Foot orthoses play core role in treatment of plantar fasciitis

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Foot orthoses play core role in treatment of plantar fasciitis

http://www.biomech.com/current_full_article/?ArticleID=192

Practitioners prescribe different forms of orthoses, along with other

nonsurgical modalities, for patients.

By Andria Segedy

The foot is critical for maintaining function, balance, and

coordination while walking. However, thousands of Americans step out

of bed every morning with an excruciating throbbing sensation in the

foot and heel. Plantar fasciitis, a common form of heel pain related

to microtearing or stretching of the plantar fascia, is one of the

conditions most frequently seen by foot and ankle orthopedic

surgeons, according to the American Academy of Orthopaedic Surgeons.

Nonsurgical treatment is effective for up to 85% of these patients.1

The combination of foot and ankle stretching exercises, anti-

inflammatory medication, patient weight loss, and the use of orthoses

has proven to be a recipe for the successful treatment of plantar

fasciitis. Current research is trying to determine the differences—or

similarities—among over-the-counter, prefabricated, and custom-molded

orthoses in treating plantar fasciitis.

" The condition of plantar fasciitis has stayed the same forever. What

is changing is the technology to see what could be causing it, " said

Matt Arciuolo, CPed, owner of Footstar Pedorthics Centers in Milford,

CT.

Arciuolo predicts a hike in the number of plantar fasciitis cases in

light of the trend in increased body weight in adults.

There is universal support for nonoperative treatment options for

recalcitrant plantar fasciitis among practitioners, according to

G. , MD, an orthopedic surgeon with Orthopaedic Associates of

Grand Rapids, MI, and a cochair of the Public Education Committee of

the American Orthopaedic Foot and Ankle Society.

" Ideally, treatment modalities are those that take stress off the

arch: good shoes, arch supports, stretching of the calf muscle and

the plantar fascia, and weight loss, " he said.

One prospective randomized trial1 compared several nonoperative

treatments for proximal plantar fasciitis, including custom and

prefabricated orthoses. Researchers from the University of

California, San Francisco, recruited 236 patients (160 women and 76

men) aged 16 years or older. Most had reported a duration of plantar

fasciitis symptoms of six months or less.

The subjects were randomized prospectively into five treatment

groups. All groups performed stretching of the Achilles tendon and

plantar fascia in a similar manner. One group was treated with

stretching only, while the other four groups stretched and used one

of four shoe inserts. These were a silicone heel pad, a felt pad, a

rubber heel cup, and custom-made polypropylene orthotic device. After

eight weeks of treatment, patients were reevaluated and each group

showed improvement. The silicone insert group improved by 95%; the

rubber insert group, 88%; the felt insert group, 81%; the custom

orthosis group, 68%; and the stretching only group, 72%.

Combining all the patients who used a prefabricated insert,

researchers found that their improvement rates were higher than those

assigned to stretching only (P = 0.022), and those who stretched and

used a custom orthosis (P = 0.0074).

Researchers concluded that, when used in conjunction with a

stretching program, a prefabricated shoe insert is more likely to

produce improvement in symptoms as part of the initial treatment of

proximal plantar fasciitis than a custom polypropylene orthotic

device.

Pressure reduction

In San , data collection for a study that is evaluating the

effects of foot orthoses on plantar pressures among people with

diabetes should be completed by early September. The research is

being overseen by Gordon Bosker, CPO, CPed, an instructor-researcher

at the University of Texas Health Sciences Center and a clinician at

the Texas Diabetes Institute.

The study, investigating three foot orthoses, might help establish

better guidelines for practitioners providing optimal foot care to

patients with diabetes.

The study calls for 42 participants to wear an extra-depth

running shoe with a custom-molded trilaminar insert, a prefabricated

trilaminar insert without modifications, or a contoured over-the-

counter shoe insert made out of plastazote and polyurethane.

Ten more participants were added to the study to test a dynamic

orthosis measuring device for plantar pressures, which is already on

the market, according to Bosker. The device measures the plantar

surface pressure when ambulating, and the data then get sent to the

manufacturer for molding the custom insert.

" We are comparing the measuring device's molded inserts with the

three inserts in the original study, " he said. " With only 10

subjects, it's just a pilot study to determine if more research is

warranted. " Bosker presented a poster on the research at the Annual

Meeting and Scientific Symposium of the American Academy for

Orthotists and Prosthetists in February. & #8194;Initial data show there are

some benefits to the use of either OTC or custom-molded arch

supports. " It would appear that for certain areas of the foot, a

custom insert is more & #8194;effective than an over-the-counter version

because it reduces the pressure load, " Bosker said. " But because this

is the early research stage, we don't know if it is a trend. "

In the study, the foot was divided into five sections: heel, midfoot,

first to third metatarsal, fourth to fifth metatarsal, & #8194;and the great

hallux. Several of these areas responded better to customized inserts

than to the others.

