Orthoses in the Treatment of

Rearfoot Problems
ELLEN SOBEL, DPM, PhD*
STEVEN J. LEVITZ, DPM†
MARK A. CASELLI, DPM‡

Orthotic management is helpful in the treatment of most orthopedic con-

ditions involving the rearfoot, including plantar fasciitis, Achilles tendon
disorders, posterior tibial tendon dysfunction, flatfoot, ankle sprains,
and problems associated with diabetes, arthritis, and equinus disorders.
A review of the effectiveness of orthoses in the treatment of these con-
ditions is presented here. An in-depth analysis of the orthotic manage-
ment of plantar fasciitis and a critical review of foot orthoses for the
pronated foot are presented. Also discussed are the rationale and ef-
fectiveness of the tension night splint in the treatment of plantar fasci-
itis, orthotic devices for the different stages of posterior tibial tendon
dysfunction, and the various categories of orthoses for off-loading the
diabetic foot. The modern ankle brace, the effectiveness of prefabri-
cated versus prescription foot orthoses, and recent developments in the
ankle-foot orthosis are also reviewed. (J Am Podiatr Med Assoc 89(5):
220-233, 1999)

The rearfoot-ankle complex is subject to numerous
orthopedic disorders ranging from such extremely
common entities as plantar fasciitis and posterior tib-
ial tendon dysfunction to such severe orthopedic
problems as Charcot’s arthropathy, rheumatoid
arthritis, neuromuscular disease, and amputations.
Orthotic therapy has been extensively employed in
the treatment of all of these conditions.
Plantar Fasciitis
Plantar fasciitis, the most common cause of plantar
heel pain, is an overuse injury characterized by heel
pain that is especially severe when the patient first
arises from bed.1-9 Management involves treating the
inflammation, removing the aggravating factors, and
rehabilitating the patient to allow a return to normal
activities.10 A variety of orthotic devices are used to
*Associate Professor and Acting Chairman, Division of
Orthopedic Sciences, New York College of Podiatric Medi-
cine, 53 E 124th St, New York, NY 10035.
†Professor of Podiatric Orthopedics, New York College of
Podiatric Medicine, New York; private practice, Ridgewood,
NY.
‡Professor of Podiatric Orthopedics, New York College of
Podiatric Medicine, New York; private practice, Ramsey, NJ.
manage this condition. Some of the most common
ones are presented here.
Heel Pads, Cushions, and Insoles
Soft heel cups both cushion and contain the plantar
calcaneal fat pad.5 In patients with heel pain caused
by fat-pad atrophy, hard-plastic heel cups (M-F Heel
Protectors, M-F Athletic Co, Cranston, Rhode Island)
position the heel pad underneath the calcaneus,
which restores the natural cushioning and compress-
ibility of the heel.11, 12 The Viscoheel SofSpot (Bauer-
feind USA, Inc, Kennesaw, Georgia) is a silicone heel
cushion that has a built-in area of softer durometer
that is designed to disperse weight around the plantar
medial tubercle of the calcaneus, the site of inflam-
mation in plantar fasciitis. Viscoelastic heel pads have
been reported to reduce the impact of heel strike on
the leg and low back by as much as 50%.13-17 In one
study, all patients who wore viscoelastic heel inserts
for treatment of plantar and posterior heel pain im-
proved rapidly.18 In another report, reduction or ab-
sence of heel pain was experienced in 73% of 30 pa-
tients who wore the Viscoheel SofSpot for 1 month.19
Although the sorbothane material used in visco-
elastic heel pads is widely used and considered to be

