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Pathologies

Healthy feet are truly wonders of human biomechanical architecture. Their ability to both propel us forward and yet cushion each step make them one of the most fascinating areas of human form and function. Containing ΒΌ of all the bones in our body and an array of muscles, tendons and ligaments, it is not surprising that at some point a problem will occur.

BIOMECHANICAL FOOT CONDITIONS

Poor foot structure can result in abnormal walking, foot instability and abnormal pressure areas. These biomechanical conditions, which are numerous, can affect children, adult athletes and the elderly. Treatment for improper foot mechanics consists of proper footwear and orthotic devices to realign and maintain the anatomical angular relationship between the segments of the feet andlegs.


BIOMECHANICS, GAIT ANALYSIS AND ORTHOTIC DEVICES

A biomechanical assessment is an integral part of any lower extremity evaluation. Faulty foot mechanics can and does translate into heel, ankle, shin, knee, hip and low back pain. Custom orthoses are made via prescription only. Performance Medical Group is currently using advanced computer technology to assist the clinician in prescribing the most effective orthotic device available today. Custom orthoses can be helpful in treating many conditions in various deformities and diseases. These include sports injury, geriatrics, diabetics, arthritics, children's flat feet, occupational leg and foot fatigue, annoying corns and calluses, painful heel condition etc.


SOME OF THE MOST COMMON FOOT CONDITIONS TREATED TODAY

ACHILLES TENDONITIS
ARTHRITIS
BUNION (in medicalese, hallux valgus)
CALLUSES
CHONDROMALACIA (Runner's Knee)
CORNS
DIABETES
HAMMER TOES
ILIO-TIBIAL BAND (Friction Syndrome)
MORTON'S NEUROMA
PLANTAR FASCIITIS
SHIN SPLINTS

 

ACHILLES TENDONITIS

What is it?
Achilles tendonitis is a condition wherein the Achilles tendon, at or near insertion to the posterior aspect of calcaneus, (heel bone) becomes inflamed and causes pain. The Achilles tendon is one of the longest and strongest tendons in the body. It is avascular and therefore slow to heal. The Achilles tendon attaches at the heel bone and runs up the bottom of the leg to the calf.

How is it caused?
An important factor to be considered is that of abnormal pronation or abnormal supination. Faulty biomechanics may be the blame for the disorder. When the Achilles tendon is activated it pulls the foot into plantar flextion (that is, it lowers the front part of the foot towards the ground). When a person is walking, running or engaged in athletic activities, the calf muscle acts to decelerate the lower leg and foot (when the heel is planted on the ground, the calf muscles prevent the lower leg from going forward too fast and causing an imbalance). The action of the calf muscles strains the Achilles tendon- but not abnormally, unless a problem exists like abnormal pronation or abnormal supination of the foot, which tilts the heel bone to the inside or the outside. When that happens, the Achilles tendon will be pulled, perhaps beyond its comfortable limit, to compensate for the tilting heel bone.

What are the common symptoms?
Patients complain of severe pain felt in the back of the ankle but pain in the Achilles tendon will vary in location depending on where the inflammation and /or tearing is occurring. If the tendon is being stressed where it joins with the two calf muscles, the discomfort will be felt in the lower leg; if the problem exists where the tendon attaches to the heel bone, the pain will be felt in that area.

How is it treated?
Since the problem is usually the over-pronation, the patient should be fitted with custom orthotics. Tightness in the tendon itself can be helped by an extra heel lift added to the orthotics. The patient can expect a slow recovery over a period of months.


ARTHRITIS

Arthritis is defined simply as an inflammation of a joint. There are approximately eight forms of arthritis or arthritic type conditions that can affect the joints of the feet and the lower legs. All of which cause pain, inflammation and limited movement of the joints. The most common are: osteoarthritis, rheumatoid arthritis, psoriatic and gout. Osteoarthritis is by far the most common with rheumatoid arthritis second.

Osteoarthritis
Most orthopaedic experts do not consider osteoarthritis to be a disease. A simple wear-and-tear process in any body joint can precipitate an inflammation, because of the breakdown of the cartilage tissue that normally keeps bone from rubbing against bone. Cartilage tissue can be unduly stressed and broken down by abnormal forces in the joint, forces that often result from a biomechanical fault in the lower limbs. If athletes place excessive stress on lower limbs while performing or exercising, the joints in the lower extremities will be subject to more wear-and-tear than those people who do not participate in strenuous activity. It is not disease that is destroying the stressed joint but excessive biomechanical forces are causing the condition. Apply this reasoning to the tires on your car. Even the best tires with the most cautious driver will have to be replaced eventually. The tires are neither diseased nor faulty, just worn out. The same applies to the joints of our body.

