• Southern California Edison Orthotics Case Study


    Purpose

    The purpose of the Orthotics Pilot Study was to determine if Ergonomic Medical Grade Foot Orthotics would prevent and reduce musculoskeletal symptoms and associated diseases effecting load bearing joints of the body. These biomechanical conditions create bone, joint, muscle fatigue, strains, sprains and lost days in linemen and groundsmen in the T&D divisions within SCE which leads to a high workers compensation claim history.

    Custom orthotics are used in the prevention and treatment of disease and injuries in Olympic and professional athletes. In addition, physicians have used them in the treatment of disease and injury in medical patients for many years and their efficacy should provide similar benefits for a working population such as the group within our study. We believe that by providing Ergonomic Foot Wear solutions, we will be able to prevent injuries and disease and improve the quality of life by providing more comfort and improving function and thereby enable SCE to proactively manage and reduce workers compensation claims using biomechanical – ergonomic intervention programs.

    It is also hypothesized that the utilization of the 3DO System for testing and electronic casting will result in superior orthotics than those produced from conventional casting methods. The ability of the 3DO System to gather comprehensive data on static load bearing pressure points, weight distribution, and gait testing provides the tester and orthotics lab with important additional information in creating more advanced orthotics. Further, the portability of the system and the speed of which testing can be completed lends itself to mass customization in industrial applications.

    History

    For 60 years, Ergonomic Orthotics have proven to be effective modality in minimizing or eliminating symptoms in patients with neck, shoulder, spine, hip, knee, foot and ankle problems by focusing on maximizing closed kinetic chain mass displacement, (weight) effecting the body by controlling complex tri-motion function of the foot as it impacts the ground.

    A health questionnaire was designed and circulated to determine the scope and nature of the problems. Upon written interviews with the linemen and groundsmen, 65% responded with the complaint of various chronic musculoskeletal pains including the lower back, neck and shoulders. 

    Method

    Edison employees at two service centers were offered the opportunity to volunteer for a pilot study to evaluate the effectiveness of Orthotics. They were given a free scanning of static and dynamic weight-bearing on a dual functioning 3-D static and dynamic Imager. Those who demonstrated abnormal scans were then recommended to purchase Orthotics at a significantly reduced rate understanding that they came with a 100% satisfaction guarantee for a full refund. Of the 112 employees available, 70 entered the study with the understanding that were would be a 1 month, 3 month, and 6 month follow-up.  

    Six Month Follow-up Survey Summary:

    * Only 41 employees where available the day of survey collection.
    * 4 had either never worn or stopped wearing them for various reasons
    * 2 employees had complaints that were related to the shoe/boot and are being resolved.
    * Does the Orthotic help you with your job? 62% Yes, 20% sometimes
    * Do you have less pain now (prior to health questionnaire) from using the Orthotics?
    o 20% said a little
    o 40% said moderate improvement
    o 25.7% said significant improvement
    * Help improve chronic problems? 57% Yes, 20% sometimes, 14% No
    * Do you wear them daily? 86% Yes, 11% sometimes, 3% No
    * Rate the value? 37% very valuable, 49% somewhat valuable
    * Would you recommend Orthotics to your family and friends?
    * 86% said Yes
    * 10% said No

    Data Results Discussion

    The subjective data reflects a positive response from the T & D linemen and groundsmen.

    The purpose of the pilot study is to determine the effectiveness of the Orthotics at addressing the following concerns:

    Does it help with the job?

    The survey shows that 62% of the employee available on the day of data collection felt that the Orthotics helped them with their jobs.

    Is it reducing physical symptoms and complaints?

    Almost 86% responded with either a little, moderate, or significant improvement with the use of the Orthotics.

    Is it helping in reducing or preventing injuries?

    Both service Centers report that there has not been an injury or accident since the beginning of the study.

    Additional Notes

    At one month and three months, phone surveys were conducted at random. Results were favorable and most complaints were resolvable with Orthotic adjustment.  The six-month survey (see attached) has places for written feedback. Most of the employees had both written and verbal positive feedback. It is my recommendation that we continue to locate the other members in the study and collect their comments.

    Conclusion

    The preliminary results which represents a four month ( Huntington Beach) and six month (Saddleback) evaluation demonstrates and confirms in part the effectiveness we were attempting to prove. It must be noted that further symptom reductions will occur over the next six to eight months as the workers continue to wear and comply to the utilization of Ergonomic Orthotics. The goal is to stress the importance of wearing Orthotics as much as possible (work, home, sports and play). Generally compliance should be good because of the benefits (relief of pain, fatigue etc…), however we may want to consider some educational material and follow-up to ensure compliance which will justify greater benefits to employee and employer.

    There were also considerable problems noted in the boot wear being worn by employees. With the mechanically demanding positions and environments the T&D workers are faced with many of them wore improper foot wear (oxford shoes, cowboy boots, and severely broken down foot wear). We attempted to educate them on proper fitting boots, but it is apparent we could have had even greater results if we had a compliance program which met recommendations established by OSHA, NIOSH. The Orthotic is only as good as the boot in which it fits. Especially in cases with broken down foot wear which distorts the quality of biomechanical control of the Orthotic since the Orthotic is meant to work in a bottom sole which is parallel to the floor surface.