220 Journal of the American Podiatric Medical Association

an excellent shock absorber, shoe inserts made of
sponge rubber were found to be more shock-absorbent
than sorbothane inserts in a carefully controlled study
testing the shock absorption of shoe-insert materi-
als.20 Patients with sports-induced Achilles tendinitis
that was treated with sponge-rubber heel pads and
physical therapy were also observed to have more
improvement in gait than those treated with visco-
elastic-polymer sorbothane heel pads and physical
therapy.21 Poron (Rogers Corp, East Woodstock, Con-
necticut) insoles have been found to be effective in
the treatment of heel pain, although there was no sig-
nificant difference in relief of heel pain when mag-
netic foil was added to the Poron insole.22
Custom-Made and Prefabricated Foot Orthoses
Ligament-cutting experiments in cadavers have shown
that the plantar fascia is the primary ligamentous re-
straint to arch collapse,23 and sectioning the plantar
fascia causes arch sag in individuals operated on for in-
tractable plantar fasciitis.24 The plantar fascia is in ten-
sion when the foot is loaded in weightbearing. During
weightbearing, the body weight is distributed between
the two feet and converted into tensile force in the
plantar fascia.25 A decrease in strain should occur with
an adequate foot orthosis.26 In a study of arch stability,
foot orthoses improved stability in 14 loaded cadaveric
specimens as compared with loading in cadavers in the
barefoot state.27 Kogler and associates26 found that the
University of California Biomechanics Laboratory
(UCBL) orthosis, a custom-made soft full-foot orthosis
casted in a semiweightbearing position, and a custom-
made semirigid full-foot orthosis casted in a semi-
weightbearing position significantly decreased the
strain in the plantar aponeurosis compared with the
barefoot control and were considered effective arch
supports. In contrast, the Root functional foot orthosis,
a prefabricated foot orthosis, and a shoe alone did not
significantly decrease strain in the plantar aponeurosis
as compared with the same barefoot control.
The functional foot orthosis has been recommend-
ed as a treatment modality in cases of severe plantar
fasciitis.28, 29 The most common indication for pre-
scription foot orthoses in symptomatic runners was
excessive pronation and plantar fasciitis.30 A foot or-
thosis should support the arch, relieve pressure in
the tender area, and provide cushioning.31 Biome-
chanically, the foot orthosis should maintain the sub-
talar joint in its neutral position and the midtarsal
joint in the stable pronated position,32 which will theo-
retically improve abnormal lower-extremity function.33
Foot orthoses for the management of plantar fasci-
itis in athletes are evaluated in terms of their ability to
Volume 89 • Number 5 • May 1999
reduce heel and arch pain, reduce pronation, and re-
turn athletes to normal sports activities. In the treat-
ment of 43 painful heels using customized rigid-plas-
tic foot orthoses, 81% had complete relief after the
orthosis was worn for 3 months.34 Similarly, in a ret-
rospective study of 222 runners, 74% of symptomatic
runners with plantar fasciitis obtained great or com-
plete relief with orthotic shoe inserts, while 8% had
slight or no improvement and 6% said the orthoses
made their condition worse; the remaining 12% devel-
oped a new foot problem.30 Patients with plantar
fasciitis who were treated with a functional foot or-
thosis using either a Root neutral negative-impression
casting technique or a Blake 25° inverted casting
technique reported an 80% reduction in pain.33
Orthotic devices have been shown to be effective
in returning injured athletes to full functioning. In
one study, 78% of runners who sustained running in-
juries were able to return to their previous running
programs with the use of foot orthotic devices.35 The
orthoses used in this study resulted in a significant
reduction in maximum pronation compared with a
barefoot control group of six runners.35 Similarly,
70% of injured recreational athletes were able to re-
turn to previous levels of activity after receiving
semirigid functional foot orthoses.36
A comparative study found that custom-made foot
orthoses reduced heel pain from plantar fasciitis sig-
nificantly better than viscoelastic heel cups or anti-
inflammatory therapy.37 In another study comparing
insert materials, there was no significant difference in
40 patients treated for heel spur syndrome with either
Rohadur (Teltscher Corp, Mt Kisco, New York) or TL-61
(Medical Material, Westlake Village, California) func-
tional foot orthoses.38 Eighty-five percent of patients
in this study had improvement of their conditions.
In several studies, subjects running with semirigid
orthoses in their shoes demonstrated significant de-
creases in maximal pronation as compared with sub-
jects running in shoes without inserts.35, 39-41 Rigid
orthoses and orthoses inverted 25° also reduced pro-
nation in runners.42 Maximal pronation during walk-
ing has also been reported to decrease in subjects
wearing shoes with orthoses when compared with
the same subjects wearing shoes alone.39, 43, 44 In con-
trast, Rodgers and Leveau45 found that pronation was
not significantly reduced in runners wearing a func-
tional polypropylene foot orthosis in the shoe. There
was no significant difference in reduction in rearfoot
pronation in patients wearing Spenco (Spenco Medi-
cal Corp, Waco, Texas) inserts versus custom-made
foot orthoses 46 or between casted foot orthoses and
low-density polyethylene thermoplastic (Vitralene,
Stanley Smith & Co, London, England) over-the-
221
counter arch supports.47 Rearfoot orthotic devices
were found to reduce vertical and anteroposterior
ground-reactive forces during ambulation.48 Howev-
er, the authors thought that the rearfoot orthoses
theoretically should have reduced medial and antero-
posterior ground-reactive forces.48
A rearfoot varus post has frequently been added
to a functional foot orthosis in order to allow normal
but not excessive subtalar joint pronation during the
contact phase of gait.49 Empirically, the effect of
adding a rearfoot post to the functional foot orthosis
is variable. In one study, a semirigid, total-contact
foot orthosis reduced forefoot vertical forces; how-
ever, adding a 6° rearfoot varus post had no effect on