However, this degeneration can come sooner than later, when you allow a biomechanical fault to continue untreated. You are helping along the wear-and tear process in your feet, legs, hips and low back, because you are constantly placing undue stress on those joints in order to walk or run.

Abnormal biomechanical forces cause about 90 percent of all common foot pain including osteoarthritis. However, with proper mechanical adjustments for example, the wearing of orthotics further wear and tear can be prevented, and pain can be drastically reduced, or even eliminated altogether in many cases.

Rheumatoid Arthritis
Unfortunately, rheumatoid arthritis is a disease that has yet to be tamed. Although it is rarely life threatening, it can drive a person insane at times because of the relentless pain.

It is not brought on by wear-and-tear but is thought to be an auto-immune condition in which the body's own immune system mistakes the joints for foreign matter and attacks the joints to destroy them. Usually, relief for painful joints in the feet or ankles will require custom made shoes and soft inserts to take much of the normal weight off the diseased metatarsal heads. It is important that a rheumatologist, a specialist well versed in the various diagnostic methods of treatments, treat this disease.

Gout
Gout is a systemic disorder that affects the big toe joint. This joint is the largest in the area of the body that is farthest from the heart. Which means the circulatory system is less able to remove impurities from this joint than from others. Uric acid a waste product of the urea cycle collects in the joint in the form of crystals. This can produce excruciating pain and is often mistaken for osteoarthritis.

Actually, a simple blood test to measure the amount of uric acid in the blood can in most cases determine whether or not the patient has gout.

If gout is not properly treated, it will eventually cause permanent changes in the big toe joint. Once the existence of gout has been confirmed, drugs can be prescribed that will control uric-acid levels in the blood.

Psoriatic Arthritis
One of the most common types of psoriasis that affects the foot is know as pustular psoriasis. It affects the soles of the feet (and the palms of the hands) and appears without a trace of any other form of the disease in the area. The diagnosis can be made fairly easily with a culture of the lesion to rule out any other infections.

A complication of psoriasis is psoriatic arthritis, which is definitely a systemic disease as rather than from wear and tear. Because of its nature, I believe that psoriatic arthritis suffer ought to be placed in the hands of a rheumatologist for proper evaluation and treatment.


BUNION (in medicalese, hallux valgus)

What is it?
A bunion literally defined is hallux (big or great, toe) and valgus (deforming away from the midline). What it means is that there is a deviation in the big-toe joint. An abnormal big toe deviates from the shape of a normal big toe. There are three degrees of bunions: mild, moderate and severe. Bunions are not hereditary, although the tendency to over-pronate, which is the cause of bunions, has a hereditary component.

What is the cause?
Normally "toe-off" occurs from the plantar surface of the big toe. Over-pronation can cause the propulsion phase of stance to take off from the medial aspect of the phalanges of the big toe instead of the plantar surface. As a result, there is a retro grade force into the joint, which pushes it out medially and stretches the joint capsule. This tearing and stretching of the joint capsule as well as the wear and tear on the cartilage cause the pain. What a person with a bunion winds up with is often a grotesquely shaped toe as a result of opposing forces that do not counterbalance each other without causing a deformity.

What are the common symptoms?
Patients complain of pain in the MP joint and have a deformed (medially deviated) big toe.

How is it treated?
Since the problem is over-pronation, the patient should be fitted with custom orthotics and can expect a recovery over a period of months. Orthotics will not cause the physical deformity to regress, but will arrest any further progression and likely stop the pain. It is important to note however, that when the bunions are severe and require surgery, the bunion can be corrected, but will develop again unless the root cause is corrected. Since over-pronation is the root cause, orthotics are still necessary.


CALLUSES

What are they?
Calluses are nothing more than a build up of thick skin to protect a part of the body that is being subjected to undue stress. The pressure is caused by poor weight distribution on the foot due to a biomechanical fault.

What are the common complaints?
Patients will complain of pain right under where the callus has formed. When the bottom of the foot is subjected to the pressure of body weight when a person is standing or in stride, the area where the callus has formed will hurt because ultra sensitive nerve endings that are so close to the surface layers of the skin are irritated.

How is it caused?
It is imperative to understand that a callus is a symptom of a disorder, not the direct cause of your discomfort. As mentioned the main reason is usually due to a biomechanical fault that is cause by abnormal pronation. The foot rolls across the metatarsal heads, distributes the weight of the body unequally on the separate heads-distinctly one at a time, rather than equally in conjunction with each other in a normal "rolling" motion. This added stress on the burdened metatarsal head causes inflammation of the area, and a callus forms to protect the sore spot.

