After writing a previous post criticizing some rhetoric and propaganda on plantar fasciitis¹, I got a couple of complaints that I did not say how to treat it! I didn’t as that was not the purpose of the article! Plantar fasciitis is so common, that everyone is an expert in it. Self diagnosis and self treatment is the most common approach; but it still becomes an extraordinary chronic problem with so many suffering from it for years. The internet is a huge source of snake oil, woo and pseudoscience when it comes to plantar fasciitis, so no wonder it does become such a common chronic problem, when there is no reason for it to.
The biggest problem with plantar fasciitis treatment is that its natural history is that it tends to get better on its own (just look at the responses in the placebo groups of clinical trials on it). It may take a while to get better and it may hurt a lot while it does get better, so treatment is still warranted. However, this means that whatever treatment, running shoe change, running technique change, snake oil application, woo, or magical potion, etc that is implemented may or may not be the reason it got better in any one case as the condition may have just been ready to get better on its own at about the same time. See the post I did on Why Ineffective Treatments Sometimes Work. This means that so many who tout snake oil and woo for plantar fasciitis as something that had worked for them, so they do what they can to hawk that treatment as the secret sauce or magical cure that clinicians are hiding from them or don’t know about (often in a $19.95 eBook – certainly cheaper than going to the doctor!). Just look at some of the comments after my previous post. One runner claimed that his maximalist Hoka One One shoes cured his plantar fasciitis; the very next post was from a running saying that the Hoka One One’s caused his plantar fasciitis and based on that he advises everyone to avoid those shoes. Based on those two anecdotes, what should a clinician do? Get all plantar fasciitis cases into Hoka One Ones or get all plantar fasciitis cases out of maximalist running shoes? Can you see the problem?
Because of this dilemma, that is why we need to rely on properly controlled clinical trials to determine if any treatment is more effective than a placebo, so if we use that treatment we know we are going to get an effect.There is some good data on some aspects of plantar fascitiis management to show what is better than a placebo, but this is still lacking on other treatments. None of the snake oil and woo you see touted for it has been subjected to clinical trials, yet somehow they are allowed to ‘sell‘ it and still claim it works, usually based on nothing more than a few anecdotes and the wishful thinking fallacy. Even those treatments that have been subjected to properly controlled clinical trials do not provide all the answers as the actual protocol that was used to apply the treatment may or may not be the same in the way it was used in the clinical trial as the way some use it in clinical practice. Given that, there is still a long way to go in the clinical trials of different approaches to the management of plantar fasciitis. It also means that the snake oil touters and the woo meisters get free rein to suck people in.
Then you have what I call the ‘one hit wonders‘. This is those who use only one tool in their armamentarium and they use that one tool to treat them all; and usually think that everyone else should also use that one tool! Given the natural history of plantar fasciitis, they will probably, anecdotally, get a reasonable success rate in their eyes. This happens as they mostly see what they want to see (see: Why Ineffective Treatments Sometimes Work).
The approach I apply is not only based on the way that I interpret the best available evidence, but as the evidence is lacking in other areas, I apply those three concepts I have mentioned in many posts (eg): biological plausibility, theoretical coherence and consistent with the available evidence. Like any other overuse injury the approach I take to plantar fascitis is no different: reduce the load in the damaged tissues; increase the ability of the tissue to take the load; facilitate the healing of the damaged tissue. This of course, assumes that the diagnosis of plantar fasciitis is actually correct (there are a lot of other things that can cause pain under the heel).
A. Reduce the Load in the Damaged Tissues:
As plantar fasciitis is due to too much cumulative load in the plantar fascia, then it makes intuitive sense to reduce that load at least in the short term to allow the tissues to heal. There are several strategies that can be used for this:
1. Stop running! Or alternatively modify the running activity; do an alternative activity; cut back a bit; have more rest days; above all, use common sense.
