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Outcome of Different Orthotic Techniques For The Management of Plantar Fasciitis

INTRODUCTION
Excessive load and tension at the point of insertion of plantar fascia lead to inflammatory condition known as plantar fasciitis (PF). Plantar fasciitis is a major cause of the pain at the plantar aspect of the heel; the common site of pain is the medial tubercle of calcaneus (Roxas 2005; David & Lori 2004; Quaschnick 1996; Chandler & Kibler1993). Treatment remedies include both surgical and non-surgical interventions. Non surgical or conservative treatment comprises Non Steroidal Anti Inflammatory Drugs (NSAIDs), stretching, icing, physical therapy and orthotic management including foot orthosis and night splints (AFO), shoe modifications, low dye taping and walking casts (Kavros, 2005; Roxas, 2005; Young, Rutherford & Niedfeldt 2001). The aim of orthotic management is relief pain; reduce stresses on plantar fascia and increase in shock absorption. Also to maintain normal alignment of the foot to allow the fascia to heal. The aim of this paper is to discuss the outcomes of different orthotic devices and techniques for the management of PF in terms of pain relief, resolution of the symptoms and improvement in the anatomical and biomechanical condition.

Signs and Symptoms
Pain is classical symptom of PF, patient feels sever pain when he takes first few steps after sleep or long period of rest. It is sharp, knife like and piercing pain at the medial aspect of the heel and lessens or resolve as patient worm up. Prolong standing will also cause pain along with stiffness. There is localized tenderness of the tissue at the site of the pain. Tenderness can be felt when toes are hyper extended and ankle is dorsiflexed. A calcaneal spur is visible in the X-ray of affected foot (Cole, Craig & Gazewood, 2005; Young, Rutherford & Niedfeldt, 2001).

Etiology And Risk Factor
Etiology of plantar fasciitis is multifactoral, including anatomical, biomechanical and environmental factors. Anatomical factors include flat foot, cavus foot, obesity, and leg length discrepancy and fat pad atrophy.Biomechanical factor are equinus, weak plantar flexors, weak intrinsic muscle and excessive pronation at subtalar joint, whereas trauma, walking bare foot, walking on rough surface for a long time are included in environmental factors (Martin, Hosch, Goforth, Murff, Lynch & Odom, 2001; Gross, Davlin & Evanski 1991).

PATHOLOGY OF PLANTAR FASCIITIS (PF)
Plantar fascia is attached to the medial tubercle of calcaneus proximally and metatarsal head distally. With weight bearing it stretched and micro tears of fascia occur as well as tearing of periosteum at point of attachment of fascia. During rest these micro tears undergo healing and remodeling results in the formation of big bony mass or scar, the heel spur (Young, Rutherford & Niedfeldt, 2001; Quaschnick, 1996; Ryan, 1995; Corrigan & Maitland, 1994). There are inflammatory responses in plantar fascia from disorder of collagen fiber as result of repetition of excessive stress leads to chronic degenerative changes (Stadler, Johnson & Stephens, 2003).

In PF, Plantar flexors strength is decreased and gastro-soleus complex is tightened. Excessive pronation causes instability of hind foot, which leads to more strain on the origin of plantar fascia. Entrapment of medial calcaneal branch of posterior tibial nerve also causes pain. (Roxas 2005; Young, Rutherford & Niedfeldt, 2001; Quaschnick, 1996).

TREATMENT MODALITIES
Both surgical procedures and conservative managements are used to treat plantar fasciitis. Application of ice, use of NSAIDs, stretching and strengthening exercises for gaestrosoleus tightness and plantar flexors strength are non-surgical intervention as well as the orthotic management. Orthotic management is accomplished with use of different types of foot orthoses, heel pads, night splints, low dye taping and walking casts (Kavros, 2005; Sobel, Levitz & Caselli,
1999; Lynch, Goforth, Martin, Odom, Preece & Kotter, 1998).