How are Calluses treated?
Orthotics are used to correct the weight distribution problem. Once the biomechanical fault has been eliminated, an ordinary callus will disappear slowly by itself. Usually over a six to twelve month period. A medical professional should treat serious more painful calluses.


CHONDROMALACIA (Runner's Knee)

What is it?
The runner's knee syndrome has its roots in the abnormal motion of the kneecap. It is a condition wherein the cartilage on the back of the patella (knee cap) is irritated and painful because it rubs against the medial femoral condole. The back of the kneecap is covered with cartilage that normally glides smoothly in the groove, but if the kneecap were to move off center in that groove during its motion while a person is in stride, it would rub against the sides of the groove, much like a bowling ball racing erratically down the gutter of the alley.

What are the common symptoms?
The irritated area becomes swollen and inflamed, and acute pain radiates from the top of the kneecap. Stiffness can occur when a person has been sitting with a bent leg for over a couple of hours, and the pain will become quite pronounced when a person is going up or down stairs. In severe cases, there will be occasional painful grinding in the joint when the knee is bent.

How is it caused?
There are three major causes of runner's knee, assuming the joint and the kneecap themselves are normal, and sometimes they all act together to promote the condition. The three are: week or malfunctioning quadriceps muscles above the knee, faulty biomechanics of the foot and lower leg, and a dysfunctional patellar tendon below the knee. A foot that abnormally pronates tends to turn a person's knee to the inside. When that happens, there is undue stress on the knee joint itself, and the kneecap can deviate from its normal path in its groove as the leg tries to compensate for the abnormal pronation.

How is it treated?
If the cause is a biomechanical foot fault resulting in over-pronation the patient should be fitted with orthotics and will likely experience pain relief within weeks and complete recovery within months. (Generally 2-3 months)


CORNS

What is a Corn?
A corn by definition is a protrusion on the top or the side of the toe. About two-thirds of all corns appear on the top of the toe and develop in response to a contraction of the offending toe. The remaining one-third generally appears on the sides of toes.

How is it caused?
Corns are caused primarily by a biomechanical fault. One of the primary causes of corns on the top of the foot is the "hammer toe" which is usually contracted and bent. This situation develops over a period of years and unfortunately, a person will not notice its development until the area begins to hurt and fitting into shoes can be painful. When the muscles and tendons on the top and bottom of the foot malfunction, the biomechanics of the toe involved will also become abnormal. The most common result is a hammer toe. Once a hammer toe exists, a corn is not too far behind.

What are the common symptoms and complaints?
In the case of the corn, patients will complain of pain right at the site of the corn. In the case of the hammer toes, patients will develop pain at the toes joint and also find it more difficult and painful to fit into their shoes.

What is the treatment?
Since in both cases the culprit is usually a biomechanical fault, the easiest and most conservative approach is to be fitted with a pair of custom orthotics to correct the underlying problem. In severe cases a more invasive surgical approach is necessary.


DIABETES



Of all the endocrine-based systemic diseases, diabetes is by far the most devastating to your lower extremity. Diabetes affects the lower leg and particularly the foot in many ways. Regardless of whether you suffer from type 1 or type II diabetes, the effect on the foot is similar. In general diabetics are at risk for serious lower leg and foot complications because of naturopathic and circulatory dysfunction. Neuropathy involves the loss of sensation in the nerves that supply the lower leg and foot due to altered blood glucose levels. The danger with the loss of sensation is that the diabetic patient does not feel the bottoms of their feet, as they normally should. A simple scratch or irritation from a tight shoe can go unnoticed and result in an open lesion. Diabetes also effects the circulation in the lower leg and foot. Circulatory disorders often manifest themselves first in the feet, because the lower extremities are farther from the heart than any other part of the body. Once again the altered blood glucose levels causes both macro and micro vascular impairment to occur. In simple terms the arteries, both small and large, become blocked resulting in reduced blood flow to the foot. Reduced blood flow translates into decreased healing power, which is the main reason why diabetic patients take so long to heal once a problem has begun. A diabetic may develop a simple blister on a weight- bearing surface of the foot. That blister may turn into an ulcerated lesion that will be most difficult to treat and very slow to heal. Ulcers can also develop beneath calluses, corns, and ingrown toenails. Because a diabetic or any other person with a circulatory and/or a nerve disorder-can acquire a dangerous infection in a foot without feeling any discomfort, prevention becomes paramount.

