Healing Through Custom Orthotics - Part 2

Introduction

Custom foot orthotics are devices that are specialized insoles that are used to correct the mechanics of the feet, putting them in a more optimal position.  The can be incorporated into the shoe directly, or be portable in which case they can be moved from shoe to shoe.

There are many different modifications that can be made to orthotics depending on how the foot behaves.  Generally, for people who over-pronate or whose arches collapse, the orthotic will contain varying degrees of arch support to stop the arch from collapsing or over-pronating.  People who have metatarsal pain (or pain in the ball of the foot), will often have a modification called a metatarsal pad added to the orthotic.  This will actually spread the metatarsals out and lessen the stresses placed on them from the rest of the foot.

Once your feet are in alignment, less stresses are placed on other parts of the body, including the ankle, knee, hip, and low back. Your body is functioning more optimally and this can help prevent pain from occurring in these areas in the future.

Orthotics will last about one year if they are being used on an every day basis and taken care of.  They are usually covered by your insurance company as well.

Research on Orthotics

In a 2004 study of 275 patients that had custom foot orthoses for over a year, the majority of subjects obtained between 60-100% relief of symptoms with only 9% reporting no relief of symptoms. (Walter JH, Ng G, Stoitz JJ: A patient satisfaction survey on prescription custom-molded foot orthoses. JAPMA, 94:363-367).

This 2004 article review stated that the evidence suggests that foot orthoses produce reductions in pain and disability associated with plantar fasciitis (Karl B. Landorf, Anne-Maree Keenan, and Robert D. Herbert Effectiveness of Different Types of Foot Orthoses for the Treatment of Plantar Fasciitis J Am Podiatr Med Assoc 2004 94: 542-549).

In a study that measured pain relief in 64 subjects with osteoarthritis in the foot and ankle, 100% of the patients wearing orthoses had significantly longer relief of pain than those patients receiving only non-steroidal anti-inflammatory drugs (Thompson JA, Jennings MB, Hodge W: Orthotic therapy in the management of osteoarthritis. JAPMA, 82:136-139, 1992).

In a 2003 study of 102 athletic patients with patellofemoral pain syndrome, 76.5% of patients improved and 2% were asymptomatic after 2-4 weeks of receiving the custom foot orthoses (Saxena A, Haddad J: The effect of foot orthoses on patellofemoral pain syndrome. 93:264-271, 2003).

In this 1999 study, subjects experienced more than twice the improvement in alleviation of pain, and for twice as long, compared with subjects in a study using traditional back-pain treatment. (Dananberg HJ, Guiliano M: Chronic low-back pain and its response to custom-made foot orthoses. 89:109-117, 1999).

Custom orthotics are great for your health and well-being and feel fantastic under your feet.  Your health and body deserve the best care possible.

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.

Iliotibial Band Syndrome

Introduction

The Iliotibial band (or IT band) is an extension of fibrous fascia that extends from the top of the plevis, down the side of the leg, and attaches to the lateral aspect of the knee. The IT band is involved in flexion and extension of the knee, and as a result, is a key player in activities such as running, cycling, weight-lifting (especially squats), and hiking.

It is commonly injured in runners. Especially those that have increased distance recently or amount of training. The IT band rubs against the tibia during knee flexion and extension, and thus becomes inflammed after repetitive movements. Pre-disposing factors include old shoes, and excessive heel wear, running in the same direction on a pitched surface, leg-length discrepancy, and lack of stretching (or warm up before stretching).

Signs and symptoms of IT Band Syndrome Include:

1. A sharp pain over the lateral femoral condyle posteriorly
2. Pain that starts half-way through a run
3. Hypertonic muscles and trigger points found in tensor fascia lata, quadriceps, and hamstrings
4. Weak hip abductors
5. Increasing pain on running or walking when the foot strikes the ground

Treatment:

Activites that aggravate the condition should be curtailed or avoided completely. If actively inflammed the RICE method of treatment should be in the fore-front (Rest, Ice, Compression, Elevation).

In the long term, orthotics can be prescribed to help improve the mechanics of the feet and to reduce stresses on the knee joint. Soft-tissue therapy, aimed at the aggravated muscles, including the IT band, can help with any residual tightness exhibited. Proper stretching should be done for the IT band, including a proper warm up before any activity or stretching is done. Shockwave treatments and/or laser can help with the healing process. A rehab program will address muscle weakenss in the hip abductors (gluteal muscles), as well as strengthening the quadriceps and hamstrings.

The following is a good stretch for the IT band. But make sure the tissue is warm before proceeding to do so. A hot towel placed on the tissue can help warm it up, or you can also do something like 20 jumping jacks, to help warm up the tissue.

1)Stand upright
2)Cross the involved leg BEHIND the opposite leg
3)Lean to the uninvolved side until a stretch is felt across the affected iliotibial band
4)Hold for 30 seconds
5)Repeat X 5

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Chronic Spinal Pain: What the Literature Says

Introduction:

For most episodes of back pain, especially when chronic, no exact pathological cause can be identified.  However, numerous clinic and scientific studies have shown that patients with low back pain do exhibit abnormal spinal motion.  This abnormal motion can be both a cause of back pain and a symptom.  For example, muscles that are strained or deconditioned can put excess stresses on the joints of the spine, producing abnormal motion.  Similarly, abonormal moving joints that can cause abnormal spinal motion can put excess stresses on the muscles and ligaments surrounding the joints.

Back pain is one of the most common neurological ailments that people suffer from all over the world.  Second to only upper respiratory infections, it is the one of the most common reasons for absenteesm from activities such as work and account for millions of dollars spent in health care costs every year.  Most cases of back pain are often self-limiting and will go away in a couple of days or so.  Other cases of back pain take much longer to resolve or lead to much more serious conditions.