  • Custom Orthotics: Theory, Indications, And Utilization


    Mark A. Matey, D.P.M. and Stephen M. Meritt, D.P.M. are Podiatrists in private practice at Methodist Medical Center.

    Custom orthotic devices are classically used for common maladies of the foot. There are two basic types of orthotics: accommodative and functional. Accommodative orthotics are used to distribute the patient's body weight away from a painful area. The role of functional orthotics is to prevent pain during ambulation and more importantly to prevent pathologic range of motion in the joints of the foot. The functional orthotic is casted to the foot in a corrected position and sent to a laboratory where a hard plastic is used to make the device. The development of new, lighter, stronger, materials has increased the variety of devices and computerization has improved the overall quality of these products. When the foot is subjected to persistent abnormal patterns of gait, a particular set of symptoms will follow. The principles of biomechanics in the lower extremity must be understood before attempting to prescribe these devices. Human gait has been described by Steindler as " a series of movements where the body moves forward and the legs are placed in front of the trunk to prevent us from falling on our faces1." This point is clearly demonstrated by watching babies take their first steps with arms flailing, body swaying from side to side, and finally falling into mommy or daddy's outstretched arms. This explanation is misleading as to the simplicity of the process. There are 26 bones in the foot alone with 17 functional joints and many more articulations. There are numerous intrinsic and extrinsic muscles of the foot innervated by 6 nerves acting on those joints. In addition, there are precise applications of all the lower extremity and postural muscles. Therefore, each has a specific function and firing order in the sequence of movements that make up gait. Therefore the act of walking must be a well coordinated psychoneural and musculoskeletal process that is both repeatable step after step and accommodates to changes in conditions1. There are many variations of this pathway that may be considered ambulation but not necessarily normal gait. Variants to normal gait can be due to congenital anomaly, anatomic variation and loss of function due to traumatic event. It is when these variants of normal gait are multiplied by years of walking that most foot pathology occurs. Each year of walking consists of over 2.5 million steps and each walking step translates to a force of 2.5 times our body weight.

    Theory

    The goal of podiatric medicine is to identify and eliminate variants to normal gait. Identification of these variations, as one may imagine, is occasionally inexact. The use of shoe inserts was documented in 1845 by Durlacher who used built up leather inlays to treat mechanical foot problems2. In 1888 Whitman used steel plates with a large medial and lateral flange to press into the navicular and cause the foot to invert. If force alone did not cause inversion, the pain elicited from the device caused contraction of the posterior tibial muscle causing inversion3. Since these early devices, many other attempts were made to control foot function with the application of a device in the shoe 4,5,6. The problem was there had been no uniform or widely accepted theory of foot biomechanics to guide therapy. It was the work of Merton Root et al begun over 30 years ago that has guided much of the theory behind the application of orthotics. Root et al considered any variation from the definition of normal foot alignment to cause abnormal foot function7. They further studied the patterns of these variations and found a particular set of signs and symptoms to correlate with particular variations. They also worked to produce a systematic clinical approach to measure these variations8 which can then be manually reduced if the deformity is non-rigid and casted in that position9. A functional foot orthosis may then be constructed attempting to restore what is considered normal function. This theory has been debated since its introduction and has been met by some skepticism. On the whole, however, Root's work has been viewed with wide acceptance and is closely incorporated into clinical practice. What exactly is "normal foot function?" Normal function is not easily defined since it may vary depending on several factors It is clear, however, that subjective complaints and objective findings confirm that foot pathology does exist and that orthotics can be applied with good clinical response10,11,12,13. There remains a need for long term, prospective, randomized, controlled trials comparing functional foot orthotics to other devices or treatments14. The best measurement of orthotic efficacy remains subjective, and the direction of current research is toward computerized models which may lead to a better understanding of the normal foot15. Since previous studies have prospectively evaluated the use of functional orthotics with two having positive and one negative outcome16,17,18, the successful widespread use of orthotic devices will have to be evaluated by clinical experience and subjective relief in the patients.

    Indications

    Biomechanics is defined as " the application of mechanical laws to living structures, as to a locomotor system19." Merton Root, one of the most important contributors to the field of lower extremity biomechanics, recently wrote that biomechanics is a necessary basic science for the field of podiatric medicine. No specialty in the field of medicine is more intimately involved, on an everyday basis, with the clinical application of biomechanics. The understanding of basic mechanics and biomechanics of the lower extremity can provide the podiatrist with an invaluable diagnostic ability that cannot be otherwise matched20. The relationship between biomechanics and orthotic devices is the attempt to change bone and soft tissue alignment of the foot extrinsically, correcting biomechanics which may have led to the functional foot problem. The changes made by surgical correction are permanent and may lead to more problems post surgery. Patients are strongly encouraged, therefore, to attempt using a functional orthotic before surgery if the patient will likely benefit. The feature of using orthotics that is most appealing, as compared to surgical reconstruction, is that their effects are reversible. The cost of orthotics is a fraction of the cost of surgical reconstruction, but the cost of orthotics is usually absorbed by the patient as few insurance companies cover the cost of orthotic care. All types of ortho-tics can be grouped into two categories: accommodative and functional. The characteristics of each category can be shared by certain devices.

