Achilles pain can apply to a number of conditions that impact upon the Achilles tendon area. Generally most surgeons refer to any condition that elicits pain in the area of the Achilles attachment as Achilles tendonitis. Specifically, the makeup of the word is, ‘tendon’ meaning tendon and – ‘itis’ – a suffix used in pathological terms that denote inflammation with its origin being from the Latin language.

Different professions have sort to be more specific in the description of the condition and thereby more closely define this area of pain to design better treatment regimes. Terms such as Achilles tendinopathy, tenopathy, tendinosis, partial rupture, paratenonitis, tenosynovitis, tendovaginitis, peritendinitis, and achillodynia have been used to describe the problems of non-insertional pain associated with this tendon1.

In this blog we will be considering the overuse and inflammatory condition that is associated with Achilles pain, with pronation and supination as main contributory elements.

The biomechanics of the condition starts at heel strike in the gait cycle. After heel strike the foot accelerates into an excessively pronated position and the calcaneus is everted, increased medial tendoachilles traction occurs and may result in transverse shearing of the tendon and sheath, eliciting inflammation and pain.

Additional stress is encountered at heel lift as inversion of the calcaneus is assisted by the gastrocnemius and soleus muscles.

Achilles (pain) Tendonitis is similar in its biomechanical action to Plantar Fasciitis in that as the foot pronates, it causes a tractional pull on the attachment and continued Subtalar Joint pronation for any length of time, will allow continuation of the tearing of the sheath. Inflammation and swelling will occur as this continues to takes place.

This action of continual stretching and bending is likened to constant bending of a piece of wire in which the wire heats up in the area of flexion and eventually dips/bends and snaps. The heat generated in the wire is similar to the inflammation that occurs in the Achilles in which inflammation is evidenced when constant stretching and strain occurs. If the patient excessively pronates constantly, the inflammation will be more prominent on the medial side and conversely, supination on the lateral side as the patient strikes with a high strike angle laterally and then proceeds to pronate through midstance, then to toe-off. Inflammation can occur on both sides due to this being the biomechanical pivot point.

The engineering graph below gives an insight into stress studies that have been conducted on building material, however, this principle has been adopted by bio mechanists as they apply it to ‘body engineering’.

Looking at the graph we have stress and strain vs time or physiological range. A to B is any material that returns to its shape over a period of time – in this case the stress and strain on the Achilles tendon is associated with abnormal foot function.

B-C is the yield point – the point at which the Achilles tendon is stretched so much that it is unable to return to its original shape. When this transpires inflammation occurs and pain is felt. At this point the patient seeks medical help, and often the symptom is treated, however the biomechanical cause may go untreated. With rest the pain may subside, repetitive stretching of the Achilles tendon will move the condition towards point D, i.e. continual flare up of the Achilles tendon may take place.

Point D is where complete rupture of the tendon may occur or a posterior calcaneal compensatory spur may develop as the body seeks to maintain the attachment.

Changes to the patients’ lifestyle e.g. job change or a new exercise routine may cause additional stress being placed on the biomechanical structure, causing aches and pains to occur in the ankle, knees, hips or even lower back pain. The additional stress on the body will most likely present as pain in an existing area of weakness, and be associated with biomechanical anomalies causing periods of pain and discomfort to occur.

Treatment

The position or point of pain can be a clear indicator of underlying factors. When pain is on the medial side of the Achilles, it is often associated with Subtalar Joint pronation – as it causes the medial aspect of the Achilles tendon attachment to elongate and tear, and will need to be treated with an anti-pronation orthotic.

When the pain is on the lateral side it may be associated with a high forefoot valgus or a high supination angle that causes the lateral attachment to elongate and possibly tear and should be treated with a forefoot valgus addition. If the rearfoot (calcaneus) is flexible a lateral posting can be applied.

