Healing Through Custom Orthotics: Part 1

Introduction

Every day I treat people suffering with back pain. My patients often attribute this pain to a wide range of factors, but one that is both common and commonly overlooked are the feet and how they impact on how you feel in other parts of your body. This will be a two part-post.  The fist part will take a look at foot behaviours and how they can lead to pain in particular areas of the body.  The second part will focus on current research on custom orthotics and how they can help deal with pain, but also to prevent pain from occurring in the first place.

Just as steel and metal girders make up the foundation for the tallest of buildings, your feet make up the foundation for your body.  When something goes wrong at the foundation, the rest of the structure is affected. By keeping your foundation strong and in alignment you are able to take the stresses off other parts of your body including knees, hips, and lower back.

How Do I Know Whether I Have A Strong Foundation?

There are a few ways to test how efficiently your feet are behaving.  First of all, listen to what they tell you.  Are you experiencing pain?  If so, when? Early in the morning as you step out of bed?  Or after walking for 5, 15, 20, or 30 minutes?  Do you have back pain, knee pain, or hip pain? Do you sprain your ankles frequently?  Look at the wearing pattern on your running shoes. Do your feel have calluses on them? All of these are excellent questions to ask yourself, and if you do experience any of the above symptoms, it's a good idea to get things checked out.

In my office, I do a variety of things to check the mechanics of the feet.  One is just observation.  Observing the height of the arch and how it behaves as you walk, is a great indication of how the foot is operating.  Postural changes are also common.  Often people lean to, or favour one side or the other. This can put more stress on one foot with regards to the other.

Another great thing I do is examine your feet through something called a Gait-Scan.  Gait-Scan is a technology whereby it takes pressure data from your feet as you stand on a force plate.  The data obtained from the Gait-Scan can help to determine more precisely, how pressure is distributed throughout the feet, and the extent to how the arches are behaving.  This information can then be used to accurately customize orthotics to your foot and its particular needs.

Keeping your foundation strong is essential in order to be pain-free and to prevent pain and problems from occurring in the future.

What Are The Types Of Feet?

An “optimal foot” acts as a foundation by providing adequate shock absorption and evenly distributing forces that occur when we walk.  In an optimal gait, the foot behaves in the following manner:

•Heel strikes the ground on the outside

•Transfer weight from the heel to the forefoot

•Foot will roll in inwards (pronation)

•Weight is distributed evenly across the forefoot.

Rolling inwards motion is the way that the body naturally absorbs shock. This is the most ideal, efficient type of gait.

Overpronation Vs. Supination

Over-pronation and supination are behaviours of the feet where either the ankle rolls inward excessively (collapsed arches) or the ankle does not roll in enough (high arches), respectively.  I diagnose these extremely common foot behaviours everyday and can design custom orthotics that put your feet in the most optimal alignment.

An overpronator's arches will collapse, or the ankles will roll inwards (or a combination of the two) as they cycle through the gait. An individual who overpronates tends to wear down their running shoes on the medial (inside) side of the shoe towards the toe area. A supinator's foot will not roll far enough when tranferring weight from heel to forefoot unevenly distributing the weight across the forefoot. An individual who supinates tends to wear down their running shoes on the lateral (outside) side of the shoe towards the rear of the shoe in the heel area.

When your foot over-pronates, or supinates, extra stresses are placed on the ankles, knees, hips, and low back. Eventually, these structures tend to give out and pain can occur as a result. Keeping your feet in balance can deal with and prevent pain from occurring

What Conditions Can Occur As a Result of Poor Foot Mechanics?

•Over-pronation

•Supination

•Meta-tarsalgia – pain in the forefoot

•Neuroma – inflammation of nerves of feet

•Achilles tendonitis

•Plantar Fasciitis

•Shin Splints

•Jumper's knee

•Low back pain

And More.....

The next post will deal with current research on orthotics and how they can help fix and prevent many of the above conditions, and more.

Plantar Fasciitis

Last reviewed: February 19, 2011.

Plantar fasciitis is inflammation of the thick tissue on the bottom of the foot. This tissue is called the plantar fascia. It connects the heel bone to the toes and creates the arch of the foot.