    Accommodative Orthotics

    Accommodative orthotic devices fit in the shoe to accommodate foot deformity. They function to transfer weight away from a painful area and place increased pressure where the foot has enough intrinsic padding to allow for better ambulation. There is no attempt to rigidly control motion around a specific joint but rather to control ground reactive forces around a specific location. Accommodative devices are applied at the location of a rigid deformity, arthritic joint or near a painful chronic skin lesion. They are particularly valuable for at risk patients with diabetes, peripheral vascular disease and neuropathy who are prone to pedal ulceration. Accommodative orthotics decrease vertical and shear force which leads to ulceration21. An example of a specific, prescription accommodative device allows pressure to be dispersed around a painful 4th metatarsal head to the adjacent areas:

    1. Two 1/8 inch layers of closed cell foam, (foam product that will not allow complete deformation and rebounds after pressure is removed), placed under the 5th metatarsal and at the periphery of any skin lesion

    2. The rest of the device made from 1/8 inch open cell foam. (Foam product that is easily deformed and will not rebound) and 1/8 closed cell foam.

    3. Metatarsal pad for placement behind the metatarsal heads (places pressure under the metatarsal shafts where there is padding from the intrinsic muscles)

    4. Spenco® top-cover ( neoprene product which has great shock absorption and reduces shear forces which cause callous formation). This is fairly simple device is made for a specific pathologic process. Obviously the scope of orthotics is broad and can be applied to many functional variations of the foot.

    Functional Orthotics

    As discussed earlier in the paper, Merton Root et al framed much of what physicians for many years knew to be true: shoe inserts make certain patients feel better. The foot operates best around a single position. Excessive deviation from that position will cause certain deformities, and Root regarded this position to be the point where the subtalar joint is neither pronated nor supinated9. Most functional orthotics attempt to capture the foot in this neutral position and then rigidly hold the foot in this position. The position must allow for both pronation and supination but not excessive end range of motion. During heel contact, pronation is wanted because the foot has to adapt to changing terrain and dissipate shock. Without pronation at heel contact, every bump or incline would cause us to fall down. Later in the gait cycle, when the weight is being sent from the rearfoot to the forefoot in preparation for propulsion, the foot should be supinating. During propulsion, the foot would like to act like one single, stable bone. The body will compensate for the floppy foot by contracting the powerful long flexors and extensors to stabilize the foot. Many forefoot problems can be directed to this mechanism, for example bunions and hammertoes. As an example, the foot that has a pathologic increase in 5th ray range of motion allows weight transfer from the rearfoot to the forefoot exerting excessive pressure under the 4th metatarsal head during forefoot loading and, therefor, causing pain. Such a problem can be treated using a functional device to restore function to the 5th ray. The patient is given a full biomechanical examination consisting of gait analysis, measurement of ranges of motion from the hip to the toes, and possibly weight bearing foot radiographs. After analyzing the above information, the foot can be casted in the desired position. One common technique is the neutral suspension cast. The cast is made using extra fast drying plaster fashioned into a moccasin around the foot. The cast is allowed to dry and then is carefully peeled from the patient's foot taking care not to disturb the impression. The cast is then evaluated and sent to an orthotic/prosthetic company. Orthotic prescriptions may range from flexible polypropylene materials to rigid acrylic or carbon/graphite composite devices. The method for making the device can range from hand constructed in the lab to a precise computer honed device. The correct device for the patient depends on the activities, pathology and preference of the individual patient. For the patient in our example, the most appropriate orthotic may be a semi-rigid polypropylene device with a full length Spenco® topcover with lesion accommodation under the 4th metatarsal head. This device will control excessive instability and distribute weight evenly during ambulation and limit pain.

    Conclusion

    Further scientific advances are necessary to produce more reliable measurement of functional pathology and lead to a better understanding of the foot in its normal state. Study of the biomechanics of the lower extremity must be considered an integral part of any treatment plan aimed at certain foot pathology. The use of both accommodative and functional orthotics provide a non-invasive, inexpensive treatment that does reduce pain in many foot deformities. The use of accommodative orthotics is a good preventive measure for those at risk, such as diabetics, neuropathic patients, or patients with vascular disease. Advances in the fields of biomaterials and computerized biomechanical assessment/manufacturing techniques will improve the reliability, reproducibility, and overall quality of custom orthoses.


    REFERENCES

    1. Wernick J. The E.D.G. system for dynamic analysis of gait. Clinics in Podiatric Medicine and Surgery. 1993; 10 (3):431-443.

    2. Durlacher L. A treatise on corns, bunions, the diseases of nails and the general management of the feet. Simpkin, Marshal, London, 1845.

    3. Whittman R. Observations on seventy-five cases of flatfoot. Trans Am Orthop Assoc. 1888; 1.

    4. Roberts PW. The influence of the os calcis on the production and correction of valgus deformities of the foot. Am J Orthop Surg. 1916; 14.

    5. Morton DJ. The human foot. Columbia University Press, New York, 1942.

    6. Levy B. An appliance to induce toe flexion on weight-bearing. J Nat Assoc Chiro. 1950; 50:887.

    7. Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. Clinical Biomechanics Corp. Los Angeles, 1977.

