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Case study- Orthotic treatment of Plantar Heel Pain

Orthotic Treatment of Plantar Heel Pain (PHP)

Single case study

Introduction

Plantar Heel pain (PHP) is generalised term which covers a wide variety of conditions the most commonly reported of these being Plantar Fasciopathy. 

The majority of cases are mechanical in nature but other common causes must be ruled out. 

Differential Diagnosis

  • Tarsal Tunnel Syndrome
  • Calcaneal Stress Fracture
  • Heel pad atrophy
  • Plantar Fasciopathy
  • Calcaneal heel spur

Plantar Fasciopathy

Common misconception - Pain due to inflammation of the plnatr fascia however inflammation is only rarely observed. The true nature of the injury is mechanical, degenerative overuse and is categorised as insertional or non-insertional. 

Causative Factors

  • Older age
  • Increaed BMI
  • Limited/excesive 1st MTPj ROM
  • Limited ankle dorsiflexion
  • Leg Legnth discrepancy
  • Reduced heel pad thickness
  • Reduced calf strength
  • Excessive foot pronation
  • Prolonged standing
  • Inappropriate fitting footwear
  • Previous Injury
  • Running surface, speed, frequency and distance per week.

Patient Demographics

Plantar heel pain pronated foot

  • Male
  • 42 years of age
  • Gradual onset pain last 2 years
  • Plantar heel pain bilaterally
  • Worse with increased activity
  • Previous treatment
    • Slimflex insole
    • 6mm semi compressed felt wedging 

 

Assessment

  • Medially deviated subtalar joints
  • FnHL (Functinoal Hallux Limitus) bilaterally with hyperextended IPJ joints
  • Unable to stand on tip toes effectively for more than a few seconds due to pain in right MPTj
  • Positive windlass mechanism
  • Balance good on Rombergs test
  • Painful Tibialis Posterior tendon insertion points and medial aspect of heel
  • Full passive below knee range of motion
  • Abductory twist present during gait.
  • Pain 9 out of 10 on NRS-11 (numerical rating scale)

Single heel raise

 

Treatment

  • Self Management advice
  • Night resting AFO
  • Functional foot orthoses
    • 6mm medial heel wedge
    • 20 deg medial heel skives
    • 1st metatarsal cut out on right
    • 4mm reverse mortons extension on both

Results

  • 2 week Follow up
    • Heel pain reduce to 5/10 from 9/10
  • 12 week Follow up
    • Heel pain completely resolved
  • If insoles not used discomfort returns with increased activity

Conclusion

Firmer insoles with high supination forces reduce soft tissue stress and associated pain. 

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