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Case Presentation Posterior Heel pain

Literature review

Literature review was conducted using PICO method on Ovid and Cochrane database. Approx. 500 articultes were found, the majority were excluded as they were not relevant to orthotic treatment. The remaining articules after applying exclusion criteria were then reviewed. Articles were also sourced using the directory of evidence based orthotic practice (DEBOP)

Evidence for treatment options as limited. Several articles advicated the use of insoles alongside other treatment options but did not discuss type of insole prescribed. Peterson et al 2007 noted inconsistent resultes in Achilles tendinopathy treatment due to multifactor origins.

Thomas et al 2919 and Saglimbenti et al 2014 both suggested heel raises to be an effective initial treatment of Achilles tendon injuries/pain, however should be used in conjunction with other therapies.

Attard et al 2012 showed night splints to be effective in reducing posterior heel pain and further demonstrated that anterior night splints were more effective than posterior night splints. Thi study however, was based upon plantarfascitis patients and not posterior heel pain. 

Hutchins et al 2009 suggested that if 1st MTPJ dysfunction was present alongside other pathologies this should be treated to limit the need for sagittal plane motino, which cna lead to altered gait kinetic and kinematics in more proximal jionts. Sobhani et al 2013 showed rocker soles to be effective in reducing the internal planterflexion moment in healthy subjects. Reduction of the internal planterflexion moment is linked to offloading of the achilles tendon. It was suggested this may be important in treatment of achilles tendinopathy. However, did state that further investigation was required of patients wiht active achilles tendinopathy. 

Patient History, Examination, Treatment Goals

23 year old male football coach presented with a 4 year history of bilateral heel pain worse on the right. These symptoms exacerbated anytime he increased his activity levels. Previous history included a tendoachilles rupture, treated conservatively with a walker boot however he did not wear this for the recommended time. Previous interventions which were unsuccessful were Physiotherapy, ultrasound and use of a night splint.
Examination found pain on palpation at the base of the Achilles tendon bilaterally and posterior mid heel right worse than the left. Restricted range of motion at the talocrural joint was found best at 90 degrees with no increased range with knee flexion. Bilateral Motions toes were found and clinical signs of functional hallux limitus, supination resistance was high in both feet Gait examination confirmed early heel rise with increased mit:Moot pronation during late stance resulting in reduced propulsion. The patient exhibited two of three sagittal plane biomechanical blockages ankle: limitation of ankle motion and a loss of motion at the metatarsophalangeal joints. This mechanically results in early heel rise and the ground reaction force(GRF) moving anterior for a prolonged period during the stance phase, this increasing the load at the attachment of the achilles tendon. The Motions toe also contributes to an increase load of the achilles tendon as the GRF moves anterior during toe off and increased loading of the achilles tendon is required to stabilse the foot to allow for propulsion.
Treatment goals were discussed and agreed 1) pain reduction 2) increased activity levels and 3) return to use of football boots instead of trainers
Illustrated below and on examination patient had a medially deviated subtalar joint (ST.)) axis. The ST..1 axis on the right is more medially deviated than the left foot. The right foot with a more medially deviated ST./ axis shows more convexity to its medial border due to the talar head and neck being medially placed in relative position to the calcaneus. When relaxed calcaneal stance position (RCSP) is viewed posteriorly the right foot shows more convexity to the area of the foot directly inferior to the medial malleolus, also an indication of the increased medial position of the talar head and neck relative to the calcaneus and the rest of the foot.

Treatment and Outcome

Custom foot orthoses were prescribed for the patient which included a 3mm polypropylene shell, a 5 degree medial rearfoot post, a medial heel skive of 6 mm in addition to a reverse mortons extension and heel raise.
Initial gait examination of the patient with the custom made orthoses in his shoes show he now displayed late midstance supination and improved propulsion. Night splints were supplied on the day of initial consultation.
The patient tolerated the custom orthoses well and by his three week follow up consultation his pain had significant reduction from 7 to a 3 on the visual analogue scale ( VAS). He reported he was able to increase activity levels. Orthoses can have influence on the significant pathological biomechanical effects of abnormal STJ axis locations and by understanding the biomechanics of the foot positive treatment outcomes can be achieved.


This poster was produced by Peter Castle, Claire Devitt and Lora McCandliss and was presented at BAPO