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Heel lifts - how do they work

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Asher, Jan 18, 2011.

  1. Asher

    Asher Well-Known Member


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    Hi all,

    I am having trouble explaining something to a student and need some help please. Its about heel lifts and how they are helpful as a treatment modality.

    So for example, if I have a patient with an anterior cavus (forefoot equinus), lets say it is stiff and they are having plantar forefoot symptoms, I would place a heel lift in the shoe, in my words, to:

    1. Increase the magnitude of rearfoot load, which will reduce the magnitude of forefoot load.
    2. Make the timing and duration of rearfoot and forefoot loading more normal such that the rearfoot is loaded for longer and the forefoot is loaded for a shorter time.

    But this explanation is not really easy to understand. Also, because in part, the higher the heel lift you use, the more load there will be on the forefoot and for longer.

    Please help!

    Rebecca
     
  2. It really is!!

    Try beating the student.

    I'd suggest talking about "escape pronation" and such, but yours is much simpler.
     
  3. Griff

    Griff Moderator

    How's this:

    - Patient has stiff forefoot equinus
    - This reduces functional sagittal plane ankle range (as some dorsiflexion is taken up just to get plantigrade)
    - Common compensatory mechanism for this dynamically is an early heel lift
    - Heel lifting earlier = more time spent on forefoot = increased plantar forefoot pressures

    ENTER HEEL LIFT

    We see reduced forefoot symptoms as heel lift changes temporal loading pattern at plantar forefoot (or in student speak the lift improves functional ankle range which delays heel lift and means less time spent on forefoot)
     
  4. efuller

    efuller MVP

    I like the above, which is conflict with below which I believe is wrong.


    In terms of heel lift, you have to understand balance and center of pressure. Your center of pressure has to be under your center of mass, because when it isn't you'll fall over. When you lean forward you will subconsciouly contract your calf muscles to shift your center of pressure under your foot forward. Have your student try slowly lean forward and note where the force is on the bottom of their foot. Then lean back and note the contraction of the anterior tibial muscle. Now stand on a heel lift and lean forward and back, same muscle actions. This disproves the notion that a heel lift will increase the load on the forefoot. On the other hand standing in a spike high heel shoe, you may choose to lean forward and put more weight on your forefoot. Where the force will be is determined by choice, up to a point. There was another thread where someone had an equinous so bad that he could not get his heel on the ground when he was standing in static stance. This guy needs a lift to get weight off of the forefoot and on to the heel.

    Eric
     
  5. Lab Guy

    Lab Guy Well-Known Member

    I really like how Ian broke it down for students...good job. Steven

    How's this:

    - Patient has stiff forefoot equinus
    - This reduces functional sagittal plane ankle range (as some dorsiflexion is taken up just to get plantigrade)
    - Common compensatory mechanism for this dynamically is an early heel lift
    - Heel lifting earlier = more time spent on forefoot = increased plantar forefoot pressures

    ENTER HEEL LIFT

    We see reduced forefoot symptoms as heel lift changes temporal loading pattern at plantar forefoot (or in student speak the lift improves functional ankle range which delays heel lift and means less time spent on forefoot)
     
  6. efuller

    efuller MVP

    Very close. the peak pressure may not change but the length of time that the pressure is high will change. aka pressure time integral.

    Eric
     
  7. Fiona_S

    Fiona_S Welcome New Poster

    Hi all, I am the student Rebecca is talking about!

    Thank you for all the explainations, I think i finally understand.

    Rebeccca has been really patient with me-trying to explain this!

    Fiona.
     
  8. Griff

    Griff Moderator

    You're right Eric - I worded that poorly. Forefoot pressures would not necessarily increase in magnitude.

    Fiona - you've got a great mentor in Rebecca! Best of luck with it all.
     
  9. Asher

    Asher Well-Known Member

    Now something that I really don't understand is using heel lifts of asymmetrical density. I believe the rule is that a heel lift using a stiffer material will make heel-off occur sooner and that of a softer material will make heel-off occur later.

    I would have thought that a stiff lift will keep the heel loaded longer.

    And when would you use heel lifts of asymmetrical density? I would have thought that if its for a leg length inequality, just lift the short leg and don't put anything under the long leg.

    Regards

    Rebecca
     
  10. Admin2

    Admin2 Administrator Staff Member

  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review.
    Rabusin CL et al
    Gait Posture. 2019 Mar ;69:224-234
     
  12. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Several comments:

    (1) Never use a heel lift, use a platform lift (heel to toe).
    (2) In the above discussion, no one has mentioned what happens above the ankle when a platform lift is placed in one shoe. The platform lift rotates the ipsilateral innominate anteriorly when results in a functional leg length discrepancy. This destabilizes the base of the spine resulting in torsions in all three body planes. This distortional pattern continues into the cranium.

    One should not limit one's vision to a specific segment in the postural chain. One must evaluate the entire postural chain (foot to jaw) when contemplating any positional change in the foot (e.g., platform lift, orthotic etc). And how that positional change in the foot will impact the skeletal framework above it.
     
  13. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Gerrard,

    I was hoping you would have jumped into this discussion when I stated that a platform lift rotates the ipsilateral innominate anteriorly. Because that is not correct, research studies have demonstrated that a platform lift rotates the ipsilateral innominate posteriorly.

    This posterior rotation of the innominate destabilizes the pelvis (frontal plane), which in turn, destabilizes the entire spine. This is why I stated above that one needs to keep a global view when using platform lifts, and not just look at the foot.