the results.50 The orthosis in this study was made of
Aliplast XPE (AliMed, Inc, Dedham, Massachusetts).50
Rearfoot posts made of methyl methacrylate (rigid)
and Birko cork (Birkenstock Footprint Sandals, Inc,
Novato, California) (compressible) were found to de-
crease initial pronation velocity in runners, which is
associated with lower-extremity injuries.51 However,
there were no differences in control of pronation be-
tween the two kinds of posting materials. In another
study, both forefoot and rearfoot posts or rearfoot
posts alone controlled abnormal pronation better than
forefoot posts used in the shoes of subjects during am-
bulation.52 Finally, Tollafield and Pratt53 found that ex-
ternally posting the rearfoot more than 4° actually in-
creased pronation as the foot rotated on the device.
University of California Biomechanics
Laboratory Orthosis
The orthosis made at the University of California
Biomechanics Laboratory (UCBL) was originally de-
signed to maintain a flexible paralytic valgus foot de-
formity in the corrected position.54 However, its use
has been extensively expanded to treat flexible flat-
foot, plantar fasciitis, and calcaneal spurs.55-58 The
UCBL orthosis is casted in the semiweightbearing posi-
tion.54 The device elevates the arch by holding the foot
in a position of forefoot adduction and rearfoot inver-
sion. In one study, patients who wore a UCBL orthosis
for 3 months had 60% to 100% relief of heel pain.55 The
UCBL orthosis was found to reduce the degree and du-
ration of abnormal pronation during the stance phase
of gait in eight patients with flatfoot.59 The UCBL or-
thosis with medial posts has been successfully used
to treat posterior tibial tendon dysfunction.60
Posterior Splint
Recently, the tension posterior night splint has been
used in the treatment of recalcitrant cases of plantar
222
fasciitis (Fig. 1).61-67 During sleep, the unbraced foot
and ankle assume a plantarflexed position because
of the normal tone in the gastrocnemius and soleus
muscles. This nonfunctional, plantarflexed position
results in tightness of the posterior muscle group and
the plantar fascia and is thought to account for the
severe pain that patients with plantar fasciitis experi-
ence with their first step in the morning as the plan-
tar fascia resumes its functional weightbearing
length.61 Stress relaxation is the decrease in stress
with time once a material under loaded condition has
deformed to a constant length.68 This is due to the
viscoelastic nature of all biological tissues. Similarly,
when the plantar fascia is kept in a dorsiflexed,
stretched position by the night splint, the biomechan-
ical phenomenon of stress relaxation occurs and the
plantar fascia relaxes in the new stretched position.
The tension night splint maintains the foot in a dorsi-
flexed state while the patient is sleeping, thereby pre-
venting tightness and contracture of the Achilles ten-
don and plantar fascia that occur as a result of the
plantarflexed posture of the foot during sleep.
The tension night splint is typically used in combi-
nation with other treatments for heel pain. A study
by Batt et al 61 showed that the night splint in con-
junction with stretching, viscoelastic heel pads, and
nonsteroidal anti-inflammatory medications was
more effective in the treatment of plantar fasciitis
than the same treatments without the night splint.
This study used an office-made plaster night splint
constructed with the ankle in maximum dorsiflexion.
The authors thought that their splint produced both
ankle dorsiflexion and toe extension, which they con-
sidered critical to maintain tension in the plantar fascia.
Eleven of 14 patients (79%) with 1 year or more of
Figure 1. Tension posterior night splint (Early Fit
Night Splint, AliMed, Inc, Dedham, Massachusetts).
Journal of the American Podiatric Medical Association
heel pain had complete resolution of pain in less than
4 months with treatment using a polypropylene ankle-
foot orthosis set in 5° of dorsiflexion, stretching, Tuli
heel cups (International Comfort Products Ltd, San
Marcos, California), and nonsteroidal anti-inflammato-
ry medication.67 The 11 patients were all asymptomat-
ic at the 9-month follow-up. Of the three patients who
did not improve, excessive weight and noncompliance
were considered factors in continuation of the problem.
Mizel and associates63 treated 57 patients who had
been symptomatic for at least 10 months with a com-
bination of a molded ankle-foot orthosis and a rock-
er-bottom shoe. At an average follow-up time of 16
months, symptoms were completely resolved in 59%
of patients and improved in 18%.
In a prospective, crossover study, Powell and col-
leagues65 treated 37 patients with recalcitrant plantar
fasciitis using a dorsiflexion night splint. In this study,
the night splint was worn for 1 month and used alone,
with no supporting treatment; thus the night splint
was evaluated as a single treatment modality. This is
in contrast to previous studies, which used shoe mod-
ification,63 exercises, heel cups, and nonsteroidal anti-
inflammatory medication along with the splint.61, 67
The night splint in this study was a polypropylene
ankle-foot orthosis with the ankle placed in 5° of dor-
siflexion and wedging at the forefoot, which provided
30° of dorsiflexion at the metatarsophalangeal joints.
Eighty-eight percent of patients reported improve-
ment at the 6-month follow-up.
Short-Leg Walking Cast
Thirty-two patients with heel pain of more than 1
year’s duration were treated with a short-leg walking
cast for an average of 6 weeks (range, 1 to 12 weeks).69
At an average follow-up time of 15 months, 25% of
the patients had complete resolution of heel pain and
61% reported improvement. The authors concluded
that casting should be tried prior to surgical interven-
tion. In another study of the outcome of nonsurgical
treatment for plantar fasciitis, a short-leg walking
cast was the most effective of numerous conserva-
tive therapies including steroid injection, rest, ice,
running shoe, crepe-soled shoe, and Tuli heel cup.70
Posterior Tibial Tendon Dysfunction
The symptoms of posterior tibial tendon dysfunction
consist of pain, tenderness, and swelling in the medial
aspect of the rearfoot that are aggravated by weight-
bearing.71-76 Posterior tibial tendon dysfunction is di-
vided into four stages; orthotic treatment is described