2. Low dye strapping. This is a very short term measure and can reduce the load in the plantar fascia immediately. The evidence supports it use. The proviso is that the strapping is actually applied correctly and in a way that does actually reduce the load in the plantar fascia. For this to work in anything other than the very short term, the tape is going to have to be reapplied at least every few days which raises issues of practicalities. For that reason, I tend not to use it. I only tend to use it if the plantar fasciitis is interfering with employment (eg they can’t work as its too painful and they have standing occupation) or its interfering with their training for a race that is coming up (and 1 above is not that practical at this stage).
3. Foot orthotics. All the studies have shown that foot orthotics for plantar fasciitis were better than a placebo, but the effect sizes were small. For a foot orthotic to be effective in plantar fasciitis, it has to reduce the load going through the plantar fascia. Stopping ‘overpronation‘ and ‘supporting the arch‘ is not necessarily going to be enough and if the design parameters are not right (eg arch support in the wrong place),they may actually increase the load in the plantar fascia. “Overpronation’ (whatever that is) has not been shown to be a risk factor for plantar fasciitis, but foot orthotics have been shown to work in numerous studies for plantar fasciitis. We know from the work of Geza Kogler that lateral wedging under the forefoot was most effective at reducing strain in the plantar fascia. We know from our own unpublished experiments that inverting the rearfoot and everting the forefoot lowers the force to get the windlass mechanism established, which would lower the forces going through the plantar fascia. From this it appears as though the design features needed to reduce the loads in the plantar fascia would be medial heel wedging and lateral forefoot wedging. Given that the RCT’s that show foot orthotics work did not specifically use these design features, we can only speculate what the effect sizes may have been if they had. In my own anecdotal experience, every time I have seen a foot orthotic that is not working in a case of plantar fasciitis, when I do Jacks test on and off the foot orthotic, there is no difference. This suggests that the foot orthotic did not have the right design features to reduce the load in the plantar fascia.
There is no doubt that foot orthotics are a very effective short to medium term strategy to reduce the load in the plantar fascia. They do not weaken the muscles (the evidence on that is clear; and neither do running shoes, while we on this topic!). As to if they are needed in the medium to longer term will depend on a number of factors (see this discussion on short or long term use). They may or may not be needed in the long term.
4. Calf muscle and plantar fascia stretching. The evidence on this is really clear with a number of studies showing both are effective. The fibers from the Achilles tendon are continuous to the plantar fascia. The stretching of the calf muscles is going to help lower the load in the plantar fascia. I generally get people to do this at least 2-4 times a days. The stretching also probably plays a role in allowing the tissues to adapt to increasing loads (see below). This may also progress to the use of night splints which has some good evidence to support it, despite the practicalities of wearing a splint in bed at night!
5. Running form changes. There is NO evidence for this and I do not believe that foot strike pattern or running technique has anything to do with plantar fasciitis (both forefoot and heel strikers get plantar fasciitis; and so do minimalist and traditionally shod runners). It does matter for other conditions, but not this one. See this discussion.
6. You often see muscle strengthening mentioned, especially of the small intrinsic muscle of the foot to take the load off the plantar fascia. There is no evidence that this helps and no evidence of any muscle strength deficits in plantar fasciitis (see some of the points I raised here). These muscles do not even fire until later in the stance phase so are not even capable of supporting the plantar fascia, even if they could! This does not mean that strengthening these muscles is not useful for other reasons; I just can not see how it helps plantar fasciitis.
B. Increase the Ability of the Tissues to Take the Load:
This is probably where the understanding and thought processes have changed the most in recent years. The concept is based on progressively and slowly increasing the load on the plantar fascia so that it can adapt to increasing loads and better tolerate the loads that are placed on it. This is a medium to long term measure and probably has to be done in the context of the principles above of decreasing the load to let the damaged tissues heal, and then going through the longer term process to load the plantar fascia and then let it adapt. It also relies on a certain amount of compliance from the runner and a long term commitment.
