My Foot Still Hurts After Months, What Gives??

Plantar Fasciitis causes really painful feet, especially in the bottom of the foot near the heel. I agree that it can be difficult to treat, and so I am going to share my "secrets".

First of all, lets establish that you actually have plantar fasciitis:
- You experience persistent pain under the foot that is worse in the morning, worse with every step.
- If you press near the heel under the foot, it HURTS
- You do better with heavy boots, or at least with stiff soled shoes
- You have had only marginal relief with NSAID's

OK, so this is how I treat this injury:
1. Ice massage every day.
2. Night Splint every night
3. Small steps in the morning
4. Low Dye tape protection
5. Ultrasound in physical therapy
6 Discontinue activity temporarily
7. After the injury calms down (about three weeks) then start stretching and strengthening
8. Custom orthotic therapy
9. Gradual return to loaded activities.


This is an example of a Plantar Fascia night splint. Some are more elaborate than others, but this one is a good one.

Lets say you try the above and it STILL does not seem better, then I have my ace in the hole....Crutches. Yep, you have to go non-weight bearing for 6 weeks, and also do all the items above as well. Honestly, I have helped hundreds of people recover from persistent Plantar Fascia inflammation using this strategy.

What is a Forefoot Varus?

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- "Supinated" and "pronated" are POSITIONS
- "Supination" and "Pronation" are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.




So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).




When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.

Who Needs Orthotics

Biomechanics is one of my favorite subjects. First of all, I believe that structure governs function. Lets face it, we are not perfectly constructed and so it stands to reason that a little help here and there might be really very helpful overall.

Orthotics, or as I prefer to say, Custom Orthotic Therapy, is appropriate when the biomechanics are such that the knee is thrown into too much valgus or varus.



Custom orthotic therapy modifies a shoe's internal structure so that the foot, ankle and leg are better aligned for efficient movement and force dispersion. Orthotics are custom made because each patient has different biomechanical problems in his or her feet. When orthotics are installed the biomechanics of the lower extremities are altered so that impact loading and movement become more efficient. Athletes can improve their quickness and balance and reduce risk of injury because orthotics improve the energy absorption characteristics of the lower quarter during impact loading activities.



There is a significant difference between off the shelf devices and custom built devices. Custom orthotics therapy is not simply “putting an arch support in the shoe.” Orthotic therapy is a biomechanical solution to a biomechanical problem. We find that in conjunction with good physical therapy rehabilitation strategies, especially hip muscle training, custom orthotics therapy is often the key intervention that helps a person recover fully.

Biomechanics: The Physics of Movement

We live in an environment that forces our bodies to react to gravitational forces. With every step we take, our skeleton's alignment and structure influence the process of absorbing and releasing the energy that motion and gravity create. The feet have two functions in life. The first is be a mobile adapter. And to do this job, our feet are highly adaptable. As they hit the ground and begin to absorb load, the motion they undergo is called pronation. The structure and alignment as well as the flexibility of our joints determine just how much energy the lower extremity chain (foot-ankle-knee-hip-pelvis-lower back) can absorb. Should the foot be restricted, the energy is absorbed higher up the chain. For different reasons, both flat and high-arched feet channel a large amount of energy to skeletal structures high in this chain—especially the knee and the hip—making those structures more susceptible to injury.

For example, it is common for the kneecap (patella) to develop pain because a flat foot forces the patello-femoral joint to absorb more energy. Running sports add "impact loading" to the equation. Running and jumping amplify the effects of failed biomechanics. Sprains and strains are likely to occur when joints are poorly aligned or when they absorb forces that should be directed to another part of the body.

A Real life example: As a down hill skier, our 30 year old male patient discovered that he had a very difficult time trying to make long carving turns. Instead his turns were short and sharp. Our patient presented with a high arch foot that had several other technical structural deficits. The biomechanical consequence of his foot mechanics was that he was unable to easily use his forefoot to control the inside edge of the ski. Instead, he had to roll his knee in to get his inside edge down. He presented in the clinic with knee pain. Manufacturing custom orthotics for his ski boots and exercise shoes that corrected the biomechanical deficit enabled him to use his forefoot to control his inside edge. The result: Long C-shaped curves and more controlled skiing, no more knee pain. Custom orthotics were the solution for his mechanical deficits.

Who benefits from Custom Orthotic Therapy?

While the medical literature does not support the idea that we all need orthotics, in our experience, anyone who is active on their feet can benefit from custom orthotic therapy. Those who stand, walk or run frequently—whether in sports,
at work or at home—will see improved performance and comfort with the aid of custom orthotic therapy. At the Sports Reaction Center, we make custom built orthotics for all types of athletic footwear, dress shoes and working shoes. If you suffer from foot, ankle, knee, hip or back pain, custom orthotics therapy could be the biomechanical solution for you. We make the devices as follows: First we evaluate the mechanical alignment of your foot. Next we cast the foot, placing the foot in a sub-talar neutral position. This position of the foot lets the pod-orthotist construct a cast of your foot in a known position. The cast is sent to a lab we use (Biomechanical Services, in Brea, California). Together with the pod-orthotist, we construct a cast with corrections that will adjust your biomechanics to optimize your function. And from that cast, the orthotics are manufactured. It takes about 3 weeks to get the finished products back, and then there is a break in period to consider as well.