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Heel cut-out in orthotic for plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Buggs, Feb 22, 2006.

  1. Buggs

    Buggs Member


    Members do not see these Ads. Sign Up.
    Hi to you all Im new here
    Im interested in hearing as much as posible on
    use of an "orthosis" with a cut out

    If you have time and will to give your view on this subject and how it relates with treatment of plantar fasciitis

    Biomechanics, opinion, expirience anything

    Thank you


    p.s. just in case was not clear here s a pic
    http://i31.photobucket.com/albums/c393/payydro/FOOT.jpg
     
  2. Buggs,

    This is an interesting modification for the treatment of plantar fasciitis that I have not come across in 15 years of teaching and practice. So from a mechanical stand point the hole may reduce pressure on the tissues within it, but will without doubt create an increase in pressure around it's perimeter. I guess (if positioned correctly) it may act in a similar fashion to a "plantar- fascial groove", but to be honest, given the apparent size and shape, I would say it is more likely to irritate the planter fascia.

    Perhaps you could tell us more about the device?

    Who was it made by and for whom, you?
    What is it made from?
    Is it posted in any way?
    Is it moulded in any way?

    Perhaps some photo's from other angles would be helpful.
    Best wishes,
    Simon
     
  3. Arse.
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Some people do use it routinely for insertional plantar fasciitis. A number of orthotic labs promote it as a prescription variable and use a poron/PPT or silicone filler. I don't use it as plantar fasciitis is due to the mechanical pull - don't see how an accomodation would help. Only way I can see it helping is that if direct mechanical pressure caused the problem, in which case its probably not plantar fasciitis. My wife uses them reoutinely and swears by them.
     
  5. pgcarter

    pgcarter Well-Known Member

    What I do in practice and teach the students at Latrobe is that plantarfasciitis is too much stress in the fascial bands, usually 1st slip. Getting the tension off it is best achieved by decreasing the distance between origin and insertion, which is best done by effective 1st ray plantarflexion....get the shape of the orthoses right and you won't have the problem.....more T-N support with a steep distal angle of descent under the 1st met shaft....no hole rquired....but I have seen it about.
    Regards Phill
     
  6. What does she use them reoutinely ( :p ) for? And when you say "swears by them", do you mean she curses because they don't help, make it hurt more... ;)

    Actually thinking about it, we we're probably told to make this as students for "heel spurs" hmmmmmmmmmm. Good to see things have moved on then.
     
  7. footdoctor

    footdoctor Active Member

    a 'hole' lot of bother for nothing

    hey buggs,

    Solid advise from all here! Really makes no sense for p/f.


    If a spur truely exists,(not that commonly lets to honest),heel holes with poron fills can be usefull,personally I would go with a horseshoe shaped poron pad around the margins of the orthotic shell for spur problems.

    You may find that if you drill a hole out of the shell it may lose some of its rigidity and you could lose some of the control offered by the device.

    Also like simon pointed out it is likely that u'll get irritation around the margins of the hole,creating discomfort.

    Basically for p/f forget it,heels spur/plantar lesion apply with caution!!

    Cheers

    Scott
     
  8. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    She uses them for every case of "plantar fasciitis" in which there is 'point' tenderness over calc tubercle... I don't and don't see the rationale for it (unless its not really insertional plantar fasciitis).

    Many (?most) labs offer this as a prescription variable. Langer have a silicone plug in a specific "heel pain" orthotic:
    http://www.langerbiomechanics.com/gallery/ControllingDevices/HeelfitFirm.jpg
     
  9. Steve The Footman

    Steve The Footman Active Member

    I have used a heel cut out with a Poron fill in rare occasions where I felt there was fat pad inflammation under the central calc. In these situations there is localised tenderness that was not related to the plantar fascia. However I would not discount out of hand the possible advantages for an enthesitis type of plantar fasciitis in reducing symptoms. I doubt a small grind out and fill would affect the control much. The hard part would be getting it in the right place as the dynamic foot does not stay in 'neutral' but rolls across the device. As long as the biomechanical causes of the plantar fasciitis were addressed it probably wouldn't hurt for symptomatic relief. Might try it and see, except it is fiddly to make yourself on a regular basis.
     
  10. Donna

    Donna Active Member

    HI Steve!