There is NO evidence to support this, but it does meet the criteria of biological plausibility, theoretical coherence and consistent with the available evidence; ie its makes intuitive sense to do this. The evidence that it is consistent with is the research that has been done on tendinopathy and the progressive resistance and overload to adapt tendons to load as part of the rehabilitation. Tom Goom did a good summary of the staging of tendinopathy and applying it to plantar fasciitis over at Kinetic Revolution. However, I do have a concern that the plantar fascia is NOT a tendon, so the research and principles developed in the context of tendinopathy may not necessarily be applicable to the plantar fascia. That does not mean its not; it means we got a way to go to get more information, data and understanding on this.
Also of relevance here is the genetic issues. A lot of work has been done on genetic risk factors for achilles tendinitis, which I presume affects the ability of the tendon to take loads. Nothing is really known about the genetic risk factors for plantar fasciitis, but they must exist and must affect the ability of the plantar fascia to take load. There is a high probability that these can not be adapted to load as well, so reliance is going to need to be placed on the strategies above to reduce load to below what the tissues can tolerate.
Nutrition also need to be considered so that tissue health is at an optimum so it can be adapted to loads.
C. Facilitate the Healing of the Tissues:
In my opinion, the above two of reducing the load in the damaged tissues and increasing the ability of the tissue to take the load are the most important and crucial parts of the management. If they are not done then the problem is more likely to be a long term chronic problem and more likely to happen again. However, sometimes the above two are not enough and direct work on the damaged tissues is needed to facilitate the actual healing of the damaged tissues, so that the load reduction can work and the tissues can be adapted to the load. I often see a lot of the treatments in this category as giving the ‘window of opportunity‘ that is needed for the load reduction and tissue adaptation to take place. The obvious example here is ICE in the early stages. A number of other treatments such as manual therapy, cortisone injections and NSAID’s came into this category. The strength of evidence for one versus the other is mixed or non-existent. For example, Andrew McMillian showed the effectiveness of the cortisone; meta-analyses are showing shockwave is effective at the appropriate doses; the data on platelet rich plasma is mixed and not clear. I tend to use treatments in this category once the load reduction is in place and there is not a short term clinical response to that.
Summary:
Hopefully all this makes sense. There is so much rhetoric and propaganda when it comes to plantar fasciitis; so much snake oil touted by woo meisters. We need to rely on the evidence, the biological plausibility and the theoretical coherence.
Start by reducing the load on the damaged tissues; then do things to facilitate the healing if there is not an immediate response; and then progress to the progressive adaption to increasing loads. It is not complicated. There is no need for plantar fasciitis to become a chronic problem.
As always: I go where the evidence takes me until convinced otherwise, and this is where the evidence has taken me.
1. I not going to get into the discussion here if its plantar fasciitis (an inflammation) or plantar fasciosis (a degeneration) or if it should be called plantar heel pain or whatever. That can wait for another time and place. Plantar fasciitis is the most commonly used term for this, so I going to use it.
Nice summary Craig, a couple of points.
I continue to be worried by the use of the term ‘plantar “fasciitis” a VERY specific diagnosis, which plantar heel pain rarely is. I know you made the comment “This of course, assumes that the diagnosis of plantar fasciitis is actually correct (there are a lot of other things that can cause pain under the heel).”, but the descriptor is used throughout the article. It is probably worth reinforcing that actual inflammation of the plantar fascia is rarely seen with plantar heel pain (presumed to be plantar fasciitis), and so the actual diagnosis of plantar fasciitis is erroneous and has implications for treatment protocols.
You mention that the fibres of the achilles tendon are “continuous with the plantar fascia”. The plantar fascia has in fact been shown to be independent of the tendo achilles in adults (Wearing et al Sports Med 2006; 36 (7), Snow et al, Foot Ankle Int 1995; 16: 418-21)
As a result, the evidence for the efficacy of weight bearing stretching of the soleus/gastrocnemius complex has been shown to be equivocal.(Rompe et al J Bone Joint Surg Am. 2010;92:2514-2522).
Keep up the great work, and here’s to your insomnia! best
Simon
I agree. I deliberately did not go that way as the post was too long already. I used the term ‘plantar fasciitis’ in the same way that we all know what it means without getting into the pedantics. Its the term that is in common usage and people know what we mean by it when we say it, even if the terminology is not quite correct.
