Orthotic Modifications for Heel Pathology

Q: For plantar fasciitis, what orthotics modifications or features do you find most impactful for this condition? Can you also share your reasoning, specifically in the context of varying foot types and biomechanical characteristics?

A: Many of the panelists in this roundtable cited a deeper heel cup as a helpful feature that they employ in their orthotics and modification strategy for plantar fascial pathology. Some specifically noted its usefulness to enhance calcaneal stability. 

Robert M. Conenello, DPM, FACFAS, FAAPSM shares that for plantar fasciopathy, he finds that one of the most impactful goals is ensuring that the hallux stays grounded during the propulsive phase of gait. To achieve this, he says he routinely incorporates a first ray cutout, along with a reverse Morton’s extension into his orthotic prescriptions. 

“(In addition to a deep heel cup,) I favor orthotics that contour closely to the arch, providing full-contact support, and I almost always prescribe full-length devices for optimal function and comfort,” he adds.

Another panelist, Marlene Reid, DPM, DABFAS, FACFAS says she often uses that deeper heel cup if the patient has a history of repeat flare-ups.  

“I find that custom orthotics are best for controlling the biomechanics that contribute to plantar fasciitis, but don’t always resolve a current episode or (cases of) chronic fasciosis. I am very specific when treating fasciitis versus fasciosis,” she notes.

Karli Richards, DPM, MHA, FACFAS, CWS explains that she initially recommends over-the-counter (OTC) insoles for plantar fasciitis to prevent increased fascial strain from potential overpronation. She agrees that a deep heel cup also supports heel stabilization and points out that this can also provide value for patients that overly supinate. If the OTC devices help the patient, but they need more support or customization than what those devices provide, she then proceeds with custom orthotics to fit that patient’s needs based on their foot type. 

“(As an example), I usually recommend a semi-rigid orthotic with cushioning and a deeper heel cup for patients who are supinators with plantar fasciitis. Also, I find a metatarsal pad is occasionally a good option for those patients with forefoot pronation,” she adds.

Lisa M. Schoene, DPM, FAAPSM, DABFAS takes a slightly different approach to what types and timing of devices and modifications that she uses. First and foremost, she shares she fabricates a traditional removable longitudinal metatarsal (L&M) pad to use throughout the full treatment course, whether acute or chronic.

“Not discussing or dispensing an orthotic initially  using this L&M pad during the full treatment course allows for a few cool things to happen; patients wear it daily, which increases compliance and resolution, its reusable, washable, and gives comfortable soft plantar fascia support, which feels good to the patient,” she explains. “It also allows for  gradual adjustments to (any) gastrocnemius/soleus tightness and compensations, and for the patients to understand the space needed for a potential device to fit into their shoes.”  

She notes that historically, she finds that if the patient does well with the L&M pad, then it is a good sign that orthotics will also work well. The pad then remains an option to revert to if the patient experiences initial difficulty in tolerating a custom orthotic.

In her traditional polypropylene full-length athletic devices for plantar fascial pathology, Dr. Schoene said she modifies the thickness of material based on weight, and chooses topcovers based on the sport or activity type. From there, she considers the use of modifications such as arch reinforcement, soft heel padding, and heel cup depth. During device follow-up, she carefully evaluates device fit and function, making in-office modifications to accommodate before sending for a permanent fix at the orthotics lab. 

Q: For Achilles tendon pathology, what orthotics modifications or features do you find most impactful for this condition, and why?

A: Most of the panelists agree that orthotic modifications can be similar for both Achilles tendon and plantar fascial pathology. However, they differ somewhat in their approaches towards using heel lifts. 

Dr. Conenello, who practices at Orangetown Podiatry in Orangeburg, NY, says that he frequently adds a laminated rearfoot lift to both orthoses in these cases. This lift can be gradually reduced in segments over time, depending on patient progress, to manage tension on the Achilles tendon while promoting improved sagittal plane mechanics during gait.

Heel lifts are also a part of Dr. Richards’ typical pathway for Achilles tendonitis, but she notes that she will adapt other features to accommodate varying foot types and biomechanics (ie medial arch support for pronation versus a softer device with lateral support for supination). 

Dr. Reid uses heel lifts independent from a custom orthotic in cases of acute inflammatory Achilles tendonitis to temporarily offload the tendon. If the patient already has a custom device, she says she temporarily adds the heel lift, but does not keep it permanently to avoid tendon contraction over time. She notes that for chronic tendinosis, though, that she finds regenerative treatments may be necessary over orthotic modification alone. 

Dr. Schoene stresses the importance of performing a comprehensive evaluation of mechanics for Achilles tendon pathology, such as leg length discrepancies, gastro-soleal issues, gait patterns, and strength/flexibility deficits, in order to best determine the right orthotic modifications including heel lifts. She adds that this can then help inform the clinician to best consider how the orthotic and/or lifts will fit inside a shoe, specifically looking at the heel counter fit and depth of heel drop. 

Reinforcing that heel lifts are best applied bilaterally, she also points out that one must also consider specific patient circumstances contributing to their use.  

“(For a patient) who does not/will not have ankle joint flexibility, (a heel lift) will probably work great, but for the patient who really needs to stretch and strengthen the posterior leg/calf it could put that improvement in jeopardy,” she says. “If a patient has a structural leg length difference due to injury or joint replacement, I will add the appropriate lift and carry it out to the end of the shell, as I want to lift the whole leg, not just lift the heel, which potentially puts the tendon in a permanently shortened position. 

She adds that, like some of the other panelists also mentioned, she will sometimes slowly wean a patient from using separate external heel lifts as symptoms resolve and as they continue to stretch and strengthen. 

Q: What other orthotic modifications do you use for different types of heel pathologies?

