Foot orthoses for people who have plantar heel pain and very flat feet

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What type of foot orthoses (i.e. midfoot or rearfoot) do you prescribe for people who have plantar heel pain and very flat feet (i.e. everted heel and a low arch profile)?

Obviously there are many variables to consider, but I was taught that midfoot foot orthoses are generally better at reducing the stress applied to the plantar fascia. However, people who have a low arch profile may not tolerate midfoot foot orthoses. Rearfoot foot orthoses would thus seem to be more appropriate, but will they irritate the origin of the plantar fascia?

 

First off, are you sure it's plantar fasciitis and not some other form of heel pain. Secondly, how do you make an orthotic that has a midfoot and not a rearfoot? A lot of the orthotics that I make have a rearfoot, midfoot and forefoot.

Eric

 

Shaun:

One must remember that plantar heel pain may be caused either by excessive magnitudes/durations of compression forces acting on the plantar calcaneus from ground reaction force and/or caused by excessive magnitudes/durations of tension forces from the plantar fascia pulling on the plantar calcaneus. Any orthosis design that reduces not only compression forces but also plantar fascial tension forces on the plantar heel, regardless of the medial arch height or the apparent frontal plane position of the calcaneus, should help make the pain better. This type of treatment model is the key to Tissue Stress Theory....where you don't even need to try and measure frontal plane calcaneal position in order to prescribe effective foot orthoses for patients.

 

Thanks for your replies Eric and Kevin.

Eric, I was referring to the highest point (i.e. midfoot or rearfoot) of the foot orthotic. This was just an example.

Kevin, thanks for your explanation, I was just seeking reassurance as I also use the tissue stress theory to treat musculoskeletal injuries, which obviously includes the prescription of foot orthoses. Thankfully podiatry students are now being taught to use the tissue stress theory, but there are still many podiatrists that prescribe foot orthoses based on simplistic and outdated theories (i.e. focussing on frontal plane heel position and prescribing 1 type of foot orthotic for all people that have a particular musculoskeletal injury).

 

Hi Shaun,

If the subtalar joint axis is medially deviated, then an orthotic with a higher medial shell/ arch might get a bit uncomfortable. You might have better luck using medial heel skives/ inverted rearfoot posting to add a supination force to this flat foot.

This is assuming you know how to assess the STJ axial position. If you don't, here's a thread discussing it...
http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=4075

And here's a paper that describes it I believe..
KA Kirby
Methods for determination of positional variations in the subtalar joint axis J. Am. Podiatr. Med. Assoc. 1987 77:228-34

 

Thanks Phil, I'm aware of and do use this clinical test.

 

Hey Shaun.. we will be discussing this issue in great detail at the www.bartoldbiomechanics seminar you will be attending in Melbourne. Stick around for lunch if you can and we can throw it around further! See your there on the 24th
S :drinks

 

....only 26 years old....that paper.....

 

lucky you were only 13 when you wrote it...

 

Thanks Simon, that sounds great, looking forward to it.

 

Hello, I use and invented the Inverted Orthotic Technique which works well for this problem. Let me know if you want any help with this. There are so many variables to use. The goal remains to transfer the weight into the arch and cushion and protect the heel. Dr Rich Blake