Causes, incidence, and risk factors

Plantar fasciitis occurs when the thick band of tissue on the bottom of the foot is overstretched or overused. This can be painful and make walking more difficult.
Risk factors for plantar fasciitis include:

• Foot arch problems (both flat feet and high arches)
• Obesity or sudden weight gain
• Long-distance running, especially running downhill or on uneven surfaces
• Sudden weight gain
• Tight Achilles tendon (the tendon connecting the calf muscles to the heel)
• Shoes with poor arch support or soft soles

Plantar fasciitis most often affects active men ages 40 - 70. It is one of the most common orthopedic complaints relating to the foot.
Plantar fasciitis is commonly thought of as being caused by a heel spur, but research has found that this is not the case. On x-ray, heel spurs are seen in people with and without plantar fasciitis.

Symptoms

The most common complaint is pain and stiffness in the bottom of the heel. The heel pain may be dull or sharp. The bottom of the foot may also ache or burn.
The pain is usually worse:

• In the morning when you take your first steps
• After standing or sitting for a while
• When climbing stairs
• After intense activity

The pain may develop slowly over time, or suddenly after intense activity.

Signs and tests

The doctor will perform a physical exam. This may show:

• Tenderness on the bottom of your foot
• Flat feet or high arches
• Mild foot swelling or redness
• Stiffness or tightness of the arch in the bottom of your foot.

X-rays may be taken to rule out other problems, but having a heel spur is not significant.

Treatment

Your doctor will usually first recommend:

• Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) to reduce pain and inflammation
• Heel stretching exercises
• Resting as much as possible for at least a week
• Wearing shoes with good support and cushions

Other steps to relieve pain include:

• Apply ice to the painful area. Do this at least twice a day for 10 - 15 minutes, more often in the first couple of days.
• Try wearing a heel cup, felt pads in the heel area, or shoe inserts.
• Use night splints to stretch the injured fascia and allow it to heal.

If these treatments do not work, your doctor may recommend:

• Wearing a boot cast, which looks like a ski boot, for 3-6 weeks. It can be removed for bathing.
• Custom-made orthotics
• Shockwave Therapy
• Steroid shots or injections into the heel

In a few patients, nonsurgical treatment does not work. Surgery to release the tight tissue becomes necessary.

Expectations (prognosis)

Nonsurgical treatments almost always improve the pain. Treatment can last from several months to 2 years before symptoms get better. Most patients feel better in 9 months. Some people need surgery to relieve the pain.

Complications

Pain may continue despite treatment. Some people may need surgery. Surgery has its own risks. Talk to your doctor about the risks of surgery.

Ankle Sprains Demystified

Typical mechanism of an inversion-type sprain of the ankle is stepping on an uneven surface (i.e. another foot). Ankle sprains are, by far, the most common sports injury. The good news is that most will almost inevitably heal within 4-6 weeks, and most show modest improvement within 2 weeks. Most commonly, ankles are sprained as a result of sudden movements such as twisting. All it takes is one awkward step, an uneven surface, or jumping and landing on another foot, that can set a barrage of symptoms into motion. It is common in sports such as basketball and volleyball when the players comes down from a jump and lands on another player’s foot. The pain results from injury to the ligaments of the foot. These ligaments are responsible for helping the joints and bones of the foot and ankle maintain stability and to prevent excessive movements. There are two main categories of ankle sprains.

1. Inversion Ankle Sprains

If you were to bet on the type of sprain, put your money on this one. Almost 90% of ankle sprains are inversion sprains. Pain is on the outside of the ankle and there is usually no pain inside of the ankle joint. There is also limited and painful dorsiflexion. The main ligament involved is known as the anterior talofibular ligament (ATFL).

2. Eversion Ankle Sprains

The other type of sprained ankle is called an eversion injury, where the foot is twisted outwards. When this occurs, the inner ligament, called the deltoid ligament, is stretched too far. Patients will have pain on the inner side of the ankle. The deltoid ligament is one of the strongest in the body, and often a fracture is present if this ligament is torn.

Commom Symptoms of Ankle Injury

There are 3 different grades of sprains, which have to do with the amount of damage to the ligaments.

