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Recalcitrant PF issue - any suggestions?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sesadler, Dec 14, 2009.

  1. sesadler

    sesadler Member


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    Greetings all!
    I have perused the site and am not finding exactly what I am looking for.
    I am treating a patient for a plantar fasciitis issue that I am just not getting ahold of.
    Pt is an active competative tennis player, in good shape and not overweight
    He was referred to me with a direct form (medium p-zote / firm puff) insert and felt the medial arch was just too pronounced. I recast him (bio-foam) and built a full length insert for his walking and court shoes using a medium-firm puff trilam with EFM base shell with a medial flange and 1st MTH drop. Initially these worked really well and then he began having dicomfort at the anterior heel - close to the pf insertion. No mod has been able to address this pain. Interestingly, he feels it primarily when walking or standing and dramatically less or not during tennis.
    I referred back to DPM for further eval and they had a low-dye tape job put on and he has responded well to that. Now getting back to the insert he feels they are much more uncomfortable than before.
    So - given that limited info - any advice? or should I just recast STJN and try for better bio-mech control. I'm a little stumped by this one.

    Thanks in advance!

    Stephen Sadler, C.Ped
    Austin, TX
     
  2. Stephen:

    First try a reverse Morton's forefoot extension to lessen, what I assume to be, excessive compression force from the orthosis on the medial band of the plantar fascia. If that doesn't work, then grind in a plantar fascial accommodation into the orthosis in the area of plantar fascial irritation. This should do the trick if the pain is what I think it is. However, clinical examination is the key in this sort of situation to determine what exact anatomical structure is symptomatic.

    Good luck.
     
  3. Steven

    One thing to consider is that when playing tennis he is probably spending a lot of time on his toes, this would reduce the irratation from the device on the anterior heel.
     
  4. sesadler

    sesadler Member

    Thanks for the reply.
    I had been considering whether a pf accommodation might be useful. I have a reverse morton's intrinsically on the existing insert using the EFM as the lateral wing sub 2-5.
    I think your last line is the key and the Pt is scheduled for an MRI so I suppose the treating DPM feels there may be something additional that may need to be dealt with.

    Pt indicated that the medial support may be too aggressive and may want to lower it, so we'll see where it takes me when he comes in for follow up.

    Thanks again!

    I really appreciate all the knowledge that's floating around in here!

    Stephen
     
  5. Airlie

    Airlie Active Member

    Sesadler

    I am not going to pretend to be an orthotics genious, but I wouldnt exclude the idea of fit of a trilam device in his different shoes. they tend to be quite wide and the medial expansion doesnt always fit all shoes very well.

    I have found with a recent patient getting discomfort with trilam and not his carbon fibre orthotics what I can only describe as Parellel lacing helped reduce midfoot pressure

    I agree with m weber that he probably is spending more time on his toes when playing tennis.
     
  6. Airlie

    Airlie Active Member

    feel free to laugh at my mis-spelling of 'genius'
     
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