Pain in the centre or both sides of the Calcaneal attachment often this is associated with supination at heel strike with ground reaction forces on the lateral side encouraging the foot to move into a pronated position at midstance to toe-off phase of gait. The lateral to medial movement may cause this to be the pivot point of traction of the Achilles tendon and will inflame or flare up the medial and lateral side of the tendon sheath and bursa. Treatment will require both treating both excessive pronation and excessive supination by using orthotic additions attached to the orthotic device to support the arch and address any forefoot valgus deformity.

When prescribing orthotics always check for any structural leg length discrepancy, especially if unilateral Achilles pain is being experienced as the longer leg can, as compensation, excessively pronate to level the pelvis.

Repetitive stress and strain on the Achilles over a period of time may cause a posterior calcaneal spur to develop as compensation. Surgical intervention to remove a Posterior Calcaneal Spur can be accomplished without detachment of the Achilles tendon. Successful surgical intervention on a posterior calcaleal spur is more successful than surgery on an Inferior Calcaneal Spur (heel spur).

Additional Treatment Option

• Foot Mobilisations: especially to check if the calcaneus is displaced posteriorly, as this will exert additional traction pressure on the Achilles.

Short term use of a heel lift on both feet (in addition to an orthotic device) to shorten the gastrocnemius muscle and relieve pressure on the Achilles attachment. Do not allow the patient to continue wearing the heel lift for more than 2-3 to reduce Gastrocnemius shortening inflammation should subside in this period of time..

• Acupuncture (or dry needling): at the point of pain can be attempted to reduce to the swelling and inflammation.

• Non steroidal Anti-inflammatory Medication: only in the early stages of the condition.

• Cortisone: is initially effective, however it weakens the ligament structure and it is advised to limit use to one or two occasions. A more conservative approach will be far more beneficial to the patient.

Corticosteroid injections into the region of pain is a common treatment for plantar fasciitis and often Achilles pain. However, such injections have been associated with serious side effects2. Acevedo and Beskin3 reported that in a group of 765 patients with a clinical diagnosis of Plantar Fasciitis, 51 were diagnosed as having a plantar fascia rupture. Of these 51 ruptures, 44 (86%) were associated with corticosteroid injection4. Therefore reliance upon this form of treatment is discouraged for Achilles pain also and a more conservative approach adopted.

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References

1 Khan KM, Maffulli N. Tendinopathy: An Achilles’ Heel for Athletes and Clinicians. Clin J Sport Med.1998 Jul;8(3):151-42.
2. LEMONT Harvey, DPM. Plantar Fasciitis A Degenerative Process (Fasciosis) Without Inflammation
3.AMMIRATI Krista M. BS, USEN Nsima, MPH May/June 2003, Vol 93, No 3 Journal of the American Podiatric Medical Association
4. ACEVEDO JI, BESKIN JL. Complications of Plantar Fascia Rupture Associated with Corticosteroid Injection. Foot Ankle Int. 1998 Feb;19(2):91-7.

General REFERENCES: BRUNKER, P., & KHAN, K. (1993) Clinical Sports Medicine, Sydney: McGraw-Hill Book Company

The question is of course: What is regarded as success?

When dealing with Orthotic therapy we are not attempting to heal and often we are not attempting to eradicate the biomechanical issue. Rather we are working within the parameters of a mechanical device to provide the patient with short, mid and long term relief to the pain and discomfort that they are suffering. We also may offer a method to stop an issue progressing to the next level.

Orthotic therapy is NOT a ‘cure all’ for every disease, however, when used in combination with other treatment modalities, can provide improved gait, reduce pain, assist in providing an enhanced quality of life to patients.

There is a wealth of information attesting to the benefits of orthotic therapy for a wide range of biomechanical conditions, such as:
• Hallux Abducto Valgus (bunions): commonly caused by a short 1st metatarsal shaft and aggravated by excessive pronation.

• Ball of Foot Pain: collapsing and rotating of the metatarsals caused by pronation.