for each of these stages.72 Orthotic treatment for pos-
Volume 89 • Number 5 • May 1999
terior tibial tendon dysfunction is based on the flexi-
bility of the foot, which becomes increasingly rigid as
the stages progress (Fig. 2). In the first and second
stages of posterior tibial tendon dysfunction, there is
flatfoot deformity with heel valgus and forefoot ab-
duction; however, the rearfoot remains flexible. For
patients with stage I and II dysfunction, a full-length,
semirigid foot orthosis in a running shoe provides
arch support and corrects the flexible deformity.71, 74
The orthosis may be constructed of leather or plastic.
Medial posts may be placed along the rearfoot. The
UCBL orthosis with a rearfoot varus post has been
recommended as a treatment modality for stage II
posterior tibial tendon dysfunction.60 The orthosis and
rearfoot varus wedge correct the flexible rearfoot val-
gus deformity and prevent the subfibular impingement
that is seen in stage II posterior tibial tendon dysfunc-
tion.60 However, this orthosis may be uncomfortable
and may not be tolerated by the patient because of the
pressure of the arch against the orthosis.77
In stages III and IV posterior tibial tendon dys-
function, there is fixed flatfoot deformity with rigid
heel valgus. Pain is more pronounced laterally at the
tip of the fibula than medially on weightbearing be-
cause of the rigid valgus angulation of the calca-
neus.76 A solid ankle-foot orthosis made of 3/16-inch
polypropylene has been recommended for treatment
of a rigid stage III deformity.74 However, the promi-
nence of the head of the talus may cause the foot to
press against the orthosis; although the orthosis may
be comfortable at first, once collapse of the arch has
occurred, patients may not be able to tolerate the or-
thosis.78 If there is significant swelling or rearfoot
Figure 2. In a case of traumatic posterior tibial tendon
rupture, treatment after surgical reattachment of the
tendon consisted of an Aircast ankle brace (Aircast,
Inc, Summit, New Jersey) and reinforcing the arch.
223
pain in stage III or IV posterior tibial tendon dysfunc-
tion, a double-upright or patellar-tendon-bearing
brace might be considered. The patellar-tendon-bear-
ing orthosis has been recommended for use in elder-
ly patients with extreme collapse of the longitudinal
arch and painful rearfoot arthrosis.74
Posterior Heel Disorders
Achilles peritendinitis is the most common injury in
runners; it is caused by repetitive irritation during
running, walking, and jumping.79-86 A firm heel lift of
approximately 1/4 to 3/8 inch or higher may be used to
shorten the distance between the origin and insertion
of the gastrocnemius-soleus complex, which relaxes
the tension in the Achilles tendon.87, 88 The primary
function of the foot orthosis is to reduce pressure on
the Achilles tendon. For patients with Achilles tendini-
tis who have excessively pronated feet, the Achilles
tendon exhibits less “whipping and bowstring action”
with the use of orthoses because the tendon remains
medial to the subtalar joint axis, which reduces the
pronatory influence of the Achilles tendon.89
Orthoses for Ankle Instability
Individuals with cavus feet are more prone to lateral
ankle inversion sprains. Theoretically, rigid forefoot
valgus forces the rearfoot into inversion when the
patient bears weight, which stresses the lateral
ankle.90 An orthosis will ease stress on the ankle by
balancing the forefoot and stabilizing the rearfoot
with 0° rearfoot posts and extrinsic forefoot valgus
posts.91 Individuals with cavus feet and frequent
ankle sprains may also be prescribed orthoses with
full-foot valgus posts. Custom-made orthotic devices
have been shown to restrict undesirable motion at
the foot and ankle and enhance joint mechanorecep-
tors to detect perturbations and provide structural
support in patients with injured ankles.92
The shoe for a patient with ankle instability might
have an outflared lateral heel—that is, the heel should
be broadened laterally to provide an “outrigger” ef-
fect, making it more difficult to turn over on the
ankle. Lateral buttressing and a valgus wedge may
also have this effect. High-top shoes provide maxi-
mum ankle stability.
Ankle braces prevent active and passive inversion
at the ankle,93, 94 improve proprioceptive capability,
and have been shown to be more effective than tap-
ing (Fig. 3).95 Athletes also report that an Aircast
brace is more comfortable than adhesive ankle tap-
ing.96 More importantly, ankle braces have not been
shown to inhibit athletic performance.96, 97
224
Figure 3. Laced canvas ankle brace (Swede-O Ankle
Lok, Swede-O, North Branch, Minnesota).
Ankle braces are effective in the treatment of later-
al ankle instability and ankle fractures. Traditionally,
the treatment for nondisplaced lateral ankle fractures
was a below-the-knee walking cast that was worn for
5 to 6 weeks after the trauma.98 In one study, 66 adult
patients with supination external-rotation ankle frac-
tures were successfully treated with either an Aircast
ankle brace or a DonJoy R.O.M.-Walker brace (Don-
Joy Co, Vista, California) for 5 weeks, with an average
time until return to work of 6 weeks.98 At 4 weeks,
70% to 80% of patients were able to walk without
pain. In a study of 20 patients with acute inversion
ankle sprains, 10 patients were treated with an ortho-
pedic ankle brace after a 10-day plaster cast immobi-
lization and a control group of 10 patients was treated
with a weightbearing short-leg plaster cast for 25
days. An earlier and more functional recovery oc-
curred in the ankle-brace group.99 Similarly, patients
treated with an Aircast ankle brace were more mobile
and used less sick-leave time than patients who were
treated with a compression bandage.100
Ankle-Foot Orthoses for Rearfoot
Equinus
Ankle-foot orthoses are widely used for the treat-
ment of different types of motor disorders.101-107 Plas-
tic ankle-foot orthoses have now largely replaced the
metal ones, with the most common materials being
polypropylene and laminated plastics.108-110 However,
patients requiring bracing who are also insensate
should be fitted for an ankle-foot orthosis with a
metal shoe attachment so that the brace is not in di-
rect contact with sensitive skin (Fig. 4).110 The poste-
rior leaf spring ankle-foot orthosis is indicated for pa-
Journal of the American Podiatric Medical Association