Kind of like one of the US Supreme Courts justices definition of pornography – he could not define it, but said ‘I know it when I see it”.
pornography and plantar fasciitis.. granted .. they ARE similar!
Great stuff as always Craig. Agree with Simon’s point though.Given the evidence, Is it not more pertinent that we start to discuss the management of plantar fasciosis and ditch the term plantar fasciitis? Although I understand that many believe that the condition may be inflammatory in the acute phase progressing to a degenerative condition chronically which seems plausible to me. How, in your opinion would you change your treatment protocol for the management of a degenerative condition over the management of an inflammatory condition? Good luck on the job front.
All the best
Scott
Thanks Scott! The big difference in management between the “acute phase progressing to a degenerative condition chronically” is the nature of the progressive loading in (B) – aka what happens in tendinopathy; assuming that we can apply the same principles to the plantar fascia (at this point I see no reason why not). (A) is still going to be the same regardless of the stage; different approaches needed in (C) as to what to use if chronic.
Scott, there is now quite good evidence for the use of medium to high intensity ESWT for chronic plantar heel pain. There is however little or no evidence for is efficacy in the acute phase, and most are recommending at least a 6 month history before using ESWT. So in this case, the treatment does change based on the duration of symptoms.
best
S
Thanks Craig and Simon.
My next question pertains to the use of foot orthotics for the treatment of plantar fasciits/osis.
I believe (nothing new here) that reducing the mechanical stress on the pathological tissue to within its zone of stress tolerance should reduce the tissue damage and allow the body to repair the damaged tissue leading to a reduction in symptoms.
How best do we achieve this?.
Objectively, we are looking to reduce net tensile load on the medial slip of the plantar aponeurosis and the compressive load at the site of insertion, the medial calcaneal tubercle.
An orthotic device which moves the orf medially will likely apply an external supinatory moment across the STJ which should reduce the tensile stress on the medial slip of the plantar aponeurosis.(maybe ??)
This can be achieved by using a medial (varus) rearfoot post, medial heel skive, high medial heel cup, low lateral heel cup etc and lat f/f valgus posting
However in so doing the compressive force applied to the medial calcaneal region will likely be greater.
Using a softer shell (low durometer eva/PU) will likely reduce the compressive stress at the site of insertion but in the average weighted subject the material will likely deform excessively on load and so apply less external force necessary to increase the external supinatory moment required to reduce the tensile load on the medial slip of the plantar aponeurosis.
So how can an orthotic device be correctly designed to reduce the tensile load and compressive load significantly?
This may well be why softer prefab devices have been shown to be equally as effective in the treatment of plantar fasciitis as semi rigid root style polyprop devices.
My guess is…..
The NET reduction in forces is fairly equal????
What do you think?
No hard facts or evidence to support my thoughts, just thought i’d see what your opinion was
All the best
Scott
Scott:
You have given an impressive description of foot orthosis function for plantar fasciitis. Good job!
Like Craig, I generally call plantar heel pain “plantar fasciitis” just because everyone will understand that term when it is used. However, in reality, the plantar heel pain that many commonly call “plantar fasciitis” is likely caused by many separate pathologies, including plantar fasciosis and also medial calcaneal tubercle bone edema (i.e. microfractures). Even though other pathologies may cause plantar heel pain, I do believe that the vast majority of the plantar heel pain I see in my busy practice are due to a combination of excessive magnitudes of tension forces acting at the origin of the plantar fascia at the medial calcaneal tubercle and/or excessive magnitudes of compression forces from ground reaction force (GRF) acting on the plantar aspect of the medial calcaneal tubercle.
Even though most podiatrists and foot-health clinicians tend to speak of the tension forces within the plantar fascia as being the prime culprit behind this plantar heel pain we see so commonly, I am convinced from my clinical observations over the past 28 years of practice and from MRI scans of many of these patients that plantar fascial tension is neither the sole cause or the inciting factor in producing plantar heel pain.