• Plantar Fasciitis & Heel Spur: excess pronation causes the fascia to elongate and tear at the attachment to the calcaneus. An inferior calcaneal spur is a secondary compensation, in which an osseous growth develops at the attachment to secure the fascia.

• Achilles Pain: repetitive over-stretching of the medial and lateral attachments of the Achilles tendon caused by both pronation and or supination, create a point of pain or stress point.

• Severs Disease (children’s heel pain): related to pronation and growth spurts in children and affects active sporting children more than sedentary ones

• Shin Splints (lateral, medial or an-terior): pronation and supination can be key contributing factors.

• Knee Pain: and collateral ligament strain due to pronatory and supinatory factors and or forefoot anomalies.

• Osgood Schlatters Syndrome (children’s knee pain): occurs due to a combination of tibial torsion, growth spurts and pronation factors.

Hip Pain: due to structural or functional leg length difference and supination/pronation factors including tight external hip rotators and structural long leg compression into the acetabulum.

Low Back Pain: unilateral and bi-lateral pronation and structural and functional leg length difference causing stress on the lower back L1-L5.

Leg Length Syndrome: when a structural leg length difference is evident the long leg may excessively pronate to level the pelvis.

A report by The American College of Foot & Ankle Orthopaedics & Medicine titled ‘Prescription Custom Foot Orthoses – Practice Guidelines’,1

Gives a wider and more comprehensive array of conditions when in their opinion are able to benefit from the application of prescription orthotic products. The ICB heat mouldable range of orthotics are a simple, cost effective efficient way to treat your patients with customised prescription orthotics and do it right in your own private clinic.

The quoted report lists

1. Proximal Lower Extremity Pathology: A. Shin Splints, B. Tendonitis (Tenosynovitis), C. Posterior Tibial Dysfunction, D. Chondromalacia Patella (Runner’s Knee, Patellofemoral Syndrome), E. Iliotibial Band Syndrome, F. Limb Length Discrepancy

2. Arthritides: A. Inflammatory Arthritis, B. Rheuma-toid Arthritis, Psoriatic, C. Arthritis, Other Inflammatory Arthritides, D. Osteoarthritis.

3. Mechanically Induced Pain and Deformities: A. Pes Cavus, Haglund’s Deformity , B. Hammer Digit Syndrome, C. Functional Hallux Limitus, Hallux Limitus and Hallux Rigidus, D. Plantar Fasciitis, E. Equinus, F. Sinus Tarsi Syndrome, G. Tailor’s Bunion (Bunionette), H. Hallux Abducto-Valgus (Hallux Valgus, Bunion), I. Pes Planus, J. Metatarsalgia, K. Sesamoiditis, L. Morton’s Neuroma (Intermetatarsal Neuroma).

4. Paediatric Conditions: A. Calcaneal Apophysitis, B. Genu Varum and Genu Valgum, C. Tarsal Coalition, D. Metatarsus Adductus.

The issue of success is really not in question, rather when where and how to use orthotics to benefit the patient is!

There are then 3 main questions regarding orthotic therapy to ask when treating patients and these are :

1. Does the patient present with a condition that has been reported to be successfully treated with orthotics?

2. Does the patient present with asymptomatic lower limb biomechanical anomalies or faulty foot mechanics? The patient can also be presented with orthotics as a preventative or prophylactic treatment.

3. Will the support and stabilisation offered by orthotic therapy enhance the overall treatment outcome? This is a personal, clinical determination to be made by the practitioner.

A consideration is:
The cost of prefabricated heat mouldable foot orthoses is relatively low, and the adverse effects of using foot orthoses are minor. (see below 2,3).

There are 3 key starter steps in orthotic therapy:

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References:

1. The American College of Foot & Ankle Orthopedics & Medicine. Prescription Custom Foot Orthoses – Practice Guidelines, December, 2006

2. COLLINS N, BISSET L, MCPOIL T, VICENZINO B. Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-analysis. Foot Ankle Int. 2007;28(3):396-412.