AIM OF ORTHOTIC MANAGEMENT OF PLANTAR FASCIITIS
PF is self-limiting condition, but it takes a long period usually 6-18 months for complete resolution of symptoms, it is frustrating for both patient and physician. Aim of orthotic management is to address the pain, excessive stresses and inflammatory condition; provide shock absorption and to deal with biomechanical adaptation like slight varus position
of the heel and excessive pronation of fore foot during heel strike that lead to pain in foot and other part of body (Roxas, 2005; Young, Rutherford & Niedfeldt, 2001). Another important goal of the treatment is to keep the plantar fascia in its proper length, during weight bearing and non-weight bearing and restore the strength and flexibility of involved tissues (Barry, Anna & Yinpu. 2002). Injuries to the foot are usually the result of varying degree and size of the kinetic and kinametic changes in the foot, the use of correct orthosis that addresses these changes will result in the relief of the symptoms (Kavros, 2005).

FOOT ORTHOSES
Foot orthoses are effective in reducing pain in heel and arch area and provide comfort by altering the intrinsic factor and realigning the foot by keeping the sub tarsal joint in neutral position and preventing forefoot pronation, thus improve activity level (Karas &, David, 2002; Sobel, Levitz & Caselli, 1999; Gill & Kiebzak 1996). This goal is also achieved by support the medial longitudinal arch with rigid foundation to reduce the tensile forces within fascia (Gross, Byers, Krafft, Lackey & Melton 2002; Joan & Mark, 2001; Sobel, Levitz & Caselli, 1999; Turlik, Donatalli & Veremis 1999; Lynch et al, 1998).
Prefabricated semi rigid orthoses are effective in pain relief either by realigning the foot or by soft cushioning effect Success rate for foot orthoses is 83-100 % and there is high level of compliance (Kavros, 2005; Landorf, Keenan & Herbert, 2004; Martin et al, 2001; Pfeffer et al, 1999; Gross, Davlin & Evanski, 1991).

Viscoelastic Heel Pads
Viscoelastic heel pads and cushions are used to replace the atrophied fat pads of the heel and act as shock absorber during heel strike to dissipate the ground reaction forces hence reducing the impact force on leg and spine. Silicon heel pads provide relief at the site of tenderness and heel spur by distributing the weight around the point. Rear foot varus post or lateral wedge reduces pronation of forefoot and reduce the stretch to fascia result in the resolution of symptoms specially the pain (Landorf, Keenan & Herbert, 2004; Seligman & Dawson, 2003; Caselli, 1999; Pfeffer et al 1999).

Night Splints
During sleeping irrespective of whether supine or prone position, foot is postured in plantar flexion due to normal tone of gastrosoleus complex, this non functional plantar flexion will result in tightness of Achilles tendon and plantar fascia. Patient will experience a sharp pain at heel when foot touches the ground during first step in the morning due to stretching of tight plantar fascia. Tension night splint in chronic PF keeps foot in dorsi flexion preventing the contraction of the plantar fascia and Achilles tendon, which relaxed in stretched position due to stress relaxation, thus proper length of fascia is maintained (Barry, Anna & Yinpu. 2002; Probe, Baca, Adams & Preece, 1999; Powell, Post, Keener & Wearden, 1998; Chandler & Kibler1993).
The results are supplemented if night splint is used in conjunct with other conservative treatment such as FO, low dye taping and NSAIDs. 100% of success is achieved by use of night splint in chronic cases although these devices have no significant effect during acute phase. Unfortunately few patients feel unpleasant to use AFO during sleep or they feel
discomfort numbness or non compliance (Ryan, 1995; Wapner & Sharkey, 1991).
The night splint made of polypropylene aligned in 5 dorsiflexion and 30 dorsiflexion at metatarsophalangeal joint by placing a wedge under forefoot could be prescribed in chronic cases.