Grade I: Grade I ankle sprains cause minor stretching of the ligament. The symptoms tend to be limited to pain and swelling. Dorsiflexion of the ankle is also painful. Generally tendons of the calf muscles become irriated, and should be addressed. Sometimes the joints of the ankle can also become immobile and locked.

Grade II: Grade II ankle sprains are more severe and involve partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. Patients usually have pain with walking, but can take a few steps.

Grade III: Grade III ankle sprains are complete tears of the ligaments. The ankle is usually quite painful, and walking can be difficult. Patients may complain of instability, or a giving-way sensation in the ankle joint.

Pain and swelling are the most common symptoms of an ankle sprain. Patients often notice bruising over the area of injury. This bruising will move down the foot towards the toes in the days after the ankle sprain--the reason for this is gravity pulling the blood downwards in the foot.

Do I need to see the doctor if I have an ankle sprain?

If you do have significant symptoms following a sprained ankle, you should seek medical attention. Signs that should raise concern include:

• Inability to walk on the ankle, for 4 steps or more
• Significant swelling
• Symptoms that do not improve quickly or persist beyond a few days
• Pain in the foot or above the ankle
• Sometimes an x-ray is needed to differentiate between a sprained ankle and a fracture. While moderate pain and swelling are common symptoms following a simple sprained ankle, symptoms such as inability to place weight on the leg, numbness of the toes, or pain that is difficult to manage should raise concern. If you think you may have done more than sustained a sprained ankle, you should seek medical attention.

What is the treatment of a sprained ankle?

Treatment of sprained ankles is important because returning to normal activities in a timely manner is important for most patients. Early treatment of a ankle sprain is the "RICE" method of treatment. If you are unsure of the severity of your ankle sprain, talk to your doctor before beginning any treatment or rehab. The following is an explanation of the RICE method of treatment for ankle sprains:

Rest:

The first 24-48 hours after the injury is considered a critical treatment period and activities need to be modified. Gradually put as much weight on the involved ankle as tolerated and discontinue crutch use when you can walk with a normal gait (with minimal to no pain or limp).

Ice:

For the first 48 hours post-injury, ice pack and elevate the ankle sprain 10 minutes at a time every 20 minutes or so, for 3-4 hours. The ice pack can be a bag of frozen vegetables, allowing you to be able to re-use the bag. Do NOT ice a ankle sprain for more than 15 minutes at a time! You will not be helping heal the ankle sprain any faster, and you can cause damage to the tissues!

Compression:

Use compression when elevating the ankle sprain in early treatment. Using an Ace or tensor bandage, wrap the ankle from the toes all the way up to the top of the calf muscle, overlapping the elastic wrap by one-half of the width of the wrap. The wrap should be snug, but not cutting off circulation to the foot and ankle. So, if your foot becomes cold, blue, or falls asleep, re-wrap!

IMPORTANT NOTE: Please remove footwear. I've witnessed people instructing shoes to be kept on during an acute ankle injury because 'it prevents swelling'. This is FALSE and shoes should be removed. If the ankle swells too much with the shoe on, it could cut off circulation and make your life more difficult. And furthermore, you need more direct contact to the area in order to ice it.

Elevate:

Keep your ankle sprain higher than your heart as often as possible. Elevate at night by placing books under the foot of your mattresses--just stand up slowly in the morning. Later, treatments involve addressing the muscle and joint issues with soft tissue treatments and an active rehabilitation program, focussing on proprioception. Laser is a modality which can help patients deal with pain and promote faster healing of the injured ligaments. Mobilizations and adjustments of the ankle joint can help promote tissue healing and create optimal mobility within the ankle complex, should mobility be compromised as a result of injury.

Ankle Braces:

One of the best pieces of experience that I can share has to do with ankle braces. They are an excellent way to compress and protect the ankle after an injury, but more importantly, can be used to help prevent you from rolling over on your ankle in the first place. I would suggest anyone who is involved in any sort of sport whereby ankle injuries are common, to invest in a pair of ankle braces. They are very much worth the effort and can save you a lot of trouble in the end.

Please visit my website for more information

References:

Wolfe, MW, et al. "Management of Ankle Sprains" Am Fam Physician 2001;63:93-104.

Osborne MD, Rizzo TD "Prevention and treatment of ankle sprain in athletes" Sports Med. 2003;33(15):1145-50.