The list of preventative measures below may help you deal with a serious infection:

  1. Do not wear tight, ill-fitting shoes that can irritate your feet to the point of inflaming them. Some ill-fitting shoes may even cut into your feet and cause the area to become infected. If you have purchased a pair of new shoes, check your feet regularly for the first few days to ensure that they are not causing any damage. Wearing a proper pair of shoes is one of the most important steps in ensuring your feet stay healthy. Soft leather, shoes with cushion soles and a deep toe box or wide forefoot is preferred. Your Performance clinician will advise you accordingly.
  2. Custom orthotics are also a must and should be worn daily. Orthotics cushion the bottom of the foot and redistribute pressure away from stressed areas thus reducing the likelihood of callus, sores ulcers and /or infection from starting.
  3. Check you feet daily, or have someone look at them if you are unable to, to ensure that no fungal or bacterial infections have erupted.
  4. Wear natural fibre cotton socks, because they absorb moisture. Dry feet are less prone to infection and inflammation. Do not wear tight, elasticized socks that will hinder circulation in the lower leg and foot.
  5. Before you step into a tub of water, check the temperature with the back of your hand to ensure that the water is not too hot. You may not be able to judge the temperature by stepping in if you have reduced nerve function in your feet. Scalded feet do not heal quickly.
  6. It is a good idea to soak your feet daily in lukewarm water and then apply a moisturizing cream. The daily dunking will help keep your feet clean and therefore less prone to infection. The cream will keep your skin from becoming too dry and, as a result, cracking, and therefore also less prone to infection and inflammation. Also this daily routine will force you to look at and touch your feet. The daily examination will help prevent any nasty condition from establishing a bridgehead that will be difficult to dislodge.
  7. It is important to have a computerized weight-bearing scan that demonstrates abnormal pressure areas across the plantar surface (bottom) of the foot. Weight bearing systems like the Performance Orthotics system can detect early signs of areas of concern. The Performance system can measure exact pounds per square inch of pressure across the entire surface of the foot.

 

HAMMER TOES

What is a Hammer Toe?
When we refer to hammer toes, we mean a contracture of the proximal joint, which is further from the front (or top) of the toe. When we talk about mallet toes, which are almost identical to hammer toes, we refer to the distal joint, closer to the end of the toe. When both joints are involved, the condition is called a claw toe.

How is it caused?
Corns are caused primarily by a biomechanical fault. One of the primary causes of corns on the top of the foot is the "hammer toe" which is usually contracted and bent. This situation develops over a period of years and unfortunately, a person will not notice its development until the area begins to hurt and fitting into shoes can be painful. When the muscles and tendons on the top and bottom of the foot malfunction, the biomechanics of the toe involved will also become abnormal. The most common result is a hammer toe. Once a hammer toe exists, a corn is not too far behind.

What are the symptoms and complaints?
In the case of the corn, patients will complain of pain right at the site of the corn. In the case of the hammer toes, patients will develop pain at the toes joint and also find it more difficult and painful to fit into their shoes.

What is the treatment?
Since in both case the culprit is usually a biomechanical fault, the easiest and most conservative approach is to be fitted with a pair of custom orthotics to correct the underlying problem. In severe cases a more invasive surgical approach is necessary.


ILIO-TIBIAL BAND (Friction Syndrome)

What is it?
The ilio-tibial band runs over the outside part of the knee joint. If stretched too tightly, the friction occurring when it contacts the kneecap will irritate it.

What is the cause?
The band may be overstretched because it is poorly developed or very short causing it to be abnormally tight to begin with. Also, a badly overpronating foot will produce an internally rotating leg, and that situation will also stress the band unduly. Occasionally the ilio-tibial band friction syndrome will be caused by too much hill running, or by running constantly on uneven, rough terrain.

What are the symptoms?
The symptoms of the syndrome are pain and tenderness on the outside of the knee at the head of the fibula and upward. Walking up and down stairs produces pain, and there is stiffness in the knee joint after a person has been sitting with knees bent for more than couples of hours. However, that pain would be concentrated more on the outside of the joint.

How is it treated?
The treatment for this syndrome is a program of exercises to properly stretch the band, ice and laser therapy to relieve the discomfort, a change in footwear, including the use of custom orthotics to correct the biomechanical fault.

 

MORTON'S NEUROMA

What is it?
A neuroma is a benign tumor of a nerve caused by an abnormal growth of nerve cells arising in response to an irritation. A neuroma in the forefoot is never more than a simple irritated pinched nerve that has erupted because of constant compression and irritation-either between metatarsal heads, or at the base of the proximal phalanges (the largest bones in the toes).

