Symptoms & Solutions

• Inflammation and tightness in plantar fascia under the medial longitudinal arch of the foot
• Generally shows itself as pain at the heel that is made worse with pressure, can sometimes lead to a tight feeling under the arch that is painful with every step.
• It is common for pain to be most prevalent in the morning when first getting out of bed, as the sufferer walks around a little bit, the pain will subside. After being off one’s feet for an extended period of time the return to walking can elicit pain once again.
• This can become chronic and last for months. It can also be quite painful with sufferers at time describing the feeling as “tearing”, or “stabbing”.

Solution

More often than not poor biomechanics are at the root of this condition. It can also be attributed to an increase in activity level or change in activities. If the medial longitudinal arch is collapsing with loading this will put increased tension into the plantar fascia. If the fascia is under abnormal loading due to a new activity the area can become inflamed.

A custom foot orthotic prescribed by a knowledgeable practitioner can correct any underlying biomechanical causes. If one was to treat the symptoms without getting to the root reason for the condition, the plantar fasciitis will have a tendency to return or not heal properly.
A few exercises to help strengthen the muscles of the foot are as follows – please note the exercises are just guidelines and may not be for all people based on their health situation.

• Standing with your feet flat on the floor about shoulder width apart, squat down towards a squatting position while trying to keep your heels flat on the floor (tightness can often be felt in the calf muscles), you can then raise up onto your tip toes, hold the low position and the raised position for about 5 seconds each*NO BOUNCING* do 10 times
• In a seated position with bare feet, scrunch a towel under your foot using your toes to draw it towards your heels. This can be done a few times, the small muscles of the foot do tend to tire quickly.
• in seated or laying position extend the knee fully. Using a towel or rope under the ball of the foot, pull the front of the foot towards your chest. It is common to feel tightness in the calf or even the bottom of the arch in the plantar fascia. Stretch and hold for about 5 seconds, relax and then repeat.

Custom Foot Orthotic Suggestions

• Rigid functional style device with plastic based on patient activity level and weight (see chart)
• Heel cushion for heel pain, heel hole for more extreme heel pain

• Collapse of the medial long arch of the foot with loading
• Mid foot instability can lead to rolling in during gait (overpronation)
• Can be congenital where some people inherit fallen aches from their parents/grandparents or can also be caused by excess body weight and improper footwear selection.
• The hormones released and weight gained during pregnancy are a common trigger for arch collapse

If left untreated, more serious issues can arise. Fallen arches can aggravate plantar fasciitis and create biomechanical inadequacies that may cause hip/knee/back pain. Bunions can also be a byproduct of excessive pronation.

Solution

Fallen arches are a biomechanical issue that can lead to plantar fasciitis – see plantar fasciitis solutions for exercises

Proper footwear selection is very important.  Avoid very flexible shoes that can be easily bent and twisted completely in half.  Generally shoes with a firm material under the middle of the arch are beneficial.  These shoes are often labeled “motion control” or “pronation control”.  It is common when the arch flattens to see the whole foot to splay out leading to a wider forefoot.  With all foot types trying on the shoe in the store and walking is a must.

Custom Foot Orthotic Suggestions

• Rigid functional style device with plastic based on patient activity level and weight (see chart)
• Heel posting to neutral for extra stability
• Rearfoot varus posting can be used when the collapsed arches are caused by a rearfoot varus deformity.
• If condition is caused by a rigid forefoot varus that is not easily reducible wedging should be done under the medial forefoot.  This will elevate the ground and restrict whole foot eversion as the great toe makes contact.

• Lack of collapse in medial arch with loading
• A stiff medial arch that does not depress when loaded can cause the foot to roll laterally with gait (oversupination) and does not absorb forces properly
• can be congenital where some people inherit high aches from their parents/grandparents or can also be caused arthritis or injury to the foot.

If left untreated symptoms are often linked to the lack of shock absorption. If the foot is not shielding the body from ground reaction forces, the knees/hips/ and low back are faced with excess loading.

Forefoot pain and nerve impingement can result with uneven loading of the forefoot.

A high arched foot with lateral instability can be at greater risk of inversion ankle sprains, especially when exposed to sports where there is a lot of jumping or lateral side to side movement (basketball, football, tennis).

Solution

• High arches are a biomechanical issue that can lead to plantar fasciitis -see planter fasciitis solutions for exercises.
• Stretching the connective tissue of the foot and the calf muscles is generally suggested to increase range of motion.

Proper footwear selection is very important.  Avoid stiff shoes with hard soles because they do not offer the extra cushion needed with this foot type.  Shoes deemed “motion control” or “over pronation control” are not suggested because they will force the already laterally loaded foot into more inversion.  Instead look for a light weight, flexible shoe for “supination control” or “neutral cushioning”.  A high arch foot will require a deeper shoe so that the top of the shoe is not too tight on the foot.  With all foot types trying on the shoe in the store and walking is a must.

• Soreness under the ball of the foot
• Pins and needles or deep aching pain

There are many causes to forefoot pain, some are more direct than others. It is very important to look at the whole picture and make a decision for treatment based on all factors.

Common causes

Collapsed transverse arch – under optimal circumstances there is a healthy arch across the ball of the foot.  Contact occurs under the first metatarsal head and 5^th metatarsal head.  Met heads 2,3,4 bridge the gap in a low arch that aids in stabilizing the front of the foot.  In some cases the metatarsal heads can drop down and actually load with forefoot weight bearing.   This can impinge nerves and cause areas of high pressure (callusing, corns, ulceration).  Nerve impingement can cause pins and needles and dull aching pain between the toes.  If left untreated a neuroma can form leading to more permanent nerve damage.