Figure 4. Double-upright ankle-foot orthosis.
tients with peripheral nerve injuries resulting in flac-
cid footdrop, where all that is needed is toe clear-
ance during the swing phase of gait. This orthosis is
fabricated by cutting the ankle trim lines behind the
malleoli, resulting in a flexible brace that provides
A B
Figure 5. A, Posterior leaf spring ankle-foot orthosis. Note that the trim line at the ankle joint is behind the malleoli.
B, Solid ankle-foot orthosis with trim lines cut anterior to the malleoli.
Volume 89 • Number 5 • May 1999
minimal mediolateral stability and may control mild
spasticity (Fig. 5A). The posterior leaf spring orthosis
was found to improve ankle function in the gait of 31
children with cerebral palsy; it reduced excessive
equinus during the swing phase, but did not improve
ankle function for push-off during the stance phase.106
The rigid, solid ankle-foot orthosis restricts all mo-
tion at the ankle and is useful for treatment of trau-
matic arthritis of the ankle or other conditions in
which complete immobilization of the ankle is re-
quired (Fig. 5B). It is also indicated for control of se-
vere spasticity and is therefore useful in the treat-
ment of stroke patients. The solid ankle-foot orthosis
has the ankle trim lines cut anterior to the malleoli,
which results in a rigid orthosis. Most patients have a
semirigid ankle-foot orthosis with the trim lines in-
termediate between those of the solid and the poste-
rior leaf spring orthoses, thereby providing enough
control for significant spasticity and support for weak
muscles, yet maintaining a degree of flexibility.
The articulated ankle-foot orthosis is a plastic
brace with joints at the ankle (Fig. 6). Hinged or-
thoses with a dorsiflexion stop to prevent plantar-
flexion beyond a right angle of the foot to the leg are
frequently employed for tone reduction to reduce
spasticity in children with spastic ankle equinus.111, 112
Ankle-foot orthoses have been shown to increase ve-
locity, stride length, and single-support percentage as
compared with walking barefoot in children with
225

