One other possible etiology that hasn’t been
mentioned for Dr. Miller’s patient with
recalcitrant plantar heel pain is atrophy of the
plantar fat pad. When Dr. Miller said that his
patient’s pain is directly beneath the heel
tubercle, are we to assume he was referring to
the medial tubercle? There are a number of
biomechanical factors to consider. Individuals
with a cavus foot can function excessively
supinated or pronated, which can cause
compression and atrophy of the medial
(excessively pronated foot) or lateral
(excessively supinated foot) plantar fat pad.
A gait analysis can reveal if the patient lacks
sufficient subtalar joint pronation and re-
supination during gait and whether the foot
remains in a supinated or pronated position
throughout the stance phase of gait. Examining
the open chain range, direction and quality of
motion of the subtalar joint in addition to a
more complete biomechanical assessment may
reveal other clues, including any asymmetry of
motion or structure.
The fact that the condition is unilateral could
suggest the presence of a limb length
discrepancy, in which case a heel lift added to
the orthotic of the shorter limb might help.
Also increasing motion in the rearfoot post may
help increase supination and pronation of the
subtalar joint during gait. Adding a 1/8 Poron
heel pad or possible a horseshoe pad in the heel
cup might also help if the problem is associated
with fat pad atrophy or inadequate subtalar
joint motion. If equinus is present, then
bilateral heel lifts might be beneficial.
And finally, since cavus feet often have
forefoot valgus, I would make sure his orthoses
have sufficient valgus support in the forefoot.
If not, try adding a valgus pad of felt or a
similar material on top of the anterior aspect
of the forefoot of his existing device to
increase their forefoot valgus support.
Mr. Jeffrey Root, jroot@root-lab.com