We must remember that GRF acting on the plantar heel with each step creates a relatively large magnitude of compression force on the skin, plantar adipose tissue, origin of the plantar fascia and on the osseous anatomy of the plantar calcaneus itself. I have seen numerous MRI scans, in my own patients, that had chronic “plantar fasciitis” that also had low grade bone edema within the subcortical areas of the plantar medial calcaneal tubercle indicating that possibly microfractures of the plantar calcaneal structure may have occurred. Of course, since the plantar fascia originates from this area and has been estimated to pull with a force equivalent to one body weight during walking (http://www.ncbi.nlm.nih.gov/pubmed/14996881), in essence, much of the pain that we see as “proximal plantar fasciitis” in our patients may not be just within the plantar fascia itself but may be in the surface of the plantar calcaneus or in the subcortical bone of the plantar calcaneus.
As such, since I don’t do MRI scans on very many of my patients with plantar heel pain, my goal when treating all patients with plantar heel pain with foot orthosis therapy is to:
1. Reduce the tension force within the plantar fascia.
2. Reduce the compression force acting on the medial calcaneal tubercle.
To accomplish that goal, I will always try to use a soft topcover on my orthosis of 3-6 mm EVA or neoprene, use a relatively deep heel cup (over 14 mm), make certain that there is excellent congruency between the medial longitudinal arch (MLA) of the orthosis and the MLA of the foot, and make certain the MLA of the orthosis does not deform excessively (i.e. orthosis MLA has insufficient stiffness) during gait. I use polypropylene for about 50% of the plantar heel pain patients receiving custom foot orthoses and I use Plastazote #3 (polyethylene foam) for the other 50%. I prefer Plastazote #3 with a 3-6 mm topcover of neoprene for those patients where I feel the main etiology of their plantar heel pain is due to excessive magnitudes of GRF acting on the plantar calcaneus during weightbearing activities.
I believe I am saying what you have already said above in your posting.
I think that Craig and Simon have also made good points above.
Have a nice weekend.
Cheers,
Kevin A. Kirby, DPM
I
I have not worried about shockwave and most other (c) interventions much lately as long as you get the foot orthotic design features right in the first place, I just do not need those sorts of interventions as much. We have learnt so much more about using them to reduce the load in the damaged tissue rather than “control pronation” or “support the arch”, The comments above probably illustrate the sorts of design features needed. The RCT’s that show foot orthotics work used foot orthotics that were designed to “control pronation” or “support the arch” and they got a small effect size — interesting to speculate if or by how much of a better results if the foot orthotic had the design features that specifically reduce load in the plantar fascia.
Kevin.
Thanks for your comments on my post.
It appears that we both believe that foot orthotics should be designed in such a fashion that they act to reduce BOTH the compression force at the insertion of the medial slip of the plantar aponeurosis and the tensile load in the tissue also.
Interestingly, on a brief search through the net for pathology specific foot orthotics for plantar fasciitis, little attention seems to be directed towards reducing compression forces at the medial calcaneal tubercle. Infact, many of the designs incorporate features which will likely apply an increased magnitude of compression force plantar to the medial calcaneal tubercle.
The majority of labs that I looked at included prescriptive measures to reduce tensile load on the P/F. Of those that I looked at all included a 4mm medial heel skive, all were semi rigid polypro shells with extrinsic rearfoot posts and minimum cast dressing as standard. Some include central heel holes with poron infill as well.
Would you likely prescribe a device with a medial heel skive for a patient with medial calcaneal pain?
In regard to my previous post regarding orthotics delivering a net reduction in forces could this be the stumbling block?
Hope you had a good weekend
Scott
Scott:
I don’t normally use a medial heel skive in patients with proximal plantar fasciitis but other podiatrists I know routinely uses the medial heel skive in these patients.
I am not sure I know what you mean by a “net reduction in forces” and how this applies to foot orthosis mechanics. Foot orthoses don’t reduce the net forces acting on the plantar foot but rather affect the magnitudes, temporal patterns and plantar locations of the ground reaction force acting on the foot.