    8. Root ML, Orien WP, Weed JH. Biomechanical examination of the foot. Clinical Biomechanics Corp. Los Angeles. 1971.

    9. Root ML, Weed JH, Orien WP. Neutral position casting techniques. Clinical Biomechanics Corp. Los Angeles. 1971.

    10. Kidd R. Forefoot valgus: real or false, fact or fantasy? Australias J Podiatr Med. 1997; 31:81.

    11. Sims DS, Cavanagh PR. Selected foot mechanics related to the prescription of foot orthoses. In Disorders of the Foot and Ankle: Medical and Surgical Management, 2nd ed. Ed by Jahss. 1991; 469.

    12. Kilmartin TE, Barrington RL, Wallace WA. The scientific basis for the use of biomechanical foot orthoses in the treatment of lower limb sports injuries: A review of the literature. Br J Sports Med. 1994; 28: 180.

    13. Kirby KA, Green DA. Evaluation and nonoperative management of Pes valgus. In Foot and Ankle Disorders in Children. Ed. by Devalentine S. 1992; 295.

    14. Payne CB. The past, present and future of podiatric biomechanics. JAPMA. 1998; 88:2, 53-63.  

    15. Woodle AS. Clinics in podiatric medicine and surgery. 1993; 10:3.

    16. Kilmartin TE, Barrington RL, Wallace WA. A controlled prospective trial of a foot orthosis for juvenille hallux valgus. J Bone Joint Surg Br. 1994; 76: 210.

    17. Budiman-Mak E, Conrad KJ, Roach KE. Can foot orthoses prevent Hallux valgus deformity in rheumatoid arthritis? A randomized controlled trial. J Clin Rheumatol. 1995; 1:313.

    18. Colagiuri S, Marsden LL, Naidu V. The use of orthotic devices to correct plantar callus in people with diabetes. Diabet Res Clin Pract. 1995; 28: 29.

    19. Dorland's Illustrated Medical Dictionary, 28th ed. WB Saunders, Philadelphia, 1994.

    20. Root ML. Forward. In Clinical Biomechanics of the Lower Extremities. Ed. by Valmassy RL, CV Mosby, St. Louis, 1996 p vii. 21. Janisse DJ. Choices for the diabetic foot. Biomechanics. 1995, 2:4.
    April, 1998/ Jacksonville Medicine


    Original Document: http://www.dcmsonline.org/jax-medicine/1998journals/april1998/Custom%20Foot%20Orthotics.htm

  • Treatment of Arch & Foot Pain


    Description

    An in-depth report on the causes, diagnosis, treatment, and prevention of foot pain.

    Alternative Names

    Bunions; Corns; Hammertoe; Plantar Fasciitis 

    Arch Pain

    Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot. It is often associated with diabetes, back pain, or arthritis. It may also be caused by injury to the ankle or by a growth, abnormal blood vessels, or scar tissue that press against the nerve. Magnetic resonance (MR) imaging and the dorsiflexion-eversion test are being used to diagnose this syndrome.

    Treatment for Tarsal Tunnel Syndrome. Pain from tarsal tunnel syndrome may be relieved by treatment with orthotics, specially designed shoe inserts, to help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are under some debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than when the cause is not known. Recovery from this surgery can take months before a person can resume normal activity. It should only be performed by experienced surgeons.

    Flat Foot

    Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over 50 but it can occur in anyone. The following are risk factors for PTTD:

    Wearing high heels for long periods of time is a particular risk for flat feet. In such cases, over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down and the arch falls. Some studies have indicated that the earlier one starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on. Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or use of corticosteroids. Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet pose any significant problems in adults is unknown. For example, a 2002 study on athletes with flat feet indicated that they had no higher risk for leg or foot injuries than athletes with normal arches.      

    Treatment for Flat Feet in Children. Children with flat feet often outgrow them, particularly tall, slender children with flexible joints. One expert suggests that if an arch forms when the child stands on tip-toes, then the child will probably outgrow the condition. Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression. In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis, which typically lengthen the Achilles tendon and adjusting tendons in the foot. One procedure uses an implant to support the arch. These procedures have potential complications and conservative methods should be tried first.

    Abnormally High Arches

    An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot. Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.  Claw toe is a deformity of the foot in which the toes are pointed down and the arch is high, making the foot appear claw-like. Claw toe can be a condition from birth or develop as a consequence from other disorders. 



    Original Document: http://adam.about.com/reports/000061_10.htm

  • Treatment of Calcaneal Apophysitis (Sever's Disease)


    What is calcaneal apophysitis?

    The heel bone is called the calcaneus. In children, there is an area on the heel bone where the bone grows that is called the growth plate, or apophysis. Calcaneal apophysitis, also called Sever's disease, is inflammation of the calcaneal growth plate that causes pain in the heel. It is the most common cause of heel pain in children, adolescents, and teenagers. 

    How does it occur?

    This inflamed heel growth plate is caused by overusing the foot with repetitive heel strikes. It may also occur from wearing shoes with poor heel padding or poor arch supports.  

    What are the symptoms?

    A child will complain of heel pain. Running and jumping usually increase the symptoms. 

    How is it diagnosed?

    The health care provider will find tenderness over the bottom part of your child's heel. In severe cases of calcaneal apophysitis, he or she may order an x-ray to be sure there is no damage to the growth plate. 

    How is it treated?

