Category Archives for "Orthotics"

Heel Pain and Plantar Fasciitis

Plantar fasciitis
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Over the past few weeks, I have seen an increasing number of patients of all ages  complaining of  Heel Pain – usually diagnosed as Plantar Fasciitis (PF).

The pain is usually persistent and occurs under the heel pad and around the heel. Often it only affects one foot, but after questioning and examination, they admit to “a bit of discomfort in the other foot.”

This extremely painful condition also called Plantar Fasciitis (PF), but strictly speaking PF causes pain into the arches and soles too, rather than just the heel.

In 1979, one of the founders of Podiatric Sports Medicine, Dr Steve Subnotnick, devoted an entire chapter to heel injuries, in his book Cures for Common Running Injuries. He was probably the original ‘running foot doctor’ when the surge in road running began to take off worldwide.

Tell me where it hurts!

The pain is usually worse in the morning when taking the first few steps and then gets less with continued movement. This pattern is repeated if you sit for a while later in the day – say in a meeting, classroom, lecture or tea-break – and stand up to walk again.

Patients always point to the exact site of pain. This is right in the middle under the heel pad. On the inside (very common) or outside of the heel and at the back.

Why does Plantar Fasciitis hurt?

Overuse is the phrase we use to explain PF! It’s a bit like saying stress. The basic cause is the malfunctioning of the person’s foot and lower limb structure, what we call your Biomechanics. The normal -for you – rocking and rolling movements are exceeded and the tissues get strained and inflamed at the very point where the plantar fascia is attached to the heel bone.

This can be caused by too much exercise such as increasing your distance and not getting enough rest. Changing the surface you run on; for example: running on a treadmill, starting running without the correct preparation, suddenly running more quickly.

Another common cause as we get older is being overweight.  Or a change of occupation where more walking or standing is required. Old worn shoes for day wear or exercise. Arthritis, a pinched nerve. All these and many more causes need to be identified.

How do you treat Plantar Fasciitis?

With difficulty to be honest! You must let your podiatrist see a good selection of your shoes. Frequently we can provide relief from the symptoms by padding, taping and some anti-inflammatories.

The basis of treatment is the biomechanical assessment to identify what goes on as you walk/run. Orthotics may be necessary, but current therapy is team-based,  so I might send you to a Physiotherapist or Biokineticist for strengthening of other muscle groups in your body.

We talk of core strengthening, to improve posture and alignment above the lower limb. If the pain is at the back of the heel gentle stretching plus raising the heeel helps. Nearly always lifting and cushioning the heel gives some relief. Wearing a higher heeled shoe also helps sometimes.

Can I avoid  it?

Yes, but not always. If you can diagnose the problem yourself then stop doing what caused the PF. We often get heel pain on holiday after a day of sightseeing or playing on the beach or more likely shopping!

Never let your trainers get badly worn, especially if they bulge on the inner side. Keep your weight under control. If you know you are going to have to do a lot of standing or walking, consider wearing your more comfortable shoes and change into your fashionable ones later.

At the first sign of pain seek professional help and advice – a proper biomechanical examnation will identify whether plantar fasciitis is the problem. Remember the basic First Aid of treating any inflammation of the soft tissues of your feet.

  • Rest;
  • Ice;
  • Compression;
  • Elevation.
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Bunion Surgery – A Painful Choice

Deciding to have bunion surgery can be one of the most difficult health decisions to make. ‘Bunions’ are a cause of distress to many thousands of people -mostly women -worldwide. Last year, I wrote about bunions and my opinion was and still is – “avoid bunion surgery if at possible, unless it is ruining your life and crippling you with pain”.

The ‘bunion’ referred to here is the bony deformity characterized by a big toe that deviates towards the rest of the toes, possibly accompanied by a second toe which is bent and overlies it.

When any surgical intervention is considered, be it the podiatrist enucleating a corn, removing part of a toe-nail or the orthopaedic surgeon realigning the foot in bunion surgery, all of us strive to do our best to achieve a satisfactory outcome, by exercising our skills to the utmost.

So you can imagine my concern to have two patients recently complaining bitterly about their unhappiness with the result of their bunion surgery. Add to this my surprise at the ‘twenty-something’ who wants surgery because she doesn’t like the look of her feet and her bunion (this one is the small thickening of the metatarsal bone with no deformity), prevents her from wearing the high fashion shoes she needs for work.

What can you say to a middle-aged, active woman who decided to have her bunion (deformed type) corrected, but after three months can only wear trainers with the toe cut out, has a swollen foot, pain and discomfort, difficulty driving, plus all the associated emotional stress? Or how do you respond to a similar woman who is now in constant pain and has had altered her walking style because the foot is rigid at the big toe joint?

To the best of my knowledge the procedures were technically successful and there is no deformity anymore. In addition we all react differently to a surgical “assault” and time does allow better healing. Also, there are numerous variations of operations and techniques available for bunion correction surgery.

