Orthoses face off in heel pain treatment
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 2 - FEBRUARY 97
Inexpensive over-the-counter (OTC) orthoses are more effective in the initial treatment of heel pain than costly custom-made orthoses, according to a 2-month prospective, randomized study of 236 patients from 10 foot and ankle centers who were evaluated for proximal plantar fasciitis.
Heel pain is the most common foot problem seen in medical practice, with 2 million new cases of plantar fasciitis diagnosed each year, says Carol C. Frey, MD, associate professor of orthopedic surgery at the University of Southern California in Los Angeles, one of the study researchers. She says that 10% of all runners suffer plantar fasciitis.
All patients in the study were free of systemic disease and had received no previous treatment. They all performed simple stretches such as wall push-ups. One group did stretching only; the other four groups used either Tuli's Standard Heel Cup (Ortho Active Appliances, Ltd, Coquitlam, British Columbia), a Bauerfeind Viscoheel (Bauerfeind USA, Inc, Kennesaw, Georgia), a custom-made polypropylene medial longitudinal arch support, or a Hapad Comforthotic Insole (Hapad, Inc, Bethel Park, Pennsylvania), Frey told a science writers symposium sponsored by the American Academy of Orthopaedic Surgeons last October in New York City .
A foot function index and analog pain scale taken before and after treatment showed that significantly more patients improved with the OTC treatments—Viscoheel (95% of patients), Tuli's heel cup (88%), and Hapad insole (81%)—than with the customized orthotic device (68%) or stretching only (72%). The findings will be presented at the annual meeting of the American Academy of Orthopaedic Surgeons in February in San Francisco.
The results are "good news economically for patients," says Frey, since OTC heel pads and cups cost $10 to $40, whereas custom orthoses average $300 to $400 and can reach $1,000. "Patients may need different orthotics for sports and dress shoes, which makes them even more expensive," she adds.
Stephen Pribut, DPM, clinical assistant professor of surgery at George Washington University Medical Center in Washington, DC, agrees that conservative treatments such as stretching, changing shoes, and wearing heel pads should be used initially for plantar fasciitis, but he has reservations about the study. "OTC devices work for a short time, but once patients increase their activity, the pain may recur," Pribut says. Furthermore, he says, 2 months is too short a time for testing custom orthotics against OTC products. "Hard orthotics require a 4- to 6-week break-in period and may need adjustment to alleviate direct pressure on the medial calcaneal tuberosity," Pribut says. "If a hard orthotic fails, consider a softer, laminated leather one." He adds that a better comparison period for testing OTC and custom orthoses would be 6 to 12 months.
Jeffrey L. Tanji, MD, associate professor of family practice at the University of California at Davis School of Medicine, says simple OTC products work well as first-line therapy along with anti-inflammatory agents and a heel cord stretching program. "If those treatments fail, then the various options include a tension night splint, an orthotic, or injection," Tanji says. Tanji cowrote a recent study (1) on the use of a tension night splint in the treatment of plantar fasciitis.
Mark L. Fuerst
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