    Your child may need to rest or do activities that do not cause heel pain. It is very important that your child wear shoes with padded heel surfaces and good arch supports. Extra heel pads may be placed in your child's shoe. Your health care provider may recommend shoe inserts, called orthotics. You can buy orthotics at a pharmacy or athletic shoe store or they can be custom-made. Your provider may also prescribe an anti-inflammatory medicine for your child. 

    When can my child return to his or her sport or activity?

    The goal of treatment is to return your child to his or her sport or activity as soon as is safely possible. If your child returns too soon the injury may be made worse, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to his or her activity will be determined by how soon your child's heel recovers, not by how many days or weeks it has been since the injury occurred. In general, the longer your child has symptoms before starting treatment, the longer it will take to get better. If the heel hurts, your child needs to rest from his or her sport or activity. Your child should rest for several days at a time and then go back gradually. Before returning, he or she should be able to jog painlessly, then sprint painlessly, and be able to hop on the injured foot painlessly. If at any time during this process your child develops further heel pain, he or she should rest for 3 to 4 more days until the pain is gone before trying to return again.  

    How calcaneal apophysitis be prevented?

    Calcaneal apophysitis is best prevented by having your child wear shoes that fit properly. The heel portion of the shoe should not be too tight, and there should be good padding in the heel. You may want to put extra heel pads in your child's shoes.


    Original Document: http://www.med.umich.edu/1libr/sma/sma_calcapop_sma.htm

  • Treatment of Charcot-Marie Tooth Disease


    Diagnosis

    A physical examination may confirm a high arch, claw toes, and muscle weakness. The Achilles (above the heel) and patellar (knee) tendon reflexes are weak or absent. Muscle strength testing can reveal atrophy and can be used to establish a baseline from which disease progression can be tracked.

    Examining and testing several family members for signs of neuropathy can help establish a diagnosis.

    Tests

    Several tests are used to determine reduced muscle responses and nerve damage.

    * A nerve conduction velocity (NCV) study measures the speed of nerve signal conduction. A patient with CMT1 has slower than normal NCV readings due to myelin deterioration.

    * Electromyography (EMG) records muscle activity during voluntary contractions and when electrically stimulated. It also determines if muscles are receiving neurological stimulation.

    * Magnetic resonance imaging (MRI scan) establishes whether the nerves in the spinal cord have been affected (rare).

    * A DNA blood test can identify some types of the disorder.

    EMG and NCV tests, which can be used in combination, are often referred to as EMG/NCV studies.  

    Treatment

    Treatment for CMT depends on the severity of symptoms and the age of the patient. The goal is to make the patient comfortable and increase the ability to perform daily activities.

    Orthotics

    Orthotics may be prescribed to improve mobility and gait, provide support, and decrease risk of injury.

    In the early stages of CMT, foot deformities can be corrected with braces that help maintain proper foot and leg alignment and reduce the risk of sprains. Splints are used on the forearm and hand. 

    If muscle weakness in the leg causes the foot to drag while walking, the patient can be fitted with a special brace that holds the foot at a 90-degree angle to the leg. If the entire lower leg is severely weakened, braces that extend above the knee and attach to the stronger muscles of the upper leg can provide adequate support.

    Custom-made shoes and/or inserts can improve gait and redistribute the weight of the body on the foot. 

    Physical Therapy

    Physical therapy helps maintain muscle strength and endurance in the affected limbs.

    Surgery

    If rigid foot deformity prevents the foot from being manipulated into proper alignment with a brace, surgery may help. The goal of surgery is to help the foot and leg function as normally as possible, so the patient can walk with minimal difficulty. When foot muscles are too weak to hold the bones in proper position, the foot bones can be surgically fused to provide stability and support.

    Prognosis

    Foot and hand deformity and walking problems are lifelong disabilities. Mental function and longevity usually are not affected, however, and most people with CMT lead productive lives.


    Original Document: http://www.podiatrychannel.com/charcot/treatment.shtml

  • Treatment of Lower Extremity Disorders


    Introduction

    Each foot consists of 28 bones, several intrinsic muscles, ligaments and tendons from the extrinsic muscles of the lower leg that influence foot function. Many foot pathologies arise from the abnormal movements of the complex joint structures within the foot. These abnormalities can also cause related knee, hip and back problems. Most of these biomechanically related problems are slowly progressive in nature. 1,2,3,7,14,17,18

    Below the ankle joint there exists a joint complex called the subtalar joint. This complex joint moves through all three body planes simultaneously. Its movement and range of motion is translated up into the leg in the form of tibial rotation and into the foot distally causing the locking and unlocking of another joint complex called the midtarsal joint.

    The Effect of an Abnormal Subtalar Joint on the Knee

    The effect of the subtalar joint on the knee as it causes the internal and external rotation of the tibia is a change in the orientation of the patella and the patella tendon. In an abnormally functioning subtalor joint this rotation of the tibia causes the patella to ride abnormally with its articulation with the femur. This common cause of chrondomalacia patella is rarely addressed or recognized. Additionally, with excessive rotation of the tibia, the collateral ligaments are strained. 3,7,12,15,16,17,19,20 Countless numbers of arthroscopic knee surgeries are preformed to correct the damage caused by an abnormally functioning subtalar joint in the foot. Even more rare is follow up treatment following the surgery to address the cause of the patellar damage. As a result, continued deterioration of the knee joint is allowed to continue.