    All of the publications below are original research studies that linked the long leg to a posterior rotation of the ipsilateral innominate bone.

    Papers that merely commented on this relationship, were ignored.

    Pitkin H, Pheasant H. Sacrarthrogenetic telalgia. II A study of sacral mobility. J Bone Jt Surg 1936;18(2):365-75.
    Drerup B, Hierholzer E. Movement of the human pelvis and displacement of related anatomical landmarks on the body surface. J Biomech 1987;20(10):971-7
    Cummings G, Scholz JP, Barnes K. The effect of imposed leg length difference on pelvic bone symmetry. Spine 1993;18 (3):368-73
    Beaudoin L, Zabjek KF, Leroux MA, Coillard C, Rivard CH. Acute systematic and variable postural adaptations induced by an orthopaedic shoe lift in control subjects. Eur Spine J 1999;8 (1):40-5.
    Young RS, Andrew PD, Cummings GS. Effect of simulating leg length inequality on pelvic torsion and trunk mobility. Gait Posture 2000;11(3):217-23.
    Zabjek KF, Leroux MA, Coillard C, Martinez X, Griffet J, Simard G, et al. Acute postural adaptations induced by a shoe lift in idiopathic scoliosis patients. Eur Spine J 2001;10 (2):107-13.
    Giles LG. Lumbosacral facetal “joint angles” associated with leg length inequality. Rheumatol Rehabil 1981;20(4):233-8.
    Krawiec CJ, Denegar CR, Hertel J, Salvaterra GF, Buckley WE. Static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes. Man Ther 2003;8 (4):207-13.
    Hanada E, Kirby RL, Mitchell M, Swuste JM. Measuring leglength discrepancy by the “iliac crest palpation and book correction” method: reliability and validity. Arch Phys Med Rehabil 2001;82(7):938-42.
     
  14. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    If you would like to view an animation that demonstrates the cephald shift of the acetabulum when the innominate bone is rotated anteriorly (which shortens the leg), go here.
     
  15. Ted Dean

    Ted Dean Member

    I use heel lifts for symptomatic Forefoot Equinus feet tht end jus proximal to the metatarsal arch and follow the curve of the met arc if not using a foot orthotic. Clinically has worked well.

    Most standard off the shelf heel lifts are pitched under the calcaneus. Do these provide a pronatory force to the foot by plantar flexing the calcaneus? Given that orthotic designs prevent calcaneus plantar flexion and a modification for dorsiflexing the calcaneus by shaving material from the cast is an orthotic modification that is sometimes (rarely) used, aren't standard off the shelf heel lifts poorly designed?

    "Talk amongst yourselves"
     
  16. Ted Dean

    Ted Dean Member

    Hopefully someone gets my sense of humor "talk amongst yourselves" equals please discuss.
     
  17. Dr Rich Blake

    Dr Rich Blake Active Member

    Ted, I think this is a wonderful point. I love full length lifts to the sulcus when I can use them. I have found them more stable then heel lifts. Heel lifts alone can increase rearfoot instability is a common observation. I do not skive them until the most distal end, but I do not object to patients wearing these types of inserts. I am going to be much better in observing it the skived heel lifts vs the level heel lifts clinically produce a difference. I can make the two types and ask patients also what seems better. Great and simple research paper!! Rich
     
  18. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Hi Ted,

    I would need more information before I could comment on using Heel Platforms (not heel lifts) for forefoot Equinus.

    If this patient presented herself to my clinic, I would do the following: (forefoot equinus can impact any weight bearing joint, up to and including the TMJ)
    • Take a complete History and Physical
    • Blood workup, including CBC and C-Reactive Protein
    • Adams Test, if positive, I would order a full spinal xray, if negative, I would order pelvic and sacral xrays.
    When was the onset of the forefoot equinus
    Unilateral or Bilateral
    Establish the cause (e.g, contracted Soleus, contracted Gastrocnemius, pathologic ankle joint)
    Run Knee Bend Test to rule out presence of PreClinical Clubfoot Deformity or Primus Metatarsus Supinatus foot structure

    With the above clinical data, I could determine the best course of action
     
  19. Dr Rich Blake

    Dr Rich Blake Active Member

    Asher, one simple rule is to unload one area my placing the load elsewhere. Therefore A heel lift may take pressure off the forefoot.
    Another rule is relaxing equinus forces can take pressure off the forefoot
    Another rule is heel lifts if sufficient to throw weight forward, may transfer weight forward onto the metatarsals, so it is based on the amount of lift and this varies patient to patient
    It is similar to treating heel pain, some heel lifts just put more weight on the heel increasing pain, and some shift weight forward decreasing heel pain. Rich
     
  20. Dr Rich Blake

    Dr Rich Blake Active Member

    I do prefer full length lifts (platform) over heel lifts also, unless a heel lift would help another problem like Achilles injuries at times. I am not a deep thinker about lifts other than that , and have had tremendous success with lifts when I observe a positive change in gait from the lifts (like less of a leaning tower). If the gait change is positive, I allow them to break in the lifts and follow their symptoms in a monthly approach. Rich
     
  21. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Hi Rich,

    Appreciate your comments. Your preference towards platform lifts is laudable. Watching the sagittal plane shift (e.g., leaning tower of Pisa syndrome) is a quick way to evaluate the impact the platform has on upper body posture.

    Also, your comment on monthly checkups and discontinuing use with a positive Pisa sign (increase forward lean) are well taken.
     
  22. Dr Rich Blake

    Dr Rich Blake Active Member

    Thanks Brian. Rich
     
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