Hi all,
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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
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Try beating the student.
I'd suggest talking about "escape pronation" and such, but yours is much simpler. -
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) -
Eric -
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) -
Eric -
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. -
Fiona - you've got a great mentor in Rebecca! Best of luck with it all. -
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 -
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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
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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. -
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. -
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.
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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" -
Hopefully someone gets my sense of humor "talk amongst yourselves" equals please discuss.
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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.
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 -
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 -
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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. -
Thanks Brian. Rich
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Adolescent Idiopathic Scoliosis Linked to Gravity Drive Pronation
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Pros and Cons of DC wedge orthoses
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