    Abnormal Subtalar Joint Motion and the Posterior Tibial Tendon

    In the foot, the movement of the subtalar joint influences the locking and unlocking of the midtarsal joint complex which is distal to the subtalar joint. When the subtalar joint functions abnormally, the locking and unlocking of the midtarsal joint functions abnormally and results in a number of foot pathologies. 1,2 One such problem is an insidious slowly progressive problem that may occur is excessive strain on the posterior tibial tendon as it passes distal to the medial malleolus. Over time this important tendon becomes dysfunctional. The result is the development of chronic tears and central degeneration of the tendon. This condition occurs more commonly in women than men with the chronic form becoming symptomatic in the fourth or fifth decades of life. The consequence of this condition is chronic pain and a significant limitation of activities (See painful adult flatfoot). Early treatment consists of a below the knee cast in an attempt to heal the tendon damage followed by wearing a functional foot orthosis to correct the abnormal function of the subtalar joint. In severe cases, surgical intervention requiring subtalar joint fusion is necessary. 4,7,8,9,10,11,14, 23

    Heel Pain

    A more common consequence of an abnormally functioning subtalar joint is plantar heel pain. This condition is often referred to as heel spur syndrome. The genesis of this problem is an abnormally functioning subtalar joint which causes the foot to pronate excessively or for a longer than normal duration during the gait cycle. As this occurs, a thick fibrous ligament called the planter fascia that is attached to the plantar aspect of the heel and fans out across the arch of the foot into the ball of the foot, is stretched excessively. This ligament begins to develop small tears where it attaches into the heel causing pain. Treatment directed at the cause of the problem, abnormal subtalar joint motion, consists of using a functional foot orthosis that corrects the abnormal subtalar joint motion. 4,5,6,7,14,18,20,21,22

    Bunions, Talors Bunions and Neuromas

    In other instances of abnormal subtalar joint function, the abnormal locking and unlocking of the midtarsal joint results in the abnormal movement of the long bones in the forefoot called the metatarsal bones. As this occurs, splaying of the metatarsals causes a widening of the forefoot.Over time, this positional abnormality becomes a fixed functional deformity resulting in the formation of a bunion (hallux abductovalgus deformity with bunion) and or a tailors bunion deformity. 1,2,24,25,26,27,28,29,30 The abnormal movement of the metatarsal bones can also result in the compression of the interdigital nerves in the ball of the foot causing neuromas. Neuromas in the forefoot are nothing more than a swelling of the interdigital nerve as a result of chronic irritation from the abnormal movement of the metatarsal bones, which pinch the nerve. This causes swelling and damage to the nerve. 1

    The abnormal locking and unlocking of the midtarsal joint also results in an imbalance between the tendons on the top of the toes (extensor tendons) and the tendons on the bottom of the toes (flexor tendons). When this occurs, digital contracture results. The resulting hammertoe deformity progresses from a flexible positional deformity to a rigid and fixed functional deformity. 1

    Tratment of Foot Pathology with Functional Orthotics

    As with all progressive medical conditions, it is best to initiate treatment early. Conservative care directed at alleviating symptoms and slowing or halting the progression of the pathology is most desirable. This is accomplished with a custom-fabricated functional orthotic device made from a durable semiflexable polypropylene material. 4,5,6,10,14,16,19,20,22,23

    The device must be made to the unique specifications of the patient if they are to accomplish the desired result. They must also be constructed to fit in normal shoe gear if possible. If the patient cannot easily wear the device then treatment failure is certain.To capture the correct specifications for the prescription of the orthotics, the prescribing physician must have a through understanding of lower extremity function. The plaster of paris molds of the foot must capture the proper position of the foot. This position is determined by the treating physician based upon measurements of the subtalar joints and midtarsal joints of the foot and the quality of their ranges of motion in relationship to the other joints of the foot and leg. A through practitioner will perform these measurements and then evaluate them relative to a brief weight bearing gait analysis.It is this author’s opinion that the treating physician can only accomplish this adequately in the physician office. In this instance, all of the elements are present to construct the appropriate custom-made device that the patient will wear. To further ensure success, the physician must have access to orthotic laboratories that understand the proper construction of a functional orthotic and one that is willing to communicate with the physician in the direction of the construction of the orthotic.

    Quite often foot, deformities will progress beyond the ability to successful treat them with functional orthotics. In these instances, surgical intervention is often necessary. It must be kept in mind, however, that surgical procedures to correct these deformities do not address the cause of the deformity. Just as the knee joint will continue to deteriorate following arthroscopic surgery if the offending condition is due to an abnormally functioning subtalar joint, so will foot deformities following surgical treatment. Generally following surgery, there is a period of relief; but many of these deformities will slowly reoccur unless the abnormal subtalar joint function is addressed .To address the reoccurrence of these abnormalities, a functional orthotic should be prescribed.

    Summary

    Many back, hip, knee, and foot abnormalities are caused by the abnormal function of a joint complex in the foot called the subtalar joint. The relative occurrence of these abnormalities can be related to the relative proximity to the subtalar joint. Therefore, the majority of pathology that arises out of an abnormally functioning subtalar joint occurs in the foot, fewer occur in the knee, and fewer yet occur in the hip and low back.