Low- Dye Taping
Taping is less expensive but more effective way of treatment of the plantar fasciitis, Though it is not considered as proper orthotic technique but still used in initial managements of planter fasciitis. Taping maintain the arch, stabilizes the metatarsal head and pronation of the foot (Cole, Craig & Gazewood, 2005; Quaschnick, 1996; Young, Rutherford & Niedfeldt 2001).
The injuries where there are very little traces of inflammation are present, tissue healing is allowed by protected or very limited ROM through taping during acute phase. Taping is also used as indicator of the Plantar fasciitis if symptoms still persist after few weeks of taping, the patient will reassessed for plantar fasciitis. If it is successful then permanent orthosis is prescribed (Brian, 2006; Landorf, Radford, Keenan, & Remond, 2005; Osbome & Allison, 2006; Chandler & Kibler, 1993).

Supportive Foot Wear
Proper shoes with proper fit and well supported arch and mid sole should be used in case of PF for proper distribution of forces. Shoes must be changed frequently and new shoes can be readjusted according to need, thus improving the symptoms. Shoe with well defined medial arch will reduce the strain in fascia. (Young, Rutherford & Niedfeldt 2001; Quaschnick, 1996; David, 1991).Older shoe will exacerbate the condition in the PF. Plantar fascia will under go tension from heel rise to toe off during gait and will cause the irritation of already inflamed ligament, which can be reduced or even diminished by modifying the commercially available shoes. Such modification include placement medial wedge to elevate arch and placement of silicon pads etc. shoe with proper fit will prevent the recurrence of disorder. (Joan & Mark, 2001; Sobel, Levitz & Caselli, 1999; Mizel, Marymont, & Trepman, 1996).

Walking Casts
In some cases casting is considered to be an effective way of treatment. This process is accomplished by wrapping ankle in neutral position or slightly dorsiflexion with fiberglass walking cast. Walking cast provides rest for heel and reduces the pressure at heel strike. These are also used to provide arch support and avoid the tightness of the Achilles tendon. (Roxas,
2005; Sobel, Levitz & Caselli, 1999; Gill & Kiebzak, 1996).

CONCLUSION
To sum up, PF is one of the common disorders of the foot that causes localized pain in the heel as well as change the functional biomechanics of the patient which in turn affect the activity level of the sufferer. The aim for orthotic management of plantar fasciitis is to deal with pain relief, correction of the posture (excessive pronation and varus heel) and hence the restoring the activities of the patient. Orthotic technique includes the foot orthosis, shoe inserts heel pads,
taping and casting of the foot. No single treatment is thought to be effective. Foot orthosis and heel pads produce relief in the pain by direct cushioning effect or by elevated arch support and controls the pronation of the foot during walking and running thus reduces the tensile forces on the foot, consequently improving the functional restorations. Heel pads also act as shock absorber at heel strike and reduce the overall impact on the leg and low back. In chronic cases the use of night splint aligned in 5 dorsi flexion cause considerable reduction in pain. Night
splints are also effective in the improving the symptoms in recalcitrant PF and reduce the formation of the micro tears. Arch taping and walking casts used to minimize the ROM at ankle during acute phase. Finally, there is no single treatment modality that is effective in the management of the PF; it is combination of the treatments that result in the resolution of the symptoms pain, inflammation and biomechanical factors.

SUGGESTED REFFERENCES:

  • Barry, L.D., Anna, N. and Yinpu, C. ( 2002) A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis. Journal of Foot & Ankle Surgery. 41(4):221-7,
  • Brian, F (2006) Plantar Fasciitis: how to maximize outcomes with conservative treatment Podiatry Today, 19 (5), 48 – 56
  • Chandler, T . and Kibler, W B. (1993) A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis. Sports Medicine, 15(5):344-52,
  • Cole, C.S., Craig, G.J. (2005) plantar fasciitis: evidence-based review of diagnosis and therapy. [Review] American Family Physician, 72(11):2237-42,
  • David O. D. (1991) A Comparison of Shoe Inserts to Taping for Painful Arches, Journal of Prosthetics and Orthotics 3(2); 84-. Gill, L H. and Kiebzak, G. M. (1996) Outcome of no surgical treatment for plantar fasciitis Foot & Ankle International. 17(9):527-32,
  • Gross, M.T., Byers, J.M., Kraft ,J.L. , Lackey, E.L and Melton K.M. (2002) The impact of custom semi rigid foot orthotics on pain and disability for individuals with plantar fasciitis: Journal of Orthopeadic And sports physical therapy 32(4):149-57
  • Joan, M. B. and Mark, W.N. (2001) Over the counter foot remedies Journal of American Family Physician 64(5) 791-6
  • Karas, M .A. and David, J.H., (2002) Compensatory Midfoot Dorsiflexion in the Individual with Heel cord Tightness: Implications for Orthotic Device Designs, Journal of Prosthetics and Orthotics 14(2); 82-93.