Firstly – go back to the surgeon and discuss your options.
Secondly – see if a podiatrist can assist with biomechanical correction or alignment and footwear advice.

With my 2 patients, one has had orthotics made and the other I referred to the surgeon, who has recommended further physiotherapy, with the possibility of another operation to remove the steel plate that is in the foot.

I will still refer patients who meet my criteria outlined above for consideration for surgery, because the final decision to undergo sugery is always taken by the patient. Unfortunately, there can be no absolute guarantees since the structure of each foot is so complicated.

So what to do about ‘bunions’? Is there an underlying systemic disease such as rheumatoid arthritis?

We must consider the patient’s age. Is the patient overweight? What is the biomechanical structure and function, not only of the feet but lower limbs and body? Have all possible conservative measures such as night splints, orthotics, insoles, appropriate footwear, been exhausted?

Be guided by the severity of loss of function, pain, discomfort and limitation of daily activities. Will the patient be able to adhere to all the post-operative requirements, expected by the surgeon?

Eventually, all these factors (plus others), must be seriously thought about before undergoing bunion surgery.

Foot Care For The Elderly-Podogeriatrics

For podiatrists, podogeriatrics – care of the feet of the elderly – is a daily cause for concern, for a variety of reasons. I know that it is a part of our professional work that is often not looked at with much enthusiasm. There are more "old" people around because we are living longer. The foot care required by the older person is usually considered ‘routine.’ There are often financial considerations, due to lack of funds.

However, in a seminal piece of research published by the Disabled Living Foundation (UK) in 1983, is was found that the elderly (people of pensionable age), were occupying 85.9% of the National Health Service (NHS) podiatrists’ clinical time. There have been many changes in NHS policy and the provision of foot care since then and also to the way podiatry is practised in the UK, but one wonders just how we are doing in South Africa.

I would guess that the majority of our elderly people don’t have access to adequate foot care from a podiatrist. This is largely due to the inbalances in the structure of health care in the country, where the majority of the older people only have access to State care not private. Hence the proliferation of other "foot carers" such as nurses, health care assistants,beauty therapists and others, all of whom have responded to specific needs.

Getting older should not be a punishment for living longer and I believe there exists a desperate need for quality foot care for the older person. Podogeriatrics is not and should not be a case of regular cutting a filing of nails plus some callus reduction, carried out in quick time for a small fee.

Today I was visited by a few "oldies". Mary has just retired from a lifetime of teaching and came complaining about her painful left foot, where she was concerned that "there is a small piece of a fixation pin poking out under my foot, because there is a sharp pain in the callus and my surgeon told me after he had removed the pin originally, that there was still a piece that he could not get out".

By carrying out a simple biomechanical examination of Mary’s feet, I was able to analyse the possible source of the problem and treatment included reducing the painful callus and at the point of greatest pressure, enucleating the corn and recommending appropriate non-adhesive padding. In the long-term a simple cushion insole will probably be necessary.

80 year-old Harry also visited me for the first time asking if I could help him with his increasingly painful left foot and salvage his old but comfortable sandals. Again a careful, but simple, assessment of the structure and function of Harry’s feet (Biomechanical assessment), led to me inserting a pair of preformed moulded insoles (orthotics), into his shoes. To further improve function I added a piece of felt at a strategic spot under the insole – an immediate sense of support and noticeable improvement of foot alignment.

The advice for the sandals was to take then to a local African kerbside shoe repairer with instructions to replace the soles appropriately.  The lesson here is that podiatric care can be a major benefit to the elderly and that it extends far beyond simple nail cutting. (Although that IS all that is required).

Nevertheless, I don’t want to spend all my days cutting and filing toe nails!! What I do enjoy is seeing results of simple care plans. What we need in South Africa is evidence of the real and perceived need for foot care amongst this age group. Then we can lobby Government for improvements in the provision of podiatry services for the elderly nationwide for all our people. 

Foot Screening for Diabetes

A diabetes foot screening takes approximately a ½ hour and when it is finished the podiatrist will be able to identify the level of risk for diabetic foot complications. In addition, if referral to another member of the diabetes care team is required it will be done. Because foot problems are one of the main complications of diabetes, the podiatrist is able to manage non-ulcerative problems and foot ulcers.

The podiatrist treats all skin and nail related foot problems. Treatment includes appropriate foot health advice, cutting of nails, reducing calluses, enucleating corns, measuring for a simple insole, moulding for a foot orthotic, or even an operation to remove an ingrown toenail – this is carried out under local anaesthetic, usually in the podiatrist’s rooms and you go home straight afterwards. The podiatrist may decide on referral to another health care professional, such as an orthopaedic surgeon or physiotherapist. 

Although most podiatrists will manage any patient who consults them, modern podiatry has seen the development of practitioners with special interests in particular foot problems, these include chronic diseases like arthritis and diabetes, sports injuries and children’s’ foot problems. Therefore it is a good idea to find out if the podiatrist has a special interest in your problem.

No referral is necessary to see a podiatrist, although many patients are referred by their health practitioner.