    Relative to the cost of treatment for these conditions, an orthotic case fee is often the most cost-effective treatment plan. Additionally, the use of orthotics following surgical intervention of chrondromalecia patella, posterior tibial tendon reconstruction, subtalar arthrodesis, planter fascial release, heel spur surgery, bunion or tailors bunion surgery and others are useful in the prevention of reoccurrence of the deformity.

    A relevant point of consideration in the successful treatment of knee and foot pathology with functional orthotics is to allow the prescribing physician, who has the knowledge and experience in the treatment of these abnormalities, to maintain complete control of the casting, measuring and choice of fabricating laboratory. None of these elements should add to the cost of the devices. Should the health plan set their fees below a level adequate to reimburse the physician for the time, expertise and outside laboratory fees, then the physician will refer the patients to an outside source not equipped to meet the patients needs and more costly treatments will eventually be needed.

    References

    1. Root, Weed, Orein Normal and Abnormal Functioning of the Foot (Clinical Biomechanics Corp, Pub 1977 LCC# 71-185067)

    2. DeValentine, Foot and Ankle Disorders in Children,(Churchill Livingstone Pub 1992

    3. Klingman RE, Foot pronation and patello-femeral joint dysfunction (J. Orthop Sports Phys. Ther 1999 July)

    4. Sobel E, et al; Orthoses in the treatment of rearfoot problems (J Am Podiatr Med Assoc, 1999 May)

    5. Tisdel CL, et al: Diagnosing and treating plantar fasciitis: a conservative approach to plantar heel pain ( Cleve Clin J Med, 1999 April)

    6. Lynch DM et al Conservative treatment of plantar fasciitis, A prospective study (J Am Podiatr Med Assoc, 1998 Aug)

    7. Krivickas LS Anatomical factors associated with overuse sports injuries (Sports Med 1997 Aug)

    8. Dyal CM et al Pes planus in patients with posterior tibial tendon insufficiency: asympotomatic versus symptomatic foot (Foot Ankle Int 1997 Feb)

    9. Kitauka HB et al Effect of the posterior tibial tendon on the arch of the foot during simulated weight bearing, biomechanical analysis (Foot Ankle Inst, 1997 Jan)

    10. Beals TC et al: Posterior tendon insufficiency diagnosis and treatment (J Am Acad Orthop Surg 1999 Mar)

    11. Smith CF Anatomy, function and pathophysiology of the posterior tibial tendon (Clin Podiatr Med Surg, 1999 July)

    12. Klingman RE et al The effect of subtalar joint positioning on patellar glide positions in subjects with excessive rearfoot pronation, (J. Orthop Sports Phys Theer, 1997 Mar)

    13. Scranton PE et al Pathologic anatomic variations in subtalar joint anatomy (Foot Ankle Int 1997 Aug)

    14. Steb HS et al Conserative management of posterior tibial tendon dysfunction, subtalar joint complex and pes planus deformity (Clin Podiatr Med Surg 1999 July)

    15. Reischl SF et al Relationship between foot pronation and rotation of the tibia and femur during walking (Foot Ankle Int, 1999 Aug)

    16. Handley A et al; Antipronation taping and temporary orthoses. Effects on tibial rotation position after exercise (J Am Podiatr Med Assoc, 1999 Mar)

    17. Hinterman B et al Pronation in runners, Implications for injuries (Sports Med, 1998 Sept)

    18. Busseul C et al Rearfoot – forefoot orientation and traumatic risk for runners (Foot Ankle Int 1998 Jan)

    19. Way MC Effects of a thermoplastic foot orthosis on patello-femeral pain in a collegiate athlete: a single subject design (J Orhtop Sports Phys Ther, 1999 Jun)

    20. Leung AK et al Biomedical gait evaluation of the immediate effect of orthotic treatment for flexable flatfoot (Prosthet orthot Int, 1998 May)

    21. Cornwall MW et al Three – dimensional movement of the foot during the stance phase of walking (J Am Podiatr Med Assoc 1999 Feb)

    22. Van Wyngarden TM The painful foot Part I Common forefoot deformities (Am Fam Physicians 1997 Apr)

    23. Van Wyngarden TM The painful foot Part II Common rearfoot deformities (Am Fam Physicians 1997 May)

    24. Goldner JT, Gaines RW: Adult and juvenile hallux valgus: analysis and treatment. (Orthop Clin North Am 7:863, 1976)

    25. Halebian JD Gaines SS Juvenile hallux valgus, (J Foot Surg 22:290, 1983)

    26. Scranton PE Zuckerman JD Bunion surgery adolescents; results of surgical treatment (J Pediatric Orthop 4:39, 1984)

    27. Hardy RH Clapham JC Observations on hallux Valgus (J Bone and Joint Surg 33:376 1951)

    28. Amarnek DL Jacob AM Oloft LM Adolescent hallux valgus, it etiology and surgical management (J Foot Surg 24:54 1985)

    29. Inman VT Hallux valgus: a review of etiologic factors (Orthop Clin North Am 5:59, 1974)

    30. Kalen V Brecher A Relationship between adolescent bunions and flatfeet. (Foot Ankles 8:331, 1988)

    Original Document: http://www.podiatrynetwork.com/document.cfm?id=63

  • Diabetes and Orthotic Therapy


    by Dr. Mark N. Charrette

    Between 1990 and 1998, diagnosed diabetes in the United States increased by 33%. [1] Chiropractic care has much to offer patients who have diabetes.