Sincerely,
Dr. Kirby
***************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine
e-mail: kevinakirby@comcast.net
Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
Voice: (916) 925-8111 Fax: (916) 925-8136
Hi Kevin.
What I meant by ‘net’ reduction was a reduction in both compressive and tensile forces.
Fair to say that a soft device will reduce compressive forces at the med calc tubercle but not reduce the tensile forces as much and that a med heel skive, varus rearfoot post etc will reduce tensile forces but increase compression force.
A device which reduces both forces will likely be the most effective?
Make sense?
Scott
Hi Craig
Although I dont always agree with you, I DO always enjoy the mental stimulation that comes from reading your blogs, With immediate hindsight, that is probably WHY I enjoy reading the blogs – you should never just read the authors you agree with (IMHO).
Am interested in your take on the evidence behind stretching for PF, as pretty much all I have read was universally awful. What do you know, or indeed what have you read that says otherwise? Havent stretched a PF/calf/achilles for over 5 years now and have a great strike rate on successfully treating them.
I use gait retraining (to reduce heel strike), intrinsic/foot strengthening (have noticed a very high correlation of muscular activation/dysfunction in PF feet – admittedly anecdotal and by my way of “measuring” that of course) as if you land with more weight on the forefoot before the heel it stands to my way of thinking the intrinsics come into play earlier than when the reverse is true. Then plenty of “posterior chain” strengthening work.
Occasionally low dye or kinesiotape, of which I choose the one I think will suit the patient best (using 20 years of clinical experience, not randomly assigned between them). Currently have a 75% “happy patient on discharge” outcome, and that from a population of the “unlucky 10%” who didnt naturally resolve over the pre-assigned 2 years of “natural process”. Pretty happy at sorting out the lady with 7 year history of bilat PF with this strategy I can tell you!
With reference to your post on the evidence being poor for K-tape, I agree it is poor, but my patient records show around 90% of patients have immediate relief of symptoms and just under 80% have sustained relief up to 3-4days. So evidence or no I am going to keep trying it for now at least.
Would appreciate your thoughts re the stretching though, or a link to where I suspect you may have already blogged about it.
Cheers
Keith
Of all the treatments for plantar fasciitis, the evidence for stretching is probably the strongest with a number of RCT’s showing it is better than a placebo (can’t say that for many other treatments for it) – that is why I put so much emphasis on it; ie 3-4 times a day.
Here are some of the studies:
http://jbjs.org/article.aspx?articleid=25987
http://jbjs.org/article.aspx?articleid=27612
http://www.biomedcentral.com/1471-2474/8/36/abstract (did not work in this one; though short stretch time)
http://www.ncbi.nlm.nih.gov/pubmed?tmpl=NoSidebarfile&cmd=Retrieve&list_uids=17666175&dopt=AbstractPlus
http://fas.sagepub.com/content/3/3/117.abstract
http://jbjs.org/article.aspx?articleid=5790
http://www.jfootankleres.com/content/4/1/19 (systematic review)
http://www.ncbi.nlm.nih.gov/pubmed/23844489?dopt=Abstract
I know Paul Bowles has some unpublished data that its not effective…
Many thanks for the reply AND the light reading list.
Cheers
Firstly Craig thankyou for your analysis of this pathology, much appreciated.
Dr Kirby, I was wondering if you get a moment could you please elaborate on how you distinguish between GRF at the plantar heel Vs tensile stress on the medial plantar fascial strip? I noticed you mentioned you scarcely use MRI to confirm diagnosis (which I agree with) however what are you clinically looking for to distinguish betweem aetiologies?
Timing of gait? Foot structure? Do you find a variance in symptomology between the 2?
Additionally you mention the importance of achieving good congruency between that the MLA of the orthotic device and plantar foot. In your clinical experience what do you find gives the best results in this context (ie casting, 3D imaging, foam box impression etc)
Kindest regards
Christian
Podiatry Student
Christian:
At this point in time considering my knowledge of this pathology, I believe that the vast majority of patients with plantar heel pain, which are non-traumatic,and are what we call “proximal plantar fasciitis” are caused both by a combination of compression force from ground reaction force (GRF) acting on the plantar calcaneus and tension force within the plantar fascia acting on the plantar calcaneus during weightbearing activities.