A: For the heel, there are a lot of factors to consider, including location of pain and how “hard” someone is on their heel strike, shares Dr. Reid, practicing at Family Podiatry Center in Naperville IL. Controlling hyperpronation with one’s custom orthotics of choice will help control forces on the pathology; but sometimes padding and additional posting requires a trial and error approach, she adds. 

“I find that evaluating both extrinsic and intrinsic posts are important for someone with Haglund’s deformity, specifically, because often just positioning the posterior heel differently in the shoe is extremely helpful,” she says.  

Also touching on Haglund’s deformity and retrocalcaneal bursitis, Dr. Richards, practicing in Chapin, SC with Lexington Podiatry and Orthopedics, usually recommends a heel lift with a cut out to decrease pressure on the bone prominence. Another option she shares is a using softer cover at the posterior aspect of the shoe, and making sure to address underlying contributory pathology in one’s modification choices.

As she frequently treats young athletes and soccer players, Dr. Richards says the most common foot pathology she sees in this group is calcaneal apophysitis. In these cases of heel pathology, she recommends heel lifts in the shoes or cleats, or a gel or EVA heel cushion to reduce forces during running. Overpronators may benefit from an OTC control insert for running shoes and a scaphoid pad for cleats, due to challenges with orthotic fit in cleat shoe gear. In her experience a low-profile device can provide some support, stability, and cushioning without significantly altering the cleat fit. She also occasionally uses an adhesive heel lift in a cleat for calcaneal apophysitis or Achilles tendon pathology. Lastly, scaphoid pads can be useful in cleats in conjunction with a low-profile insert to increase arch support. 

“I usually recommend a wider cleat, such as Adidas or Puma, which may allow for modifications if necessary. IDA cleats are also a new cleat on the market made specifically for female athletes. These cleats are designed with increased arch support and a wider toe box,” she adds.

Dr. Schoene, retired from Gurnee Podiatry and Sports Medicine Associates, recommends considering how shoe fit will impact an orthotic such as, as previously mentioned, the heel counter shape and depth, or perhaps the medial collar of the shoe.  

“Orthotics (and their modifications) will change how the foot sits inside the shoe, so evaluation for proper fit, depth, and size is important,” she explains.   

Dr. Conenello reminds readers that there’s no one-size-fits-all or “cookbook” approach when it comes to orthotic and modification design; each patient’s heel pathology requires a customized solution based on their unique biomechanical profile. That said, he shares that he generally aims to control the forefoot, as he believes it significantly influences rearfoot mechanics. 

“I prefer orthotics that are wide enough to provide adequate control while still accommodating typical shoe gear. It’s also essential to ensure patients have realistic expectations and that their orthotics are compatible with the types of shoes they wear most often,” he explained, echoing Dr. Schoene’s assertion about the orthotic/modification/shoe interplay. 

Q: Do you have any final thoughts to share on optimizing practices in orthotic modifications for heel pathology?

A: Many of the panelists agree that managing patient expectations and educating them on the role of their orthotics and modifications is key to overall success. Some noted that biomechanics and orthotics fabrication are a career-long pursuit, and that follow-up can take time even for the most experienced. Others note that evolving shoe trends can impact the types of modifications chosen over time. Sometimes, certain panelists, such as Dr. Schoene, note that tweaking a pair of orthotics from a previous practitioner with new modifications may be effective in a second opinion scenario, allowing for ease of observation and functional evaluation before proceeding with a new device. 

“It’s important to recognize that orthotics (and their modifications) are not a panacea, nor are they necessarily a lifelong requirement,” says Dr. Conenello. “Patients should understand that they’re seeking care for a pathology that requires an intervention, and that while their gait will be modified by a pathology-specific orthotic, lasting resolution often depends on more than just the device itself.” 

He also stresses the importance of consistency and a multi-layered approach to orthtoics and their modifications. Clinical pathways, including biomechanical interventions, for heel pathology do not end at symptom resolution, the panelists agreed.

Dr. Reid adds, “I always caution my patients that the orthotics, and these modifications, may not by themselves resolve their heel pain, but they are very important in controlling the forces to keep the heel pain from returning.”

The moderator, Karen Langone, DPM, DABPM, FAAPSM, facilitated the panel’s responses before adding some of her own insights. In her case, she states that she does not personally use a stock prescription or strict set of modifications for any particular diagnosis. 

“I look at the functional characteristics of the individual and focus on their function in gait and stance and then use modifications and additions to the devices that aid in redirecting the patient into better functional alignment,” she says.

She has, however, noted some choices that she gravitates towards in these cases. Dr. Langone, who practices in Hampton Bays, NY, agrees with some of the panelists in aiming to creating a stable first metatarsal head position for propulsion. She does also use heel lifts in cases of limited ankle dorsiflexion and to address limb length inequality. In conclusion, she shared a few more strategies she finds helpful. 

“I prefer a tight arch fill except in the case of rigid cavus feet. In those cases, I will drop the arch height by 10% and use scaphoid pads on the devices, giving a flexible tight fill. If I note prolonged pronation at the rearfoot, I will use a deep heel seat and medial skive.” 

Editor’s Note: For more content overall on biomechanics and orthotics, navigate to our Podiatry Today Specialty Channel on the topic at: https://tinyurl.com/4byn396t.  

For specific related content, you may wish to browse  the April 2024 podcast Orthotics Q & A on Load Management, the March 2024 Point-Counterpoint on custom versus prefabricated orthotics for children, the December 2023 podcast episode on maximizing relationships with an orthotic lab, an August 2023 episode on orthotic approaches to summer footwear, or the April 2023 Clinician Commentary on custom foot orthotics after foot and ankle arthrodesis.