    Because of circulatory concerns, diabetes patients often develop extremity problems and symptoms -- most commonly of the feet. [2,3] As the diabetic process continues, neuropathy can lead to sensory difficulties, which often allows poor shoe fit, excessive pressure and friction, and even injuries to go undetected. [4-6] The eventual result is skin ulcerations, infections (which do not heal readily), and finally amputation in some cases. [7,8]

    When treating a diabetic patient, it is the chiropractor's duty to evaluate the circulatory status in the extremities, and provide advice to help prevent the development of foot ulcers. In most people the foot is seldom symptomatic, and this is particularly true in the case of patients with a history or tendency to diabetes.

    Important Considerations

    *** Shoe fit. Proper shoe selection can be critical in avoiding excessive frictional stresses to sensitive foot tissues. [9] The last on which the shoe is built must match the shape and length of the foot. The vamp and the heel counter need to provide support without being too restrictive and irritating. The size and shape of the toe box are critical, and prominent seams or stitching can rub and chafe, with disastrous results. Adjustable closures, such as full laces, can adapt to the changes in foot size and shape that occur during the day, and Velcro-type tabs are very helpful for patients who have difficulty in lacing and tying knots. Slip-on styles are usually not recommended for patients with diabetes, due to the lack of adjustability and the need for a tight fit.

    *** Nutrition. Dietary modifications and vigilance over food intakes are required when dealing with a diabetic condition. Supplementation with vitamins, minerals, and other products can be very useful, depending on each patient's personal condition and food habits.

    *** Circulation. Circulatory status must be maintained at all costs -- through proper nutrition, regular exercise, and protection from injury. Lower extremity exercise is critical. Just regular walking can stimulate the pumping of blood and fluids through the system and prevent pooling and stasis. Gentle massage along with elevation of the legs and compression stockings (when necessary) are useful adjuncts.

    *** Shock absorption. An important consideration is preventing damage to the heel pads and absorbing the stresses of walking. The diabetic foot is particularly sensitive to the three-to-five g's of force which it must endure with every footstep. Normal shocks and stresses can result in damage and injury to sensitive diabetic feet. The sole of the shoe (insole, midsole, and outsole) must be made of materials which are comfortable, durable, and shock-absorbing.

    *** Breakdown prevention. Custom-made, flexible foot orthotics are valuable, and should be considered early in the treatment of a patient with diabetes. In the initial stages of the condition, an orthotic which is supportive of normal foot biomechanics is useful, as long as a special, shock-absorbing material such as Zorbacel is provided. Effective orthotics encourage efficient foot and lower extremity biomechanics, while at the same time diffusing pressure stresses and preventing tissue breakdown. The ideal orthotic should be designed to be very comfortable and shock absorbing, while still providing full corrective support for foot alignment and dynamics. Such an orthotic will allow your patient to continue to be active and to exercise regularly.

    In the final stages of diabetic foot problems, a purely accommodative orthotic is all that can be tolerated. This type of "compromise" orthotic will absorb shock and prevent pressure sores, but it does not support the arches and biomechanics of the foot. In this case, cut-outs and "divots" must be incorporated to allow the broken-down foot to function without excessive pressure on individual areas. It is much better to intervene early in this process and to prevent (or at least slow down) the development of this late stage.

    Conclusion

    The importance of proper shock absorption and shoe fit for the diabetic patient cannot be overstressed. Chiropractors who treat patients with diabetes must consider their need for comfortable, flexible foot orthotics which will provide support and forestall future biomechanical and tissue breakdown.

    References

    1. Mokdad AH, Ford ES, Bowman BA et al. "Diabetes trends in the U.S.: 1990-1998." Diabetes Care 2000; 23:1278-1283.

    2. Kosak GP, Hoar CS et al. "Management of Diabetic Foot Problems." Philadelphia: W.B. Saunders, 1984.

    3. Bild ED, Selby JV et al. "Lower extremity amputations in people with diabetes, epidemiology, and prevention." Diabetes Care 1989; 12:1.

    4. Harkless LB, Dennis KJ. "You see what you look for and recognize what you know." Clin Podiatr Med Surg 1987; 4:331.

    5. Gibbons WG, Freeman D. "Vascular evaluation and treatment of the diabetic." Clin Podiatr Med Surg 1987; 4:337.

    6. Huntley A. "The skin and diabetes mellitus (photoessay)." Dermatology Online Journal 1995; 1(2):[http://matrix.ucdavis.edu/DOJvol1num2/diabetes/neuropathy.html]

    7. Pecoraro RE et al. "Pathways to diabetic limb amputation: basis for prevention." Diabetes Care 1990; 13:513-521.

    8. Levin ME, O'Neal MW, eds. "The Diabetic Foot," 3rd ed. St. Louis: C.V. Mosby, 1983.

    9. Dyck PJ, Thomas PK et al., eds. "Diabetic Neuropathy." Philadelphia: W.B. Saunders, 1987.


    (Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 15 years he has lectured extensively on spinal and extremity adjusting throughout the U.S., Europe, the Far East, and Australia. He received a Bachelor's degree from Illinois State University (summa cum laude) in 1976, where he was an NCAA All-American in 1974. Dr. Charrette is a featured speaker in Foot Levelers' 50th Anniversary Conference Series.)