" We are seeing some positive results with a full-foot orthosis that

affects the first to third metatarsal, midfoot, and heel, " he

said. " That's not a surprise, but there is & #8194;very little & #8194;research to

support this. We are attempting to solidify what has been researched

to treat the diabetic patient. "

The results to date have shown that the OTC insert is effective in

certain parts of the foot, such as the heel, especially for diabetic

patients, according to Bosker.

" For other specific problems like meta­tarsal pressure, it would

appear that we would need to have the custom-molded insert, " he said.

The material used to make a custom-molded insert needs to be further

re­searched. Bosker and his team are in the process of securing

funding for an investigation to determine the best materials for the

custom-molded insert.

Patient evaluation

At Breakthrough Podiatry in Merrillville, IN, clinicians see a lot of

patients who have had heel pain ranging from six months to many

years, according to owner Bruce , DPM, the current president

of the American Academy of Podiatric Sports Medicine.

" We have a 95% to 98% rate of success in relieving pain when we use

foot and ankle manipulation along with stretching exercises to

increase the range of motion in the ankle joint, " he said. " I use Dr.

Dananberg's technique when manipulating the ankle joint for

patients who have a functional decrease in ankle joint dorsiflexion

range of motion. "

Dananberg's method of ankle manipulation, in basic terms, involves

initially adjusting the fibula head in a posterior to anterior

manner. Then, the practitioner adjusts the talar head in an anterior

to posterior fashion.

follows up the manipulation by having the patients perform

gastrocnemius and soleus stretching exercises to maintain the range

of motion as much as possible. He also provides plantar fasciitis

patients with a custom foot orthosis, which helps to eliminate pain

in most of them within three to five patient visits.

For patients who continue to have pain, will use an in-shoe

pressure analysis, or F-scan, to pinpoint problems in foot mechanics.

He will then modify the prescription of the patient's custom foot

orthosis.

" In my practice, I use custom-made devices the majority of the time

instead of over-the-counter devices, " said. " Most insurance

companies will cover the custom-made devices, and I feel this will

provide my patients with the most specific adjunct in alleviating

their foot and ankle pain. "

In some instances, will use OTC devices. But he often ends

up altering even those.

" Unfortunately, I usually have to modify most of these devices to

achieve the specific effects I want in treating patients' functional

foot and ankle problems, " said.

Arciulo also relies on in-shoe pressure mapping of his patients' feet

before he can prescribe an orthosis. The mapping helps him evaluate

where excessive pressures are being applied in the foot.

" By using orthoses, you can take upwards of 20% of the pressure off

the heel by raising the arch, because the arch is taking more of the

weight, " he said.

Also, by slightly raising the heel, the patient's center of mass can

be brought slightly forward, which reduces pressure on the heel,

according to Arciuolo. If the center of mass is brought too far

forward, however, it can exacerbate metatarsal issues.

Materials matter

Material choices for orthoses for plantar fasciitis depend on the

patient's needs and preferences and the potential for secondary

complications.

Some patients with plantar fasciitis may require really soft

orthoses, particularly those with diabetes or who have poor

sensation, according to . For individuals with normal

sensation, a semirigid or semiflexible orthosis made of foam, cork,

or a composite material is often better tolerated.

" Our experience tells us the use of a nonrigid device—something

semirigid or flexible—is better tolerated by patients with plantar

fasciitis than a rigid plastic device, " said Lowell Weil, Sr., DPM,

medical director of the Weil Foot & Ankle Institute in Des Plaines,

IL. " Rigid does a good job if there is pain in the legs, ankles, and

sometimes in the heels. "

In addition to running the Weil Foot & Ankle Institute, which has 11

locations throughout the Chicago area, Weil is the team podiatrist

for the Chicago White Sox. Each year, he and his staff see about 1500

new patients with plantar fasciitis.

Weil believes that the use of a deep heel cup is very important in

helping to support the hydraulic structure of the heel. Given a

choice, patients opt for a softer device, which is bulkier and cannot

be worn in a nice shoe, he said. An orthosis made from softer

materials such as cork, leather, or plastazote is best worn in a

running shoe.

Weil recently started offering a Vasyli orthosis, which is fabricated

on the spot. The device's neutral shell can be modified to the

patient's foot. The orthosis is low profile, or thinner than most

orthoses, and comes in several designs that can be modified with a

heat gun. The only drawback to the Vasyli orthosis is that it tends

to wear out faster than the laboratory-produced orthosis, which has a

life of 10 to 15 years, according to Weil.

In addition to the various orthotic materials now available, there

are many ways to combine all these elements to make an orthosis work

effectively for patients with plantar fasciitis.

" There's no one method to fix plantar fasciitis, " Arciuolo said. " I

can do the same orthotic style for five patients, and they will all

have different outcomes. Some respond better to stretching, some to

cushioning, and others to support. "

Andria Segedy is a freelance medical writer in Huntsville, AL.

References

1. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and

prefabricated orthoses in the initial treatment of proximal plantar

fasciitis. Foot Ankle Int 1999;20(4):214-221.