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.

The -itis versus -osis debate!!

I’m sure that you will agree that our patients are our best advertisement.  Word of mouth travels fast!  But what happens when the doctor becomes the patient?  Please read the testimonial below from one of your colleagues on the North Shore who was treated at WalkWell Rehabilitation.

As a family practitioner I thought I knew a fair bit about musculoskeletal problems and their treatments.  But after a few treatments I had learned a tremendous amount of new things about physical medicine and I have not felt better in years.  I now recommend Chris to all my patients who need physical therapy for treatment of conditions of the lower extremities.” – PhillipBurrer,MD of Family Medicine Associates

-ITIS VS -OSIS…
WHAT YOU NEED TO KNOW!!

One of the most controversial topics in orthopedic medicine is the –ITIS versus -OSIS debate.  Many health care practitioners feel that inflammation is the main source of pain in chronic conditions.  This is apparent through the use of NSAIDS, steroid injections, and modalities such as iontophoresis.  As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating chronic pain.  Evidence-based treatment is the MAIN FOCUS in my clinic.  Can we prevent the reoccurrence of pain by ONLY treating the inflammation??  What does the research tell us?

Karim Khan, MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that animal studies conclusively demonstrate that, “within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan, MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont, DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237
states that, after analyzing tissue samples from 50 plantar fasciotomies, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Almekinders, Temple, et al in “Etiology, Diagnosis, & Treatment of tendonitis: an analysis of the literature”, Med Sci Sports Exer 1998;30(8):1183-1190 state that they “found little evidence that NSAIDS and corticosteroids were helpful in treating tendinopathy.”

Because no inflammatory cells have been demonstrated in biopsies from chronic tendinopathy, some authors have abandoned the tendonitis “myth” as well as the use of steroids.  Recent studies, however, have begun to question this new opinion.  Recent placebo controlled, randomized studies of ultrasound-guided peritendinous steroid injections have been shown to be very effective in reducing the pain and thickness of Achilles and patellar tendons in athletes with chronic tendinopathy.

Fredberg et al in “Ultrasonography as a tool for diagnosis, guidance of local steroid injection..”, Scand J Rheumatol 2004; 33: 94-101 state that steroid injections “significantly reduced the average diameter of the affected tendons” and “in several cases the thickening of the tendon regresses completely.”

Koenig, et al in “Preliminary results of colour Doppler-guided intratendinous glucocorticoid injections..”, Scand J Med Sci Sports 2004: 14: 100-106 found that “neovascularization disappears” after ultrasound-guided, intratendinous injections.

Injection technique appears to play a pivotal role in the effect of the steroid on pathologic tissue.  Should the practitioner continue to inject “blindly” or use ultrasonography to guide the precise placement of steroid?  The next unanswered question is how to maximize the therapeutic benefit AFTER injection.  Fredberg also states that steroids “cannot repair degenerative changes” and attempted to explain “the high frequency of relapse” 6 mo after the first injection.  He now recommends 3-6 months of rehabilitation after injection.  At OrthoWell/WalkWell, the functional regeneration of tissue is our goal.