Comparison of Custom and Prefabricated Orthoses in the Initial Treatment of Proximal Plantar Fasciitis.

Pfeffer G, Bacchetti P, Deland J, et al (San Francisco Orthopaedic Foot and Ankle Center; Departments of Orthopaedics and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, Calif), Foot Ankle Int. 1999;20:214-221.

Little consensus exists about the best or most cost-effective treatment program for the management of proximal plantar fasciitis. This prospective, randomized, multicenter clinical trial compared the results of nonoperative treatments for proximal plantar fasciitis using 4 different shoe inserts and a program of Achilles tendon stretching exercises.

The subjects included 236 patients from 15 different clinical sites (160 women and 76 men) who were 16 years of age or older. Most reported a duration of symptoms of 6 months or less. The subjects were randomized into 1 of 5 different treatment groups. All groups performed stretching exercises for the calf in a similar manner. One group was treated with stretching only; the other 4 groups stretched and used 1 of 4 different shoe inserts: a silicone heel pad, a felt arch/heel pad, a rubber heel cup, or a custom-molded polypropylene orthotic device. The same laboratory made the custom orthoses from negative casts of the patient's foot while the subtalar joint was in a neutral position.

The researchers used an outcome measure that was based on the subject's rating of the change in their heel pain as "all better," "much better," "slightly better," "unchanged," or "worse." Each subject's rating was then dichotomized as either "response" if they indicated all, much, or slightly better, or "nonresponse" if they indicated unchanged or worse. A numeric score for pain was based on the pain subscale of the Foot Function Index Measure, a self-reported rating of pain intensity that uses a 0-to-9 visual analog scale for various activities and functions of the foot. Patients were re-evaluated at 8 weeks.

The results were reported as the percentage of subjects with a "response" answer in each group, as follows: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4) stretching only, 72%; and (5) custom orthosis, 68%. When they combined all the subjects who used a prefabricated shoe insert, the researchers found that their response rates were higher than those treated with stretching only or those who stretched and used a custom orthosis. After analysis of pain scores taken from the Foot Function Index, all treatment groups tended to show improvements over an 8-week period. The amount of improvement, however, was comparable among groups; no group experienced a significantly greater decrease in pain than any other group.

The investigators suggested that the silicone insert was most effective in shock absorption, whereas the custom orthosis was least effective in shock absorption. They concluded that a prefabricated shoe insert is more likely than a custom polypropylene orthotic device to produce improvement in symptoms as part of initial treatment of proximal plantar fasciitis.

Damien Howell, PT, OCS
Medical College of Virginia Hospitals
Richmond, Va