Orthotic Prescription for Plantar Fasciitis/Plantar Heel Pain with Justification

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Hi all!

First time posting here, so not sure if there are any rules I need to follow.
I am a Podiatry student in my last year, and I have an assignment on an orthotics prescription based on a case study we have found throughout the year. We need to be able to justify our prescription, with personal critique on what we could have done better/different and why, if, it did not work as intended.

The case is a middle-aged woman with pes cavus feet, pronation throughout gait, and an abductory twist on her symptomatic side, gastroc weakness (4/5 muscle strength testing on dorsiflexion), manual supination resistance test 5/5.

Me and the podiatrist I was shadowing provided her with some prefabricated orthotics to which we added contralateral posting (rearfoot varus post, and a lateral forefoot wedge). This is what I would have done, even if they had not suggested this prescription, but I can't find any reason for why when looking through our teaching material. I have tried searching the internet and my uni library, but everything I found was studies on valgus forefoot wedging, and not much, if any, information on valgus forefoot + varus rearfoot.

I have read a number of threads on here getting close to an answer, I believe, but nothing concrete... If there is anyone out there who can help, either by linking an article that explains it and that can be used as justification, or willing to explain how/why it may help this lady, that would be greatly appreciated!

Cheers and thanks!

 

See (3):
http://www.runresearchjunkie.com/plantar-fasciiis-how-then-do-you-treat-it/

Anything that inverts the rearfoot and everts the forefoot lowered the load in the plantar fascia.

 

Craig, thank you very much for the fast response!

 

Plantar Fasciitis/Plantar Heel Pain are symptoms, not a diagnosis. First, determine the cause (again, pronation is a symptom) and then treat that cause (etiology).

You may find this article on the Positive Health forum of help.

 

See my article on the windlass mechanism. Fuller EA The Windlass Mechanism of the foot. In JAPMA 1999 or 2000. I agree with Craig that pronation of the STJ will increase the distance from the medial calcaneal tubercle to the base of the proximal phalanx.

There is more than one cause of pronation. Do you understand the concept of location of center of pressure relative to the location of the STJ axis? There are ground caused pronators and muscle caused pronators. The varus heel wedge is good for one and bad for the other.

Contrary to the other poster, plantar fasciitis is a diagnosis.

 

Thank you Fuller for your response.

In regards to what you said about increasing the distance between the medial calcaneal tubercle and the base of the hallux, just to confirm, you're saying that this increases load on the plantar fascia right? And thus decreasing that distance would decrease load? Just want to make sure I fully understand what you're saying

Yes I am aware of the concept, I have, what I believe is, a decent understanding of this. Just to clarify, you mean in terms of the axis of the STJ and how forces on one side will affect either pronation or supination, depending on which side of the axis it is exerting its force. I am a little in the dark about muscle caused pronators, but I am willing to take a guess that this refers to intrinsic muscles causing a pronatory force on the foot.

When discussing the varus heel wedge, what did you mean it is good for one and bad for the other? Is this in terms of ground caused pronators vs. muscle caused pronators?

I too agree that plantar fasciitis is a diagnosis, at least that was what were taught, and since it is seen as an injury, or pathology, I don't see how some people see this as a symptom and not a diagnosis.

Thanks again for the in-depth reply I have always enjoyed perusing these discussion boards, both for answers to complicated questions, but also just further enlightenment of biomechanical and musculoskeletal theories, thoughts and concepts.

EDIT:
I just took the time to read through your article about the windlass mechanism. Firstly, excellent article, I may have to pass that one on to some of my peers. Secondly, that really clarifies things, I don't think I have had the windlass mechanism so eloquently explained before, which answers a lot of the unanswered questions I have previously had!

 

I disagree. Pronation describes a motion. If that motion has escaped Hip Drive (no longer directed by the transverse plane oscillations of the pelvis), it is considered abnormal (hyperpronation) but it does not describe the cause of that abnormal pronation.

As this poster indicated, it could be due to "ground cause pronators (structural ?) or muscle caused pronators (soft tissue pathology)." Determine that cause and treat that cause, not the resulting symptoms .

 

I understand what you are saying and I do agree, to an extent. In the case of someone experiencing plantar heel pain, or plantar fasciitis, if that is due to overload or increased stress of the plantar fascia due to a pes planus foot type. Correct me if I'm wrong, but is that not addressing the biomechanical abnormalities that they are exhibiting, much the same as overpronation at the pelvis?

Would you mind explaining how plantar fasciitis is not a diagnosis? Is it not a musculoskeletal condition? Wouldn't the symptoms for example be the pain or discomfort they are feeling?

 

I think you understood what I said. I do like to emphasize the load more than position. Something can be in the same position with different loads. A good way to look at treatment here is that you are attempting to decrease the distance. The distance may not change, but the load may decrease. You can tell because it hurts less.

You might want to look at the thread(s) here on arena about SALRE ( Subtalar joint Axis Location and Rotational Equilibrium.)
The STJ axis is variable across people. Some have a medial axis, some have a lateral axis, some an average axis location. Center of pressure is the average point of ground reaction force. Different feet will function differently with the location of the center of pressure in the same location because the location of the axis is different. This is a measurable thing that can tell you why feet function differently.

When the axis is medial, the location of force will tend to be lateral to the axis and ground reaction force will cause pronation. These are the people who do well with a medial heel wedge.

When the axis is lateral, the location of force will tend to cause the STJ to supinate. These feet, with no muscular control, will tend to supinate to end of range of motion. People don't like this and they will use their peroneal muscles to keep their feet flat on the floor. This is what I mean by a muscular pronator. When you give these people a varus heel wedge you will be making their peroneal muscles work harder and they will still tend to get high load sub first met head (which causes increased load in the plantar fascia) even with the varus heel wedge.

Papers that could help you here. Kirby, K Rotational equilibrium. Fuller, E Center of pressure.

Kevin Kirby and I wrote a chapter where we tried to tie all of this together in Stephen Alpert and Sarah Curran's book on lower extremity biomechanics.

 

Fantastic! Once again thank you so much for the in-depth concise explanations on rather complicated concepts.
I will make sure to have a read through both of those articles and also see if my uni has access to the book you mention.

I really appreciate your help.

 

The most common biomechanical event that results in inflammation of the long plantar ligament (Plantar Fasciitis) is a chronic stretch on the plantar ligament. What needs to be determined is the cause of the chronic stretch on this ligament. Abnormal pronation is a symptom, flexible flatfeet are a symptom, pes planus foot type is a symptom (there are multiple possible causes for a planus foot type). An overload or increased stress on the plantar fascia is a symptom (what causes that increased stress).

When one reviews the ontological development of the prenatal foot, 2 congenital foot types are identified that can result in plantar fasciitis. Read this article for a detailed explanation: Etiology of the Clubfoot, PreClinical Clubfoot, Primus Metatarsus Supinatus Deformities

IMO, Technicians treat symptoms. Physicians look for causes and treat the primary etiology, if possible.

 

This is my main criticism on the indiscriminate use of orthotics. By indiscriminate, I mean, prescribing orthotics based on symptoms without ascertaining the primary etiology.

Abnormal pronation, flexible flatfoot, plantar fasciitis, corns, bunions, hammertoes, shift in the center of pressure relative to the STJ, etc. – all of these are symptoms. Yet, in most cases, that is the justification the healthcare provides when dispensing orthotics.