HIP-KNEE-ANKLE-FOOT ORTHOTICS

HKAFO consists of a hip joint and pelvic band in addition to a KAFO. The orthotic hip joint is positioned with the patient sitting upright at 90°, while the orthotic knee joint is centered over the medial femoral condyle. Pelvic bands complicate dressing after toileting unless the orthosis is worn under all clothing. Pelvic bands increase the energy demands for ambulation.

Pelvic bands
1. Bilateral pelvic band: This band is used more commonly with its posterior metal ends located anterior to the lateral midline of the pelvis and is interconnected by a flexible belt.
2. Unilateral pelvic band: This band rarely is used because most conditions requiring a HKAFO have bilateral involvement.
3. Pelvic girdle: The pelvic girdle is made of molded thermoplastic materials, providing a maximum degree of control in patients with bilateral involvement.
4. Silesian belt: This belt has no metal or rigid band and offers mild resistance to abduction and rotation of the hip. The Silesian belt attaches to the lateral upright and encircles the pelvis.


Hip joints and locks:
The hip joint can prevent abduction and adduction as well as hip rotation.
1. Single axis hip joint with lock: This joint is the most common hip joint with flexion and extension. The single axis hip joint with lock may include an adjustable stop to control hyperextension.
2. Two-position lock hip joint: This hip joint can be locked at full extension and 90° of flexion and is used for hip spasticity control in a patient who has difficulty maintaining a seated position.
3. Double axis hip joint: This hip joint has a flexion-extension axis and abduction-adduction axis to control these motions.

KNEE ORTHOTICS (KO)

A knee orthosis (KO) only provides support or control of the knee but not of the foot and ankle. The knee joint is centered over the medial femoral condyle. If the patient does not have adequate gastrocnemius delineation so that there is a shelf for the distal end of the orthosis to rest on, the brace may slide down the leg with wear. In that case, the brace needs to extend to the sole of the foot.

  • Knee orthoses for patellofemoral disorder: These orthoses are used to supply mediolateral knee stability and to control tracking of the patella during knee flexion and extension. ThisAdd Image type of orthosis includes an infrapatellar strap KO and Palumbo KO.
  • Knee orthoses for knee control in the sagittal plane: These orthoses are used to control genu recurvatum with minimal mediolateral stability. This type of KO includes a Swedish knee cage and a 3-way knee stabilizer.
  • Knee orthoses for knee control in the frontal plane: These orthoses consist of thigh and calf cuffs joined by sidebars with mechanical knee joints. The knee joint usually is polycentric and closely mimics the anatomic joint motion. This type of KO includes traditional metal-leather KO, Miami KO, Canadian Arthritis and Rheumatism Society- University of British Columbia KO, and supracondylar KO.
  • Knee orthoses for axial rotation control: These orthoses can provide angular control of flexion-extension and mediolateral planes, in addition to controlling axial rotation. This orthosis is used mostly in management of sports injuries of the knee. This type of KO includes Lenox-Hill derotation orthosis and Lerman multiligamentous knee control orthosis.

KNEE-ANKLE-FOOT ORTHOTICS (KAFO)

KAFOs consist of an AFO with metal uprights, a mechanical knee joint, and 2 thigh bands. KAFO can be used in quadriceps paralysis or weakness to maintain knee stability and control flexible genu valgum or varum. KAFO also is used to limit the weight bearing of the thigh, leg, and foot with quadrilateral or ischial containment brim. A KAFO is more difficult to don and doff than an AFO, so it is not recommended for patients who have moderate-to-severe cognitive dysfunction.
! KAFO: This orthosis can be made of metal-leather and metal-plastic or plastic and plastic-metal. The metal design includes double upright metal KAFO (most common), single upright metal KAFO (lateral upright only), and Scott-Craig metal KAFO. The plastic designs are indicated for closer fit and maximum control of the foot, including supracondylar plastic KAFO, supracondylar plastic-metal KAFO, and plastic shells with metal uprights KAFO.