3. RICHTER, Randy R. PhD, PT; AUSTIN, Tricia M. , PhD, PT, ATC; REINKING Mark F. , PhD, PT, ATC, SCS. Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and MetaAnaiysis— Critical Appraisal and Commentary

Arch pain when wearing orthotics can be problematic as it often encourages patients to ‘give up’ on orthotic therapy.

The Plantar Fascia is a fibrous tissue that does not exhibit the capacity to stretch or elongate and so often the fascia presses onto the arch of the orthotic causing discomfort.

The fascia assists in maintaining the longitudinal arch shape, however, can be an issue when it presents as a short fascia or excessively protruding fascia.

Image show Plantar fascial drop occurring at the 1st MTPJ performs the windlass mechanism during toe off phase of gait.

A tight fascia can also contribute to plantar fasciitis and heel spur syndrome due to the tension on the attachment at the calcaneus.

A Plantar fascial groove can be used when the plantar fascia is very tight or the patient indicates that the arch of the orthotic is causing pressure in the arch area.

Generally the plantar fascia position on the orthotic device is located approximately 1 cm lateral to the medial boarder of the orthotic device.

The ICB orthotic can be easily modified using a heat gun to heat the area to be deflected.

The groove can be made using metal scissors or another similar item.

When making the groove ensure that the heat is applied only to the plantar fascia position on the orthotic device to reduce any unwanted distortion of the EVA material.

For a more permanent solution the groove can be placed into the orthotic device using either a bench grinder or Dremel hand grinder.

The groove is created 1 cm from the medial aspect and runs the length of the arch of the orthotic device.

If the patient is suffering significant pain we advise the following step by step procedure to pain relief.

The first step would be to place a plantar fascial groove as this will allow the fascia a plantar drop and take pressure off the fascia.

If pain persists due to the arch collapsing on the arch of the orthotic use a bilateral Rearfoot Inversion addition which will reduce elongation of the fascia by inverting the rearfoot .

If further adjustment is required a 1st Ray cut away or 1st MPTJ deflection will be required to reduce tension on the fascia.

Both 2/3 and Full Length deflections work effectively in reducing the tension on the fascia.

Orthotic therapy is one in which some minor adjustment may be needed when treating patients.

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Orthotic therapy often is a therapy which involves some adjustment to the prescription of the treatment device. The therapy, rather than being a ‘one size fits all’ approach is one which requires working with the patient to get the desired result.

By that we mean that different conditions will require different treatment approaches and different orthotic prescriptions to meet patient expectations and to provide required results.

Orthotic devices are mechanical devices and often an alternative approach is required due to shoe styles and other issues which impede the treatment process.

One such issue is problematic movement of additions and in this instance the metatarsal dome placement on the orthotic device.

Issues that are most prevalent are:

1) Placement on the orthotic

2) Positioning of the dome in relationship to the patients foot.

3) Soft and firm domes which to use?

4) Movement of the dome.

Usually ‘met’ domes are adhered to the dorsal surface of the orthotic.

We advise that the distal edge of the dome should approximately 5mm forward to the distal edge of the orthotic device.

The positioning will lift the metatarsal shafts and not impinge on the metatarsal joints during toe off phase.

When using a Full length device practitioners will need to establish where the orthotic ‘distal’ edge sits on the orthotic device .

In this case just fold back the forefoot of the Full length to reveal the position of the bisection of the 1st MTPJ.

Soft as opposed to Firm domes can be a matter of preference, however, if correctly positioned the patient will not find the firm domes uncomfortable to wear.

Positioning should be an outcome of the type of issues the patient present with, such as, pain or discomfort between 3rd & 4th or 2nd and 3rd met heads. Often a temporary placement is beneficial as the position can be adjusted until the patient feels that they are happy with the position. If the 3M tape is not sufficient to hold the dome in position then a more permanent fixing can be achieved with glue such as a spray glue.