How is it caused?
A neuroma may develop when poor biomechanical function of a foot causes a chronic irritation of a nerve, thereby triggering the growth of additional nerve cells. This process continues until the individual requires medical attention, because the discomfort has become too extreme. A second cause of a neuroma is ill-fitting shoes, which squeeze the forefoot and also force it to accept almost all of the body's weight during walking or running. Swelling of the foot for any reason may also cause a neuroma.

What are the symptoms?
The symptoms of a forefoot neuroma will generally vary from patient to patient, and can range from mild to severe. Patients will complain of pain between the 3rd and 4th toes usually as well as a burning and tingling sensation in the other toes.

How is it treated?
The treatment is based on the cause of the disorder. If the cause is from improper fitting shoes, the first thing to do is change the footwear permanently. If the problem is caused by a biomechanical fault, custom orthotics based on a computer gait analysis will work up to 80% of the time.

 

PLANTAR FASCIITIS

What is it?
Athletes, particularly runners, are well aware of the problem of plantar fascia. The fascia is a tendon-like band of tissue that runs on the bottom of the foot. It is attached to the heel bone and to the five metatarsal bones that are situated in the forefoot. The fascia has two tasks to perform: the first is to support the longitudinal arch of the foot, and the second is to help prevent over-pronation.

How is it caused?
Poor foot mechanics results in the Plantar fascia being twisted and torqued because the heel is stable while the forefoot is over-pronating. This shearing force causes the Plantar Fascia to become inflamed. The weakest part of the plantar fascia is the attachment to the periosteum (fibrous membrane covering the bone) at the heel. When the Plantar Fascia is being twisted, it pulls the periosteum away from the heel and causes the pain.

What are the common symptoms/complaints?
Symptoms include pain; tenderness and swelling that may be either mild to moderate or acute and debilitating. The classic characteristic of plantar fasciitis is pain in the area of the inflammation when pressure is first put on the foot in the morning. Once a person with plantar fasciitis has been walking around for a few minutes, the pain subsides, and the normal daily routine can be conducted without too much discomfort in the heel. However any lengthy time spent sitting or lying during the day will bring on the pain, as soon as weight is again put on the foot.

How is it treated?
Successful treatment usually consists of reducing the stresses on the overstretched tendon by the use of a custom orthotic. Since in most cases of plantar fasciitis, the culprit is over-pronation. The reason that the orthotics provide permanent long-term relief is that they eliminate the excessive torsion of the plantar fascia by preventing over-pronation of the foot. When the foot no longer over-pronates, there is no need for the plantar fascia to overextend itself to the point where it may tear.

Helpful "Heeling" Tips
Rest Your Foot - This will keep the swelling and pain to a minimum and prevent making the condition worse.

Ice The Area - This will help to reduce the inflammation and allow the area to feel better.

Stretching - Roll a tennis ball under your arch, or roll your foot over a small juice can backwards and forwards. These stretches reduce the strain put on the plantar fascia and thus allow for a reduction in symptoms and pain.

Custom Orthotics - Properly made they are the key to controlling over pronation and the recommended course of treatment for plantar fasciitis.

 

SHIN SPLINTS

What is it?
A shin splint is really periostitis ( a tearing of the lining of the bone away from the bone ), as in the case of plantar fasciitis. It occurs between the knee and ankle joints. There are two variations of this condition, namely medial and lateral. Which of these you develop depends on where the periosteum (lining ) is being torn away from the tibia, and by which muscle in the leg.

Anterior Shin Splints

How is it caused?
The Tibialis anterior is an anti-pronator due to its insertion on the medial aspect of the foot. During over-pronation the tibialis anterior has to fire constantly to oppose the over-pronation thus causing hypertrophy (swelling) of the tibialis anterior. Due to the fact that the anterior compartment is tightly constricted, the swollen tibialis anterior can cause an obstruction of blood flow which, in turn, can cause severe pain due to lack of oxygen.

Medial Shin Splints

How is it caused?
The Tibialis posterior is an anti-pronator due to its insertion on the medial aspect of the foot. During over-pronation the tendon of the tibialis posterior is stretched and pulled upon excessively thereby attacking the weakest area, namely its origin on the periosteum of the tibia. Small pain fibres of the periosteum are torn which causes the pain.

How is it treated?
Medial and Anterior Shin Splints : Since the problem is the over-pronation, the patient should be fitted with custom orthotics and will likely experience relief as there is a high rate of success with orthotics. Ice and rest will also help relief the inflammation.

 

 

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