  1. A double upright metal KAFO: This is an AFO with 2 metal uprights extending proximally to the thigh to control knee motion and alignment. This orthosis consists of a mechanical knee joint and 2 thigh bands between 2 uprights.
  2. A Scott-Craig orthosis consists of a cushioned heel with a T-shaped foot plate for mediolateral stability, ankle joint with anterior and posterior adjustable stops, double uprights, a pretibial band, a posterior thigh band, and knee joint with pawl locks and bail control. Hyperextension of the hip allows the center of gravity falling behind the hip joint and in front of the locked knee and ankle joint. With 10° of ankle dorsiflexion alignment, it allows a swing-to or swing-through gait with crutches. This orthosis is used for standing and ambulation in patients with paraplegia dueto spinal cord injury (SCI).
  3. The supracondylar plastic orthosis uses immobilized ankle in slight plantar flexion to produce a knee extension moment in stance to help eliminate the need for a mechanical knee lock. This orthosis also resists genu recurvatum and provides mediolateral knee stability.
  4. A plastic shell and metal upright orthosis consists of a posterior leaf spring AFO with double metal uprights extending up to a plastic shell in the thigh with an intervening knee joint.
  • Knee joints: The mechanical knee joint can be polycentric or single axis. Polycentric is used for significant knee motion, and a single axis is more common and is used for knee stabilization. Single axis knee joints include the following:
  1. Free motion knee joint: This joint has unrestricted knee flexion and extension with a stop to prevent hyperextension. The free motion knee joint is used for patients with recurvatum but good strength of the quadriceps to control knee motion.
  2. Offset knee joint: The hinge is located posterior to the knee joint and ground reaction force; thus, it extends the knee and provides great stability during early stance phase of the gait cycle. This joint flexes the knee freely during swing phase and is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop.
  3. Drop ring lock knee joint: The drop ring lock is the most commonly used knee lock to control knee flexion. The rings drop to unlock over the knee joint while the knee is in extension by gravity or manual assistance. This type of joint is stable, but gait is stiff without knee motion. A ball bearing on a spring can be added just above the drop lock to keep it from slipping up as the patient ambulates. Patients over 120 pounds usually feel more secure with both medial and lateral drop locks.
  4. Pawl lock with bail release knee joint: The semicircular bail attaches to the knee joint posteriorly, and it can unlock both joints easily by pulling up the bail or backing up to sit down in a chair. A major drawback is the accidental unlocking while the patient is pulling his or her pants up or bumping into a chair. Adjustable knee lock joint (dial lock): The serrated adjustable knee joint allows knee locking at different degrees of flexion. This type of knee joint is used in patients with knee flexion contractures that are improving gradually with stretching.
  5. Ischial weight bearing: Most individuals in a KAFO sit partially on the upper thigh band unless the cuff is brought up above the ischium.

Knee cap and strap: The knee cap can be placed in front of the knee in the orthosis to prevent flexion of the knee. A medial strap is used for genu valgum and a lateral strap is used for genu varum. These buckles wrap around the upright in the same way as ankle straps.

Plastic shell and metal uprights moldedknee-ankle-foot orthosis with drop lock joints.

Offset knee joint knee-ankle-foot orthosis.

SHOES, FOOT ORTHOTICS, ANKLE FOOT ORTHOTICS

Shoes
Shoes are the important foundation of the lower limb orthosis. Shoes are used to protect and warm the feet, transfer body weight while walking, and reduce pressure or pain through redistributing weight. Shoes should be comfortable and properly fitted.
They should be at least 1 cm longer than the longest toe and correspond to the shape of the feet.
The shoe can be divided into lower and upper parts. The lower parts consist of the sole, shank, ball, toe spring, and heel. The upper parts include the quarter, heel counter, vamp, toe box, tongue, and throat.