Figure 6. Articulated ankle-foot orthosis (center).
Note the ankle joint built into the plastic orthosis. The
orthosis on the left is a solid ankle-foot orthosis. Note
the high medial flanges built into the foot plate and
the additional two straps on the ankle and distal foot,
all of which are tone-reducing features. The orthosis
on the right is a total-contact ankle-foot orthosis with
a tone-reducing anterior shell.
spastic equinus and crouch gait.113 However, the re-
sults of studies comparing the various ankle-foot or-
thoses for spastic equinus conditions in children and
adults are conflicting. In a case study comparing solid
and hinged ankle-foot orthoses in a child with cerebral
palsy, the solid ankle-foot orthosis was found to block
the needed foot and ankle mobility.114 Articulated or-
thoses decreased the sit-to-stand time in preambulato-
ry children with cerebral palsy.115 In a study of 14 chil-
dren with spastic hemiplegia, both a hinged ankle-foot
orthosis with plantarflexion stop and a solid ankle-
foot orthosis improved cadence, velocity, and step
length; however, the hinged orthosis produced a more
dynamic and physiologic gait pattern.116 Similarly, in
another study, both orthoses with a plantarflexion
stop and solid ankle-foot orthoses increased stride
length and temporal-distance characteristics equally in
children with spastic cerebral palsy.117
A dorsiflexion-assist modification may be added
to an ankle-foot orthosis to spring the foot into dorsi-
flexion automatically when the foot enters the swing
phase of gait. However, in a study of five hemiplegic
adults using dorsiflexion-assist orthoses versus or-
thoses without spring loading, no significant differ-
ences in 10-m walking time were found.118 The cylin-
der of the assist device was heavy and noisy, and
patients did not like it; they preferred their old or-
thoses. The authors concluded that the dorsiflexion-
assist ankle-foot orthosis was not superior to the or-
thosis with no assist device.118 In a study of children
226
with spastic equinus, the supramalleolar orthosis ap-
peared to offer no improvement in gait over the solid
ankle-foot orthosis.119 In conclusion, although new
developments in orthoses are often helpful, the new
orthosis is not automatically more effective than the
original orthosis simply because it is new.58, 120
Orthotic Devices for Treatment of
Arthritis of the Subtalar Joint
It is estimated that the ankle and subtalar joint are in-
volved in 10% to 56% of patients with rheumatoid
arthritis.121-123 Shoes are the most important conser-
vative treatment for patients with rheumatoid arthri-
tis.124, 125 The shoes should be lightweight and have
extra depth, with a high toe box to accommodate the
contracted digits. Metatarsal bars shift weightbearing
away from tender or high-pressure areas. The insert
and sole of the shoe may be excavated about bony
prominences such as the deviated talar head, which
occurs in the valgus foot. Shoe modifications that
provide stability to the rearfoot include a strong
counter, a longitudinal arch support, and a 1/4-inch
medial heel and sole wedge.126 Spenco may be used
as an insert to decrease shear, and Plastazote (Apex
Foot Products, South Hackensack, New Jersey) may
be used to disperse weightbearing by providing more
total contact. The purpose of the orthosis for the pa-
tient with severe arthritis is generally accommoda-
tive and supportive, and to provide cushioning. Heel
cups and the UCBL orthosis have been recommend-
ed for patients with rheumatoid arthritis who have
heel pain,127 although the fragile skin of the foot in
such patients may not tolerate a UCBL orthosis.128
Studies have shown that prefabricated foot or-
thoses and off-the-shelf orthopedic shoes are as effec-
tive for individuals with rheumatoid arthritis as more
expensive orthoses and shoes. In a well-controlled
study conducted over a 3-year period, functional post-
ed foot orthoses provided no significant benefit over
placebo orthoses in limiting disability and pain.129
Groups wearing both types of orthoses reported im-
provement. In this study, the functional orthosis con-
sisted of a custom-made Rohadur material that had
posts at the rearfoot and forefoot. The placebo ortho-
sis was a thin polyvinylchloride shoe insert without
posts. It should be noted that Rohadur has never been
the material of choice for use in shoes of patients
with rheumatoid arthritis, and a more accommodat-
ing, shock-absorbing, custom-made semirigid foot or-
thosis might have been more effective than placebo
orthoses. In another study, patients with rheumatoid
arthritis who wore off-the-shelf orthopedic footwear
for a 2-month period had significantly less pain and
Journal of the American Podiatric Medical Association
better function than patients in a control group who
did not receive any special shoe.130
When arthritis affects the ankle, a solid ankle-foot
orthosis made of either plastic or metal may be indi-
cated. A solid orthosis may also be indicated for treat-
ment of a totally collapsed arch with a painful bursa
under the talar head or for severe instability of the
subtalar and/or ankle joint (Figs. 4 and 5B).131

