5/9/2011 9:56 AM
I had a patient present in my office today with a two-year history of fairly classic plantar fasciitis. She had seen a podiatrist during that time and had multiple treatments, which included orthotic devices, physical therapy, multiple injections bilateral, and standard anti inflammatory measures. She sought me out to get a second opinion because she has not seen much improvement. The patient was a pleasant 31-year-old woman who was obese. Pertinent biomechanical findings were a pes planus foot type. She had an everted heel in stance and nearly complete collapse of the medial arch. In gait, she showed fairly rapid midtarsal joint collapse, eversion of the heel, and stayed maximally pronated throughout gait.
She was wearing her only pair of orthotics today. These were made by the previous podiatrist 9 months ago. They were carbon fiber orthoses. They had no post, a shallow heel cup, a fairly narrow width, and the arch did not conform very closely to the arch of her foot. Needless to say, these orthoses were not providing much support and she essentially pronated right through them.
This seems like a fairly straightforward problem. If we can reduce tension on the plantar fascia, then we should be able to reduce this patient’s symptoms. To do so, however, it is going to require much more aggressive orthoses than she currently has. She decided she would like to proceed with a new pair of orthotic devices (even though her insurance benefits for orthotics had been used up on her first pair and she would have to pay for these out of pocket).
We are going to make her orthoses that have a minimum fill and 2 degrees of inversion, so they conform close to the arch of the foot (a 1996 study by Kogler showed that orthoses that conform close to the arch of the foot are more effective at reducing tension on the plantar fascia). They will have a deep heel cup and wide width with a medial flange, so that there is surface area under the entire foot. We will incorporate a medial skive and a rearfoot post to help reduce heel eversion.
My expectation is that this patient will do very well with this orthotic prescription. There is nothing indicating that this is anything other than plantar fasciitis.
I guess the take home message here is that just because the patient already has custom othotics, does not mean that they have had adequate orthotic therapy. When patients present with long-standing plantar fascial pain, be sure to critically evaluate any orthoses they are currently using, and be ready to explain to the patient why their current devices may not be effective and what an effective device would do for them.