    Would you expect that a change in covering material make any difference, i.e a full Spenco or poron cover vs. plain vinyl? I've previosuly had patients with plantar fasciitis respond to a full length "soft" cover more readily, but perhaps this is because a soft device is thought to be more comfortable than a hard device by some patients! Is it in the mind? :confused:

    Donna
     
  11. Even though the photo of the insole you provided is a little odd (i.e. the hole is anterior-medial to the medial calcaneal tubercle), the idea of trying to reduce the ground reaction force (GRF) on the plantar calcaneus by using an accommodation technique is nothing new. Regardless of what is written in the literature regarding plantar heel pain, it is quite evident to me from treating this condition with numerous pads and orthosis modifications that different patients respond positively to different modifications.

    Part of the reason for this, I believe, is because plantar heel pain may be caused by either excessive compression forces from GRF acting directly on the medial calcanel tubercle during the first half of stance phase and/or excessive tensile forces from the plantar aponeurosis and plantar intrinsics that originate from the medial calcaneal tubercle acting on the plantar calcaneus during the latter half of stance phase. I discussed this concept originally in this thread: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1682

    I have not actually used a hole cut out in an orthosis, yet, to treat this condition but have written a newsletter (March 1994) on a modification where I use a "plantar heel bubble" filled with PPT or spenco to decrease GRF on the medial calcaneal tubercle. I also commonly use plastazote #3 orthoses with Spenco topcovers with 1 mm thick lateral heel cup expansion thickness (to decrease radius of curvature of heel cup) that I then will grind a concavity on the plantar-central heel to decrease central calcaneal GRF.

    All of these modifications work on the premise that decreasing the GRF on the most symptomatic area of the plantar heel will make the patient more comfortable and hopefully help them heal their condition. And in many of my patients, this is the premise I use with fairly good success in improving and healing their painful plantar heels.

    However, some of my patients are so heavy (over 100 lbs ideal body weight) that trying to get them to have reduced GRF on their plantar heels with an orthosis modification is like trying to prevent an extra 100 pound hammer from causing plantar heel tissue damage with every strike on the heel. However, stay tuned for the patented Kirby Helium Weather Balloon-Belt (only for outdoor use) that is guaranteed to reduce the plantar heel GRF in even the most obese patients. ;)
     
  12. conp

    conp Active Member

    Hi Kevin,
    Are you targetting obese tenors for these Kirby Helium Weather Ballon Belts. I would. If it's not the Helium giving them a higher register then it surely will be the proximal pull of the belt making them hit the high notes!!
    Cheers
    Con
     
  13. Proper placement of groin harness is essential for proper function (and avoidance of personal dysfunction) of the Kirby Helium Weather Balloon Belt. ;)
     
  14. Buggs

    Buggs Member

    hi

    thanks for reply

    the method of a cut out was recomended to me me by one doctor
    ( i think he really belives that the cut out stops the "spur" from causing
    more pain)
    the insoles are not manufactured or sold as
    far as i know ( the pic was done by me to demonstrate things)

    his instructions were very primitive... as this cut out might seem
    the cut out should be in the point of max tenderness and the size is individual
    so basicly you by the material and experimentate

    but i wont lie
    -it does provide some relief
    i also cant explain how that is done
    so thats why i posted this to here your opinions
    maybe it has something to do with the thichening of the fasia near the calcanel bone, maybe the position of the thickend fascia acts as intruder beneath the foot
    (i have found that most of the "heel lifts" make the pain worse so i just conected it to that) and increasing the pull on the fascia...just my thought

    anyway this method was an idea, like i said, but with the molded orthosis
    it would be maybe better
     
  15. Stanley

    Stanley Well-Known Member

    When you palpate the foot you cause it to hurt in the affected part. :eek: When the patient walks they put pressure there also. You are removing pressure from the painful area, and this helps. :D
    Removing tension from the plantar fascia, does not preclude you from making the patient comfortable.
    We have to get past the concept of functional vs. accomodative orthotics. Orthotics can do both. :)
     
  16. Chuck Langman

    Chuck Langman Welcome New Poster

    I have been using a cut out on patients where the pain is located more plantarly than plantar medial. I usually use PPT/Poron but would use silicone if my lab would be willing to use it. I agree with the post saying the pressure at the edge of the hole is greater but I use a Ucolyte topcover (Spenco delaminates to often) to soften the blow. The cushioning can be a great help but you still run into fit issues when it gets too thick. If you can run your thumb medially to laterally over the heel and feel the bony prominence then chances are they need some extra cushioning, either intrinsic (as Kevin Kirby described) or extrinsic to the foot.
     
  17. Freeman

    Freeman Active Member

    Kevin, I knew that reading the Darwin Awards somehow would help in our field. Enough helium baloons can shut down LAX again ( lawn chair Larry, with beer, bb gun, helium baloons etc, 1982).

