Plantar fasciitis (heel spur syndrome) is a common foot problem in
athletes and accounts for approximately 7 percent of the injuries to the
lower extremity. With each running step, the athlete subjects the
plantar fascia to tremendous cyclic loading. In some athletes, this
produces a mechanical irritation to the plantar fascia, resulting in an
inflammatory response and pain.
The irritation is the result of
biomechanical deformities such as limb length discrepancy, gastrocsoleus
equinus, and excessive foot or leg varus, producing midtarsal and
subtalar hyperpronation. In turn, this pronation produces a stretch of
the plantar fascia as well as unwanted pulling on the origin of the
fascia (the medial calcaneal tubercle).
The classic history of
plantar fasciitis is marked by the insidious onset of sharp pain at the
fascial insertion of the plantar surface of the anteromedial calcaneus.
With these patients, you'll note arch fatigue and generalized soreness
on the sole of the foot. The patients will usually tell you that the
pain is more severe when they get up in the morning and eases some after
walking. You'll also commonly hear that pain decreases during the
middle of a run, but returns at the end of the day.
Upon palpation,
you'll typically detect heel tenderness anteromedially at the origin of
the plantar fascia on the medial calcaneal tubercle. However, keep in
mind that the patient may have pain along the entire length of the
plantar fascia. If you note tenderness over the distal and midportion of
the plantar fascia, your patient may have the less common distal
fasciitis. If the entire heel is tender, it may be a stress fracture,
calcaneal apophysitis (Sever's disease) in a child, or possibly a bone
tumor.
Although plantar fasciitis treatment often includes
nonsteroidal oral medication, local steroid injections, ice after the
run, ultrasound and stretching exercises, your main focus should be on
treating the biomechanical imbalance. Employing orthotic devices can
play a key role in this endeavor.
WhenYou Should Use Heel Pads And Cushions
The
first line of relief for treating plantar fasciitis, heel cushions
provide extra shock absorption in the heel area. They help absorb the
shock of heel strike in walking and running. Heel pads are generally
constructed of polyvinyl chloride, silicone, leather, polyethylene foams
like Plastizote, and thermoplastics.
Soft heel cups cushion and
contain the fat pad. They are effective for a plantar calcaneal bursitis
or plantar heel spur syndrome. When you're treating patients who have
heel pain as a result of fat pad atrophy, employing hard plastic heel
cups (M-F Athletic, Cranston, RI) can sometimes be effective in
positioning the heel pad underneath the calcaneus, restoring the natural
cushioning and compressibility.
You may also consider the Anti-Shox
heel cradle (Apex, South Hackensack, N.J.), which is made from a firm,
open cell polymer. Designed to cup the heel, this orthotic provides both
shock absorption and support. Another option is the SofSpot Viscoheel
(Bauerfeind, Germany). This silicone heel cushion has a built-in area of
softer durometer that is especially designed to disperse weight around
the plantar medial tubercle of the calcaneus.
Sometimes, using a heel
lift is helpful in shifting pressure to the forefoot. Keep in mind that
a heel lift in the shoe should be no thicker than one-quarter inch.
An Overview Of Custom And Prefabricated Foot Orthoses
There
are a variety of orthotic devices that you can use inside the shoe to
provide support, increase shock absorption or influence foot position.
Orthoses include dynamic insoles, heel cushions, prefabricated
commercial foot orthoses and custom foot orthoses. Using an orthosis can
help you reduce arch strain associated with plantar fasciitis.
When
it comes to dynamic insole orthoses, you can construct them from Spenco
(Spenco Medical Corp., Waco, TX), which is a closed-cell neoprene
impregnated with nitrogen bubbles.
Prefabricated foot orthoses are
commercially available in a wide variety of styles. Employing pre-made
orthoses is adequate for treating many athletes with plantar fasciitis.
They are also significantly less expensive than custom-made orthoses.
You
can fabricate a custom-made orthosis from a negative plaster impression
of the patient's foot. The orthosis is composed of the shell, a layer
of material next to the foot and the posting, the material that fills in
the space between the shell and the shoe. You can add materials such as
metatarsal pads to the device to customize it further.
Using a
custom-made foot orthosis may be required when you're treating a more
severe athletic foot injury. Custom foot orthoses can be made of leather
or plastic. Leather gives the patient more comfort, allows easy
orthotic adjustments and is able to absorb 30 percent of its weight
before it feels wet. You'll find that using a whale pad design and deep
heel seat leather orthosis is well suited for treating the painful heel
caused by plantar fasciitis.
It's more important to use a custom
device for the cavus foot type as opposed to the hyper-pronated foot,
which will generally improve with a well-constructed prefabricated
orthosis.
Can The UCBL Orthosis Make An Impact?
The University of
California Biomechanics Laboratory (UCBL) orthosis was originally
designed to maintain a flexible paralytic valgus foot deformity in the
corrected position. However, since then, DPMs have used it extensively
to treat flexible flatfoot, plantar fasciitis and calcaneal spurs.
The
UCBL is casted in a semi-weight-bearing position. Employing this device
allows you to elevate the arch by holding the foot in a position of
forefoot adduction and hindfoot inversion. Patients should wear it with a
large shoe, such as a running sneaker. While the UCBL is not suited for
running, you can use it to treat more recalcitrant conditions until the
athlete is capable of returning to sports activities.
What About The Posterior Night Splint?
A
classic treatment for Achilles tendinitis, the posterior night splint
has been widely used by DPMs to treat plantar fasciitis as well. In one
study, physicians were able to resolve recalcitrant plantar fasciitis
with a night splint in 11 of 14 patients.
The splint is an ankle-foot
orthosis (AFO) positioned in about 5 degrees of dorsiflexion. Patient
would only wear this at night. In stretching the Achilles tendon and
plantar fascia, this device prevents contractures of the Achilles tendon
and plantar fascia that occur as a result of the plantar-flexed posture
of the foot during sleep.
You can fabricate the posterior splint
from plaster or fiberglass, or simply obtain the commercial device,
Universal Plantar Fasciitis Orthosis (Orthomerica Products, CA).
Regardless of the splint you use to immobilize the foot and ankle, you
must ensure that it offers a good fit and maintains the desired position
once you've applied the device.
In fabricating the splint, the
patient lies prone as you initially place a stockinette on the leg. Then
you would proceed to mold five to six layers of six-inch plaster
splints (or three to four layers of fiberglass) to the lower extremity
from the toes up to behind the knee. You should allow an extra two
inches when measuring with the dry splints because the splint shrinks
after immersion.
Then you can add overlapping side splint stirrups.
Doing so adds strength to the cast and prevents it from failing in
plantar flexion. Using a circular Ace bandage allows you to hold the
entire splint in place. You can also dip the Ace bandage in water to
help with molding.*
References Source: By Mark A. Caselli, DPM and Ellen Sobel, DPM, PhD & Podiatry Today 19-03-06
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