Orthotics for patient with heel pain

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I have a 40 yr old pt with heel pain.I will be casting him for an orthotic in a few weeks(he is going to Florida).Sincehis pain is in the heel,ifigure i would incorporate a 16 to 18 mm heel cup.I read an article stating that a deeper heel cup is not necessary.Othersalient findings:he has limblength discrepancy(left leg is shorter and that is the symptomatic leg),he has decreased ROM B/L hallux and he has 2 degrees RF valgus.I am going for the deep heelcup.Does anybody have any insights into this?

 

What do you mean by heel pain i.e. can you be more specific?

Ian

 

At the risk of sounding patronising...what I say to my undergrad students is What structure hurts? What mechanism causes the pain? Can you alter this situation with orthoses?
Until you have answered these questions in Aus it would not be considered all that appropriate to prescibe orthoses....other than the need to pay the kids school fees of course....
Regards Phill Carter

 

The heel pain in question is typical calcaneal spur pain at the plantar aspect of the medial tubercle.

 

How did he respond to strapping, padding and exercises?
Regards

 

I strapped himon the initial visit.I incorporated a Campbell strap with a lowdye.I will be evaluating him for orthoses on the next visit.Thank you for asking.

 

Hi John

If your pt is a PF sufferer (existence of a spur is a questionable single course of heel pain -at least on the research stuff thats been mentioned on this site) then I have found the following approach to be the most successful for me.


Rigid to semi-rigid orthoses, moderate heel cup depth.
Transverse frictions (the absolute key in this) not only to the site of pain but along the whole of the plantar fascia. Need to build this into the charge as it could require 4-5 sessions.
Massage and frictions along the Post tib from points of insertion to behind and just superior to the medial malleoli.
Any residual issues left over appear to have responded to needling of trigger points in the Gastroc.

Orthosis type I make in this case is a vertical heel with an intrinsic forefoot balance platform and a 2mm medial heel skive (rather than rely on a deep heel cup).

Whilst I might note LLD I do not worry about LLD until I have the pt in the orthoses. My own experience is that what we consider to be the affect of LLD is linked quite a lot to a greater asymetric inroll at the MTJ. Once in orthoses and the MTJ levels are improved I re-evaluate the LLD invovlement. If appropriate I might incorporate a raise.

Hope this helps.

Ian

 

If the causative mechanism seems to be tensile stress on the plantar fascia both before and after heel lift then you could try greater plantarflexion of the 1st ray to get stress of the plantarfascia, a lateral forefoot wedge can help too, this should allow the windlass mechanism to establish with a lower threshhold force....and keep tension off the plantarfascia for larger fractions of stance phase.
In other words a fairly rigid device with a steep angle of descent planatr to the first met shaft, get the focus of device high point back under the T-N joint and fold it down to the ground from there....a Mod Root style device with a shape reminiscent of a Blake.
Then add an EVA overlay blending anteriorly keeping the 5th met head about 6mm off the floor tapering down to the floor medially under the 2nd met head and then blending to the floor just posterior to the web spaces. The device can then flex but helps keep 1st ray plantarflexed.
Regards Phill