change in plantar fascia strain using heel lifts.  However, heel lifts have been shown by Trepman et al4 in 2000 to decrease the compressive forces in the tarsal tunnel.  Benno Nigg5, a researcher in Canada, has also published over 200 articles on biomechanics.  He has stated that based on his results, custom foot orthotics, on average, control only 2-3 degrees of motion.  This would be his kinematic results, however, he has done a lot of enlightening research on the kinetic effects of foot orthotics. A little bedtime reading for you!

Paul Scherer6,7,DPM has published several articles on the effects of custom orthotics on the 1st MTP joint. The concept of maintaining the first ray in a plantar flexed position unloads both the 1st MTP joint as well as the plantar fascia. Howard Dananberg8,DPM has also written several articles on this topic. Doug Richie9,DPM has been a great resource for the evidence behind the treatment of plantar fasciitis as well as posterior tibialis dysfunction.  You may have heard of the Richie brace.  Dr Richie states that the “most effective foot orthotic for plantar fasciitis is one that hugs against the navicular and flares away from (or plantar flexes) the first ray.”

1.Kogler, G. F.; Solomonidis, S. E.; and Paul, J. P.: Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin. Biomech., 11: 243-252, 1996.

2.Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of   wedges on loading the plantar aponeurosis, An in vitro study. J Bone and Joint Surg Am. 81:1403-1413, 1999

3.Kogler GF, Veer FB, Verhulst SJ, Solomonidis SE, Paul JP.

The effect of heel elevation on strain within the plantar aponeurosis: in vitro study.

Foot Ankle Int. 2001 May;22(5):433-9.

4.Trepman E, Kadel NJ: Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle Int 20(11):721, 2000

5.Nigg, B. Biomechanics of Sport Shoes. 2011

6.Scherer PR, Sanders J, Eldredge, DE, et al. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc 2006;96(6):474-481.

7.Scherer,P. Recent Advances in Orthotic Therapy. 2011

8.Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc. 1986; 76(11):648-52

9.Richie,D. Offloading the plantar fascia: What you should know. Podiatry Today, Vol 18. Issue 11, Nov 2005.

10.Mueller MJ, Hastings M, Commean PK, et al. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech 2003;36(7):1009-1017.

11.Mueller MJ, Lott DJ, Hastings MK, et al. Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. Phys Ther 2006;86(6):833-842.

12.Ki SW, Leung AK, Li AN. Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods. Prosthet Orthot Int 2008;32(3):356-362.

So what’s up with the Shape-Ups?

So what’s up with the claims made by these toning shoes??

I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.

So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.

And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.

And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.

And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.

But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.

What kind of foot orthotic do you need??

Have you been asked this question? Let me help you with the foot condition that you probably diagnose most often – plantar fasciitis!!

The purpose of foot orthotics with a diagnosis of plantar fasciitis is to decrease the strain on the plantar fascia. Kogler, in his articles in Clinical Biomechanics, has provided evidence highlighting the effect of several variables on plantar fascia strain. Let me give you a summary:

  • Heel lifts do NOT decrease the strain on the plantar fascia
  • A wedge placed under the outside of the forefoot decreased the strain.
  • A wedge placed under the inside of the forefoot increased the strain.
  • Foot orthotics that raise the apex of the arch and prevent excessive loading of the first ray (the inside part of foot) are the most effective in reducing plantar fascia strain.

The foot orthotic should be custom molded, fit snugly up against the navicular bone, and flare away from the outside aspect of the foot. The orthotic can include a post under the outside 4 metatarsal heads. We call this post a reverse Morton’s extension. It will allow the first ray  to be in a downward position relative to the other metatarsals. As a result, we decrease the strain on the plantar fascia.

At WalkWell, biomechanical analysis is our specialty. We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy. We hope to hear from you soon!!

Plantar Fasciitis and Foot Orthotics.

The purpose of foot orthotics with a diagnosis of plantar fasciitis is to decrease the strain on the plantar fascia.  Kogler, in his articles in Clinical Biomechanics, has provided evidence highlighting the effect of several variables on plantar fascia strain.  Let me give you a summary:

  • Heel lifts do NOT decrease the strain on the plantar fascia
  • A wedge placed under the lateral aspect of the forefoot decreased the strain.
  • A wedge placed under the medial forefoot increased the strain.
  • Foot orthotics that raise the apex of the medial arch and prevent dorsiflexion (loading) of the first ray are the most effective in reducing plantar fascia strain.

