Plantar fasciitis - treatment with an orthotic
When you're a hammer, everything looks like a nail, right? So when you're a podiatrist, is everything treated with an orthotic? Like so much in life, there's no single answer, but let's explore the question.
In my experience, I've known a few, true biomechanical evangelical podiatrists who are hyper-focused on their art. These doctors are very intellectual in their practice of lower extremity biomechanics. Their exam is comprehensive and includes a non-weight bearing biomechanical exam and gait exam. And their tool of choice? Rx orthotics. I do want to stress that these are doctors who I really trust. They're bright, logical and help many, many patients.
On the other hand I've seen orthotics mills. These are doctors who use orthotics to put their kids through college. And this practice isn't just with physicians. One local example in my community is a retail store that sells arch supports for $400 a pair. These are stock out-of-the-box arch supports. Wow.
So where's the middle of the road? How do you know when an orthotic is indicated or when it's just an up-sell? The first thing is trust. Whether it's your auto mechanic, dentist or podiatrist, trust is at the heart of the interaction. As an example, on a recent rip to see my dentist, he told me I needed three major build-ups on my teeth. I nodded in agreement trusting him. But then he went a step further and showed me digital images of my teeth once he had carved out the decay. Holy cow! From the images I was amazed that he would be able to rebuild my teeth. And my auto mechanic - he always has the old parts. He always takes the time to explain to me why the circuit went out on a switch or why a particular valve was plugged. I trust these people and as a result, I value them in my life.
Prescription vs non-prescription orthotics
And orthotics? Has your doc tried a few methods of treatment prior to the introduction of the orthotics? Has he or she spent a reasonable amount of time explaining your foot condition? As you can see from my example of my dentist and my auto mechanic, there's a period of building trust. The same holds true in a significant purchase like a pair of orthotics.
And what about plantar fasciitis? Do you really need a pair of orthotics to treat plantar fasciitis? As in the examples described above, there's a number of treatment options that can be used during the period of building trust. In my experience, the use of calf stretches and a heel lift has helped 7/10 of my patients reach a point where they're pain free. This is particularly true in recent onset cases of plantar fasciitis. For many folks with plantar fasciitis who have failed to respond to conservative care (stretches and heel lifts), or their plantar fasciitis has been present for more than three months, they're going to need a higher level of care. And that might just include orthotics. I find some of the best orthotic candidates are folks who work in occupations where they can wear tennis shoes or boot and are on their feet for extended periods of time. Examples that come to mind include grocery store clerks, warehouse workers, nurses, teachers and landscapers.
How do orthotics treat plantar fasciitis? First, they act as a heel lift to weaken the calf. As we've said before though, raising the heel and weakening the calf can be easily done with an inexpensive heel lift. So why the orthotics? My logic for their use is two-fold. First, with each step, as the heel hits the ground, the foot starts to look for what it needs to do next. The foot runs through a check list of issues to include - am I on a flat surface or a hill? What kind of shoe am I in? Is that shoe supportive? How high is the heel on the shoe? And the list goes on and on. An orthotics make that list shorter. When the heel hits the ground the orthotic provides a reliable, supportive surface. Step after step, the orthotic is in place making the foot more efficient. At day's end, the foot has performed less work. Less work means fewer issues with over-use syndromes. And as we've described before, plantar fasciitis is an over-use syndrome.
And the second benefit of an orthotic is the support at mid-stance of gait. Mid-stance is that position your foot takes as your body weight passes over the foot. A well build orthotic will also decrease work in mid-stance. Less work, less over-use syndromes, right? You've got the picture.
So do you really need an orthotic to treat plantar fasciitis? Maybe. But when indicated, an orthotic can be a powerful, long last solution in the treatment of plantar fasciitis.
Jeffrey A. Oster, DPM
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