Acute Lower Back Pain:

Acute back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature, and the result of trauma to the lower back or a disorder such as arthritis.  Acute pain in the low back can be due to a number of things including sports injuries, work around the house, slips and falls, posture at work (either sitting or lifting), and other stressors of the spine.

Symptoms:

Symptoms may range from muscle ache to shooting or stabbing pain (due to muscle or nerve referral), limited flexibility and/or range of motion, or an inability to stand straight. Pain felt in one part of the body may radiate from a problem elsewhere in the body (for example, neck pain can cause shoulder, elbow and arm pain). Some acute pain syndromes can become more serious if left untreated. Lower back pain unrelated to trauma or other known cause is unusual in pre-teen children, although, heavy backpacks can strain the back.

Chronic Lower Back Pain:

Chronic back pain is measured by duration, pain that persists for more than 3 months is considered chronic. It is often progressive and the cause can be difficult to determine.  Often, in addition to the musculoskeletal complications contributing to the pain, many psychological causes can also be identified.  Being in pain for a long period of time does affect mental attitude.  The person may become depressed mental attitude due to length of having the pain, having tried various treatments that have not worked, being off work and not making money or feeling useless, not being able to do the things they enjoy like playing sports, gardening, walking, etc etc.

A study by Giles and Muller (2003) that appeared in SPINE, compared the effectiveness of 3 different common treatments of chronic low back pain, in terms of their effectiveness.

Medications:

Patients with chronic spinal pain that seek the care of physicians frequently report high unmet needs and expectations.  The common drugs that are prescribed for low back pain include NSAIDs (Non-steriodal anti-inflammatory drugs), which essentially just mask the problem and fail to get to the root cause of the pain. As well the adverse reactions to NSAIDs have been well documented, including:

• Gastrointestinal toxicity, which can manifest as stomach bleeding and ulcer formation (extremely common)
• Allergic reactions
• There is currently insufficient evidence in the literature for the use of NSAIDs for chronic low back pain, although they may be effective for short-term symptomatic relief.  Over 6,000 people die every year from the use of over-the-counter anti-inflammatories.

Acupuncture:

Evidence on acupuncture for the treatment of chronic spinal pain is growing in it's favour.  Some evidence in a meta-analysis stated that acupuncture works quite well for low back pain as well as neck pain.  The current levels of evidence of high quality randomized controlled clinical trials of acupuncture for chronic low back pain is enough to warrant its practice.  The side effects of acupuncture are very low in comparison to medical treatments.

Spinal Manipulation (SMT):

SMT has been extensively researched and shown to be effective for acute low back pain in the short-term, and has been shown to be much more favourable comparable to medical care for long-term low back pain in terms of disability.  Patients undergoing chiropractic treatments were found to be more satisfied after one month of treatment.  The SMT performed was a high-velocity low amplitude thrust to the affected joint (as determined by the examiner) to mobilize the joint.

Study Protocol:

Patients were taken from an outpatient clinic at a multi-disciplinary hospital and were assessed by a sports medicine physician to determine whether they met the criteria for this study.  They were included if they were determined to have uncomplicated (mechanical) low back pain for a minimum of 13 weeks and less than 17 years.  They did not participate in the study if they had nerve root involvement, spinal anomalies, previous surgery, spondylolisthesis greater than grade 1, and/or leg length inequality of greater than 9mm with scoliosis.

The patients were randomized to medical treatment, acupuncture, or SMT group.  In total 36 patients were allocated to each of the treatment groups. Appointments were 20 minutes in length 2x per week for up to 3 months.  NSAIDs prescribed were Celebrex, Vioxx, or paracetamol.  Improvements were measued using disability questionaires, visual analog scale, pain frequency (1- no pain to 6-constant pain), cervical and lumbar spine range of motion (ROM), and straight leg raise (SLR).

Results:

	Manipulation		Acupuncture		Medication
Asymptomatic Patients at 9 weeks	9		3		2
Outcome Measures	Initial	Final	Initial	Final	Initial	Final
VAS Back	6	3	6	7	5	5
VAS Neck	6	5	6	4	5	6
Oswestry (back pain questionaire)	22	14	30	26	32	32
NDI (neck questionaire)	28	22	37	30	47	42
Lumbar Sitting flexion	50	39	49	47	54	51
Lumbar Standing flexion	40	30	54	56	56	52
Cervical sitting flexion	40	40	30	40	32	38
Cervical sitting extension	40	42	32	40	40	35
Disability questionaire	54	68	47	49	41	49

SMT yielded the best results by far over all of the outcome measures, with the exception of the NDI in which acupuncture was shown to have better results over manipulation.  Medication had the worst outcome measure of all 3 treatments. 9 patients with chronic spinal pain became ASYMPTOMATC.  The current study had rigorous protocols and a wide range of outcome measures, in which the 3 treatment regimes acted as controls for the others.  Any likely placebo effect would like be distributed across all of the 3 treatments.  SMT was, by far, the superior treatment for cases of chronic spinal pain, with every fourth patient being ASYPTOMATIC.  Acupuncture was found to be a little more effective for neck pain and disability.  The medical treatments caused adverse reactions in 6.1% of patients, that disappeared once the medication was stopped.  One final important note, is that since these patients all had CHRONIC spinal pain it is very unlikely that they would have improved by 'natural history' or 'self-limiting' improvements.

Reference:

Gilles, S., and Muller, R. 2003. Chronic Spinal Pain: A Randomized Controlled Trial Comparing Medication, Acupuncture, and Spinal Manipulation. SPINE, Volume 28(14): 1490-1503

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.