    I have used "heel spur" accommodations with pretty good success, in combination with a long plantar groove. I do believe that keeping the arch from excessive lengthening and flattening is big help as well as reducing pronatory load on the first ray. I use more 2-5's than I use to and seem to have good results with them.
    Freeman
     
  18. gangrene1

    gangrene1 Active Member

    Orthotic adjustment

    <ADMIN NOTE> Merged with previous thread on this topic

    For cases which have been diagnosed with plantar fasciitis, the sports med docs would prefer the podiatrists to create an aperture on the medial turbercle of calcaneum area. The aperture will be filled with poron then.

    I was just wondering if anyone has done something similar on such adjustment on the orthotics at all? If so, what is the outcome like?

    cheerios:dizzy::dizzy:
     
    Last edited by a moderator: Jan 29, 2008
  19. Re: Orthotic adjustment

    We talked about this before- I'm sure Craig can link the thread for you. I've tried it- patients didn't like it, but I know others have employed it with success.

    The potential problem I see is with the elevated pressure you get round the edge of a hole.
     
  20. Kenva

    Kenva Active Member

    Re: Orthotic adjustment

    Hi,

    It has to come down to what kind of force is giving the complaints. You could say that vertical pressure in an issue during the acute stage and needs to be taken into account when prescribing/making the orthotic device. On the other hand, and maybe more important, is figuring out what created the inflammation of the plantar fascia.
    IMHO, The pulling force of the plantar fascia on the medial tubercle is going to be the main point in your treatment plan.
    I see it more as treating symptoms or the cause of the fasciitis!

    Ken
     
  21. Re: Orthotic adjustment

    I have used this modification in some patients with good success. However, I have not found this modification necessary in most patients with plantar heel pain in order to make them asymptomatic. Therefore, I am not quite sure which patients need this specific modification and which patients don't need this modification in order to make them asymptomatic. The only time I definitely think this orthosis modification is indicated is if, during examination, the plantar heel has a painful nodule/bursa plantarly [best detected by manually rubbing over the plantar heel with a little K-Y jelly on the skin of the plantar heel] or has had plantar heel surgery and has painful plantar heel scarring.

    Hope this helps.
     
  22. Mart

    Mart Well-Known Member

    Re: Orthotic adjustment

    Couple of things to add.

    Kevin, the kind of PE findings you describe here I think I also occasionally identify, and guess what, I have a look with Diagnostic ultrasound.

    What has surprised me is that I have found only one case with hypo-echoicity within the plantar fibro-fatty pad which would indicate bursa or fluid filled cyst, or evidence of inflammation with power doppler.

    This one case I am almost certain was the result of irritation caused by a poorly constructed rigid shell which irritated the medial margins of the fat pad and appeared to create some fluid filled defect which resolved after replacing foot orthoses.

    What I think I can see more commonly is a change in density or “flow” of the plantar fibro-fatty pad and only see this with palpation at the edge of the site when watching the US image.

    Whilst this doesn’t prove that you have not seen actual cases of bursa or cysts within the plantar fascia I wonder how frequent they really are present when we find this palpable “defect”.

    This leads me to believe that in the cases which I have seen, either the collagen fibres which are responsible for restraining the fat pad at that site are somehow changed altering resilience or simply that the fatty tissue has somehow altered its density.

    You mentioned a while ago the possibility of sub- periosteal inflammation or bone edema as possible root of plantar heel pain which would not be detectable with US but has been shown with the limited studies existing which use MRI.

    I still regard this as plausible in my DD and am grateful for your suggestion of having the patient differentiate modulation of pain according to peaks occurring at heel contact or heel raise and resolution during swing to narrow down “aggravating forces” as compressional, tensile or mixed.

    In this context for those who appear to have mechanical cause of pain I will usually try, when purely a “initial contact” pain “ simply using “Tulis heel” as an initial approach which is often adequate to resolve problem, or attempt to explore autosupport defect if “propulsive phase” (tensile) pain is present.

    Occasionally I find people with both compressive and tensile aggravated pain, and to get complete relief modify a foot orthoses with neoprene compliant plug beneath the calc tubercles in those who continue to experience the compressional pain in spite of reducing component of tensile pain.

    Whilst we may struggle to definitively diagnose root cause of plantar heel pain, identifying aggravating factors is realistic, and I feel often, although we may have notions about the true causes of pain that we can rarely test them for sure.

    The point being, can anyone really prove they understand the root cause(s) of plantar heel pain they treat? If not, we are really treating the symptoms backed by personal theory in most cases and there is nothing wrong with that, this in response to what I interpreted as a disparaging remark from another member.

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
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