Orthotic Devices for Treatment of the

Diabetic Rearfoot
Orthotic devices for treatment of the diabetic foot re-
duce pressure and redistribute it more evenly through-
out the foot. Orthoses for the diabetic foot include in-
soles and foot orthoses, prefabricated walking braces,
total-contact casts, ankle-foot orthoses, and prosthe-
ses for the amputated foot. Foot orthoses for patients
with diabetes are most commonly soft and accom-
modative and have good cushioning. The orthosis and
Figure 7. Prefabricated walking brace (Equalizer,
the shoe must work together to disperse callosities Royce Medical Co, Camarillo, California) for patient
and protect the foot from hard walking surfaces. with Charcot foot deformity.
Total-contact casting is the treatment currently
recommended for Wagner stage 1 and 2 neuropathic
plantar ulcers. This casting provides equalization of
plantar foot pressures and generalized off-loading of Charcot’s foot.137 Recently, the Charcot Restraint Or-
the foot.132 However, no significant differences were thotic Walker orthosis (Orthotic Service, Brea, Cali-
found in plantar pressure measurements between fornia) has been found useful in treating patients
conventional short-leg casts and total-contact casts with neuroarthropathy. The Charcot Restraint Or-
in healthy volunteers,133 or in patients with Charcot’s thotic Walker is a rigid, custom-made, full-foot-enclo-
midfoot collapse and rocker-bottom deformity.134 The sure ankle-foot orthosis (Fig. 8).138 It provides immo-
prefabricated below-the-knee walking brace can bilization and protection during the prolonged healing
sometimes be substituted for cast treatment for neu- of diabetic neuroarthropathy. In a study of the effects
ropathic ulcers and immobilization of Charcot’s foot of the Charcot Restraint Orthotic Walker orthosis, 18
in diabetic patients (Fig. 7).135 No significant differ- patients rated it good to excellent and none reported
ences in peak pressure were found in ten healthy male
subjects wearing a prefabricated walking brace and a
total-contact cast.132 The authors concluded that the
prefabricated walking brace was a convenient and
useful treatment for neuropathic plantar ulcerations
of the foot.
The prefabricated walking brace (Fig. 7) and the
ankle-foot orthosis (Figs. 4 and 5 A and B) are com-
monly used in the treatment of patients with diabetic
foot problems. The ankle-foot orthosis has been rec-
ommended for closing ulcers in the diabetic foot and
preventing their recurrence.136 The walking brace
provides the necessary stability while allowing easy
donning and doffing for physical therapy sessions
and during washing and sleeping. A rocker-bottom
sole or ankle joints may be added to facilitate ambu-
lation. The total-contact, bivalved, rocker-bottom-
sole ankle-foot orthosis was shown to be effective in Figure 8. Charcot Restraint Orthotic Walker orthosis
controlling complications in 14 individuals with for treatment of patients with a severely deformed foot.