The only test I know of which seems to give some clinical clue as to whether it is the compression force or tension force acting on the plantar calcaneus which is the predominant pathological force in causing the plantar heel pain is one I developed and described in August 2006 called the “Heel Pain Gait Test”. I described this test in my second Precision Intricast newsletter book. Here is an excerpt from a handout I gave in my workshop on “Clinical Tests for the Modern Podiatrist” at the Biomechanics Summer School in Manchester, UK, in 2011.
“11. Heel Pain Gait Test: When I perform the gait examination of a patient with plantar heel pain, the heel pain gait test involves specifically asking the patient at what time during the stance phase of gait that their heel is most painful. Is their plantar heel more painful when it first hits the ground at heel contact, or is their plantar heel more painful during late midstance when the heel is ready to lift from the ground? If the patient says that their plantar heel is more painful at heel contact, then the test indicates that the primary etiology of the patient’s pain is due to the compression forces from ground reaction force acting on the plantar heel at heel contact. If the patient, instead, says that their plantar heel is more painful at late midstance, then the test indicates that the primary etiology of the patient’s pain is due to the tension forces from the plantar fascia pulling on the plantar heel at late midstance. Many patients, however, will report pain at both heel contact and late midstance phases of gait which probably means that both compression and tension forces are more equally responsible for the patient’s pain. In addition, the pain at heel contact will be further modified by walking on a soft surface versus a hard surface, since the heel will not hurt as much at heel contact when it is cushioned by a soft surface. [First described in: August 2006 “Mechanical Etiology of Plantar Heel Pain and Heel Pain Gait Test” newsletter in: Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 187-188.]
As far as foot orthosis medial longitudinal arch congruency is concerned, I still use neutral suspension plaster casting and will use minimal arch fill in the positive cast/3D software to help make certain that the plantar arch of the orthosis is redirecting GRF from the plantar heel to the plantar arch of the foot optimally. I believe any casting or scanning method used to produce a 3D image of the plantar foot for manufacture of a custom foot orthosis can work to treat proximal plantar fasciitis. However, with this in mind, care must be taken by the foot-health clinician to ensure that the proper 3D morphology of the orthosis and the proper stiffness of the medial arch of the orthosis is also achieved in the resultant orthosis regardless of the casting/scanning method used to ensure proper orthosis fit and function..
Hope this helps.
Cheers,
Kevin A. Kirby, DPM
Wow.Thankyou so much for the detail of this response and how comprehensively you have addressed the questions I raised. I really didn’t expect that.
I’m going to buy your intricast newsletter series, actually wishing I’d done so earlier
Kindest regards Kevin
Hey folks! Thanks for the great posts. I have been experiencing pf pain continuously for a year. I have tried calf stretching and over the counter orthotics to no avail. I had started to buy into the minimalism/foot strengthen arguments, but Craig’s site here has made me reconsider.
I am not a runner, but am overweight (5’9″/315 lbs) and have a job where I am on my feet 70% of my day. So after reading these posts I am thinking I need an orthotic as you kind doctors described. The question I have as a consumer is where do I get an orthotic built in this way? How can I ensure that my dpm and/or orthotist is hip to your medicine? I’m in Oklahoma if anyone knows a practitioner out here.
Thanks!
Patrick
Curious Patrick. Did your PF / PHP ever resolve? If so, what strategies did you try and what do you feel helped the most?
Craig mentioned PF often resolved in its own so it’s fun to see what you tried and if you felt it helped or not.
Thanks for the great article.
It’s information like this that really makes a difference for plantar fasciitis sufferers.
As for myself, I managed to overcome my plantar fasciitis after 10 years with natural remedies like this:
(spam removed)
Thanks again!
No you didn’t. You are just a spam link dropping idiot. F off.