Often patients complain that the metatarsal dome addition has a tendency to peel off the dorsal surface due to getting caught on their socks as they place their foot into the shoe.

The remedy for this issue is to create an ‘intrinsic’ metatarsal dome, that is, create the metatarsal dome in the actual orthotic device– Intrinsic—built in or become part of the device. 

Completing the intrinsic dome modification will remove the likelihood of the addition peeling off or getting caught on the patients sock.

ICB orthotics are 100% EVA material which moulds well under heat and is highly adaptable.  To effect this adjustment practitioners will need to establish the position on the patients foot where the metatarsal dome is to be positioned.

Place the correct size Dome—Small for small foot Large for Large foot on the Plantar surface of the orthotic and draw the shape of the dome.

Remove the Dome and using a Heat gun apply heat to area that you wish to deflect.

Next place the FIRM dome on a hard flat surface and position the orthotic on top in the correct position for moulding.

Once you are able to see the shape of the dome you can apply 3M tape to the dorsal surface of the dome in readiness to apply to the plantar surface of the orthotic.

At this point a decision can be made as to whether you wish to use the firm dome OR another material such as felt or poron to infill and maintain the shape of the in-built dome.

The shape can be cut and glued into the cavity and then ground flat on the base for the best fit.

Often practitioners ask if there is really any reason that they should bother heating and moulding the ICB orthotic product.

Whilst the product can be used directly out of the presentation pack and placed into the shoe, heat moulding provides an added dimension in maximising patient compliance.

Generally we recommend that upon observation if the rearfoot position is lower than +3° or greater than +6° heat moulding will definitely benefit the patient. The ICB product exhibits a 5° rearfoot varus Intrinsic angle to assist in realignment of the calcaneus.

When treating rearfoot greater than 5° – 6° will be beneficial and for more pes planus foot types reducing the average 42° arch height will provide more comfort for the patient.

When a deflection is required to deflect around a callus etc. practitioners can use a spoon to make a deflection directly in the product.

Often practitioners have to deal with highly unusual foot issues and the use of an adaptable heat mouldable product can be extremely helpful. Product should be chosen with the mindset that they have the capability to be modified and when the situation arises they then have the tools to perform that particular function for the patient.

The moulding above may seem extreme , however this product was actually customised for a patient in Asia.

The patient suffered an injury and the foot was set in a particular position which created a functional right long leg.

The patient refused further surgery and requested conservative treatment. This extreme moulding was combined with shoe wear that had a large heel height such as a boot to provide the desired result for the patient.

Practitioners are encouraged to experiment and use alternate methods of moulding to the patients foot shape. One such method is pictured, the foot and orthotic is wrapped in a bandage in the ideal or STJN position due to the patients inability to weight bear.

Difficulty can be experience when treating children and so alternate moulding methods should be experimented with in an endeavour to be able to treat the entire patient base.

Issues with treating children and heat moulding can be overcome by using a non weight bearing moulding method as seen below.

This non weight bearing method can be very effective. The use of the Anterior Alignment Method for ideal or STJN is recommended to establish positioning.

The ICB normal method of moulding is in weight bearing position, however, alternate methods can be used to treat patients whilst maintaining the patients ideal position.

Generally product that does NOT have a material cover can be heated on the dorsal and plantar surface, whereas with covered product such as, seen below , should only be heated on the plantar surface to avoid burning the material cover.

A recent development in the ICB product is the reduction in the heat time that is required to attain the optimum level of elasticity in the EVA material.

Close observation to the heating process is necessary to produce a well moulded product. Re-moulding is possible with the ICB Heat mouldable product, albeit with some loss of density integrity in which 5-7% softening of the molecular structure will be experienced on the re-heating of the product.