Volume 89 • Number 5 • May 1999 227

significant activity restrictions while wearing the or-
thosis; all patients believed that their quality of life
was markedly improved by use of the orthosis.138 In a
more recent report, all patients wearing the Charcot
Restraint Orthotic Walker orthosis noted varying
measures of improvement in symptoms and function
at an average 12-month follow-up.139
The patellar-tendon-bearing orthosis is one of the
original orthoses for off-loading the rearfoot and
leg.140 It has a pretibial component in which the pa-
tient rests the upper leg and knee during ambulation
(Fig. 9). Patients are trained to walk by sinking their
weight into the pretibial shell, and the weight is
transferred down the uprights to the floor, bypassing
the leg and rearfoot. When patients are trained to walk
properly with the patellar-tendon-bearing orthosis, it
has been found to reduce weightbearing on the leg
and rearfoot up to 60%.141 The patellar-tendon-bearing
orthosis is indicated for patients with fractures of the
leg and rearfoot, and to remove weight in a painful
diabetic Charcot rearfoot. The orthosis is available in
metal and plastic varieties, and it must have a solid
ankle to work properly.142, 143
Prostheses for the Rearfoot Stump
The goals for biomechanical management of partial
foot amputations are to restore stability, maintain
support, and protect function in the residual foot.144
Figure 9. Patellar-tendon-bearing orthosis for treat-
ment of Charcot’s foot with dislocated ankle joint.
228
The shoe, stocking, and orthosis work together as a
unit in protecting a patient with a partially amputated
foot.145, 146 For example, silicone-insole socks have
been shown to be more effective in reducing horizon-
tal shear than cotton socks (Fig. 10).145 Amputations
involving one or more digits or a lateral ray usually
can be managed with just a good shoe and insert.
When the amputation is through the metatarsal heads,
it is managed with a foot orthosis with a filler. Howev-
er, when the amputation is more proximal to the
metatarsal heads, an above-the-ankle partial foot
prosthesis is required.147, 148 This can be in the form of
an ankle-foot orthosis with forefoot filler (Fig. 11). If
the amputation is through the midtarsal joint with
only the rearfoot remaining, equinus contractures are
likely to occur, and a Chopart’s amputation prosthesis
may be necessary (Fig. 12).149 Ground-reactive forces
have been shown to be reduced in patients with
Chopart’s amputations who walk with a Chopart’s am-
putation prosthesis.150 Syme’s amputation involves re-
moval of the entire foot and requires utilization of a
Syme’s amputation prosthesis (Fig. 13 A and B).151
Summary
Foot orthoses have been shown to relieve pain, reduce
rearfoot pronation, and improve function in patients
with orthopedic conditions involving the rearfoot.
However, several studies have found that prefabri-
cated foot orthoses are often as effective as custom-
made foot orthoses in the treatment of plantar fasci-
itis and rheumatoid arthritis. Orthoses for the diabetic
foot serve to accommodate and off-load high-pres-
Figure 10. An elastic cotton stocking with silicone
stump liner (ComfortZone Partial Foot Sock, Silipos
Co, Buffalo, New York) is used for patients with mid-
foot amputation to protect the distal stump.
Journal of the American Podiatric Medical Association
 Figure 12. A clamshell Chopart’s prosthesis is used
for patients with Chopart’s amputation with equinus
contractures.

Figure 11. Proximal, transmetatarsal amputation re- B

quires treatment with an ankle-foot orthosis with fore-
foot filler.

Figure 13. A, Syme’s amputation prosthesis. Note the medial window that opens. Syme’s amputation traditionally
left patients with a large, bulbous stump, and the medial window was necessary for patients to insert the foot into
the narrow waist of the orthosis. B, Same patient shown in A wearing the Syme’s amputation prosthesis.

sure areas. The prefabricated walking brace has been
shown to be as effective in equalizing plantar pres-
sures as the total-contact cast in the diabetic foot. In
cases of neuromuscular disease, the dorsiflexion-as-
sist ankle-foot orthosis and the supramalleolar ortho-
sis offered no advantage over the solid ankle-foot or-
thosis. In contrast, a hinged ankle-foot orthosis was
more effective than a solid ankle-foot orthosis in im-
proving gait in children with cerebral palsy.
Acknowledgment. Edwin Vazquez for the pho-
tography.
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