Rocker Shoe

Blucher style orthopedic shoe

Diabetic shoe

Foot orthosis
The foot orthosis extends from the posterior border of the foot to a point just posterior to the metatarsal heads. This device is used to accommodate the abnormal foot to help restore more normalized lower limb biomechanics.

  1. Custom Foot Orthotic Shoe insert: This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. It encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls.
  2. Heel cup: The heel cup is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially,and laterally up the side of the heel. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot.
  3. Sesamoid insert: This addition to an orthosis is an insert amounting to three quarters of an inch with an extension under the hallux to transfer pressure off the short first metatarsal head and onto its shaft.

ANKLE-FOOT ORTHOTICS (AFO)
An AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexors, plantar flexors, invertors, and evertors. AFOs are used to prevent or correct deformities and reduce weight bearing. The position of the ankle indirectly affects the stability of the knee with ankle plantar flexion providing a knee extension force and ankle dorsiflexion providing a knee flexion force. An AFO has been shown to reduce the energy cost of ambulation in a wide variety of conditions, such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of poliomyelitis, and spastic hemiplegia in cerebral infarction.

  1. Thermoplastic AFOs: These devices are plastic molded AFOs, consisting of the following 3 parts: (1) a shoe insert, (2) a calf shell, and (3) a calf strap attached proximally. The rigidity depends on the thickness and composition of the plastic, aswell as the trim line and shape. Thermoplastic AFOs are contraindicated in cases of fluctuating edema and insensation.
  • Posterior leaf spring (PLS): The PLS is the most common form of AFO with a narrow calf shell and a narrow ankle trimline behind the malleoli. The PLS is used for compensating for weak ankle dorsiflexors by resisting ankle plantar flexion at heel strike and during swing phase with no mediolateral control.
  • Spiral AFO: This AFO consists of a shoe insert, a spiral that starts medially, passes around the leg posteriorly, then passes anteriorly to terminate at the medial tibial flare where a calf band is attached. The spiral AFO allows for rotation in the transverse plane while controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion.
  • Hemispiral AFO: This AFO consists of a shoe insert with a spiral starting on the lateral side of the shoe insert, passing up the posterior leg, and terminating at the medial tibial flare where the calf band is attached. This design is used for achieving better control of equinovarus than the spiral AFO can.
  • Solid AFO: The solid AFO has a wider calf shell with trim line anterior to the malleoli. This AFO prevents ankle dorsiflexion and plantar flexion, as well as varus and valgus deviation.
  • AFO with flange: This AFO has an extension (flange) that projects from the calf shell medially for maximum valgus control and laterally for maximum varus control.
  • Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion.
  • Tone-reducing AFO (TRAFO): The broad footplate is used to provide support around most of the foot, extendingdistally under the toes and up over the foot medially and laterally to maintain the subtalar joint in normal alignment.

The TRAFO is indicated for patients with spastic hemiplegia.

Modular ankle-foot orthosis with ankle foot double adjustable hinged joint

Double uprightmetal AFO

Carbon plastic orthosis with footplate.

REFERENCES

  1. Braddom RL, Dumitru D, Johnson EW, et al, eds. Lower limb orthoses. In: Physical Medicine and Rehabilitation. 1st ed. WB Saunders Co;1995:333-358.
  2. Merritt JL. Knee-ankle-foot orthotics: long leg braces and their practical applications. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 1. 1987:67-82.
  3. Molnar GE, Alexander MA. Orthotics and assistive devices. In: Pediatric Rehabilitation, Rehabilitation Medicine Library. Lippincott Williams & Wilkins;1985:157-177.
  4. Tan JC. Orthoses. In: Practical Manual of Physical Medicine and Rehabilitation. 1st ed. Mosby-Year Book;1998:178-228.
  5. Rubin G, Bonarrigo D, Danisi M. The shoe as a component of the orthosis. Prosthet Orthot Int.1976;30(2):13-25