Custom Foot Orthotic Suggestion

• Extra cushioning with cutouts can be used to offload boney prominences or ulceration (met accom pad with submetatarsal cutouts).  Metatarsal pads will lift and spread the transverse arch and help re-establish the proper forefoot positioning.  If the extra pressure is causing sesamoiditis a reverse morton’s extension can offload the 1^st MTPJ.

Injury – if there is trauma to the foot internal scar tissue can stiffen up the movement of the metatarsal head, if there is a fracture to the metatarsal head it may not glide smoothly around the neighboring metatarsals.  Generally an injury will lead to some form of arthritis over time.

Due to tremendous number of variables involved with an injury, multiple techniques may need to be used in unison with each other based on the specific needs of each case.

Arthritis– the forefoot needs to be able to invert and evert with walking.  This allows shock absorption and proper balance for gait biomechanics.  Arthritis can make movement between the metatarsal heads and shafts painful or even restricted.

Custom Foot Orthotic Suggestion

• Extra cushioning to help absorb some of the forces.  Generally a cushioned soft orthotic is recommended for arthritic feet.  If the foot is forced into a fully corrected position it can become very uncomfortable if the joints are arthritic.  Stiff material can be added to restrict motion when the joint is painful through extension or flexion

Bunions– bunions can become painful and arthritic with time.  The first metatarsal phalangeal joint will start to go into a position of subluxation if not addressed properly.  The ensuing hallux abductovalgus will drastically change the joint range of motion and become arthritic.  Bunions are seen as a boney prominence on the medial side of the foot and need to be considered when purchasing footwear.

Hammer toes– curling or bent position of lesser toes while at rest.  Generally caused by improper fitting shoes, the narrow toe box of dressy shoe styles can crowd the toes and cause structural changes over time.  High heeled footwear place a great deal of stress on the ball of the foot and also force the lesser toes into an abnormal position where the tendons and muscles can become short.   A shallow toe box can rub against the toes and lead to callusing/corns and ulceration.

Custom Foot Orthotic Suggestion

The footwear must be examined, if the footwear is of improper style or fit education is of paramount importance.  It is common to see a collapsed transverse arch with hammer/claw toes.  See above topic for suggestions.  Lifting and spreading the metatarsal heads will usually straighten the toes out.

It is not uncommon for people to have one leg that is longer than the other. For most people this is of no concern and symptoms do not arise. Muscles in the legs, back and hips will work to balance out minor differences. In some cases the difference is too large for the body to accommodate or the muscles are weakened and a lift needs to be added to the shortened side. This will level out the pelvis and can help with painful nerve impingement. Please note that functional leg length discrepancies caused by muscle imbalance are generally resolved with strengthening and stretching the affected muscle groups. Anatomical/skeletal differences are situations in which a physical lift can be considered.

There are multiple ways to measure leg length discrepancies, each with their own positives and negatives. It is generally worth measuring the patient multiple times on each side, this allows for a better picture of what is really going on and helps eliminate some inconsistencies. Once a patient has been measured and the difference calculated it is generally wise to start with a smaller lift and gradually increase the height until the symptoms are relieved. A good starting place with a lift is to add one half of the difference in leg lengths to the shortened side. If the patient has been walking without a lift for 50 years the body may be slow in adapting and you have to treat each individual on a per case basis. Most people do not need the full amount compensated for and if a very aggressive initial approach is taken compliance can become a significant factor.

If the required lift is small and less than 3mm (1/8th inch) it is generally not suggested to intervene unless there are symptoms. For larger lifts of 8mm (3/8th inch) the shoe must be considered. Shallow casual style shoes with no removable liners cannot comfortably fit lifts or are restricted to very small ones. Most athletic shoes with liners that come out will only have room for less than 1 cm of lift. If the lift required is larger than this, the shoe will have to have the sole modified. Building the lift right into the shoe itself alleviates potential fit issues but does limit the patient to only having that shoe with the proper support. Not all shoes can be modified and they external appearance of the footwear will be altered.

Children may show signs of leg length discrepancy as they grow and develop. They may have a short left leg on their initial visit and after a few months of growth the right leg may now be short. For this reason it is generally wise to observe and take note rather than to intervene. There are circumstances where an injury has damaged a growth plate, the difference is large or even suggested by a physician/specialist. These cases would be taken as exceptions and lifts can easily be done for a smaller foot.
cons

Patients with diabetes should be treated gently. They are at a much higher risk of ulceration and infection. With decreased blood flow and nervous sensation to the feet the smallest blister or cut can become life threatening if not treated properly. Some suffers have little to no feeling in their feet and toes. They will not notice an area of high pressure that has actually worn a hole in the skin and is now open to a potentially serious infection. It is wise to check the feet thoroughly for calluses or cuts and educate the patient on daily at home foot checks. Nail trimming is advised to be done by someone with experience and sterile instruments. Cold feet that do not have a quick capillary refill are initial signs that extra care should be taken when treating someone with diabetes. Patients will often describe the feet as burning or even tingling when a neuropathy is present.

Solution

Neuropathy being more of a byproduct of the diabetes will not be cured using insoles. The insole will be used to alleviate areas of high pressure. A very aggressive device may cause areas of high pressure that have the potential for ulceration. A very soft cover is recommended. It will cradle the foot and offload areas that are exposed to more pressure. A flexible device although not going to correct any significant biomechanical issues can offer support without exposing the patient to unnecessary risk. It is also very wise for the patient to be very diligent with any insoles by daily checking their feet for red pressure points or spots of high wear on the cover. These areas can be adjusted for a more comfortable fit ensuring the patient is safe and happy.

Shells more accommodative from Left to Right on table

Archfill can be used to stiffen the arch and create a more functional device with a less rigid plastic

*NOTE* Archfill will make the device thicker and take up more space in the shoes