The foot orthotic should be custom molded, fit snugly up against the navicular, and flare away from the lateral aspect of the foot.  The orthotic can include a post under the lateral 4 metatarsal heads.  We call this post a reverse Morton’s extension.  It will allow the first ray i.e. the first metatarsal and medial cuneiform to be plantar flexed relative to the other metatarsals.  As a result, we decrease the strain on the plantar fascia.

At WalkWell, biomechanical analysis is our specialty.  We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy.

DO FOOT ORTHOTICS CONTROL ALIGNMENT??

Foot orthotic devices (FOD’s) are widely used and prescribed for foot conditions ranging from diabetes to overuse injuries to plantar fasciitis.  A myriad of prefabricated and custom devices are now available.  The method by which the practitioner prescribes a device is determined more by his or her previous clinical experience than by conclusive scientific evidence.  The variability of FOD’s used in research as well as the prevalently small sample sizes (<20 subjects) makes it difficult to extrapolate useful clinical information.  There is, however, strong evidence that selected FOD’s prevent injury reoccurrence in runners and athletes in general.  FOD’s have also been shown to reduce impact loading by 10-20%.  What research does NOT prove is that foot orthoses control alignment like we think they do!!

The majority of foot orthotic research focuses on control of rearfoot motion in the frontal plane.  While there are numerous studies that demonstrate NO effect on rearfoot motion, most report that FOD’s result in control of some aspects of rear-foot motion such as peak eversion, eversion excursion, and/or eversion velocity.  The average amount of rear-foot motion control reported in the literature is on the order of 2-3 degrees.  That’s it!  The question is whether this 2-3 degrees is clinically significant—or can the observed control be explained in a different way?

WalkWell Foot Orthotics
Is   DIFFERENT   from   the   competition!!!

Each patient at WalkWell is evaluated by an orthopedic physical therapist with 19 years of experience treating disorders of the lower extremity and fabricating custom foot orthoses.  The evaluation includes a gait analysis and a complete biomechanical assessment.  Special materials of varying density and firmness are directly molded to the foot in order to create a completely CUSTOM orthotic WHILE YOU WAIT!!  The process is complete in ONE HOUR.

PROPER FIT IS GUARANTEED!!!

Each patient is thoroughly educated in proper footwear, stretching, and pain management strategies.  All follow-up adjustments are included.  Simply refer your patient to WalkWell Orthotics and we will do the rest!!

How do FOOT ORTHOTICS work?

Foot orthotic devices (FOD’s) are widely used and prescribed for foot conditions ranging from diabetes to overuse injuries to plantar fasciitis. A myriad of prefabricated and custom devices are now available. The method by which the practitioner prescribes a device is determined more by his or her previous clinical experience than by conclusive scientific evidence. The variability of FOD’s used in research as well as the prevalently small sample sizes (<20 subjects) makes it difficult to extrapolate useful clinical information. There is, however, strong evidence that selected FOD’s prevent injury reoccurrence in runners and athletes in general. FOD’s have also been shown to reduce impact loading by 10-20%. What research does NOT prove is that foot orthoses control alignment like we think they do!!

The majority of foot orthotic research focuses on control of rearfoot motion ie your heel turning in or turning out.  While there are numerous studies that demonstrate NO effect on rearfoot motion, most report that FOD’s result in control of some aspects of rear-foot motion such as total motion or speed of motion.  The average amount of rear-foot motion control reported in the literature is on the order of 2-3 degrees. That’s it! The question is whether this 2-3 degrees is clinically significant—or can the observed control be explained in a different way?

WalkWell Foot Orthotics
Is DIFFERENT from the competition!!!

At WalkWell you are evaluated by an orthopedic physical therapist with 20 years of experience treating disorders of the lower extremity and fabricating custom foot orthoses. The evaluation includes a gait analysis and a complete biomechanical assessment. Special materials of varying density and firmness are directly molded to the foot in order to create a completely CUSTOM orthotic WHILE YOU WAIT!! The process is complete in ONE HOUR.

PROPER FIT IS GUARANTEED!!!

You are thoroughly educated in proper footwear, stretching, and pain management strategies. All of the above PLUS any follow-up adjustments for a very affordable price!!