To start maintain the heat gun at a distance of approx. 10-15cm. The heating process commences by using 3 circular motions on the plantar surface located in the medial arch area concentrating on the words RIGHT & LEFT and then a further circular motion on the plantar heel area.

Continue until the words RIGHT and LEFT tart to Melt indicating that the thermal heat level has been attained.

Request that the patient inserts the UN HEATED product in their shoe as this will provide foundational stability and avoid causing a functional leg length.

Next remove any factory fitted shoe innersole and place the heated product in the shoe.

Place the foot to be moulded in the ideal or neutral position using the Anterior Alignment method and Talo Navicular method.

Maintain for 30-40 seconds. Then remove the product and allow to cool down approx. 1-2 minutes and commence the procedure again for the alternate foot.

Often the orthotic device requires some adjustment to suit the patient and assist in alleviating the pain that they may be suffering.

One such deflection is a plantarflexed 1st or 1st Ray (metatarsal) cut away deflection.

A plantarflexed 1st metatarsal phalangeal joint (MTPJ) sits plantarflexed to the lesser metatarsals and can be a fixed osseous or mobile condition which can result in the patient suffering from Sesamoiditis (inflammation or bifurcation of the sesamoid apparatus). A supinated foot position and forefoot Valgus can often accompany this condition.

Sesamoiditis – impingement of the Sesamoid apparatusTo assess for a plantarflexed 1st place the foot in the neutral and take hold of the lesser metatarsals (2nd to 5th). Using the thumb and pointer finger to grip the 1st MTPJ and lesser metatarsals – the amount of dorsiflexion and plantarflexion should be 5mm up and 5mm down from the axis of the lesser metatarsals.

Plantarflexed 1st assessment

The image (above) indicates a mobile plantarflexed 1st, having limited dorsiflexion with significant plantarflexion.

If the joint will not move then it is a fixed Plantarflexed 1st, meaning that there is no dorsiflexion or it is minimal, and that it sits in a fixed plantarflexed position.

Treatment for a Fixed Plantarflexed 1st will be a ‘1st ray cut away’ deflection created in the orthotic which will provide 1st metatarsal relief and support to the lesser metatarsals.

Plantarflexted 1st deflection

Creating a 2/3 or ¾ length cut away

Step 1
Place the device on the base of the foot and draw an arc around the 1st metatarsal Phalengeal joint sits.

Step 2
Ensure that the 1st MTPJ is free to plantarflex and grind or linish the orthotic so that the contour is comfortable for the patient by using a hand grinder or bench grinder.

Some time the amount of support provided by the orthotic under the lesser metatarsals is insufficient and the patient will continue to feel pain under the 1st MTPJ. In this case more support may need to be affixed to the transverse arch of the orthotic to support the lesser metatarsals.

To increase support in the transverse arch, measure the difference between the axis of the lesser metatarsals and the 1st MTPJ, then add a forefoot addition wedge to the orthotic to support the lesser metatarsals. The forefoot addition should be positioned with the thickest side to-wards the distal edge of the orthotic.

To assess the amount of additional support required when the 1st MTPJ is mobile, if for example the measurement is 8mm in plantarflexion and 2mm dorsiflexion to the lesser metatarsals, subtract the 2mm from the 8mm, thus providing the required amount of support – in this case 6mm or 6°.

This type of orthotic adjustment is called a ‘2-5 Metatarsal Bar’, which can effectively decrease pressure on the metatarsal heads by supporting the metatarsal shafts.

When modifying a Full Length orthotic product to create a 1st ray trench follow the steps below:

Step 1
Mark out the width of the trench by placing the foot of the orthotic and scribing a line between the Hallux and the 2nd Phalange.

Step 2
Mark the line on an angle to allow the posterior position of the 1st MTPJ to be unimpeded by the orthotic arch.

Step 3
Place the device on a firm surface when grinding with a Dremel Hand grinder and remove the eva material leaving 1mm on the plantar surface and remove excess material behind the 1st MTP Joint.

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